Changing trends in clinical manifestations of laryngeal tuberculosis

OBJECTIVES/HYPOTHESIS: Despite the dramatic decrease in the incidence of laryngeal tuberculosis, the disease has gained new interest as a result of claims that it has changed its clinical patterns. The aim of this study is to evaluate the changing trends in clinical manifestations of laryngeal tuberculosis. STUDY DESIGN: Retrospective clinical analysis. METHODS: Clinical analysis of 22 patients with pathologically confirmed laryngeal tuberculosis was carried out retrospectively. RESULTS: Patients' ages ranged from 22 to 75 years. The male-to-female ratio was 2.14 to 1. The most frequent chief complaint was hoarseness. The true vocal cord and the false vocal cord were commonly involved, and 11 patients showed single lesions. Among 22 patients, only 7 had active pulmonary tuberculosis, and 9 were proven to have normal lung status. The patients with active pulmonary tuberculosis showed more ulcerative and multiple lesions. The patients with normal lung status showed nonspecific, polypoid, and single lesions. All patients responded satisfactorily to antituberculous medication. CONCLUSIONS: The clinical manifestations of laryngeal tuberculosis have changed and seem to be different from those of classic reports. It can even occur without pulmonary tuberculosis, and the characteristics of lesions seem to be more nonspecific. It might be important to consider tuberculosis in the differential diagnosis of nonspecific laryngeal disease.     

Changing trends in the nature of vocal fold motion impairment

PURPOSE: Vocal fold motion impairment (VFMI) continues to be a dominant issue in laryngology. The objective of this study is to examine a contemporary population of patients with newly diagnosed VFMI and detect changes in the nature of the cases compared with previous reports. MATERIALS AND METHODS: Eighty-four patients with newly diagnosed VFMI are identified from the first author's clinic over a recent 1-year period. Patient demographics, etiology, side, and nature of the impairment are determined from retrospective chart review. RESULTS: Of the 84 patients, 47 (56%) are women and 37 (44%) are men. The average age of all patients is 53.4 years. Seventy-five (89.3%) of the 84 VFMIs were unilateral, with 11% (9/84) being bilateral. The left side was affected in 52% (39/75) of the patients; the right side was affected in 48% (36/75) of the unilateral cases. The motion impairment was complete in 61.3% (46/75) of the unilateral cases and partial in the remaining 38.7% (29/75). With regard to etiology, iatrogenic causes were the most prevalent with 47.6% (40/84) of the patients. Idiopathic cases comprised 36.9% (31/84) of the patients. Neoplasms (7.1%, 6/84) and miscellaneous causes (7.1%, 6/84) accounted for smaller portions of the remainder. Of the iatrogenic VFMI cases, 27.5% (11/40) followed cervical spine operations. Chest, intracranial, and thyroid surgery accounted for 6 (15%) patients each, as did endotracheal intubation (n = 6, 15%). CONCLUSIONS: Compared with previous reports, the incidence of iatrogenic cases reviewed here is relatively high. Anterior cervical spine surgery surpassed thyroidectomy and all other procedures as the most common cause of iatrogenic VFMI in this contemporary study.     

Changing trends in the success rate of anterior cricoid split

OBJECTIVES: We determined the historical trends at our institution in the extubation success rate, defined as avoiding tracheostomy, for infants with acquired laryngotracheal stenosis (LTS) who undergo anterior cricoid split (ACS) as primary treatment. METHODS: We performed a retrospective chart review of all neonates with acquired LTS treated with ACS between 1989 and 2005. Successful extubation rates were assessed over the study's time period. Student's t-test was used to compare identified subgroups. RESULTS: Thirty-one neonates (14 male, 17 female) were identified, with an average gestational age of 27.6 weeks. During 1989 to 1995, a successful cumulative extubation rate of 71.4% was achieved in 14 children. By 2005, though, following a further 17 children, the successful cumulative extubation rate had dropped to 54.8%. The extubation rate in the time period 1996 to 2005 specifically was only 41.2%. The factor identified that most significantly correlated with this change was the difference in average duration of preoperative intubation. Relatively higher numbers of significant neurologic, respiratory, and cardiac comorbidities were identified both in the 1996 to 2005 grouping and in the ACS failure grouping. CONCLUSIONS: The success rate of ACS as a means of avoiding neonatal tracheostomy appears to have declined over the past 10 years at our institution. A prolonged period of preoperative intubation, as well as associated increasingly significant comorbidities, may be explanatory for this change. Revising the accepted selection criteria for ACS, or broadening the indications for alternative techniques, may be warranted.     

