Molecular stratification of subglottic stenosis to identify therapeutic pathways

PROJECT OVERVIEW

Subglottic stenosis (SGS) is a progressive fibrotic disease that causes narrowing of the subglottic trachea. Causes are autoimmune (granulomatosis with polyangiitis (GPA) or ANCA-negative vasculitis), iatrogenic (after intubation or trauma) or idiopathic, with an incidence of 1 in 400 000 patients per year1. Idiopathic subglottic stenosis (iSGS), affects premenopausal women, presenting during pregnancy or perimenopause2. The cellular and molecular mechanisms underlying these similar but distinct disease subtypes are not well understood. Recent single-cell sequencing studies across the three subtypes compared with normal tissue demonstrated increased immune cell infiltration within the affected region, with distinct patterns of fibroblasts and macrophages along with lymphocytes and dysregulated oestrogen signalling within the affected region. Epithelial barrier dysfunction, immune cell infiltration and extracellular matrix remodelling seem to centre the general disease process in all aetiologies; however, to varying degrees. These studies have been limited by sample size, and further work is needed to better define SGS subtypes and help target treatment1–3.
Currently, treatment consists primarily of repeated surgical dilations to manage symptoms, which include dyspnoea, stridor, and dysphonia. In severe cases, patients require open resection of the fibrotic segment or tracheostomy. All surgically treated patients have a high risk of recurrence and have significant long-term morbidity affecting quality of life1,4. Systemic immunosuppressants improve SGS in patients with GPA in observational studies, and this has led to the use of these drugs in iSGS. Rituximab and methotrexate significantly increased time between surgical interventions[3]. This raises the suggestion that immunosuppression might be a therapeutic option for more patients with iSGS. A better understanding of the underlying mechanisms of disease across subtypes would help to identify patients likely to benefit from this approach and pave the way for trials.

This project aims to:

1. Integrate existing sequencing datasets to compile a comprehensive atlas of SGS across different aetiologies and use it to identify common and differing cellular composition, gene expression, pathways and interactions, aiming to identify candidate drivers of idiopathic SGS.
2. Use existing clinical samples to validate candidate drivers of SGS at the protein level with particular focus on pathways which may provide insight and rationale for the efficacy of rituximab and/or methotrexate.
3. Utilise established fresh tissue collection pipelines to collect samples for growth to form cell lines and organoids for in vitro validation and perturbation studies to provide a mechanistic rationale for potential future clinical trials.

This disease predominance in females over males is poorly understood and poorly affects quality of life; therefore, this project would align with the new Government’s Women’s Health Strategy and the National Institute for Health and Care Research commitment to improving women’s health and addressing conditions that disproportionately affect women.

KEYWORDS

Subglottic stenosis, fibrosis, single-cell transcriptomics, extracelullar matrix, immunosuppression

TRAINING OPPORTUNITIES

This project benefits from a multidisciplinary supervisory team with expertise in matrix immunology, stromal cell and immune biology in fibroproliferative diseases, together with specialist clinical expertise in Ear, Nose and Throat (ENT) surgery. This close integration of lab-based research and clinical translational research will ensure our clinical project incorporates relevant questions and patient needs. The Kennedy Institute of Rheumatology is a renowned biomedical research centre that combines discovery science, clinical translation and experimental medicine. Oxford University Hospitals NHS Foundation Trust is a specialist tertiary centre providing state-of-the-art ENT services and access to patient cohorts, clinical specimens and insight into disease management in a clinical setting.

This project will provide training in computational approaches with integration of single-cell RNA sequencing and bioinformatics. It will also include spatial transcriptomics and proteomics from clinical samples, cell and organoid culture and clinical-academic career development.

KEY PUBLICATIONS

1. Lin RJ, Zeng PYF, Fung K, Khan H, Cecchini MJ, Woo E, et al. Cohort-level clinical trajectory and molecular landscape of idiopathic subglottic stenosis for precision laryngology-a study of the Canadian Airways Research (CARE) group. EBioMedicine 2025;114:105629. https://doi.org/10.1016/j.ebiom.2025.105629.
2. Xue C, Wang W, Zhuang Q, Lin Y, Zeng Y. Integrating single-cell and bulk RNA-Seq to unravel the molecular mechanisms of airway stenosis. Funct Integr Genomics 2026;26:10. https://doi.org/10.1007/s10142-025-01794-9.
3. Awadallah AS, Bowen AJ, Ali HM, O’Byrne TJ, Padilla HM, Khalil YH, et al. Methotrexate and Rituximab Use in Highly Recurrent Idiopathic Subglottic Stenosis. The Laryngoscope 2025;135:168–75. https://doi.org/10.1002/lary.31686.
4. Gelbard A, Shilts MH, Hoke A, Strickland B, Motz K, Tsai H-W, et al. Idiopathic Subglottic Stenosis and the Epithelial Interface of Host and Environment. Journal of the American College of Surgeons 2025;241:180–92. https://doi.org/10.1097/XCS.0000000000001340.
5. Buckley CD, Midwood KS. Tracing the origins of lung fibrosis. Nat Immunol 2024;25:1517–9. https://doi.org/10.1038/s41590-024-01934-6.

THEMES

Fibrosis, immunity, inflammation, translational medicine

CONTACT INFORMATION OF ALL SUPERVISORS

Professor Christopher Buckley

Professor Kim Midwood

Professor Stuart Winter

Dr Caroline Morrell