[TWO CASES OF LARYNGEAL EDEMA CAUSED BY SUBLINGUAL ALLERGEN IMMUNOTHERAPY]

Sublingual immunotherapy is a widely used treatment, and serious adverse reactions such as anaphylaxis are rare. We report two cases of laryngeal edema as adverse reactions to sublingual immunotherapy, which could be continued due to a change in the administration method. Case 1 presents a 15-year-old male suspected to have had anaphylaxis due to the dust at the age of 6 years. He started treatment with Miticure® and developed laryngeal edema 30 minutes after taking the 10000JAU dose on the 10th day. laryngeal edema was treated with intravenous infusion. Case 2 presents a 48-year-old woman. She started treatment with Cidacure® and developed respiratory distress and laryngeal edema 1 hour after taking the 5000JAU dose on the 5th day. she had resolved mildly without therapeutic intervention. In both cases, the patients were switched to sublingual spitting, resumed with the initial dose cautiously, and were able to continue. Sublingual immunotherapy is a safe treatment, but sudden adverse reactions may occur. Laryngeal symptoms may be treated by changing to the sublingual spitting method, but laryngeal findings should be examined, and the dosage should be carefully increased.

Management of Laryngotracheal trauma: A review of current trends and future Directions

Laryngotracheal trauma is rare but can pose serious threats to one's life. Presenting symptoms vary according to the severity of injury. Immediate Airway control is first step in the management, intubation should be considered by a senior member of the trauma team if the injury is minor while tracheostomy should be reserved for more severe injuries. Evaluation by a fibre-optic laryngoscopy and CT scan should be done whenever possible. Reconstruction is done according to the site involved using suture, titanium miniplates and stents. Tissue engineering has added a new horizon in this management but up till now complete laryngotracheal regeneration is very far-fetched, but tissue regeneration at individual sites have shown some positive results. More work needs to be done in this less explored field including laryngeal transplantation.

[Analysis of respiratory complications in 922 severely burned patients]

OBJECTIVE

To discuss the distribution of the respiratory complications in severely burned patients and the prevention and treatment experience against them.

METHODS

Medical records of 922 adult patients with severe or extremely severe burn hospitalized in our burn ICU from January 2005 to December 2012 were screened and retrospectively analyzed, including patients transferred from other hospitals, patients with total burn area above 50% TBSA, the distribution and treatment of respiratory complications, and the mortality. Data were processed with chi-square test.

RESULTS

The constituent ratio of patients transferred to our hospital was 71.1% in 2007 and 40.2% in 2010, while it remained about 50.0% in the other years. The ratios of patients with total burn area larger than 50% TBSA and that of patients with respiratory complications (χ(2) = 2.637, P > 0.05) showed no significant changes each year. Among these 922 burn patients, 523 patients suffered respiratory complications, among which laryngeal edema (50.9%, 266 cases), pulmonary infection (21.6%, 113 cases), and ARDS (11.9%, 62 cases) were the main components, with no significant change each year (with χ(2) values respectively 6.132, 6.319, 0.016, P values above 0.05). Among the patients with respiratory complications, except for 36 were not treated actively, 487 were treated by ventilator among which 228 had undergone tracheostomy, and the constituent ratios in the 8 years were close. Fifteen patients died, with 2 died of laryngeal edema, 3 of ARDS, and 10 of sepsis or MODS as a result of sepsis.

CONCLUSIONS

Patients with severe burns were at high risk of respiratory complications, among which laryngeal edema was common, followed by pulmonary infection and ARDS. Prophylactic tracheostomy, mechanical ventilation, wound therapy, and anti-infection were all effective measures of prevention and treatment against these complications.

[Case of upper airway stenosis after accidental ingestion of neutral detergent containing cationic surfactant (HDQ Neutral)]

We had a case of upper airway stenosis after accidental ingestion of neutral detergent containing cationic surfactant (HDQ Neutral). An 85-year-old man was transported to our hospital by ambulance after ingesting 50 mL of HDQ Neutral. On arrival, he had an edematous buccopharyngeal membrane with bleeding. Laryngeal edema was observed by laryngoscopy, and severe upper airway stenosis occurred. He also had hypoxemia and was therefore intubated and put on mechanical ventilation. After admission, his respiratory condition was stable. On day 3, upper airway edema had improved and extubation was performed. He was cured without other complications. Surfactants generally have low toxicity but can cause damage to the mucous membrane of the respiratory tract and gastrointestinal tract. Therefore, immediate evaluation and treatment are needed for intoxication with them. They can also cause harm to circulation dynamics or the central nerve system, and careful follow-up is therefore needed.