Changing trends in the occurrence and subsite distribution of laryngeal cancer in Finland

Cancer of the larynx represents worldwide approximately 1–2% of all cancers and generally occurs predominantly in males. Based upon many reports, the age-adjusted incidence of laryngeal cancer has been rising in recent years, especially among women. Squamous cell carcinomas arising in the glottic region are the most common of all laryngeal cancers and more prevalent than the supraglottic ones. Subglottic disease is still rare. The Finnish Head and Neck Oncology Group evaluated the present occurrence of laryngeal cancer by site and gender in Finland. The annual age-standardized incidence of laryngeal cancer is 3.2 per 100,000 for men and 0.3 per 100,000 for women. The proportion of females in the five university centers reviewed was 5%. During the 30-year time period from the early 1960s to the 1990s there has been a significant decrease in the laryngeal cancer incidence rates for males, but no change for females. Finland thus seems to be the only Western country with clearly declining occurrence rates in recent decades. In the same time period a clear decrease in the incidence of bronchial cancer has occurred in males and an increase in females. The results also show that in all five university hospital districts glottic cancer became more common (50–68%) in the late 1980s and 1990s, which is opposite to the situation in the 1960s when supraglottic localizations (65%) dominated in Finland. Received: 26 September 1998 / Accepted: 27 January 1999     

ACE-inhibitor induced angioedema

ACE-inhibitor induced angioedema is a non-allergic drug-related side effect. Inhibited bradykinin degradation leads to an unphysiological enhanced bradykinin plasma level with vascular leakage and, consequently, to angioedema. ACE-inhibitor induced angioedema develop rapidly in the head and neck region. Typical sites of manifestation are lips, tongue, and larynx. Novel pharmacotherapies may allow a causal treatment of the ACE-inhibitor induced angioedema in the future.     

Treatment of hereditary angioedema

Hereditary angioedema is a rare familial disease caused by the defect of complement C1esterase inhibitor (C1-INH). It is characterized by recurrent acute edema of the extremities, the face, the respiratory tract and the gastrointestinal tract. Acute laryngeal edema usually produces laryngeal obstruction. Two cases have been treated since 1986, one of them had been admitted for forty-five times because of recurrent acute laryngeal edema. Investigations showed two families with a high incidence of this disease. Laboratory examination showed a remarkable decrease of C1-INH and C4. Tracheotomy is indicated in patients with laryngeal edema. Great success was achieved in two patients treated with danazol.     

Drug-Induced,life-threatening angioedema revisited

Few drug reactions are more life threatening than the sudden development of edema involving the mucosal and submucosal layers of the upper aerodigestive tract. Drug-induced angioedema is a recognized entity of angiotensin-converting enzyme (ACE) inhibitors, and despite reports in medical journals and drug insert warnings, captopril and enalapril continue to be widely prescribed. As these drugs are efficacious and usually well-tolerated in the treatment of mild forms of hypertension, their popularity is rising. From June 1, 1984 to August 1, 1991, 36 patients with angioedema secondary to ACE inhibitors presented at the Medical College of Virginia Hospitals. Thirty were successfully managed with medical therapy. Two were intubated, 1 had placement of a nasal trumpet, and 3 required tracheostomies. Of extreme importance is the recognition that angioedema resulting from ACE inhibitors is probably not immunoglobulin E (IgE) mediated and that antihistaminics and steroids may not alleviate the airway obstruction. The otolaryngologist must be prepared for the need of possible early surgical intervention.     

Management of the airway in patients with angioedema

Angiodema can be frequently encountered in clinical practice, and usually represents transient areas of tissue edema and erythema. In general, lesions involve the deep dermis as well as subcutaneous or submucosal sites and can affect multiple organ systems, including the respiratory and gastrointestinal tracts. Although the underlying cause for the angioedema is frequently not known, it can result from atopy, specific antigen sensitivities, physical stimuli, as well as disorders that affect the complement cascade. These latter entities may be congenital or acquired. Pathogenesis for angioedema is generally thought to be activation of mast cells or basophils, with subsequent release of histamine and other mediator products which can induce inflammatory changes. In most patients with physical and allergic causes of angioedema, swelling can usually be treated with epinephrine, antihistamines and/or steroids. Management of the airway in such patients is usually symptomatic, although certain patients require hospitalization for supervised care. On the other hand, patients with hereditary angioedema do not often respond well to these agents. In such patients, we currently add infusions of epsilonaminocaproic acid as well as nembulized racemic epinephrine to our therapeutic regimen, but even this may not be satisfactory. At the National Institute of Allergy and Infectious Disease, endotracheal intubation is usually preferred to tracheostomy for securing a temporary airway, though certain patients may require placement of tracheostomies for better control of the airway. Patients with frequent recurrences of airway obstruction are rarely seen--even among those patients with known hereditary angioedema. However, such patients may require tracheal fenestrations to secure long-term protection of the airway. The Institute's experiences in the management of patients with angioedema are reviewed, and therapies employed are described.     

