Laryngeal sporotrichosis causing stridor in a young child

Fungal infections of the larynx are rare entities that must be considered in the differential diagnosis of the patient who presents with laryngeal symptoms. We present an unusual case of initially recurrent and then persistent stridor in a 19-month-old girl, unresponsive to 4 months of antibiotic and steroid therapy. Upon our laryngoscopic examination, the patient was noted to have an ulcerated, granulomatous process involving the larynx. She also had an erythematous papule on the left thigh. Fungal cultures of both sites grew Sporothrix schenckii. The patient was treated with systemic antifungal medications and had complete resolution of her symptoms. We discuss the pathophysiology and possible source of this unusual form of sporotrichosis, the first such case reported in a child. We emphasize the role of empiric steroid therapy in exacerbating and eventually enabling dissemination of the infection. We also review the manifestations of sporotrichosis infections of the head and neck. This case demonstrates the vital importance of careful diagnosis and proper treatment of stridor in children.

[Acute laryngeal dyspnea]

Laryngeal dyspnea is a life-threatening emergency situation. The diagnosis is clinical and made from the association of: inspiratory bradypnea, intercostal and sus-sternal inspiratory depression, with or without stridor. The aetiologies are most often laryngeal tumours or inflammatory oedema; incidence of epiglottitis has decreased due to vaccine against Haemophilus influenzae. Airway obstruction due to foreign body includes acute laryngeal dyspnea and reflex paroxysmal coughing without fever. Management of a laryngeal dyspnea depends on the aetiology and the severity of clinical symptoms. Medical treatment associates racemic epinephrine aerosol, steroids, and oxygenation. In the presence of severe dyspnea, intubation after anaesthetising the patient and positive pressure ventilation is required.

[Laryngeal lesions in secondary cutaneous and mucosal syphilis]

Clinical variants of laryngeal lesions in patients with early syphilis are reviewed. A case of secondary syphilis with a laryngeal lesion is reported in a female who developed aphonia. Basing on laryngoscopic findings, an otorhinolaryngologist made the diagnosis "chronic laryngitis, singer's nodules". The authors infer that painless laryngitis of long duration without signs of inflammation and resistant to standard treatment should be tested for syphilitic etiology. Therefore, the patient's blood should be taken for Wasserman reaction while the patient should be consulted by venereologist.

Cricoarytenoiditis in Rheumatoid Arthritis: Radiologic and Clinical Study

The cricoarytenoid (CA) joint involvement in rheumatoid arthritis (RA) is not uncommon. In this study, clinical assessment, laryngeal endoscopy, and high-resolution computed tomography (HRCT) were used in 15 patients with RA to evaluate the diagnostic criteria of CA joint involvement. Symptoms owing to CA joint involvement were present in 66.6% of the patients. The frequency of involvement was 13.3% on laryngeal endoscopy but 80.0% with HRCT assessment. The most common HRCT findings were CA prominence (46.6%), density and volume changes (46.6%), and CA subluxation (39.9%). In some of the patients, soft tissue swelling (20%) near the CA joint and narrowing in the piriform sinus (33.3%) were also observed. Radiologic abnormalities related to CA joint involvement generally precede clinical symptomatology. Therefore, HRCT evaluation may be a useful method in the assessment of CA joint involvement in RA patients to exclude possible causes of laryngeal signs and symptoms.

[Laryngeal infection by Rhodococcus equi in patient with AIDS]

The Rhodococcus equi is an aerobic gram positive pleomorphic bacillus, that was isolated for the first time like a producer of bronchopneumonia in young horses. Every time more often, it is being recognized as a pathogen in humans, mainly in the immunodepressed population. We described a case, until now exceptional, of laryngeal infection by Rhodococcus equi in a patient with positive serology for the virus of the human immunodeficiency (HIV), and we reviewed some clinical and epidemiological characteristics of the infections by this germ. The treatment is riphampicine and/or erythromycin, being the prognosis bad, because usually they are immunodepressed patients.

Prolonged ulcerative laryngitis

Acute and prolonged laryngitis commonly are diagnosed and treated by primary care physicians. These ailments come to the attention of the otolaryngologist when symptoms are prolonged despite treatment. Since the beginning of 1991, the senior authors (RTS, JRS) have recognized a clinical syndrome defined by prolonged hoarseness, prolonged laryngeal inflammation, and vocal fold ulceration. Patients are frequently young, nonsmokers, and nondrinkers who have had an upper respiratory infection prior to, or associated with, the onset of laryngeal symptomatology. Patients may be affected for up to 1 year despite aggressive medical therapy. This review of 14 patients highlights the features of this previously undescribed entity.

