Laryngeal involvement in juvenile idiopathic arthritis patients

Juvenile idiopathic arthritis (JIA) is an autoimmune diseases characterized by chronic arthritis and systemic manifestations. Autoimmune diseases can affect the upper airways including the larynx. The aim of this study was to investigate laryngeal involvement in JIA patients and its possible association with JIA disease parameters. Fifty consecutive JIA patients were screened for laryngeal abnormalities using flexible fiberoptic laryngoscope and laryngeal computerized tomography. Laryngeal abnormalities were detected in nine (18%) of our cases, with cricoarytenoiditis in six cases (12%) and a rheumatoid nodule in the pyriform fossa in only one case (2%). Diffuse congestion and edema of the posterior part of the larynx with normal vocal cord mobility was detected in two cases (4%). In our study, laryngeal abnormalities were significantly higher in patients with polyarticular seropositive disease subtype and also were significantly higher in patients with longer disease duration, higher disease activity scores, and those with erosive disease. JIA may affect the larynx. Laryngeal involvement in JIA patients is more in polyarticular seropositive cases. JIA patients have to be subjected to thorough otolaryngologic examination for early diagnosis and prompt management.

[The risk factors of the respiratory complications occurrence after tracheal extubation in the surgery of the thyroid gland]

There were examined 400 patients after tracheal extubatton performance, to whom thyroidal surgery was done. The rate and causes of occurrence of respiratory complications were studied up. Laryngeal oedema was revealed in 5.5% patients, injury of laryngeal nerves--in 3.0%, postoperative hemorrhage--in 1.2%. For the respiratory complications occurrence the risk factors are following: thyroidal cancer, polynodous goiter, subtotal thyroidectomy, extrafascial thyroidectomy, the operation duration, hard trachreal intubatlon, the patients age and gender.

Laryngopharyngeal Abnormalities in Hospitalized Patients With Dysphagia

OBJECTIVES

To determine the prevalence of laryngopharyngeal (LP) abnormalities in hospitalized patients with dysphagia referred for flexible endoscopic evaluation of swallowing (FEES).

STUDY DESIGN

Retrospective, blinded review by two otolaryngologists of 100 consecutive FEES studies performed and video-recorded by a speech-language pathologist (SLP).

METHODS

Two otolaryngologists reviewed videos of 100 consecutive FEES studies on hospitalized patients with dysphagia for the presence of abnormal LP findings.

RESULTS

Sixty-one male and 38 female patients comprised the hospital dysphagia cohort. The mean age was 62. One subject could not be evaluated because of the severity of the retained secretions, leaving 99 subjects in the cohort. Seventy-six percent had been previously intubated, with a mean intubation duration of 13 days. The overall prevalence of abnormal LP findings was 79%. Forty-five percent of the patients presented with two or more findings, which included arytenoid edema (33%), granuloma (31%), vocal fold paresis (24%), mucosal lesions (17%), vocal fold bowing (14%), diffuse edema (11%), airway stenosis (3%), and ulcer (6%). There was a significant difference in LP findings between those individuals who had or had not been intubated.

CONCLUSIONS

Hospitalized patients with dysphagia are at high risk for LP abnormalities, particularly if they have been intubated, and may benefit from either 1) an initial joint examination by the SLP and otolaryngologist or 2) an otolaryngologist's review of the recorded examination conducted by the SLP. Such otolaryngology involvement could identify airway stenosis patients at an earlier stage, initiate granuloma treatment sooner, enable earlier biopsy of unexpected lesions, and allow follow-up of mucosal and neuromuscular findings that do not respond to medical management.

Videostroboscopic Characteristics of Young Adult Female Smokers vs. Nonsmokers

OBJECTIVES

The purpose of this study was to provide a foundation of information concerning the early effects of smoking on the laryngeal structures and phonatory physiology of young adult women using videostroboscopy.

STUDY DESIGN

Cross-sectional, observational.

METHODS

Subjects were 34 female nonsmokers and 30 female smokers (Total N=64) between the ages of 18 and 30 years of age. For the purposes of this study, a smoker was defined as any subject who, at the time of this study, had smoked at least two cigarettes per day for at least 1 year. All subjects in the nonsmoker category were those who, at the time of this study, did not smoke and who had not smoked for at least 5 years before the study. Videostroboscopic evaluations were rated by experienced judges on various parameters describing the structure and function of the laryngeal mechanism during comfortable pitch and loudness phonations.

