Methotrexate Therapy for Idiopathic Subglottic Stenosis

Objectives: Idiopathic subglottic stenosis (ISGS) is a rare, inflammatory cicatricial stenosis at the level of the cricoid cartilage and upper trachea. Surgical options range from dilation to cricotracheal resection and reconstruction, but there is no proven medical alternative therapy. Methotrexate is a mainstay of treatment for certain autoimmune disorders, including Wegener’s granulomatosis, a disease in which subglottic stenosis is a common problem. We conducted a preliminary evaluation of methotrexate for the treatment of ISGS. Methods: A retrospective study was performed from September 2001 to May 2008 of patients with biopsy proven, recurring ISGS, who were treated with methotrexate. Patient demographics, methotrexate dosage and route, treatment duration, side effects, and length of follow-up were analyzed. Results: Four female patients diagnosed with ISGS with average age 44.8 years (range 29-63) were included. Patients received methotrexate 15-25 mg once weekly, typical doses for patients with Wegener’s granulomatosis. Treatment duration averaged 19.25 mo (range 6 to 29 months). Three of four patients reported subjective improvements in breathing that worsened after discontinuation of the drug. One patient had progression of stenosis. No severe adverse effects were reported. Mean follow-up was 72.25 months. Conclusions: Our initial trial of methotrexate for ISGS resulted in improved breathing symptoms during therapy in most patients. We propose that methotrexate be considered within the multi-modality therapy usually necessary for ISGS patients. Additional prospective studies may provide evidence that methotrexate can stabilize or improve laryngotracheal stenosis in ISGS patients.