Lemierre's syndrome as a consequence of acute supraglottitis

Lemierre's syndrome comprises internal jugular vein thrombosis following oropharyngeal sepsis and is a rare and serious condition. It is most commonly caused by the anaerobe Fusobacterium necrophorum and typically presents as metastatic sepsis to the lungs and joints. Thrombosis is demonstrated by computed tomography (CT) of the neck, and it is routinely treated with intravenous antibiotics and anti-coagulation. We describe a case of Lemierre's syndrome following acute supraglottitis. The clinical features were of retrograde intracranial thrombosis, rather than the more usual metastatic sepsis.

[Relationship of pathological gastroesophageal reflux and some symptoms of chronic laryngeal and pharyngeal inflammation]

Sixty eight patients with laryngeal and pharyngeal complaints have undergone both otorhinolaryngological and gastroenterological examinations. Most of the examinees were diagnosed to have pathological gastroesophageal reflux (PGER). Typical complaints for heartburn and eructation occurred in less than half the patients with PGER. It is proposed to conduct a gastroenterological examination of patients with persistent chronic inflammation of laryngeal and pharyngeal mucosa.

[Influence of voice onset on the perceptual analysis of dysphonia]

The perceptual analysis of voice for 40 dysphonic and normal subjects was studied according to the GRBAS method and with the consensus of three experts. In order to evaluate the effects of voice onset on the evaluation by the jury, we presented two sample materials for each subject: a sustained /alpha/ and the same sustained /alpha/ for which voice onset was suppressed. In a blind test, the two sample materials were presented in the same session in a random way. The jury did not notice the sustained /alpha/ for which voice onset was suppressed.The influence of voice onset on the jury was based on the percentage of identical answers for each material. Our results show that the influence of voice onset is correlated with the dysphonic level. Voice onset would be of major importance for intermediate dysphonia (G1, G2), whereas it seems not to exert any influence in the case of normal voices (G0) or severe dysphonia (G3).

The prevalence of voice disorders among day care center teachers compared with nurses: a questionnaire and clinical study

The acceptance of voice disorders by day care center teachers as an occupational disease is not an invariably established practice. This is due to the lack of reliable evidence of a higher risk for voice disorders in this profession. To find out the risk of voice disorders, an epidemiological study was conducted among day care center teachers (n = 262), using hospital nurses (n = 108) as a control group. Symptoms were charted by a questionnaire. In a clinical examination made by a laryngologist, the voice quality was assessed and the laryngeal status noted. Teachers at day care centers had significantly more voice disorders than did nurses. Vocal nodules and laryngitis findings appeared significantly more frequently among day care center teachers than among those in the control group. The results prove voice disorders to be more frequent among day care center teachers than among control group subjects, and also that the main cause for this may be a higher vocal loading among day care center teachers than among control group subjects.

Supraglottitis complicated by mediastinitis

A rare case of supraglottitis complicated by mediastinitis is presented. Despite aggressive treatment with broadspectrum intravenous antibiotics, the patient persisted to have generalized supraglottitis. Subsequent computed tomography (CT) scanning revealed that she had developed a frank fluid collection starting at the suprasternal notch, extending retrosternally into the superior mediastinum. She recovered with conservative management and did not require aggressive mediastinal drainage as advocated by the literature.

Critical influenza virus infection

OBJECTIVE

To determine the risk of death from influenza infection in children with chronic underlying disease.

METHODOLOGY

An 18-year retrospective study of children with 'critical' influenza A or B virus infection, defined as requiring admission to intensive care or resulting in death, but excluding laryngotracheobronchitis (LTB). Influenza infection was diagnosed by viral culture and/or immunofluorescence of respiratory secretions. Patients with LTB were analysed separately.

RESULTS

There were 27 cases of critical influenza virus infection over the study period, comprising 26 admissions to the intensive care unit (excluding LTB) and one death on the general wards. Thirteen (48%) of the 27 children had chronic underlying disease. In addition, 12 children with LTB were admitted to the intensive care unit. The LTB children were older and less likely to have chronic underlying disease. Nosocomial infection caused seven (26%) of the 27 critical infections. Nine (33%) of the 27 children with critical influenza died. Six (46%) of 13 children with chronic underlying disease and influenza admitted to intensive care died, compared with three of 14 (21%) without any underlying disease (odds ratio = 3.1, 95% confidence interval 0.6-14.0).

