Changing trends in angioedema

Angioedema can be a life-threatening event presenting to otolaryngologists, emergency medicine physicians, and other physicians. Recent reports suggest an increasing role of angiotensin-converting enzyme inhibitors (ACEIs) in the causation of angioedema. Sixty-four cases occurring between 1994 and 1998 were identified and examined retrospectively. Fifty-eight percent of patients presenting with angioedema were using ACEIs. Ninety-four percent of patients overall, and 92% of patients with ACEI-associated angioedema, were African-American. Tongue, lip, facial, and supraglottic edema were most common. Treatment included intubation in 13% and intensive care unit monitoring in 20%. Nearly all patients were treated with corticosteroids and antihistamines. There were no deaths. Angioedema associated with ACEI use appears to be much more common than previously reported. African-American patients may be at higher risk for angioedema with ACEI use. Successful management was achieved with observation, expectant airway management, corticosteroids, and discontinuation of ACEIs. Patients without airway obstruction or pharyngeal or laryngeal edema who improved with treatment and observation were successfully treated as outpatients.     

Angioedema: 6 years experience with fourteen cases

Objective

To study the difference in the findings between the causes of angioedema and the characteristics of angioedema induced by angiotensin receptor II blockers (ARBs), and to investigate whether laboratory examinations for acute phase inflammatory markers can aid in diagnosis and predict airway risk.

Methods

We retrospectively reviewed fourteen cases of patients with angioedema that were treated from 2000 to 2006. Data were collected regarding age, sex, location of the edema, cause, time course of resolution and laboratory examinations (leukocyte counts, serum C-reactive protein (CRP) level, complement function and the activity of C1 esterase inhibitor).

Results

The causes of angioedema were ACEIs in six patients (42.9%), candesartan (ARB) in three (21.4%), HAE (types 1 and 2) in two, and unknown in three. Of these patients, 71.4% exhibited edema in the floor of the mouth, irrespective of the cause. Two patients with edema induced by candesartan exhibited both lingual and laryngeal edemas. The remaining one with candesartan-induced edema exhibited edema in the neck and mediastinum and pleural effusion.The average time to resolution was 4.1 days, ranging from one to twelve days. The edema in eleven patients resolved with conservative therapy, while three patients underwent tracheotomy. In two patients with candesartan-induced edema, although the edemas resolved completely after cessation of candesartan administration, the edemas reappeared in the same locations, two and thirty days after the cessation of candesartan for each patient.None of the patients with angioedema induced by ACEIs exhibited elevation of serum CRP levels. No significant differences were found for leukocyte counts and serum CRP levels between patients with angioedemas induced by ACEIs, ARB and those of unknown cause. No significant differences were observed in the above findings between the patients who underwent tracheotomy and those who did not. Two patients exhibited low C4 levels, and one of the two exhibited no activity of C1 esterase inhibitor.

Conclusion

Consistent with previous reports, angioedema in the floor of the mouth extending to the tongue should be considered as a possible risk factor for airway compromise. Laboratory examinations for acute phase inflammatory markers are not useful for diagnosis and are not predictive for airway intubation and tracheotomy. Angioedema induced by candesartan can present in anomalous sites and reappear following drug cessation even if the edema has resolved completely.     

Angiotensin II receptor blocker-induced angioedema in the oral floor and epiglottis

We report the rare case of angioedema (also known as Quincke edema), which was induced by valsartan, an angiotensin II receptor blocker (ARB). ARBs are a new class of antihypertensive agent that is developed to exclude the adverse effects of angiotensin-converting enzyme inhibitors. In theory, ARBs do not contribute to the occurrence of angioedema because they do not increase the serum level of bradykinin, the responsible substance for angioedema. However, some reports of ARB-induced angioedema have recently been published. In this study, we present the forth case and the first Asian case of angioedema due to valsartan, which is one of the ARBs. Otolaryngologist should be wary of the prescribing ARB and discontinue ARBs treatment soon, if angioedema is recognized.     

Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management

Angioedema is a nonpitting edema of which the presentation ranges from benign facial swelling to airway obstruction managed by intubation or tracheotomy. The presentation of this disease is reviewed, and a treatment algorithm based on initial signs and symptoms is proposed for proper airway management. We performed a retrospective review of 108 patients treated in 2 tertiary care centers in the Washington, DC, area over a 5-year period. Ninety-eight patients (90.7%) were African-American, and 81 (75%) were female. Seventy-four patients (68.5%) were taking angiotensin-converting enzyme inhibitors (ACEIs). A classification system was developed based on the location of the edema at initial presentation: 1) isolated facial swelling and oral cavity edema, excluding the floor of the mouth; 2) floor of mouth and/or oropharyngeal edema, and 3) oropharyngeal edema with glottic and/or supraglottic involvement. Fourteen patients (13%) needed airway intervention, 2 of whom underwent a cricothyrotomy after a failed intubation attempt. Eleven (78.6%) were taking ACEIs. The indication for each intubation was massive tongue and floor of mouth edema. The patients were extubated 48 to 72 hours later. No patient demonstrated symptom progression after medical treatment was initiated. Therapy included discontinuation of the ACEI or other inciting agent, a high-humidity face tent, an initial dose of intravenous antihistamines, and a continued course of intravenous steroids. Within 48 hours, most patients had a resolution of their edema. Only cases of significant tongue and oropharyngeal edema took longer than 48 hours to resolve. The ACEIs are a common cause of angioedema. Left untreated, angioedema may progress to involve the oropharynx and supraglottis, resulting in a life-threatening airway compromise. Marked floor of mouth and tongue edema are the indications for airway intervention. An algorithm based on the initial presentation is essential for proper airway and patient management. Once treatment has begun, angioedema is nonprogressive and often resolves within 24 to 48 hours.     

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.     

Angioedema associated with angiotensin II receptor antagonists: challenging our knowledge of angioedema and its etiology.

INTRODUCTION: Use of angiotensin converting enzyme inhibitors has long been associated with angioedema. Increased levels of bradykinin caused by the inhibition of angiotensin converting enzyme have been thought to be responsible for this side effect. Angiotensin II receptor antagonists (AT2 blockers), such as losartan potassium (Cozaar; Merck & Co., West Point, PA), are a new class of antihypertensives developed in part to eliminate cough and angioedema associated with ACE inhibitors. These agents act by selectively binding to angiotensin II receptor sites, thereby eliminating the hypertensive effects of angiotensin without affecting local and systemic bradykinin levels. We present three cases of AT2 receptor antagonist-induced angioedema, and examine its significance in the treatment of angioedema and its proposed etiology. METHODS: A retrospective chart review and review of the literature. RESULTS: Three patients taking the AT2 blocker losartan presented with mucosal swelling in the head and neck clinically consistent with angioedema. All three patients had prior episodes of angioedema while on losartan. Two patients presented with involvement of the anterior tongue and face that resolved within 12 hours of discontinuation of the losartan and a course of intravenous steroids. The third patient experienced recurring episodes of angioedema that eventually required a tracheotomy for airway compromise. After discontinuing the losartan and receiving a course of intravenous steroids, the angioedema resolved in 5 days. The patient was decannulated 10 days after onset of symptoms. CONCLUSION: Angioedema is a potentially life-threatening condition commonly associated with ACE inhibitor use. AT2 blockers bind to angiotensin II receptor sites and have no demonstrable effect on local or systemic bradykinin levels. We present three cases that demonstrate AT2 blocker-induced angioedema. They were all complicated by the fact that the inciting agent, losartan, was not discontinued after the initial episode and resulted in recurrent episodes of angioedema, one of which required surgical airway intervention. The incidence of AT2 blocker-induced angioedema brings into question prior theories on the etiology of angioedema and bradykinin's role in its pathogenesis.     

