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Spray Cryotherapy for the Treatment of Glottic and Subglottic Stenosis

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Spray Cryotherapy for the Treatment of Glottic and Subglottic Stenosis The Laryngoscope VC 2010 The American Laryngological, Rhinological and Otological Society, Inc. Case Report Spray Cryotherapy for the Treatment of Glottic and Subglottic Stenosis William S. Krimsky, MD; Michael P. Rodrigues, MD; Navara Malayaman, MD; Saiyad Sarkar, MD to manage despite a variety of surgical and endoluminal Objectives/Hypothesis: Functional partial occlu- approaches. Surgical interventions, such as resection or sion of the glottic and subglottic areas by stenosis and tracheostomy, and endoluminal interventions, such as di- strictures is challenging to manage despite a variety of surgical and endoluminal approaches that are prone to lation, stenting, and ablation, are often combined with complications and inconsistent outcomes. We report one another with variable and inconsistent results. here the first three human cases of glottic and subglottic Given the potential complications and inconsistent out- narrowing treated with spray cryotherapy alone or in comes of surgery, alternative approaches to managing combination with balloon dilation. glottic and subglottic stenoses are needed. Although Study Design: Institutional review board- prior work with cryoprobes in the aerodigestive tract approved clinical human trial. demonstrated some normalization of the mucosa and a Methods: A 42-year-old female with idiopathic more controlled wound response, there remained issues subglottic strictures, a 74-year-old female with glottic with mechanical injury and the degree to which the tem- strictures and vocal cord stenosis following neck radi- perature of the target tissue could be reduced.1 ation, and a 33-year-old female with strictures from a previous tracheal stent were treated by four cycles of Noncontact spray cryotherapy is a novel modality a 5-second cryotherapy spray alone or with balloon di- that has been used extensively in the gastrointestinal (GI) lation. The effects of treatment were observed up to 6 tract. Studies in the GI tract have demonstrated eradica- months, 12 weeks, and 9 months, respectively. tion of intramucosal carcinoma,1 effective treatment of Results: In all cases, patency of the stenosed human papillomavirus infection,2 and hemostasis3 provid- areas was achieved with minimal bleeding and at ing for a submucosal injury without the potential for least some degree of normalization of the glottic and mechanical injury and normalization of the mucosa with a subglottic mucosa. Airway patency and laryngeal controlled wound response. Additionally, cryotherapy has functions were restored without complications. also been used as adjuvant therapy in patients undergoing Conclusions: The use of spray cryotherapy transoral resection of early glottic cancers and has been alone or in conjunction with balloon dilation is a 4 promising and effective therapeutic approach to treat- shown to improve voice quality in these patients. These ing glottic and subglottic narrowing. findings, combined with the breadth of evidence regarding Key Words: Spray cryotherapy, glottic stenosis, cryotherapy in dermatology and other fields, suggest that subglottic stenosis, balloon dilation. treatment with spray cryotherapy may be an appropriate Laryngoscope, 120:473–477, 2010 modality for primary or adjunctive treatment of glottic and subglottic stenosis to modify the wound response, and INTRODUCTION when appropriate, combined with balloon dilation. Herein, Narrowing of the glottic and subglottic areas from we present the first three cases in the treatment of glottic either congenital or acquired stenosis remains difficult and subglottic stenosis accompanied by granulation tissue with spray cryotherapy. From the Department of Pulmonary and Critical Care (W.S.K., S.S.), the Department of Otolaryngology (M.P.R.), and the Department of Internal Medicine (N.M.), Franklin Square Hospital, Baltimore, Maryland, U.S.A. MATERIALS AND METHODS Editor’s Note: This Manuscript was accepted for publication Spray cryotherapy was performed with the CryoSpray October 28, 2009. Ablation System (CSA System, Model CC2-NAM; CSA Medical, William S. Krimsky, MD is a consultant for CSA Medical. Inc., Baltimore, MD), which has 510(k) clearance by the US Send correspondence to William S. Krimsky, MD, 9103 Franklin Food and Drug Administration and European Conformity/CE Square Drive, Suite 300, Baltimore, MD 21237. E-mail: wkrimsky@ mark for use in Europe (as a cryosurgical tool in the field of gmail.com general surgery, specifically for endoscopic applications). The DOI: 10.1002/lary.20794 CSA System, a noncontact method of cryotherapy, was used to Laryngoscope 120: March 2010 Krimsky et al.: Spray Cryotherapy for Stenosis Treatment 473 TABLE I. Patient Treatments. Initial Dose Pneumatic Dilation Subsequent Dose Total Time, min Patient 1, 43-year-old 4 cycles  5 sec Sequential dilation with 8-9-10–mm 2 cycles  5 sec 28 Caucasian female CRE balloon, followed by dilation with 12-13.5-15–mm CRE balloon Patient 2, 74-year-old 4 cycles  5 sec Sequential dilation with 8-9-10–mm 2 cycles  