CONCLUSIONS

Critical life-threatening influenza virus infection was uncommon, but the mortality was high (33%), particularly in children with chronic underlying disease. Nosocomial infection with influenza was an important cause of admission to intensive care.

Presumed laryngo-pharyngeal reflux: investigate or treat?

A review of a combined gastroenterology and laryngology clinic was conducted to determine the effectiveness of treatment and the predictive value of clinical findings and investigations. Data were collected prospectively. Investigations were performed according to clinical criteria. Patients with symptoms suspected to be due to laryngopharyngeal reflux (based on a positive oesophageal pH test and/or changes on videolaryngoscopy consistent with posterior laryngitis) were treated with omeprazole for at least two to three months. There were 87 patients; the most common symptoms were cough (38 per cent) and hoarseness (36 per cent); 77 per cent had some symptoms suggestive of gastro-oesophageal reflux. Sixty-seven patients were given omeprazole. A good response to laryngo-pharyngeal symptoms was seen in 37 patients (55 per cent). The presence of reflux symptoms was not a predictor of a good response. Increasing severity of oesophageal acid exposure over the 24 hours of pH testing was associated with a better symptom response (Spearman rank correlation, p = 0.01). Posterior laryngitis was not associated with the response to treatment, although there was a trend towards an association between improvement in laryngitis (after treatment) and improvement in symptoms (p = 0.08). The response to proton pump inhibitors was lower than other published results. Oesophageal pH monitoring may have a role in predicting which patients will respond to proton pump inhibitors. This study does not support the decision to treat with anti-secretory therapy, based only on the presence of posterior laryngitis.

[ENT diseases associated with allergic rhinitis: a review of the literature]

Various diseases of the upper airway, such as acute or chronic sinusitis, otitis media, pharyngitis or laryngitis, snoring and sleep apnea syndrom, may be associated with allergic rhinitis. The relationship between these pathologies and the allergic rhinitis has been well established from a clinical and epidemiological point of view, but the pathophysiological mechanisms remain uncertain. A good knowledge of symptoms and the performance of explorations, such as nasal endoscopy for sinusitis, are important in order to take care of these associated diseases. When upper airway diseases are associated with allergic rhinitis, treatment of rhinitis must generally be reinforced. Treament of associated disease will be specific to each disease, and sometimes surgery is required, specially in case of chronic sinusitis. In all cases, the pneumologist, allergologist and ENT physician should work in close collaboration.

Diagnosis and management of chronic laryngitis associated with reflux

Chronic laryngitis symptoms are commonly seen in otherwise healthy people. This article reviews recent progress in our understanding and effective treatment of chronic laryngitis. Clinical experience and prospective treatment and outcome studies have demonstrated objective evidence of the efficacy of treating patients with chronic laryngitis symptoms with nocturnal antireflux precautions and acid-suppressing medications. The role of pH testing and most common errors in treatment are reviewed.

24 hours prior to curtain

A retrospective review was conducted of 40 singers presenting with acute voice problems prior to performance. The purpose of this study was to determine the reasons for seeking emergent voice treatment, the types of acute voice disorders, and the performance outcome. The patients were assessed by age, singing style, years of experience, chief complaint, laryngovideostroboscopic findings, and treatment regimens. The outcomes were classified as full, restricted, or no performance. The majority of patients were classical singers. Laryngovideostroboscopy frequently revealed a pattern of early glottic contact at the mid-portion of the membranous vocal fold in patients with acute laryngitis. Experienced singers uniformly sought treatment many days before their performance compared with inexperienced singers who presented closer in time to performance. Six patients initially withheld information, which had a bearing on their acute management. The results of this study suggest that there is a need to accurately diagnose and treat the singer's emergent problem and educate singers regarding early evaluation of medical problems. With modern evaluation techniques and multi-modality treatment, 85% of the singers proceeded to full performance without negative sequelae.

[Upper airway obstruction (foreign bodies excluded)]

Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapidly assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertrophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.

[Role of inhalation therapy in respiratory emergencies in children]

Three modes of inhaled therapy are available for the administration of bronchodilators in acute respiratory diseases in children: spacer devices, nebulizers, inhaled powders. Principles, medications available in France, and dosages, are presented. Acute asthma is the main indication.

