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Published online: 2024-01-24

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Subglottic stenosis of the larynx in granulomatosis with polyangiitis. A case report and review of the available literature

Ewelina Machura-Porębska1, Przemysław Kotyla1, Robert Pieczyrak1, Magdalena Kopeć-Mędrek1, Barbara Buc-Piorun1, Klaudia Palka1

Abstract

Granulomatosis with polyangiitis (GPA) is a rare systemic connective tissue disease marked by necrotising granulomatous inflammation and inflammation of small and medium-sized vessels. Due to its varied clinical presentation, GPA presents a major challenge for both clinicians and patients. Subglottic stenosis of the larynx (SGS) is a rare manifestation of GPA and is observed in 16–23% of patients. The aetiopathogenesis of this phenomenon is not fully elucidated. There was no correlation between the presence of airway narrowing (stenosis) and the activity and course of the disease. Subglottic stenosis can be a life-threatening condition with a need for urgent tracheotomy. The treatment of choice is immunosuppressive therapy with follow-up surgical treatment, usually using endoscopic approaches. A case of a 46-year-old female patient with SGS in GPA is presented. The patient reported severe dyspnoea, reduction of exercise tolerance and speech impairment. Intravenous pulses of corticosteroids were administered urgently and current immunosuppressive treatment was intensified, achieving a significant improvement in the patient's general condition. 