RESULTS

Results showed significant relationships between smoking and the increased presence of edema, erythema, and abnormal laryngeal color. In addition, smokers were observed to have significantly more occurrences of abnormal phase symmetry and increased glottal gap size during the closed phase of phonation. Glottal gap size was significantly correlated with the number of cigarettes smoked in the lifetime.

CONCLUSIONS

The findings of increased erythema and edema in this study are consistent with previous descriptions of the effects of smoking on laryngeal structures, whereas our observations regarding glottal gap size and phase symmetry are unique contributions derived from the stroboscopic method. The results of this study indicate that observable signs of laryngeal irritation and disturbed phonatory physiology occur even in young adults with relatively brief smoking habits.

Anaphylactoid reactions to Dextran 40 and 70: Reports to the United States Food and Drug Administration, 1969 to 2004

BACKGROUND

Clinical dextrans, such as Dextran 40 and Dextran 70, are associated with anaphylactoid reactions caused by dextran-reactive immunoglobulin G antibodies. When infused immediately before clinical dextrans, dextran 1 significantly reduces the incidence of severe anaphylactoid reactions. The objective of the study was to describe the frequency and characteristics of reports submitted to the United States Food and Drug Administration (FDA) for anaphylaxis or anaphylactoid events after clinical dextran administration.

METHODS

We searched the FDA's Adverse Event Reporting System for reports associated with a clinical dextran and describing anaphylaxis/anaphylactoid reactions. Our case definition for a probable anaphylaxis/anaphylactoid event required signs or symptoms from at least two body systems, with at least one sign or symptom being hypotension, vasodilation, or respiratory difficulty, and onset within 60 minutes. Other reports were considered possible cases if the reporter specifically described the reaction as anaphylaxis or an anaphylactoid reaction. Premier RxMarket Advisor provided estimates of total US hospitalizations with clinical dextran or dextran 1 administration from 2000 to 2004, based on discharge billing data from a sample of US hospitals. The IMS National Sales Perspective provided estimates of total doses of dextrans sold in the United States from 1999 to 2004, based on volumes of dextrans sold in a sample of retail and nonretail outlets.

RESULTS

The FDA received 366 clinical dextran adverse event reports from 1969 to 2004, of which 90 (24.6%) were anaphylaxis/anaphylactoid events. The ratio of hospitalizations where clinical dextran was administered to hospitalizations where dextran 1 was administered was 28.4:1. The expected ratio would be 1:1 if all clinical dextran patients had received dextran 1 pretreatment. The ratio of clinical dextran doses sold to dextran 1 doses sold in the United States was 38.6:1.

CONCLUSIONS

A high proportion of adverse event reports for clinical dextrans described anaphylaxis or anaphylactoid reactions. Hospital discharge and product sales data suggest that dextran 1 has not been used consistently before clinical dextran administration in recent years. To reduce the risk of anaphylactoid reactions, physicians should consider routine administration of dextran 1 before the infusion of a clinical dextran.

Severe food anaphylaxis: 107 cases registered in 2002 by the Allergy Vigilance Network

BACKGROUND

The prevalence of food allergies increases, relating to diet modifications. The consumption of new foods--exotic foods or foods originally used for animal feed, new proteins, neo allergens due to the use of new technologies and soon, Genetically Modified Foods--are in the spotlight.

OBJECTIVE

It is essential to develop a system of food allergy vigilance encompassing the full range of foods being consumed. Understanding this imperative leads logically to the suggestion of developing an allergy vigilance network taking advantage of the ongoing experience of allergists "on the ground".

METHODS

The French Allergy Vigilance Network is subscribed to by 302 allergologists (267 of whom are French). The aims of the Network are to record cases of severe anaphylaxis, to establish an epidemiological data bank from prospective multicenter studies, and to monitor the allergic risk from novel foods.