[Respiratory distress in pediatric admission and emergency services. Epidemiology and evaluation criteria]

The medical part of the activity in the emergency units increased and has been ascribed to the raised number of infants or children admitted for acute dyspnea. This review is based on the published reports and the experience from the paediatric emergency unit from the Rouen area with 450,000 inhabitants, in France. We put forward the known epidemiological data and discussed the available means for the practitioner, which could help him in the decision to hospitalize. This review suggests that algorithms of treatment and severity evaluations must be set up in paediatric emergency units in order to validate them and specify the children who requires hospitalisation.

Laryngeal mucosal histology in laryngomalacia: the evidence for gastro-oesophageal reflux laryngitis

OBJECTIVE

To describe the histopathological changes of the mucosa in laryngomalacia; look for any relationship with gastro-oesophageal reflux and to describe the histological changes of reflux laryngitis in laryngomalacia.

METHODS

We examined serial histological sections from nine cases of laryngomalacia, who had aryepiglottoplasty and compared the histopathological features with five cases of postintubation inflammatory laryngitis and five age-matched autopsy specimens of normal larynx.

RESULTS

Five of the cases of laryngomalacia had mild inflammation in the form of basal cell hyperplasia and chronic inflammation close to the basement membrane. Deeper subepithelium was oedematous. Two cases had moderate and two cases severe inflammation. The latter showed ulceration and a dense band of chronic inflammation in the immediate subepithelium with underlying oedema. Three of the cases had gastro-oesophageal reflux proven by barium swallow. Two of these showed intraepithelial eosinophils.

CONCLUSIONS

A band of inflammation of variable intensity just beneath the epithelium with oedema deep to it is the most important histological feature of laryngomalacia. The presence of intraepithelial eosinophils appears to be a histological indication for reflux aetiology of the inflammation.

[Ear, nose, and throat manifestations in patients with primary immunodeficiencies]

OBJECTIVE

To determine the flowgram for the timely diagnosis of the immunodeficiencies congenital primary, based on the demonstrations otorrinolaringol recurrent chronicles to difficult control, with or without associated systemic diseases.

MATERIAL AND METHOD

Retrospective study, descriptive and observational that included patient with diagnostic of primary known immunodeficiency. They were checked the clinical files to know their evolution and medical treatment-surgical.

RESULTS

They were found 10 patient with diagnostic of some primary immunodeficiency; this was made based on the infectious symptoms otolaryngal chronic recurrent to difficult control; they were six men and four women between the four and 36 years old. They were found the following immunodeficiencies: one of hyper-IgM, three by IgG, variable common three, a deficit with C3 of the complement, two of IgA more atopia.

CONCLUSIONS

The chronicle sinusitis or recurrent and the otitis mean chronicle or recurrent can be the only demonstrations of a patient with primary immunodeficiency. The immunology evaluation must include, at least: hematic biometric completes with differential, seric levels of immunoglobulins, the same as subclass of IgG, C4 and C3 of the complement, response to immunization with proteins (diphtheria and tetanus), and polysaccharide antigens (pneumovax).

Obstructive inflammatory laryngeal disease in three cats

Three cats with upper respiratory tract obstruction due to laryngeal inflammation are presented. Cervical radiography showed the presence of a soft tissue mass in the laryngeal region in all cases, and laryngoscopy allowed direct visualization of a mass associated with the larynx. Laryngeal samples were obtained by a combination of fine needle aspiration, cutting biopsy forceps, by ventral laryngotomy, and at post-mortem. Histopathology of the laryngeal samples showed the presence of a predominantly granulomatous inflammation, with macrophage and lymphocyte infiltration. One case was euthanased due to severe dyspnoea. The remaining two cases underwent combined medical (corticosteroid and antibiotic) and surgical (permanent tracheostomy or excision of laryngeal tissue by ventral laryngotomy) treatment. One case died of an undetermined cause 15 weeks after surgery while the other case remains clinically well 20 months after diagnosis. Recognition of the existence of granulomatous laryngitis is important as clinical signs and radiographic findings are indistinguishable from laryngeal neoplasia.