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References

  1. Szyfter W, Wierzbicka M, Gawecki W, et al. [The reasons of laryngo-tracheal stenosis: a review of literature and analysis of 124 patients]. Otolaryngol Pol. 2009; 63(4): 338–342.
  2. Eliachar I, Chan J, Akst L. New approaches to the management of subglottic stenosis in Wegener's granulomatosis. Cleve Clin J Med. 2002; 69 Suppl 2: SII149–SII151.
  3. Ugan Y, Doğru A, Aynalı G, et al. A clinical threat in patients with granulomatosis polyangiitis in remission: Subglottic stenosis. Eur J Rheumatol. 2018; 5(1): 69–71.
  4. Jagpal N, Shabbir N. Subglottic Stenosis. In: Shabbir N. ed. StatPearls [Internet]. StatPearls Publishing, Treasure Island (FL) 2022.
  5. Smith MM, Cotton RT. Diagnosis and management of laryngotracheal stenosis. Expert Rev Respir Med. 2018; 12(8): 709–717.
  6. Klink T, Holle J, Laudien M, et al. Magnetic resonance imaging in patients with granulomatosis with polyangiitis (Wegener's) and subglottic stenosis. MAGMA. 2013; 26(3): 281–290.
  7. Terrier B, Dechartres A, Girard C, et al. French Vasculitis Study Group. Granulomatosis with polyangiitis: endoscopic management of tracheobronchial stenosis: results from a multicentre experience. Rheumatology (Oxford). 2015; 54(10): 1852–1857.
  8. Kur-Zalewska J, Tłustochowicz W. In: Puszczewicz M. ed. Reumatologia. Wyd. II. Medical Tribune, Warszawa 2016: 211–235.
  9. Rottem M, Fauci AS, Hallahan CW, et al. Wegener granulomatosis in children and adolescents: clinical presentation and outcome. J Pediatr. 1993; 122(1): 26–31.
  10. Wojciechowska J, Krajewski W, Krajewski P, et al. Granulomatosis With Polyangiitis in Otolaryngologist Practice: A Review of Current Knowledge. Clin Exp Otorhinolaryngol. 2016; 9(1): 8–13.
  11. Pajor AM, Kwiatkowska S, Kroczyńska-Bednarek J, et al. Acute laryngeal dyspnea as first presentation of granulomatosis with polyangiitis. Pneumonol Alergol Pol. 2015; 83(3): 216–219.
  12. Guardiani E, Moghaddas HS, Lesser J, et al. Multilevel airway stenosis in patients with granulomatosis with polyangiitis (Wegener's). Am J Otolaryngol. 2015; 36(3): 361–363.
  13. Jennings CR, Jones NS, Dugar J, et al. Wegener's granulomatosis--a review of diagnosis and treatment in 53 subjects. Rhinology. 1998; 36(4): 188–191.
  14. Robson JC, Grayson PC, Ponte C, et al. DCVAS Investigators. 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology classification criteria for granulomatosis with polyangiitis. Ann Rheum Dis. 2022; 81(3): 315–320.
  15. Zimmermann-Górska I, Tuchocka-Kaczmarek A, Goncerz G. Choroby reumatyczne. In: Gajewski P, Tuchocka-Kaczmarek A, Goncerz G. ed. Interna Szczeklika. Medycyna Praktyczna, Cholerzyn 2022: 2117.
  16. Gottschlich S, Ambrosch P, Kramkowski D, et al. [Wegener's granulomatosis in the head and neck region]. HNO. 2004; 52(10): 935–45; quiz 946.
  17. Millet A, Pederzoli-Ribeil M, Guillevin L, et al. Antineutrophil cytoplasmic antibody-associated vasculitides: is it time to split up the group? Ann Rheum Dis. 2013; 72(8): 1273–1279.
  18. Smith RM, Jones RB, Jayne DRW. Progress in treatment of ANCA-associated vasculitis. Arthritis Res Ther. 2012; 14(2): 210.
  19. Kur-Zalewska J, Tłustochowicz W. Zapalenia małych naczyń. In: Puszczewicz M, Tłustochowicz W. ed. Reumatologia. Wyd. II. Medical Tribune, Warszawa : 211–235.
  20. Wiik A. Rational use of ANCA in the diagnosis of vasculitis. Rheumatology (Oxford). 2002; 41(5): 481–483.
  21. Fuchs HA, Tanner SB. Granulomatous disorders of the nose and paranasal sinuses. Curr Opin Otolaryngol Head Neck Surg. 2009; 17(1): 23–27.
  22. Trimarchi M, Bussi M, Sinico RA, et al. Cocaine-induced midline destructive lesions - an autoimmune disease? Autoimmun Rev. 2013; 12(4): 496–500.
  23. Martinez Del Pero M, Jayne D, Chaudhry A, et al. Long-term outcome of airway stenosis in granulomatosis with polyangiitis (Wegener granulomatosis): an observational study. JAMA Otolaryngol Head Neck Surg. 2014; 140(11): 1038–1044.
  24. Girard C, Charles P, Terrier B, et al. Tracheobronchial Stenoses in Granulomatosis With Polyangiitis (Wegener's): A Report on 26 Cases. Medicine (Baltimore). 2015; 94(32): e1088.
  25. Belloso A, Estrach C, Keith AO. Supraglottic stenosis in localized Wegener granulomatosis. Ear Nose Throat J. 2008; 87(7): E11–E14.
  26. Langford CA, Sneller MC, Hallahan CW, et al. Clinical features and therapeutic management of subglottic stenosis in patients with Wegener's granulomatosis. Arthritis Rheum. 1996; 39(10): 1754–1760.
  27. Aravena C, Almeida FA, Mukhopadhyay S, et al. Idiopathic subglottic stenosis: a review. J Thorac Dis. 2020; 12(3): 1100–1111.
  28. Gluth MB, Shinners PA, Kasperbauer JL. Subglottic stenosis associated with Wegener's granulomatosis. Laryngoscope. 2003; 113(8): 1304–1307.
  29. Quinn KA, Gelbard A, Sibley C, et al. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology (Oxford). 2019; 58(12): 2203–2211.
  30. Schokkenbroek AA, Franssen CFM, Dikkers FG. Dilatation tracheoscopy for laryngeal and tracheal stenosis in patients with Wegener's granulomatosis. Eur Arch Otorhinolaryngol. 2008; 265(5): 549–555.
  31. Costantino CL, Niles JL, Wright CD, et al. Subglottic Stenosis in Granulomatosis With Polyangiitis: The Role of Laryngotracheal Resection. Ann Thorac Surg. 2018; 105(1): 249–253.
  32. An J, Song JW. Life-Threatening Subglottic Stenosis of Granulomatosis with Polyangiitis: A Case Report. Medicina (Kaunas). 2021; 57(5).
  33. Henes FO, Laudien M, Linsenhoff L, et al. Accuracy of Magnetic Resonance Imaging for Grading of Subglottic Stenosis in Patients With Granulomatosis With Polyangiitis: Correlation With Pulmonary Function Tests and Laryngoscopy. Arthritis Care Res (Hoboken). 2018; 70(5): 777–784.
  34. Alam DS, Seth R, Sindwani R, et al. Upper airway manifestations of granulomatosis with polyangiitis. Cleve Clin J Med. 2012; 79 Suppl 3: S16–S21.
  35. McDonald TJ, DeRemee RA. Head and neck involvement in Wegener's granulomatosis (WG). Adv Exp Med Biol. 1993; 336: 309–313.
  36. Taylor SC, Clayburgh DR, Rosenbaum JT, et al. Clinical manifestations and treatment of idiopathic and Wegener granulomatosis-associated subglottic stenosis. JAMA Otolaryngol Head Neck Surg. 2013; 139(1): 76–81.
  37. Hernández-Rodríguez J, Hoffman GS, Koening CL. Surgical interventions and local therapy for Wegener's granulomatosis. Curr Opin Rheumatol. 2010; 22(1): 29–36.
  38. Almuhanna A, Almahboob A, Alhussien A, et al. Current Therapeutic Approaches to Subglottic Stenosis in Patients With GPA: A Systematic Review. Ear Nose Throat J. 2021 [Epub ahead of print]: 1455613211036246.
  39. Poo SX, Pepper RJ, Onwordi L, et al. Sirolimus use in patients with subglottic stenosis in the context of granulomatosis with polyangiitis (GPA), suspected GPA, and immunoglobulin G-related disease. Scand J Rheumatol. 2021; 50(1): 52–57.
  40. Nouraei SAR, Obholzer R, Ind PW, et al. Results of endoscopic surgery and intralesional steroid therapy for airway compromise due to tracheobronchial Wegener's granulomatosis. Thorax. 2008; 63(1): 49–52.