Angioneurotic edema of the upper airways and antihypertensive therapy

Angioneurotic edema is a non-pitting edema which is usually limited to the skin and the mucous membranes of the face and upper aerodigestive tract. The risk of acute upper airway obstruction makes angioneurotic edema a concern for emergency room physicians, internists and otolaryngologists because prompt recognition of the condition and immediate institution of therapy is essential for proper airway management. Angiotensin-converting enzyme (ACE) inhibitors have recently been associated with angioneurotic edema, the probable link being the reduction in angiotensin II and the potentiation of bradykinin, resulting in vasodilatation, increased vascular permeability and angioedema. We report four cases of acquired angioneurotic edema, which were probably related to ACE inhibitor use. These cases are discussed, including a review of the literature, methods of diagnosis, pathophysiology and treatment of angioedema. Care should be taken when antihypertensive ACE inhibitor treatments are started and patients should be warned of the potential risk of angioneurotic edema.     

Complication rates after operations for benign thyroid disease

Controversy persists concerning the use of total thyroidectomy in benign thyroid disease and varying complication rates have been reported. We evaluated the safety of total thyroidectomy or lobectomy in benign thyroid disease. During a 5-year period, 102 patients were operated on for benign thyroid disease, including multinodular goiter (n = 55), solitary nodule (n = 18), toxic nodular goiter (n = 22) and Hashimoto's thyroiditis (n = 7). Recurrent laryngeal nerves were routinely investigated during dissection. Total thyroidectomy was performed in 27 cases, unilateral total lobectomy with isthmectomy in 38 and unilateral total, contralateral subtotal lobectomy in 37. One (0.9%) temporary superior laryngeal nerve palsy, 1 (0.9%) temporary recurrent nerve palsy and 1 (0.9%) temporary hypoparathyroidism occurred. Wound seroma developed in 2 patients (1.9%). There were no deaths or permanent complications. This study shows that total thyroidectomy or lobectomy can be done with minimal morbidity in cases of benign thyroid disease affecting the whole gland.     

Management of infected carotid artery rupture

Carotid artery rupture (CAR) is a life-threatening complication of head and neck cancer, and infection complicates its management. The purpose of this study was to review our experience with the treatment of infected CAR and to summarize the existing literature on this topic. We retrospectively reviewed the medical records of patients treated in our department from 2000 to 2011 and re-analyzed cases reported in the literature during the same time period. We analyzed etiology, anatomic location, treatment, and rates of recurrent hemorrhage for each case. A total of 46 episodes of infected CAR occurred in the four patients in our own records and 27 patients described in the literature. Twenty-eight patients suffered from various head and neck cancers and underwent surgical resection, and 27 of them subsequently received radiotherapy or radiotherapy combined with chemotherapy (the 28th patient died before radiotherapy due to severe blood loss). The most common site of bleeding was the common carotid artery (33/46, 71.7 %). Seventeen cases (17/45, 37.8 %) were treated with surgical ligation, 20 (44.4 %) with stent placement, and 7 (15.6 %) with embolization. Surgical ligation had a lower rate of recurrent bleeding (2/17, 11.8 %) than stent placement (12/20, 60.0 %) when used for the treatment of infected CAR (P = 0.037, Chi squared test). Our results suggest that surgical ligation is an effective option in the management of infected CAR and may be the best choice to prevent recurrent hemorrhage. The complication rates, however, may be high when the common carotid or the internal carotid arteries are ligated.     

