Predicting airway risk in angioedema: staging system based on presentation.

Angioedema is an immunologically mediated, anatomically limited, nonpitting edema that can lead to life-threatening airway obstruction. To predict the risk of airway compromise in angioedema, we retrospectively reviewed 93 episodes in 80 patients from 1985 to 1995. Intubation or tracheotomy was necessary in 9 (9.7%) cases. Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). Voice change, hoarseness, dyspnea, and stridor were present in patients requiring airway intervention (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases. No deaths were caused by angioedema. Airway risk in angioedema may be predicted by anatomic site of presentation, allowing appropriate triage with preparation for airway intervention in selected cases.

Use of postoperative chest x-ray after elective adult tracheotomy.

Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear Nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the Boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. Postoperative hemorrhage was the most common complication (3.6%). Pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax.

Head and neck cancer screening among 4611 tobacco users older than forty years.

We implemented screening for squamous cell carcinomas of the oral cavity, pharynx, and larynx with symptom assessment and systematic inspection of the oral mucosa by primary care practitioners at health care sites serving inner-city residents of Boston; 4611 tobacco users older than 40 years were screened, and 313 with specific criteria were referred to otolaryngology for diagnostic evaluations. In these screened patients, the prevalence of oral mucosal lesions was almost 13% and prevalence of persistent hoarseness was more than 11%. Although the identification of these cancers was rare (nearly 3%), abnormal findings were seen in more than 70% of referred patients. These clinical and histologic diagnoses are described. We have documented the range of pathologic conditions in high-risk patients screened for upper aerodigestive tract malignancy.

Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A.

Adductor laryngeal breathing dystonia (ALBD) is a rare disorder in which patients have persistent inspiratory stridor, usually normal voice, and cough. Physical exam is characterized by paradoxical movement of the vocal cords on inspiration. These patients have involuntary action-induced spasms of the adductor laryngeal muscles on inspiration. There has been no uniformly satisfactory treatment for the disease. Speech therapy, psychotherapy, and pharmacotherapy have all had limited success. We report the successful use of botulinum toxin type A in seven patients with adductor laryngeal breathing dystonia. All patients received bilateral thyroarytenoid injections. All patients had toxin effect within 72 hours, reaching maximal effect within 2 weeks with sustained improvement for an average of 13.8 weeks. Adverse effects included breathy voice and mild choking on liquids. Both resolved, on average, within 2 weeks. This retrospective study supports the safe and effective use of botulinum toxin type A in the treatment of adductor laryngeal breathing dystonia.