Antihypertensive drug-induced angioedema causing upper airway obstruction in children

Objective

Angioedema is a well-described complication arising from the use of antihypertensive agents in the adult population. However, its occurrence and potential for upper airway compromise in pediatrics has only been sporadically reported in the literature. Our objective is to report and review the occurrence of antihypertensive-induced angioedema in the pediatric population and the potential for airway compromise.

Methods

Charts of 42 patients admitted to Cincinnati Children's Hospital Medical Center with the discharge diagnosis of angioedema (ICD-9 code 995.1) from January 2000 to January 2010 were reviewed. Of the 42 charts, 3 cases had angioedema induced by antihypertensive drugs and all 3 resulted in upper airway obstruction. Summary and findings of the data collected from the medical chart review included demographics, chief complaint(s), past medical history, hospital course, antihypertensive drugs used, diagnostic test(s), medical treatment, and time from onset of symptoms to resolution. In addition, a PubMed literature search using the terms angioedema and antihypertensive drugs was performed to review its occurrence in pediatrics. The previous literature case reports were compared to our cases to further characterize and emphasize the clinical features of this occurrence in children and adolescents.

Results

Despite the well-known occurrence of antihypertensive drug-induced angioedema causing airway obstruction in adults, only 4 case reports have been previously published in children. At our institution, we describe 3 children who developed acute angioedema with upper airway obstruction after the chronic use of antihypertensive medications [2 drugs in the ACE inhibitor class (enalapril and lisinopril), and 1 drug in the calcium channel blocker class (CCB; amlodipine)]. In all 3 cases, the symptoms resolved within 1 week after the antihypertensive agent was discontinued.

Conclusion

Upper airway obstruction can occur at any age when taking antihypertensive drugs. Particular caution should be applied to ACE inhibitors and CCBs in this regard. With the increasing use of antihypertensive agents in the pediatric population, clinicians should be alert to the possibility of angioedema with upper airway obstruction as a potential lethal adverse effect.     

Pediatric angioedema: ten years' experience.

OBJECTIVE: To clarify the cause, clinical course, and management of children with angioedema. DESIGN: Retrospective review. SETTING: Urban tertiary care hospital for children. PATIENTS: Consecutive sample of all children hospitalized from January 1, 1987, to December 31, 1997, with the diagnosis of angioedema. Complete records permitting analysis were available for 10 patients. MAIN OUTCOME MEASURES: Sex, age, site, symptoms at initial examination, cause, therapeutic management, and clinical outcome. RESULTS: Seven boys and 3 girls, a mean age of 7.7 years, had angioedema of the head or neck, most often facial (8/10 [80%]). Manifesting symptoms, in addition to swelling, were tenderness or pain in 4 children (40%), dyspnea in 3 (30%), dysphagia (including drooling and spitting) in 3 (30%), and hoarseness in 1 (10%). Angioedema was due to food in 4 children (40%), insect bites in 3 (30%), infection in 2 (20%), and an antibiotic in 1 (10%). Treatment was pharmacological in all cases. No child required intubation or tracheotomy. Care in the intensive care unit was necessary for 1 child (10%). CONCLUSIONS: Pediatric angioedema exhibits a different cause and clinical manifestations than does adult angioedema. Prompt diagnosis and early treatment with an intravenous corticosteroid, an antihistamine, and/or epinephrine lead to rapid resolution and may, in appropriately staffed settings, avoid the need for care in the intensive care unit or airway intervention. Management algorithms based on adult experience must be modified to account for the milder pediatric manifestations of this immunologic disease.     

Hereditary angioedema: report of a case

Hereditary angioedema is caused by an absolute deficiency or the functional inactivity of C1 esterase inhibitor in plasma. A precise diagnosis is important because, unlike allergic forms of mucocutaneous edema, this condition does not respond to epinephrine, antihistamines, or corticosteroids. We report the case of a 24-year-old man who experienced an acute attack after he had stopped taking his prophylactic medication.