From the expert’s office: localized neural lesions following tonsillectomy

Due to various reasons, localized neural lesions following tonsillectomy are presumably an under-reported complication in the literature. This study was undertaken to compile our experiences including a literature review to disseminate useful insights in the etiology and prognosis of this rare entity. A retrospective chart review of expert reports written by at least one of the authors for malpractice claims in relation to tonsillectomy was undertaken. Additionally, a retrospective analysis of 648 patient documents that had undergone tonsillectomy in 2001 at our institution and a comprehensive literature review were performed. The research was restricted to the item “localized neural lesion”. Seven cases from the expert’s offices, one of our patients who had undergone tonsillectomy at our institution and 122 cases from the literature matched our search criteria. Including our own cases, the glossopharyngeal nerve was affected in 82 patients. Other lesions encompassed injury of the hypoglossal nerve as solitary (15) or combined (5) lesion, recurrent nerve paralysis with (2) or without additional nerve lesions (7), facial nerve paralysis (10) in combination with other nerve lesions (1), and a lingual nerve deficiency as solitary (4) or combined lesion (9). A single report existed for lesion of the phrenic nerve. There were five reported cases with blindness and nine cases with Horner’s syndrome. Albeit rare, localized neural lesions may occur as a troublesome complication following tonsillectomy and/or means to achieve hemostasis. Some of these cases may not result from the dissection itself but injection procedures. Surgical dissection should include careful mouth gag insertion and meticulous dissection to minimize the risk of localized neural complications. A long-term follow-up is recommended for patients with dysgeusia related to glossopharyngeal nerve injury and patients with recurrent nerve dysfunction. Other lesions are much less likely to resolve in the long-term. Localized neural lesions should adequately be included in the informed consent for tonsillectomy as well as for surgical treatment of post-tonsillectomy hemorrhage.     

Monopolar Electrocautery in Adenoidectomy as a Possible Risk Factor for Grisel's Syndrome

Objectives/Hypothesis Grisel syndrome is a nontraumatic atlantoaxial subluxation after an inflammatory process in the upper cervical region. It results from a peripharyngeal infection as well as a rare complication following adenotonsillectomy. After the introduction of monopolar suction electrocautery in adenoidectomy, an increased incidence of Grisel's syndrome has been observed. The purpose of the study was to evaluate monopolar suction electrocautery as a possible risk factor. Study Design Retrospective chart review along with current measurements of monopolar and bipolar electrocautery during adenoidectomy. Methods The charts of 1431 consecutive cases of adenoidectomy were reviewed before (n = 710) and after (n = 721) the introduction of monopolar suction electrocautery for intraoperative hemostasis. Moreover, energy of delivered current of electrocautery was measured in 30 pediatric patients during adenoidectomy. Results Three cases of Grisel's syndrome occurred as a postoperative complication in 721 adenoidectomies (0.4%) after the introduction of monopolar suction electrocautery. In contrast, no Grisel's syndrome was observed in 710 procedures before the use of monopolar electrocautery. Current measurements demonstrate an almost fourfold higher level of electrical energy using monopolar electrocautery compared with bipolar coagulation for bleeding control in adenoidectomy. Conclusion Monopolar suction cautery in adenoidectomy may be considered as a risk factor for Grisel's syndrome.     

Acute epiglottitis in adults. Our case load in 11 years

We report a retrospective study of 20 cases of acute epiglottitis in adults admitted at our hospital between 1991 and 2001. We gather a series of variables: Patient sex, age, year and month of admission, personal history, initial clinical symptoms, complementary tests asked, given treatment, evolution and hospital average stay. We found an obvious predominance in male (19:1 with respect to female), with an average age of 45 years. The main symptoms were dysphagia-odynophagia (85%), followed by fever (55%) and pharyngocervical pain. Dyspnea was confirmed in 9 of 20 patients (45%); 5 of them required airway control with the help of intubation in one case, urgent coniotomy in three cases and tracheotomy in another one. A patient suffered from an acute mediastinitis and required assistance and medical i.v. extended treatment in UCI. We show a case of another patient who suffered sudden cardiorespiratory arrest a followed by death. He did not present previous dyspnea. Acute epiglottitis in adults is a rare pathology with a good prognosis in general, but may lead to an unpredictable and serious complication even in the absence of airway blockage. We carry out a medical literature review in this respect.     