Treatment of laryngeal hereditary angioedema

BACKGROUND

In the emergency department, patients with laryngeal swelling and an inconclusive patient history may receive treatment for allergy-mediated angioedema. Intubation may be necessary if the patient does not respond to treatment. Because angioedema subtypes respond to different interventions, a correct diagnosis is vital.

OBJECTIVES

Review the differential diagnosis of angioedema and characteristics differentiating subtypes. Discuss therapies for angioedema subtypes. Introduce therapies for prevention and acute treatment of hereditary angioedema (HAE).

CASE REPORT

A 10-year-old girl presented with laryngeal swelling unresponsive to diphenhydramine, methylprednisolone, and epinephrine. It was later revealed that she had a family history of HAE, was C1 inhibitor deficient, and enrolled in a clinical study of acute HAE treatment. She was given 1000 units of nanofiltered C1 inhibitor and was able to swallow within 30 min. She was prescribed routine prophylaxis with C1 inhibitor concentrate and has had no subsequent severe HAE swelling attacks.

CONCLUSION

This case illustrates the need for providers to consider HAE in light of available diagnostic testing and recent Food and Drug Administration approval of specific therapies for HAE.

A review of the pathophysiology, diagnosis, and management of allergic reactions in the dental office

Since more than 50 million people in the United States have allergies, knowledge of the management of allergic reactions in the dental office is extremely important. Appropriate care may range from a simple referral to a primary care physician to lifesaving measures implemented during acute anaphylactic reactions. The authors present a basic review of the pathophysiology of allergic reactions and provide information detailing the diagnosis and management of allergic reactions that may be encountered in the dental office. Utilizing this information, the dental practitioner and ancillary staff will have a thorough understanding of allergic reactions and be prepared to successfully identify and treat these reactions.

[Tardive endolaryngeal oedema from blunt laryngeal trauma]

INTRODUCTION

Mild to moderate blunt laryngeal injuries are frequent. Under the present management regimens patients are hospitalized for 24h observation due to the potential risk of developing endolaryngeal oedema. This group of patients is poorly described in the literature, and the aim of this study was to estimate the incidence of acute and especially tardive endolaryngeal oedema as well as the association between type of injury, symptoms and findings to improve existing evaluation criteria and treatment regimens.

MATERIALS AND METHODS

A retrospective analysis of 130 cases exposed to mild to moderate laryngeal injury was performed. The mechanism of injury, symptoms, findings and treatment were registered.

RESULTS

Strangulation was the most common type of injury which was seen in 43% of cases, while stranglehold, fall and blow were observed in 29, 14 and 14%, respectively. Dysphagia was reported by 55%, while hoarseness was observed in 17% and stridor in 5%. Fibreoptically, 33% had endolaryngeal pathology. Twenty cases received treatment, 110 were observed. Immediate intubation was performed in 2.3% of the cases. In the observation-group, more patients were exposed to self-inflicted strangulation (p = 0.01). Fall and blow accidents were more frequent in the treatment than in the non-treatment group (p = 0.03). More patients in the treatment group had dyspnoea (p < 0.001), stridor (p = 0.001), hoarseness (p = 0.007) and endolaryngeal pathology (p < 0.001) than in the non-treatment group.

CONCLUSIONS

In general, mild to moderate blunt external laryngeal injuries seem rather harmless and should need no further treatment. Nevertheless, any injury against the paediatric larynx and injuries related to fall-accidents or genuine hangings are associated with an increased risk of a respiratory threat. No patients in this study developed tardive laryngeal oedema.

New medical therapy: hyperbarics

This article reviews the essentials hyperbaric medicine. Specifically, we review the basic mechanism of action, the six most common indications for treatment, methods of accessing care, typical treatment concerns, and effectiveness of hyperbaric medicine.

Penetrating air gun wound in the neck

BACKGROUND

Injuries from air weapons can be serious and potentially fatal. It has been estimated that up to four million such weapons exist in UK households.

CASE REPORT

We present the case of an 8-year-old boy who sustained a penetrating neck wound from an air gun. Use of the flexible laryngoscope in the resuscitation room allowed localization of the gun pellet in the airway.

CONCLUSIONS

This approach, combined with careful clinical assessment led to immediate removal by direct laryngoscopy, thus avoiding the morbidity of unnecessary surgical exploration.

