Dear Editor,
1.
We reviewed the letter to the editor by Abadifard et al. in response to our article regarding the Endoscopic Resection and Reconstitution (ER) procedure for idiopathic subglottic stenosis (iSGS). We appreciate the critical appraisal and the positive feedback on our methodologic detail and on the importance of highlighting iSGS patient centered priorities.
We agree that using the index ER procedure date rather than the final laser resurfacing date in future surgery‐free interval calculations would standardize these among patients. Moreover, this change would increase our absolute intervention‐free interval by approximately 4 months.
Our rationale for using peak expiratory flow rate as a key study outcome is based on a body of literature that shows peak expiratory flow is logarithmically proportional to luminal airway size [1, 2]. PEF maintenance conveys objective evidence for ER procedure success in preserving a long‐term patent airway. This study's retrospective multi‐institutional design did not include routine capture of patient reported voice, breathing, and swallow outcomes, but those were published in our initial review of 9 ER cases [3].
Regarding epithelial biology postulation, we would like to highlight the leaky barrier hypothesis central to iSGS pathology. A dysfunctional epithelial barrier is hypothesized to cause iSGS, in which airway epithelium is susceptible to microbial invasion, which activates immune cells leading to fibrosis [4, 5]. Prior studies have found that this dysfunctional epithelium has reduced thickness, is depleted of basal progenitor cells, and has decreased mucin expression [5, 6]. Ongoing epithelial cellular and molecular studies will allow for a better understanding of disease pathogenesis and explain how the ER procedure successfully reconstitutes a healthy segment of upper airway epithelium.
We agree that use of the Clavien‐Dindo Scale of Surgical Complications would provide a more uniform understanding of the complications that arise from ER, and we will use this scale in future reports. Reassuringly, only a single patient of ours had a Grade 4 complication in which re‐intubation and intensive care were required. In addition, there were two Grade 3 complications (intraoperative tracheal bleeding requiring bronchoscopy and vocal cord paralysis requiring injection medialization), two Grade 2 complications (mucus plug and skin graft infection needing antibiotics), and one Grade 1 complication (intermittent laryngospasm requiring an emergency department visit).
Overall, your suggestions should be thoughtfully incorporated into future studies evaluating ER procedure outcomes as these will enable standardization. We thank you for reflecting upon and carefully analyzing our work detailing the ER procedure for our iSGS patients' benefit.
Funding
The authors have nothing to report.
Conflicts of Interest
There are no conflicts of interest to report.
References
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