[Acute respiratory insufficiency in children]

Acute respiratory distress in children is often a consequence of asthma. Other causes are subglottic laryngitis, epiglottitis, aspiration of a foreign body, acute bacterial pneumonia or pneumothorax. History and physical examination should differentiate between the various diseases. Asthma is characterized by recurrent symptoms and signs, while this is not the case with the other causes of acute breathlessness described. An asthma exacerbation is often preceded by one or more prodromes. In case of aspiration of a foreign body, like a peanut, immediate action is needed to prevent irreversible damage to the airways. Subglottic laryngitis and epiglottitis are both characterized by an inspiratory stridor; in case of epiglottitis immediate action is needed, while in case of subglottic laryngitis observation time is available in most cases. Pneumothorax as a cause of acute breathlessness is rare in childhood; it should be considered in male smoking leptosomic asthmatic adolescents.

[Cervical necrotizing fasciitis]

Necrotizing fasciitis is a severe fatal soft tissue infection characterized by necrosis of fascia. It was caused by polymicrobial infections with aerobe and anaerobe. Although it commonly involved abdomen, extremities and perineum, it might also occur in head and neck. One case of CNF arising from pharyngolaryngitis was reported. A review of the literature with the clinical presentations, bacteriology, diagnosis and treatment was presented. The key to successful management is early recognition, broad-spectrum antibiotics and prompt aggressive surgical intervention with medical support and hyperbaric oxygen therapy.

Pharyngolaryngitis caused by Neisseria meningitidis

Neisseria meningitidis is a causative agent of life-threatening cases of meningitis and sepsis, but it can also cause mild and self-limiting bacteraemia. Patients with N. meningitidis sepsis or meningitis often describe signs of upper respiratory tract infection before the onset of invasive disease. Viral respiratory infections have been associated with invasive meningococcal diseases and they may contribute to these prodromal symptoms. N. meningitidis can be cultivated from the throats of asymptomatic carriers and it likely enters the circulation through the upper respiratory tract. However, it is unclear whether N. meningitidis can cause simple pharyngitis. Here we describe a case of acute fulminant pharyngolaryngitis caused by N. meningitidis as verified by positive blood cultures.

[The application of frequency-domain harmonics-to-noise ratio in the acoustic analysis of the normal voice and the abnormal voice]

The frequency-domain relative harmonics-to-noise ratios were analysed in 36 normal women and 30 patients who had suffered from abnormal voice. The result indicated: the frequency-domain relative harmonics-to-noise ratios of the normal voice were distributed stably and the relative harmonics-to-noise ratios of the diseased voice differed obviously from that of the normal one above 1,700 Hz (P < 0.01). The frequency-domain relative harmonics-to-noise ratio was considered as a valuable parameter in distinguishing normal voice and diseased voice.

Airway complications in patients with infection caused by HIV

Numerous problems may be identified in the airways of patients with HIV infection. In many cases, these airway conditions represent exaggerations of infections seen in the immunocompetent host. However, in other instances, they represent manifestations of unique problems, infectious and/or neoplastic, that are a consequence of the profound immunosuppression seen in the patient with infection due to HIV.

Reinke's edema: phonatory mechanisms and management strategies

Reinke's edema (RE) has been associated typically with smoking and sometimes with vocal abuse, but aspects of the pathophysiology of RE remain unclear. To gain new insights into phonatory mechanisms associated with RE pathophysiology, we used an integrated battery of objective vocal function tests to analyze 20 patients (19 women) who underwent phonomicrosurgical resection. Preoperative stroboscopic examinations demonstrated that the superficial lamina propria is distended primarily on the superior vocal fold surface. Acoustically, these individuals have an abnormally low average speaking fundamental frequency (123 Hz), and they generate abnormally high average subglottal pressures (9.7 cm H2O). The presence of elevated aerodynamic driving pressures reflects difficulties in producing vocal fold vibration that are most likely the result of mass loading associated with RE, and possibly vocal hyperfunction. Furthermore, it is hypothesized that in the environment of chronic glottal mucositis secondary to smoking and reflux, the cephalad force on the vocal folds by the subglottal driving pressure contributes to the superior distention of the superficial lamina propria. Surgical reduction of the volume of the superficial lamina propria resulted in a significant elevation in fundamental frequency (154 Hz) and improvement in perturbation measures. In almost all instances, both the clinician and the patient perceived the voice as improved. However, these patients continued to generate elevated subglottal pressure (probably a sign of persistent hyperfunction) that was accompanied by visually observed supraglottal strain despite the normal-sized vocal folds. This finding suggests that persistent hyperfunctional vocal behaviors may contribute to postsurgical RE recurrence if therapeutic strategies are not instituted to modify such behavior.