RESULTS

In 2002, 107 cases of severe anaphylaxis were recorded: anaphylactic shock--59.8% (one fatal), systemic reaction--18.7%, laryngeal angio-edema--15.9%, acute severe asthma--5.6% (one fatal). The main allergens identified were peanuts, nuts, shellfish, lupine flour and wheat flour. Action has been taken as a result: information by industry on inadequate labeling, withdrawal of wrongly labeled batches, and university hospital centers have been encouraged to establish the allergenic safety of their catering services.

CONCLUSION

Setting up such a network in other countries would lead to a significant advance in knowledge of the peculiarities of allergies relating to a wide variety of eating habits.

Treatment of Reincke's edema among different professional groups: presentation of results

OBJECTIVES

Reincke's edema is one of the most common voice disorders in adults. The main purpose of our study, was to analyze factors that may influence the development of this disease. We also estimated the results of surgical treatment.

MATERIALS AND METHODS

The research was performed on a group of 261 patients with Reincke's edema treated in the ENT Department of the Medical University of Wrocław in the years 1994--2000. In the study population, women were in a majority and teachers formed the largest occupational group (30%) followed by salespersons (15%). Most of the patients (86%) were tobacco smokers. All of the patients underwent detailed videostroboscopic examination of the larynx and perceptual analysis of the voice quality before and after treatment.

RESULTS

The symmetry of vocal cords before and after treatment was found in 75 patients. Lack of symmetry before treatment, and proper symmetry after surgery was observed in 71 subjects. Fifty patients showed less symmetry after treatment, and 65 patients were asymmetric before and after surgery. The difference between the symmetry of vocal folds before and after treatment was at the border of statistical significance (p = 0.069). The number of patients with full vocal cords closure increased after treatment. This difference was statistically significant (p = 0.032). The periodicity of vocal cord movements was significantly higher after treatment (p < 0.001).

CONCLUSIONS

The perceptual assessment of voice, before and after treatment, revealed statistically significant post-treatment improvement in voice quality.

First survey from the "Allergy Vigilance Network": life-threatening food allergies in France

The Allergo-vigilance Network including 200 French allergologists and 28 European ones, has three objectives: to index the cases of lethal or prelethal anaphylaxis, to evaluate the prevalence of food allergies, clinical pictures and allergens, and to implement the post-marketing surveillance of the allergic risk of novel foods. The first survey dealing with life-threatening food allergies leads to an estimation of 15,000 to 30,000 reactions per year in France. The AVN could be a helpful tool for public health organizations.

Reinke's edema and risk factors: clinical and histopathologic aspects

PURPOSE

The purpose of this study was to evaluate retrospectively the distribution of histologic damage and its correlation with various risk factors in a group of patients affected by Reinke's edema.

MATERIALS AND METHODS

The study subjects comprised 125 patients with bilateral Reinke's edema consecutively presenting at the Department of Otorhinolaryngology, "La Sapienza" University, Rome. The patients were divided into 4 groups according to Hellquist, Lundgren, and Olofsson's histologic classification and were then further categorized according to the number of cigarettes they smoked daily. Average exposure to cigarette smoke, occupation, habitual voice use, and gastroesophageal reflux were also considered.

RESULTS

Fifty-two patients did not exhibit histologic lesions, 64 patients were histologically classified as Group 1 (epithelial hyperplasia and/or keratosis with or without mild dysplasia), and 6 patients exhibited moderate dysplasia (Group 2). In 3 patients, histologic examination showed evidence of unilateral carcinoma in situ (Group 3). Forty-four patients suffered recurrences within the first 2.5 years. Both daily cigarette consumption and duration of exposure to cigarette smoke were found to influence the severity of the histologic lesion. An association with gastroesophageal reflux was observed in 4 patients (3.2%). Prolonged vocal abuse did not prove to be a noteworthy factor in our study.

CONCLUSIONS

The main risk factor for Reinke's edema and for its recurrence is tobacco use. Our study results showed that the clinical manifestation of this disease is related to the number of cigarettes smoked daily and the duration of exposure to smoke. Longer durations of exposure to cigarette smoke result in higher degrees of histologic damage.