Device nonuse among adult cochlear implant recipients.

OBJECTIVE: To examine the causes and prevalence of previous and current device nonuse among adults who have received cochlear implants. STUDY DESIGN: Retrospective case review. SETTING: Adult tertiary referral center for cochlear implantation. METHODS: Two hundred fourteen consecutively implanted adult patients. The length of implant use ranged from 1 month to 14 years. MAIN OUTCOME MEASURE: A period of 4 consecutive weeks of nonuse of cochlear implant, including both obligatory and elective nonuse. RESULTS: Twenty-nine adults (13.6% of implantees) were identified as having at some stage not used their device for a period of more than 4 consecutive weeks. The main reason was device failure (n = 11). Ten adults are current nonusers (4.7% of implantees). Reasons include surgical complication necessitating explantation (n = 3), comorbid illness (n = 3), elective nonuse (n = 2), audiologic complication (n = 1), and device failure (n = 1). CONCLUSION: The overall prevalence of device nonuse was noted to increase slowly with time. The role of psychologic factors in contributing to the decision of an individual to elect to opt out of device use remains unproven.     

Endoscopic repair of cerebrospinal fluid leaks after neurosurgical procedures

OBJECTIVES: Endoscopic repair of cerebrospinal fluid (CSF) leaks has proven to be effective and safe. CSF rhinorrhea is a well-known complication of neurosurgical procedures in the anterior cranial fossa. We present a series of endoscopic repairs of CSF rhinorrhea secondary to neurosurgical procedures. STUDY DESIGN: Retrospective review of 13 cases. METHODS: Thirteen patients are included in the study. Eleven had CSF leaks after hypophysectomy, one after clipping of an anterior circle of Willis aneurysm, and one after posttraumatic frontal lobe debridement. Leaks were identified intraoperatively during the neurosurgical procedure (n = 8) or with intrathecal fluorescein injection during a separate procedure (n = 5). Repair was performed by exposing the skull base defect, debriding the defect margins, and sealing the defect with a free mucosal graft or abdominal fat. RESULTS: Leaks were identified in the sphenoid (n = 12) and posterior ethmoid (n = 1) sinuses. Nine patients had lumbar drains placed. One patient had recurrence of CSF rhinorrhea 2 months after initial repair requiring a revision procedure. No other recurrences were noted. One patient developed postoperative meningitis requiring intravenous antibiotics and a prolonged hospital stay. No other postoperative complications were observed. CONCLUSIONS: Endoscopic repair is a safe and effective treatment for CSF rhinorrhea encountered as a neurosurgical complication.     

UPPP术后并发症发生率及危险因素分析

目的:探讨UPPP术后24 h内并发症的发生率及其危险因素,为早期预防术后并发症的发生提供理论依据.方法:回顾性分析162例接受UPPP手术的阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者,按照有无发生术后并发症进行分组,比较2组患者术前及术中各项临床指标的差异,对重要的临床参数作单因素及多元逐步Logistic回归分析.结果:31例(19.1%)患者术后24 h内出现并发症,包括呼吸并发症21例(13.0%),心血管并发症6例(3.7%),术后出血9例(5.6%).并发症组和无并发症组之间在BMI、AHI、LSAT及困难插管等方面均差异有统计学意义(均P<0.05).多因素回归分析显示,BMI(OR=1.136)、AHI(OR=4.828)及困难插管(OR=1.971)为术后24 h内出现并发症的独立危险因素.结论:OSAHS患者术前BMI、AHI及麻醉困难插管是预测术后24小时内出现并发症的主要指标.对于肥胖、严重OSAHS患者及插管困难患者,应提高警惕,做好围术期处理,避免术后并发症的发生.     

