Methotrexate in the Management of Laryngotracheal Stenosis: A Narrative Review

Laryngotracheal stenosis (LTS) involves narrowing of the proximal upper airway that can cause obstructed airflow and respiratory distress. LTS can be caused by intubation, previous tracheotomy, trauma to the neck, chemical inhalation, burn, inflammatory and autoimmune diseases, and other conditions. LTS can be chronic and recurrent. LTS can be life-threatening in some cases; so, it is important to understand all available treatment options. Methotrexate is a known treatment for autoimmune diseases, and given the autoimmune and inflammatory etiology of some cases of LTS, it has been considered as a viable treatment option. The purpose of this review is to analyze existing literature that examined the use of methotrexate in the management of LTS.

We identified 10 articles for inclusion in our narrative review. Patients in this review had various etiologies, including post-intubation subglottic stenosis (SGS), relapsing polychondritis, idiopathic SGS, rapidly recurrent nonvasculitic LTS, granulomatosis with polyangiitis, Immunoglobulin G4-related disease, and microscopic polyangiitis. Across all studies, methotrexate was administered weekly at a dose between 2.5 mg and 25 mg, and the duration of treatment ranged from 2 months to 11.4 years. In most cases, methotrexate appeared to result in improvement of symptoms, including longer intervals between operative interventions, increased post-drug recurrence intervals, no recurrence of stenosis following drug initiation, tracheotomy-dependent patients being decannulated, or patients reporting at least some clinical improvement after starting treatment. While methotrexate was tolerated well in most patients, not all patients experienced relief of their symptoms, and adverse events were reported in some cases.

Methotrexate is a widely used and well-understood drug that has been associated with documented cases of improvement of symptoms when used in the management of LTS. Benefits of methotrexate for the management of LTS for some patients include rapid airway improvement, stabilization, and long-term management; with mild side effects that can be monitored, methotrexate should be considered when treating a patient with LTS.