Acute supraglottitis in adults: early indicators of airway obstruction

PURPOSE

To show that cardinal signs of upper airway obstruction are characteristically absent in the early phases of potentially fatal supraglottitis.

PATIENTS AND METHODS

The hospital records of 9 previously healthy adults who died from autopsy-proven supraglottitis within 12 hours after sudden onset of severe sore throat.

RESULTS

Six patients who were discharged from the emergency room with a diagnosis of pharyngitis died at home within 4 hours after dismissal. Three patients suspected of supraglottitis were admitted and treated medically; by the time signs of respiratory obstruction appeared, attempts at airway intervention failed. None of the 9 patients presented with symptoms or signs of respiratory distress, but all gave a history of fulminant sore throat associated with chills and fever. In all patients, the pulse rate was above 100 per minute.

CONCLUSION

In the early phases of acute supraglottitis, the most reliable indicator of impending airway obstruction is a rapidly developing severe sore throat. Dyspnea, tachypnea, retractions, stridor, and cyanosis are manifestations of advanced stages of the infection and should not be awaited to determine the need for airway intervention.

Correlation between instability of fundamental voice frequency and malignant infiltration of vocal fold nerve endings

Performing systematically acoustical objective voice analysis in patients with chronic chorditis and glottic cancer we detected a certain number of cases with exceptional acoustical pattern. In 7 of 50 patients with chronic chorditis this acoustical pattern was highly specific demonstrating frequent changes of fundamental frequency in short time interval. In 31 of 50 patients with glottic cancer the same phenomenon was recorded. Histology revealed in 6 of those 7 patients with clinical diagnosis of chronic chorditis invasive cancer of the vocal fold. Detailed and more sophisticated techniques (PAF Halmi for elastic and collagen fibres and neurohistochemical technique S-100 and NSE for nerve elements) demonstrated mainly preserved layer structure of vocal fold lamina propria and infiltrated nerve endings. Such histological findings strongly suggest that cancer infiltration is responsible for rapid changes of fundamental frequency (via mucosal reflexes) although vibratory segments are regular because of preserved layer structure. Such findings could contribute to better understanding of laryngeal control mechanisms and laryngeal mucosal reflexes in human. Also this acoustical sign may be a useful diagnostical parameter for very early diagnosis of glottic cancer. This is possible because of the great sensitivity and complexity of phonatory function.

Effect of omeprazole on the course of associated esophagitis and laryngitis

Esophagitis has increasingly been implicated as a cause of chronic laryngitis and there is some evidence that gastro-esophageal reflux disease (GERD) is more common in patients with laryngitis. The aim of this study was to evaluate whether patients with esophagitis and laryngitis responded to treatment with omeprazole. Of 74 consecutive patients with endoscopically proven GERD, 21 had laryngitis. These 21 patients with associated esophagitis and chronic laryngitis were treated for 4 weeks with omeprazole 40 mg per day. After 2 weeks of treatment and at the conclusion of the study, 2 weeks later, esophagoscopy and laryngoscopy were performed and the patients responded to a questionnaire on their symptoms. The follow-up period was 1 year. Twenty-one of the 74 patients (28.4%) had esophagitis (grade I, n = 12; grade II, n = 9) and associated laryngitis (grade I, n = 14; grade II, n = 7). The severity of the esophagitis accorded with the severity of the laryngitis. After 2 weeks' treatment with omeprazole, both the esophageal and the laryngeal symptoms had improved in all 21 patients. Endoscopically, the healing rates were 62% for esophagitis and 33.3% for laryngitis. At the end of the study period, at 4 weeks, all patients were symptom-free and the esophagitis and laryngitis had healed completely. No patient suffered from drug-induced side effects. Patients with associated laryngitis and esophagitis should be given adequate anti-reflux therapy. Both the laryngeal and esophageal symptoms improved with the omeprazole treatment, suggesting that reflux was the underlying etiology.

