We need to treat SGS more like an inflammatory disease rather than a clogged pipe. —Michael Johns III, MD
Explore This Issue
August 2020
Open surgery is associated with more significant risks than endoscopic procedures, including the potential for significant postoperative voice changes. The benefit of open surgery is the potential for durable long-term cure, which enables patients to avoid repeat procedures every one to three years.
In the largest prospective comparative study to date, the investigators of the North American Airway Collaborative examined 1,056 iSGS patients across 40 participating institutions. The aim of the study was to measure days from initial surgical procedure to recurrent surgical procedure and evaluate quality of life issues, including vocal changes and postoperative complications (JAMA Otolaryngol Head Neck Surg. Published online Oct. 31, 2019).
Of the 810 patients who were evaluated, 75% underwent endoscopic dilation, 15% had endoscopic resection with medical therapy (ERMT), and 10% underwent open resection. The findings of the study mirrored clinical experience: Endoscopic dilation, the least invasive technique, was associated with a higher recurrence rate compared with the other procedures. Specifically, 169 of 603 patients who underwent endoscopic dilation (28%) required recurrent surgery during the three-year study compared with only one of 86 patients undergoing open surgery (1.2%) and 15 of 121 patients (12.4%) in the ERMT group.
One interesting result was ERMT’s efficacy, Dr. Gelbard noted. ERMT offered significantly improved disease control compared with endoscopic dilation, with minimal impact on phonatory function, particularly when compared with open resection. Whether ERMT’s reduced disease recurrence rate was associated with surgical technique, postoperative medications, or a combination remains unclear and is an active area of research.
Another surprising finding of the study has been the patient’s perception of their outcome after surgery, Dr. Gelbard noted. Although cricotracheal resection had the highest perioperative risk and the greatest impact on postoperative voice outcomes, the patients who underwent this surgery rated their global quality of life as the highest among the treatment options at 360 days.
“Seeing how well people did with an open resection was interesting,” Dr. Gelbard said. “Prior to the study, there had been a bias among some surgeons that the open resection technique was more invasive and the endoscopic approach more appropriate to preserve voicing. Patients’ experience offers a wrinkle to this bias. It appears that some patients with iSGS … are willing to trade some loss of voice function for a life without worrying about breathing and undergoing recurrent surgeries.”
One of the biggest challenges now is tailoring the treatment options to patient preferences. When meeting with a patient, Dr. Gelbard spends most of the consultation reviewing the risks and benefits of each of the iSGS treatment options available. “I believe providing all the information up front about what their treatment options are, and how those different approaches will impact their life, helps patients feel more in control of their disease, and allows them to select a treatment approach that matches their priorities.”