Evolution and Outcomes of Subglottic Stenosis and the Maddern Procedure Part I

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology head and neck surgery. Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center in our Head and Neck Institute. You can follow me on Twitter @PaulCBryson and you can get the latest updates from our institute by following @CleClinicHNI. Today I'm excited to talk with Dr. Robert Lorenz. He's a head and neck surgeon in Cleveland Clinic's Head and Neck Institute, my colleague, and our director of Complex Airway Reconstruction. Dr. Lorenz, let's start by having you share some background on yourself for our listeners, where you're from, where you trained, and how you came to Cleveland Clinic.

Robert Lorenz: Sure. I actually did my residency in Cleveland Clinic and started in 1996. I then went on to do a head and neck fellowship down at Vanderbilt and then came back to Cleveland Clinic and it was a unique time because we had a number of leaders in laryngeal stenosis. And then as I began my practice in 2003, they successively retired. And so a lot of that practice kind of came into over my way. And Mike Benninger then joined and he of course shared the practice with me. Also, don't forget, our rheumatologic colleague, so Gary Hoffman, who is the chairman of our rheumatology department, spent several years at the NIH with a guy named Bob Lebovics, who's a laryngeal specialist in New York City, and they had really pioneered the use of steroid therapy injected for rheumatologic airway stenosis when they were at the NIH.

So when Gary Hoffman came here to Cleveland in the nineties to head up our rheumatology department, a huge influx of autoimmune stenosis of the airway also followed him. And of course, Carol Langford also came from the NIH and Alex Villa-Forte, who's primarily a rheumatologic practice, all these people have got primarily vasculitis type practices. So even though airway stenosis due to vasculitis is a rare entity, just the volume is significant. So I kind of entered into that milieu, and as a head and neck surgeon, I had done quite a bit of open airway reconstruction and we just didn't have that. Most of it was endoscopic. So combined with Mike Benninger and myself was really inundated with a lot of patients with a complex airway stenosis. Then went away to another Cleveland Clinic entity across the world in Abu Dhabi. But those years, I got a chance to reflect, what could be done differently? What are we doing that could be innovated upon?

And it was at that time that I met up with Dr. Guri Sandhu, who practices in London. I was going to school in London at the time, and he was experimenting with this concept of a resection endoscopically of stenosis of the airway, followed by a relining of the voice box where the resection had occurred. And he called this the Maddern procedure, it is the first patient's name who underwent that procedure. And the concept here is not really all that novel in that you look through the larynx and you resect and remove all the stenotic portion usually of the subglottis. But the real innovation was the concept of relining of that. So he often will use the concept of a burn or a contracture where you have to place some type of relining substance so that the body doesn't try to re-heal that part of the airway. So kind of an aggressive resection of the stenosis and then a relining with some kind of epithelium. It could be dermal, it could be epidermis, it could be buckle, et cetera, to stop the body from relining. That in and of a nutshell is the Maddern procedure.

Paul Bryson: I appreciate you sharing that. It sounds like quite a bit of evolution in what you've seen in training, the early parts of your practice, and then seeing what some other folks were doing around the world. I was wondering if you could take a little step back and maybe aside from describing your own evolution and what you've seen and managed, what have you seen with the patient experience with airway stenosis, both from the rheumatologic and to the entity known as idiopathic subglottic stenosis? Aside from some of the surgical innovations, what have you seen with these patient populations with regards to diagnosis or any barriers to care?

Robert Lorenz: Well, let's go backwards. So in the eighties and nineties when I first started medical school and then training, there was a lot of traumatic causes for airway stenosis, and I think there was a tremendous amount of high pressure cuffs that were being used, just a lot of chronic intubation, for example, so inherited a lot of traumatic airway stenosis. Then on the rheumatologic side, kind of a different wave of patients, as I mentioned, in Cleveland Clinic because of the expertise we had here. But don't forget, this was prior to c-ANCA p-ANCA being the kind of mainstay of blood testing for, at the time it was called Wegener's granulomatosis, now renamed GPA. So we were biopsying people, we were biopsying their inferior turbinates. We were biopsying sometimes their subglottis or even their kidney, believe it or not, to diagnose these granulomatous diseases. Then the new blood tests, serologic tests, came and so those are almost kind of not very common nowadays that you actually do a biopsy for those vasculitides.

In addition, rituximab became almost a standard of care for vasculitis, and that has done a tremendous job. I remember seeing patients who are very, very sick. That really seems to have revolutionized the treatment of vasculitis. So all of that said, what happened is, as I came back to Cleveland in 2011, after Dr. Sandhu had kind of introduced this Maddern procedure, came to this group of refractory patients, a lot of whom had idiopathic subglottic stenosis, and they had formed a Facebook page. And that Facebook page really coincided with the emergence of social media within the medical field where patients with rare diagnoses, one out of 400,000, were really suffering in isolation, and as soon as they could get online and share common experiences, they were searching for a provider who had some volume, some of a patient cohort to work with. And that's how indeed a lot of these ended up coming to Cleveland.

