From the Guidelines
For a patient with moderate sinus disease without polyps and mild subglottic stenosis, I recommend a medical management approach as the first line of treatment, specifically using intranasal corticosteroids and nasal saline lavage, as suggested by the most recent and highest quality study 1. This approach is appropriate given the patient's condition, as it addresses the inflammatory component of sinus disease and has a lower risk of complications compared to surgical intervention, especially considering the presence of mild subglottic stenosis.
- The patient should use intranasal corticosteroids, such as fluticasone, at a dose of 400 mcg once or twice daily, depending on severity.
- Nasal saline lavage should be performed twice daily to help reduce inflammation and clear out mucus.
- If the condition does not improve after 3 months, culture should be performed and long-term macrolide therapy instituted, as recommended by 1.
- The presence of mild subglottic stenosis warrants caution regarding immediate surgical intervention, as intubation and surgical manipulation could potentially worsen the stenosis.
- Medical management should be tried for at least 4-6 weeks, with follow-up evaluation to assess response.
- If symptoms persist or worsen despite adequate medical therapy, then surgical options could be reconsidered, taking into account the patient's overall condition and the potential risks and benefits of surgery, as discussed in 1 and 1. The patient should also be advised to avoid known irritants or allergens that may exacerbate their condition. It's worth noting that the level of evidence for some therapies may be open to debate, as discussed in 1, but the recommended approach is based on the most recent and highest quality study available.
From the FDA Drug Label
These trials evaluated the total nasal symptom scores (TNSS) that included rhinorrhea, nasal obstruction, sneezing, and nasal itching in known allergic patients who were treated for 2 to 24 weeks. The FDA drug label does not answer the question.
From the Research
Treatment Options for Moderate Sinus Disease and Mild Subglottic Stenosis
- For patients with moderate sinus disease and no polyps, the provided studies do not offer a direct course of action, as they primarily focus on subglottic stenosis or chronic rhinosinusitis with nasal polyps 2.
- In cases of mild subglottic stenosis, watchful waiting may be considered as a therapeutic approach, depending on the degree of stenosis and other factors 3.
- Surgical management, such as laryngotracheal reconstruction, partial cricotracheal resection, and anterior cricoid split, may be necessary for more severe cases of subglottic stenosis 3, 4, 5.
- The optimal modality of treatment for subglottic stenosis is often a combination of endoscopic and open surgical treatment 4.
- In some cases, CO2 laser excision may be used to remove subglottic masses, as seen in a case report of sinus histiocytosis with massive lymphadenopathy and subglottic stenosis 6.
Considerations for Treatment
- The selection of the most accurate treatment is key to success, reducing the number of surgeries and preventing complications 3.
- Treatment outcomes may vary, with some patients achieving good ventilation, swallowing, and voice qualities, while others may experience dysphonia or respiratory distress 3, 4.
- There is no clear treatment protocol for patients with subglottic stenosis, and treatment approaches may need to be tailored to individual cases 4.