[Hyperbaric oxygen therapy in case of the neck diffuse phlegmon with very hard clinical course]

A case of 56 year old woman, diabetic (non-diagnosed before), suffering from diffuse phlegmon of the neck and acute submucosal laryngitis as a peritonsillar abscess complication is presented. Tracheotomy, abscess tonsillectomy with evacuation of peritonsillar abscess and extensive skin incisions of the neck with separation of tissue layers followed by drainage were performed at the beginning of hospitalization. This was regarded as responsible for stopping the violent development of the disease and saving the life of patient. Pathological bacteria were Streptococci (anaerobic and aerobic). Apart from the application of antibiotics (piperacyl, amikin, metronidazole) the patient was treated by hyperbaric oxygen (pressure 2,5 ata, one hour per day, on 6-9 day of treatment). Furthermore she was treated with oxygen applied through the tracheotomy tube during 5 days. In the authors' opinion the early performance of surgical procedure is necessary in the phlegmon of the neck as in the presented case. It is to be remembered, that these patients may suffer from other diseases like diabetes, non-diagnosed earlier. It has been noticed that significant improvement may be obtained by using the hyperbaric oxygen in the treatment of such cases.

[Laryngeal diphtheria in a young woman causes diagnostic difficulties--case report]

A case of severe laryngeal diphtheria in a young woman was presented. Initially, the presence of a foreign body in the larynx of this patient was suspected. The differential diagnosis of a foreign body should include diphtheric laryngitis as this may cause obstruction of the respiratory tract. This can lead to severe complications.

Stridor in patients with HIV infection

The immunodeficiency which results from HIV infection is associated with a range of opportunistic infections and tumors which may present with the symptoms of upper airways disease. This paper presents three cases of stridor from different causes in patients with HIV infection, all of whom recovered following treatment. The management of this problem requires consideration of the likely aetiology which, in those with advanced immunodeficiency, includes bacterial and fungal laryngitis and epiglottitis as well as rapidly growing laryngeal tumours. Recommendations for the treatment of those with HIV infection who present with severe or rapid-onset stridor should include a combination of aggressive airway intervention and broad-spectrum antibacterial and antifungal agents. Laryngeal biopsy for histology and culture is particularly important for those patients who fail to respond to the aforementioned treatment.

[Acute herpetic stenosing laryngitis in children]

Herpetic acute stenosing laryngitis (ASL) in 6 infants was compared clinically to catarrhal ASL and latent herpetic infection in 6 infants with acute respiratory disease. Labial, oral and nasal herpes was observed only in 2 patients with herpetic ASC which in the other 4 patients was diagnosed only at laryngoscopy, thus laryngoscopic picture is a key prompting in diagnosis of herpetic ASL.

[Kinin antagonists in the treatment of acute stenosing laryngotracheitis in children]

The treatment of 97 infants aged from 3 months to 2 years included: nasotracheal intubation (56 patients); i. v. injection, drops (77 patients) or aerosol inhalations (20 cases) of trasylol, kontrikal or gordox; inhalations of epsilon aminocaproic acid (12 cases); glucocorticoids (locally, inhalations, laryngeal drop infusions); local and oral bioantioxidants; noradrenaline for local vasoconstriction. The addition of antikinin medication to the complex of pathogenetically differentiated means which are also proteolytic enzyme inhibitors reduced the frequency and duration of tracheal intubation, duration of laryngeal stenosis by half. Systemic and local administration of antikinin drugs is advocated starting on the first post-diagnosis days, except cases of advanced acute inflammation in the presence of infiltrates in the cavum infraglotticum when antikinin, antihistamine and vasoconstrictors proved ineffective.

The effect of serial in vivo passage on the expression of virulence and DNA stability of an infectious laryngotracheitis virus strain of low virulence

The effect of 35 serial passages in vivo on an infectious laryngotracheitis virus strain of low virulence was examined in terms of effect on virulence and DNA stability. Within 3 passages in live chickens there was evidence of increasing respiratory distress. Severe respiratory distress (with death in some cases) was observed after the 6th passage, except when there appeared to be a transient decline in pathogenicity following short term storage of the virus inoculum at -70 degrees C. Restriction endonuclease analysis of viral DNA derived from the original inoculum and the final passage did not reveal any genomic alteration. It is postulated that there is a potential for live ILTV vaccines to cause outbreaks of clinical disease in the event of inadequate or incomplete vaccination procedures.

Gastroesophageal reflux laryngitis resistant to omeprazole therapy

Gastroesophageal reflux disease (GERD) is known to cause a variety of symptoms that lead a patient to seek otolaryngologic care. New advances in the treatment of GERD have enabled otolaryngologists to eliminate most of the signs and symptoms caused by acid reflux. Omeprazole, the most recent pharmacologic advancement, has been reported to be universally successful in controlling acid release from the stomach of patients with GERD. This report describes a series of patients with GERD for whom high-dose omeprazole therapy was not successful in completely reducing gastric acid levels of GERD symptomatology.