Most of my patients are from out of state. Almost all are women who with idiopathic disease. I now have one man. But other than that, every single one of them, over 200 patients, all are women. Obviously hormonally related, right? And it was be that emergence of the social media paired with the surgical innovation, paired with, we pride ourselves in on great patient experience. So we don't treat people when they're from far away as if they're down from the street. We don't say come back next week and we'll go over your blood work. Why don't we take a look in a month again? Well, you can't look if they're coming from Albuquerque.

In a month, you have to work with their home providers or you have to work with them and their presentation. You've got to talk about peak flow meters at home that they can then report in. You can do a virtual visit, but as far as you repeating an endoscopy whenever is best for the patient, sometimes you have to work with what you've got as far as who they're seeing with at home, et cetera. So that's it. A large need paired with that social media connection paired with the innovation and then good results from the Maddern procedure, all of that paired together, that's how the population really took off.

Paul Bryson: I want to dive into the Maddern procedure here a bit, but also if we had some time I wanted to go over before you get to the Maddern procedure, I understand that airway dilation, a steroid injection, and sophisticated anesthesia management are critical to that patient experience in the operating room and having good functional outcomes maybe before going to the Maddern procedure or other open airway reconstructive measures. Can you speak a little bit about to the evolution and approach with anesthesia in the OR? And then we'll dive into some of the Maddern results and outcomes.

Robert Lorenz: Yeah. Speaking of the technology that we have in the OR, I trained prior to the onset of balloon dilation. And so if you go back to the mid-nineties, we were using the old fashioned bougie dilator, which for those of you who don't use it, that's almost an esophageal dilator, shaped like a V. And although it was effective, it does really run the risk of having interarytenoid injury, injury to the cricoarytenoid joint. And the worst possible scenario is kind of denuding the mucosa between the two retinoids. So now you've taken an isolated subglottic stenosis and you've created combination of subglottic and glottic stenosis with fixation of the posterior commissure. And so that's what we were doing with then. Then the onset of the balloon dilation came out, but we didn't really have radio controlled expansion balloons until the late 1990s, just a huge advancement in the technology, and it's much safer.

I actually wrote an article back from the nineties when I was training where we were not using the controlled radio expansion. We actually had a rupture of the trachea because we just didn't have the technology. Now there's a limit to how far the balloon can go up, thank goodness, and I think it's a much safer situation. So that's on the surgical side. On the anesthesia side, we've been using jet ventilation for a long time. You can talk about the monsoon, which is a high frequency jet ventilation, but the real exciting part that we've been using now is this high flow oxygenation nickname, thrive, which essentially creates kind of a pocket of oxygen in the oral cavity, oral pharynx, and believe it or not, these patients, again, usually women, often kind of in their healthy years of anywhere between 20 to 50 and often thin, and they can maintain their oxygenation with this type of anesthesia for extended periods of time.

The benefit are several fold. One, the jet tends to kind of fog the endoscopes that we use, and it's challenging to see what you're doing. Two, it reduces the barrel trauma of the lung parenchyma from the forceful jet that's going in. And so I think just those advancements between the thrive, the balloons, the high frequency jet ventilation, I think it's just a much safer situation. Now let's move over to what you describe, which is the steroid therapy. So again, this is hearkening back to the 1992 article from Lebovics and Langford and Gary Hoffman that showed in rheumatologic disease the addition of direct injection of steroids into the subglottic really extended out the interval between dilations that are needed. Now let's move over to the work of Ramon Franco out of Boston that showed that steroid injections by themselves without any dilation can actually regress disease and sometimes get patients into remission from disease, which is really exciting.

Talk about a traumatic therapy. You're not talking about any dilation whatsoever. You're talking about just injection of steroids. When I talk to patients, I talk about a keloid, hypertrophic fibroblasts of the keloid that if you cut a keloid off, that thing just comes right back. What do you need to do? You need to actually inject steroid and then a month later inject steroid until you see involution of the keloid secondary to inhibition of the fibroblasts. That's essentially what we think is going on in the subglottis for these patients who are responsive.

Now, not all patients are responsive, and not all patients go into remission, but it is a less invasive option for patients that I actually don't do. I don't do office injection of steroids. I have outstanding colleagues who do do that, and they're just great at it. Right? You just talk about the anxiety of having somebody inject something in your airway in the office. It's just not something that I was really astute at, and when I've got colleagues who are fantastic at it, I refer my patients over to them. You don't know any of these colleagues. Do you?

Paul Bryson: I might know a few.

Robert Lorenz: Dr. Bryson's, one of my most talented in office injection colleagues, but also Dr. Rebecca Nelson, Mike Benninger, William Tierney, they're all fantastic.

Paul Bryson: We're lucky to have a good team with a lot of diverse training backgrounds. Rob, such a great discussion. Let's continue with this topic and really dive into the Maddern procedure in our next episode. Thank you, Rob.

For more information on subglottic stenosis treatment at Cleveland Clinic, please visit ClevelandClinic.org/SubglotticStenosis. That's ClevelandClinic.org/SubglotticStenosis, and to speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Dr. Lorenz, thanks for joining Head and Neck Innovations.

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