[Allergy emergencies in children: care at school]

Half of the life of children is spent in schools. Emergencies may occur, due to food anaphylaxis or other allergic causes. Main clinical pictures are anaphylactic shock, laryngeal angioedema, acute asthma. Lethality is a risk. Recent French rules go into more details about the management of emergency cases and the need of training for teachers and other members of the educational staff. The need to use injectable i.m. adrenaline is underlined in a protocol with consents of parents and agreement of all parties. Eviction diets are not yet guaranteed so that parents are allowed to provide their children with suitable meals. The authors debate about the indications of such protocols.

[Polyps, nodules, and Reinke edema. An epidemiological and histopathological study]

A retrospective epidemiological and histopathological review was made of 258 patients. Forty had laryngeal polyps, 35 vocal fold nodules, and 41 Reinke edema. One hundred forty-two records were excluded for lack of epidemiological or histopathological data. No dysplastic changes were observed in nodules or polyps. One patient with edema had mild dysplasia. The epidemiological data showed that voice abuse or misuse was the main factor in patients with vocal fold nodules; smoking was the main factor in polyps and edema.

Incidence and predictors of postextubation laryngeal edema in pediatric patients with congenital heart disease

Laryngeal edema developed in 10.1% of studied patients with congenital heart disease after cardiac surgery. The 181 patients were divided into two groups; those with laryngeal edema (group 1) and those without laryngeal edema (group 2). The mean ages in group 1 and 2 were 10 and 22.9 months. Group 1 patients were younger on average than those of group 2 (p < 0.05). The differences in the cardiopulmonary bypass time and anesthesia time between the two groups were not statistically significant. The duration of intubations and ventilatory support before and after the onset of laryngeal edema and the period of the ICU stay were longer in group 1 than in group 2 (P < 0.05). A predictor of postextubation laryngeal edema was not found in our patients from above mentioned parameters. We conclude that the higher incidence of laryngeal edema may be due to young age (most were under 1 year of age), and duration of intubation and ventilatory support.

Pharyngography after head and neck irradiation: differentiation of postirradiation edema from recurrent tumor

OBJECTIVE

In patients previously irradiated for head and neck carcinomas, persistent soft-tissue thickening in the larynx and pharynx makes it difficult to distinguish between postirradiation edema and recurrent epidermoid carcinoma. The goal of this work was to characterize the standard double-contrast pharyngographic appearance after irradiation and to differentiate this appearance from that of recurrent or residual neoplasms.

MATERIALS AND METHODS

The posttreatment pharynogograms in 43 patients treated with radiotherapy for malignant tumors of the head and neck were retrospectively reviewed. The pharynx had been included in the radiation field in each case. We characterized the posttherapy appearance and identified radiographic signs that could be used to distinguish normal postirradiation edema from recurrent tumor.

RESULTS

Soft-tissue thickening of normal laryngeal and pharyngeal structures and laryngotracheal aspiration were common nonspecific findings on posttherapy pharyngograms, each occurring in 39 of 43 patients. Epiglottic enlargement and laryngotracheal aspiration did not correlate with the presence of residual or recurrent neoplasm. Asymmetric swelling was more common ipsilateral to the original neoplasm and did not necessarily indicate a malignant tumor. Mucosal irregularity, ulceration, and a demonstrable focal mass were the only significant predictors of recurrent or residual tumor; at least one of the three findings was present in 17 of 19 patients with neoplasm correctly identified by pharyngography.

CONCLUSION

Double-contrast pharyngography is a useful means of diagnosing pharyngeal tumors in patients who have had radiation therapy. Radiographic signs of neoplasm (ulcer, mucosal irregularity, and a focal mass) can be used to distinguish recurrent tumor from nonmalignant changes after irradiation.

Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study

Because laryngeal edema (LE) after tracheal extubation is likely to result from an exudative response, corticosteroids often are given routinely as a preventive treatment. No adequate controlled study supports this strategy, however. A prospective, randomized, placebo-controlled, double-blind, multicenter trial that included 700 consecutive patients requiring tracheal intubation and mechanical ventilation was conducted to determine risk factors for LE occurrence after tracheal extubation in adults and to evaluate the efficacy of corticosteroids in its prevention. One hour before extubation, patients were given either an intravenous bolus of 8 mg dexamethasone or a placebo. Patients were divided into two groups: 1) those in whom short-duration intubation (SDI, less than 36 h) was administered; and 2) those in whom long-duration intubation (LDI, more than 36 h) was administered. Minor LE was diagnosed when either stridor or laryngeal dyspnea, or both, occurred; major LE was diagnosed when reintubation due to LE was required, with LE evidenced during direct laryngoscopy. The overall incidence of LE was 4.2% and varied among the six participating centers from 2.3 to 6.9% (not significant). In only seven patients (1%), all with LDI, was tracheal reintubation required for LE. Laryngeal edema occurred more frequently after LDI than after SDI (7.2 vs. 0.9%; P less than 0.001). It also was more frequent in female than in male patients (20/284 vs. 8/379; P less than 0.05), irrespective of intubation duration and treatment. There was no association between LE and either difficulty/route of intubation or admission diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Irradiated volume and arytenoid edema after radiotherapy for T1 glottic carcinoma

From May 1982 through December 1986, 116 T1 glottic carcinomas were treated with radiotherapy in a prospective randomized study to determine the effect of radiation field size. Patients were treated with a total dose of 60 Gy over six weeks using 4 MV X-ray, wedge filter and shell. Local control rates treated with a field size of 5 x 5 cm2 and 6 x 6 cm2 were 93% and 95%, respectively. Persistent laryngeal edema occurred in 4% of cases treated with 5 x 5 cm2 and 21% with 6 x 6 cm2 (p less than 0.02). The rate of late laryngeal edema was dependent upon the treatment volume. A larger treatment field yielded a higher minor complication rate without improvement of local control rate.

The predictive role of bioeffect dose models in radiation-induced late effects in glottic cancers

Late radiation-induced laryngeal oedema for different doses per fraction was analyzed in 208 cases with squamous cell carcinoma of the vocal cord. The series comprised 156 cases with T1N0M0 and 52 cases with T2N0M0 lesions. Radical radiotherapy was given with three different regimens delivering 3.33 Gy, 2.5 Gy, and 2.25 Gy per fraction. There were 52 cases of late radiation-induced laryngeal oedema. A strong correlation (p less than 0.015) between the dose per fraction and the risk of the late complication in the vocal cord has been demonstrated. The analysis suggests that the empirical models like Nominal Standard Dose (NSD) or Time-Dose Factors (TDF) do not predict correctly the late normal tissue reactions for different dose fractionations. The analysis with extrapolated response dose (ERD) values of the linear-quadratic (L-Q) model also fail to correlate with the late complications (p greater than 0.5). Care should be exercised when using these bioeffect dose models to calculate regimens iso-effective for late damage, even when modest changes in fraction size from 2 to 3 Gy are contemplated.

Endoscopic examination of the neonatal larynx at extubation: a prospective study of variables associated with laryngeal damage

Despite postmortem and clinical studies, the etiological factors that determine why only a proportion of intubated neonates develop subglottic stenosis remain unclear. This prospective study was initiated to identify factors that were associated with laryngeal abnormalities secondary to intubation. Thirty neonates were examined at extubation by two independent observers blinded to the neonate's ventilatory history. Thirty-six possible prognostic indicators were recorded for each neonate. After screening by univariate (chi 2) analysis, 10 indicators were selected for further analysis. Of these 10 selected only two indicators showed an association with the laryngeal appearance. Active neonates had significantly more abnormalities in the supraglottis (P = 0.004) than those who were quiescent. Younger neonates had more abnormalities in the glottis though the significance level was marginal (P = 0.056). Other prognostic indicators, including birthweight, gestational age, duration of intubation and frequency of intubation, were not significantly related to laryngeal appearance. This study supports the hypothesis that the etiology of laryngotracheal stenosis is multifactorial, and has identified two possible etiological factors: age and neonatal activity. Neonatal activity has not been identified previously as an etiological factor. The contribution of individual factors may vary from one neonatal unit to another, as a result of variation in intubation, ventilation and extubation policy. This could explain the inconsistency in etiological factors identified by previous studies. It is therefore not yet possible to recommend a standard technique for the ventilation of premature neonates that would further reduce the incidence of laryngotracheal stenosis.