[Allergy and acute stenosing laryngotracheitis in children]

An allergological examination of 144 patients suffering from acute stenosing laryngotracheitis revealed food, drug, bacterial allergy of exudative diathesis in 62.5% of the cases. Allergic children had laryngostenosis of degree II and more advanced two times more frequently, whereas recurrences (12 cases) occurred primarily in children in premorbid condition. Allergy of shown to contribute to the onset of acute stenosing laryndotracheitis as allergic subjects are more susceptible to respiratory bacterial and viral infection. Local factors are mostly responsible for this. The author offers recommendations on more advanced treatment of acute stenosing laryngotracheitis with consideration of allergic aspects.

[Clinical studies on minocycline in infantile acute pharyngolaryngitis with cough]

Among cases of infantile acute pharyngolaryngitis with cough as a chief complaint, 21 cases that the involvement of bacterial infections has been demonstrated were given minocycline (MINO) and the effectiveness and safety of MINO were investigated. 1. Regarding the clinical effectiveness, the number of cases assessed as markedly effective was 9 (43%) and that as effective was 8 (38%), so that the effectiveness rate was 81%, and particularly, in the infections caused by Haemophilus influenzae, MINO showed a high effectiveness. 2. Five strains of Streptococcus pneumoniae, 2 strains of Streptococcus pyogenes and 16 strains of H. influenzae, a total of 23 strains of pathogenic bacteria were isolated, and MINO showed high activities against not less than 80% of these strains. 3. The bacteriological effect in terms of the rate of eradication was 71%, and that of H. influenzae was as high as 88%, while S. pneumoniae remained in 3 of 5 cases. 4. Adverse reactions were observed in 2 cases (10%), 1 case each of abdominal pain and stomatitis, and both of them were improved after the treatment termination. 5. Regarding the usefulness, which was comprehensively assessed using clinical effectiveness and safety as criteria, the number of cases evaluated satisfactorily useful was 8 (38%) and that as useful was 8 (38%), so that the overall usefulness rate was 76%. From the above results, it was confirmed that MINO is a drug having high efficacy and safety against infantile acute pharyngolaryngitis with cough as a chief complaint caused by H. influenzae.(ABSTRACT TRUNCATED AT 250 WORDS)

Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy?

The purpose of this study was to identify a cohort of children with laryngotracheitis (croup) who may be safely discharged from the emergency department (ED) after treatment with nebulized racemic epinephrine (RE), corticosteroids, and prolonged observation. Consecutive children (younger than 13 years of age) presenting to the ED with the diagnosis of laryngotracheitis were evaluated prospectively according to a croup scoring system. Sixty-one patients (4 to 108 months of age) with persistent inspiratory stridor at rest after 20 minutes of mist therapy who received nebulized RE (0.05) mL/kg of a 2.25% solution) and intramuscular dexamethasone (0.6 mg/kg) were enrolled in the study. Patients were observed in the ED while croup scores were assessed at 15, 60, 120, and 180 minutes. Croup scores were significantly improved (analysis of variance, P < .01) throughout the observation period in 31 patients (51%) who were discharged from the ED. Only one patient returned within 48 hours for further cool mist therapy. The maximum benefit from RE therapy was seen at 60 minutes. If a child had persistent resting stridor or a croup score greater than 2 at that time, hospitalization was inevitable. The 30 patients admitted to the hospital were younger (19.1 v 27.8 months) and had higher pretreatment croup scores (5.7 v 4.1). This was the first prospective study to identify a subset of children who have received RE to be safely discharged home after observation in the ED.

Bacterial laryngotracheitis associated with toxic shock syndrome in an adult

Nonmenstrual toxic shock syndrome (TSS) in adults has been associated with various staphylococcal respiratory tract infections, including pharyngitis, tonsillitis, pneumonia, and postinfluenza respiratory tract infections. In children, nonmenstrual TSS has also been described as a complication of bacterial tracheitis. We describe the case of a 40-year-old woman who presented with laryngotracheitis as well as clinical and laboratory evidence of TSS. Culture of her sputum samples yielded pure growth of Staphylococcus aureus, which was shown to produce TSS toxin 1 (TSST-1). The patient responded promptly to therapy with iv clindamycin. We discuss the association of TSS with staphylococcal laryngotracheitis and the role of clindamycin in the treatment of TSS. To our knowledge, there are no previous reports of TSS complicating laryngotracheitis in adults.