5 sec 37 Caucasian female CRE balloon, followed by dilation with 12-13.5-15–mm CRE balloon Patient 3, 33-year-old 4 cycles  5 sec No dilation performed None 35 Caucasian female The treatment cycle begins when the targeted area is covered with a visual ice field. Cycle is complete after 5 seconds. Subsequent cycles begin after visual thaw (i.e., loss of ice field) has been achieved. This takes approx 30 to 40 seconds. CRE ¼ controlled radial expansion. apply medical-grade liquid nitrogen (À196C), directly to the balloon and repeat dilation with a 12-13.5-15–mm CRE balloon. tissue via a low-pressure, disposable 7-French cryocatheter Spray cryotherapy was then delivered to the dilated wound but introduced through the vocal cords through the working chan- with two cycles of 5-second sprays in an attempt to modify the nel of a therapeutic flexible bronchoscope (Olympus BF-X1T160 injury response. The patient tolerated the procedure well, and or BF-X1T180; Olympus America Inc., Center Valley, PA). A no adverse events occurred. This treatment led to complete waiver was obtained from the Medstar Institutional Review remission of the patient’s hoarseness and profound improve- Board (Hyattsville, MD) such that the data might be reviewed. ment in her breathlessness within 7 days. Follow-up at 1, 3, Patients initially received four cycles of 5-second spray and 6 months post-treatment confirmed the patient had near cryotherapy with a complete thaw of the treated area between complete luminal patency of the airway without evidence of each application (Table I). If needed, balloon dilation followed restricturing or granulation tissue. She remains symptom free using appropriately sized balloons (controlled radial expansion and no longer requires use of corticosteroids. [CRE] balloon; Boston Scientific, Natick, MA) with subsequent Glottic stricture and vocal cord stenosis following delivery of an additional two cycles of 5-second spray cryother- radiation. A 74-year-old Caucasian female with a 53-year his- apy after the mechanical injury. The balloon dilation was either tory of smoking and gastroesophageal reflux disease had performed after the patients were suspended using a Lindholm recently completed 28 of 33 sessions of radiation therapy for a laryngoscope or through a laryngeal mask airway. recent diagnosis of squamous cell carcinoma of the right vocal Freeze and thaw techniques were monitored by direct vis- cord. Over the preceding month, she had developed progressive ualization. The duration and extent of the cryogen spray to the severe dyspnea, stridor, and hoarseness. selected site was at all times under the control of the physician. A month prior to presentation, when the symptoms began, All cases were performed in the operating room under general she had received a Solu-Medrol taper for her shortness of breath anesthesia. along with a ventilation/perfusion scan that was negative for pul- monary embolism. Four weeks later, evaluation with fiberoptic laryngoscopy by speech, language, and pathology revealed a web- Case Presentations like circumferential occlusion of the glottic opening with a 4- to Three cases of glottic and subglottic stenosis, one of which 5-mm aperture likely a consequence of her radiation therapy. A was accompanied by granulation tissue, are presented here. All bronchoscopy and suspension microlaryngoscopy confirmed laryn- three patients were treated with low-pressure spray cryother- geal stenosis secondary to web formation from the midcord to the apy either alone or in combination with balloon dilation. anterior commissure. (Fig. 2) The patient was treated with four Tracheal stenosis of unclear etiology. A 43-year-old cycles of 5-seconds of spray cryotherapy. This was followed by di- Caucasian woman with a history of gastroesophageal reflux, lation with an 8-9-10–mm CRE balloon, then further dilation chronic allergic rhinitis, and no history of smoking presented with with a 12-13.5-15–mm CRE balloon. A subsequent two cycles of stridor, hoarseness, and trouble breathing. The dyspnea and stri- 5-second spray cryotherapy was delivered. Airway patency was dor had progressively worsened over the preceding 24 months. She achieved with an increased postprocedure lumen to approxi- received a speech, language, and pathology evaluation after she mately 12 to 15 mm in diameter. developed hoarseness and a change in voice quality. She had car- At 12 weeks postprocedure, repeat speech, language, and ried the questionable diagnosis of severe asthma, which was pathology evaluation along with flexible laryngoscopy demon- diagnosed roughly 2 to 3 years prior to the development of her strated a normal appearance of her vocal cords and larynx hoarseness and was treated with increasing amounts of oral corti- without any return of her previous symptoms. In addition, pul- costeroids with marginal control of her symptoms. monary function tests demonstrated an increase in her peak Flexible laryngoscopy was performed and revealed a sub- flow rates of nearly 180% (1.82 L/min–5.03 L/min). glottic stricture beginning at the distal end of the thyroid Tracheobronchomalacia with partial obstruction of cartilage and extending down to the second tracheal ring.
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