Microvascular free tissue transfer in reconstructing skull base defects: lessons learned

OBJECTIVE: To demonstrate the effectiveness of microvascular free tissue transfer in reconstructing complex skull base defects. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was conducted identifying patients with anterior or lateral skull base defects, or both, who underwent microvascular free flap reconstruction. Appropriate demographic, pathological, and preoperative and postoperative clinical data were collected and analyzed. RESULTS: Thirty-five patients with skull base defects were identified, including 8 women (Mean age, 43.9 y; age range, 28-75 y) and 27 men (mean age, 57.9 y; age range, 19-85 y). Defects were secondary to trauma in two cases, whereas the remaining 33 cases were secondary to ablative procedures for a variety of malignant tumors, of which squamous cell carcinoma was the most common (n = 18). The average defect surface area was 89.3 cm(2), and 36 free flaps were used. The most commonly used flap was the rectus myocutaneous (n = 20); however, six different flap types were employed, including three radial forearm fascial flaps. In all, there were seven flap-related complications and there was one total flap loss. A total of 43 postoperative complications occurred in 23 patients, with the most common complications being grouped as intracranial (n = 10), orbital (n = 9), and cardiac (n = 9). The perioperative mortality rate was 5.7%, and the average hospital stay was 13.5 days (range, 7-37 d). CONCLUSIONS: The use of microvascular free tissue transfer for reconstruction of complex skull base defects has proven highly successful in the large series presented in the current study. The versatility and reliability of free flaps for such reconstruction are discussed, and helpful hints are given to minimize the complication rate.     

Osteomyelitis of the jaw and osteopetrosis

Osteopetrosis (Albers-Sch?nberg disease) is a rare sclerosing bone disorder in which osteomyelitis of the jaws is a frequent complication. Treatment of osteomyelitis is difficult and may lead to large resection. We report three new cases and we review the literature.     

Endoscopic management of extruding medialization laryngoplasty implants

BACKGROUND: Medialization laryngoplasty (ML) is a commonly performed procedure for vocal fold motion impairment with glottic incompetence. Although implant extrusion is a well-known risk of ML, management of this complication is rarely mentioned in the literature. The aim of this study was to review our experience with endoscopic implant retrieval for a group of patients with extruding ML implants. METHODS: All patients identified in our institution from January 1989 through August 2004 with a history of ML and extruded implants were identified. Case management was reviewed, including information on presentation, management techniques, and outcomes. RESULTS: Five patients presented with extruding ML (Gore-Tex [n = 2] or silastic [n = 3]) implants. All patients presented with worsening dysphonia and evidence of fullness and/or granulation tissue at the extrusion site. Endoscopic removal was performed using either sharp dissection or CO2 laser dissection. After removal, four patients underwent vocal fold injection augmentation. CONCLUSIONS: Endoscopic removal appears to be a safe, effective, and even preferred alternative to external transcervical removal in selected cases of extruding implants.     

The incidence of microlaryngoscopy associated complications

BACKGROUND: The frequency of local and cardiovascular side effects of microlaryngoscopy is generally underestimated.There are no data available in the literature from recent and prospective clinical trials. PATIENTS AND METHODS: We examined 81 patients between 03/1998 and 03/2000 who underwent microlaryngoscopy in our department. This was done following a standard protocol before, during and after surgery. Side effects of endotracheal intubation were avoided by using supraglottic jet-ventilation. RESULTS: In 79% of our cases we encountered side effects due to the microlaryngoscopic procedure.86% of them were reversible lesions,hematomas and edemas of the mucous membranes or mild cardiovascular dysregulations. In two cases there was a dental complication (one fracture, one dislocation), and seven cases of moderate hemodynamic effects were noted. CONCLUSIONS: The incidence of tissue damage caused by microlaryngoscopic endoscopes is much higher than commonly assumed in clinical practice.This has to be explained to the patient when obtaining his written consent to a certain microlaryngoscopic procedure and to be considered during the postoperative follow up.The consequent use of tooth protection and a good control of muscle relaxation and analgesia can be effective in preventing side effects.     

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.