Quincke-Ödem: Diagnose und Management von 102 Patienten mit plötzlichem Larynxödem

BACKGROUND

Hereditary angioedema (HAE) is extremely rare and clinically characterized by recurrent and self-limiting skin, intestinal and life threatening laryngeal edema. Because of the danger of asphyxiation, it is vital that acute attacks of laryngeal edema be interrupted immediately. The aim of this study is to provide information on the incidence, diagnosis and treatment of laryngeal edema with upper airway obstruction in general and due to HAE.

METHODS

102 patients with swelling of the larynx and difficulty in breathing (stridor) and 21 patients with a manifest HAE were surveyed at the Department of Otorhinolaryngology, Head and Neck Surgery of the Ludwig-Maximilians-University of Munich from 2001 to 2004.

RESULTS

63% of the laryngeal swellings with airway obstruction were due to radiotherapy in cancer and the intake of ACE-Inhibitors. Just 22% were due to allergic reactions. Only one patient (< 1%) suffered from HAE. All patients were treated with intravenous steroids and anti-histamines successfully, except the HAE patient. After emergency coniotomy the patient was treated with purified C1 inhibitor concentrate (C1-INH).

CONCLUSIONS

According to our experience almost all patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids and anti-histamines. In contrast these drugs have no effect on HAE. Replacement therapy with C1-INH has proved to be effective. The challenge is to realize whether an airway obstruction is due to HAE or not. In this case, careful observation, the right medication and an appropriate airway management are lifesaving. The possibility of sudden airway obstruction and asphyxiation must be discussed with these patients and their relatives.

Difficult airway management after carotid endarterectomy: utility and limitations of the Laryngeal Mask Airway

This case series details successful management of life-threatening airway obstruction after carotid endarterectomy. In the first case, ventilation was restored with a Laryngeal Mask Airway. In the second case, laryngeal mask airway rescue was unsuccessful, necessitating percutaneous transtracheal jet ventilation and subsequent endotracheal intubation with direct laryngoscopy.

One-year follow-up results of combined use of CO2 laser and cold instrumentation for Reinke’s edema surgery in professional voice users

The purpose of this study was to present our experience with combined use of CO2 laser and cold instrumentation for Reinke's edema surgery and to evaluate 1-year follow-up results of the technique in a series of professional voice users. Fifteen patients with Reinke's edema who underwent microlaryngoscopic surgery were included. Videolaryngostroboscopy, perceptual and acoustic voice analyses were performed before and after surgery. During the 1-year follow-up, no recurrence of Reinke's edema was encountered. Significant postoperative improvement was obtained in the quality of voice, in terms of GRBAS scores, Fo, jitter, shimmer and NHR. No evidence of laryngeal cancer was found on the histological examinations. Combined use of CO2 laser and cold instrumentation provides a reliable and safe method for Reinke's edema surgery, and cessation of smoking, voice rest and control of the laryngopharyngeal reflux contribute to the success of surgery. We consider that the removal of redundant mucosa of the vocal fold reduces the risk of the recurrence of Reinke's edema and provides better quality of voice. However, it does not imply that our method is superior to others', but this procedure constitutes an effective treatment of choice for Reinke's edema patients, including professional voice users.

Factors that predict the need for intubation in patients with smoke inhalation injury

Early identification of smoke inhalation patients who will require intubation is crucial. We conducted a retrospective chart review to identify predictors of respiratory distress in patients who present with smoke inhalation injury. Our study involved 41 patients who had been treated in the emergency room at a regional burn center. Eight of these patients required intubation. Intubation was positively correlated with physical examination findings of soot in the oral cavity (p < 0.001), facial burns (p = 0.025), and body burns (p = 0.025). The need for intubation was also predicted by fiberoptic laryngoscopic findings of edema of either the true vocal folds (p < 0.001) or the false vocal folds (p < 0.01). No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p = 1.0). Also, multivariate analysis revealed that facial burns correlated significantly with edema of the true vocal folds (p = 0.01) and body burns correlated significantly with edema of both the true (p = 0.047) and false (p = 0.003) vocal folds. We conclude that patients with soot in the oral cavity, facial burns, and/or body burns should be monitored closely because these findings indicate a higher likelihood of laryngeal edema and the need for intubation.

Management dilemmas in laryngeal trauma

Laryngeal trauma is an uncommon injury. This has made it difficult for a common management pathway to evolve and controversies remain. Methods of airway control, usage of investigations and the role of stents or plates in surgical management are reviewed. It is important not to delay treatment due to the poor voice and airway outcome of chronic laryngeal stenosis.

Acute airway compromise after brief exposure to a Dieffenbachia plant

Dieffenbachia is a common domestic plant. Oral contact with the plant usually is associated with minimal consequences. However, chewing on the stem or the leaf of the Dieffenbachia can result in painful oropharyngeal edema and the inability to speak or handle secretions. Airway compromise has been reported only in a pediatric ingestion. We report a case of an adult who bit into the stem of the plant thinking it was sugar cane. He instantly spit out the remaining stem and despite this brief exposure, oropharyngeal edema developed refractory to medicinal therapy, requiring surgical airway management. The exact mechanism of edema is not known; therefore, methods of treatment are variable. We recommend caution when presented with a patient exposed to Dieffenbachia. Even the patient who initially seems stable may have an airway that will quickly deteriorate.

Steroid injection for Reinke's edema using fiberoptic laryngeal surgery

OBJECTIVE

Since 1990, we have performed steroid injections into the vocal fold under topical anesthesia using fiberoptic laryngeal surgery (FLS) in an outpatient clinic. The aim of this study was to retrospectively assess the usefulness of this treatment method in 44 patients with mild Reinke's edema.

MATERIAL AND METHODS

Using fiberoptic monitoring of the larynx, a curved injection needle was inserted via the oral cavity and triamcinolone acetonide was injected into Reinke's space of the bilateral vocal fold.

RESULTS

Remission or improvement was observed in almost all patients in terms of both patients' self-rating of hoarseness and endoscopic vocal fold findings The maximum phonation time was a mean of 9.0 s before operation and 11.4 safter operation, and this increase was significant (p < 0.01). Voice pitch also improved, from 168 to 181 Hz, in female patients, and this increase was also significant (p < 0.05).

CONCLUSION

Steroid injection is considered to be useful for treating mild Reinke's edema.

The cuff leak test to predict failure of tracheal extubation for laryngeal edema

OBJECTIVE

Laryngeal edema secondary to endotracheal intubation may require early re-intubation. Prior to extubation the absence of leak around an endotracheal tube may predict laryngeal edema after extubation. We evaluated the usefulness of a quantitative assessment of such a leak to identify the patients who will require early re-intubation for laryngeal edema.

METHODS

This prospective study included 76 patients with endotracheal intubation for more than 12 h. The leak, in percent, was defined as the difference between expired tidal volume measured just before extubation, in volume-controlled mode, with the cuff inflated and then deflated. The best cut-off value to predict the need for re-intubation for significant laryngeal edema was determined and the patients were divided into two groups, according to this cut-off value.

RESULTS

Eight of the 76 patients (11%) needed re-intubation for laryngeal edema. Patients requiring re-intubation had a smaller leak than the other patients [9 (3-18) vs 35 (13-53)%, p<0.01]. The best cut-off value for gas leak was 15.5%. The high leak group included 51 patients, of whom only two patients (3%) required re-intubation. The low leak group included 25 patients, among whom six patients (24%) required re-intubation ( p<0.01). The sensitivity of this test was 75%, the specificity 72.1%, the positive predictive value 25%, the negative predictive value 96.1% and the percent of correct classification 72.4%.

CONCLUSIONS

A gas leak around the endotracheal tube greater than 15.5% can be used as a screening test to limit the risk of re-intubation for laryngeal edema.

The use of the air leak test and corticosteroids in intubated children: a survey of pediatric critical care fellowship directors

INTRODUCTION

Uncertainties exist regarding the value of the air leak test or use of steroids for preventing post-extubation stridor and extubation failure in children.

OBJECTIVE

Determine the practice preferences of pediatric critical care physicians regarding the air leak test and administration of glucocorticosteroids to prevent airway edema.

METHODS

A 14-question survey regarding the value of the air leak test, use of glucocorticosteroids, and management of airway edema in intubated children was sent to all North American pediatric critical care fellowship directors affiliated with medical school teaching hospitals.

RESULTS

The response rate was 85% (58/68). Seventy-six percent (44/58) routinely check for air leak prior to extubation. The physicians who check for air leak were more likely to delay extubation in order to administer glucocorticosteroids (60% [26/43] vs 15% [2/13], p = 0.01). An air leak of >or= 30 cm H(2)O was more likely (than >or= 20 cm H(2)O) to result in delaying extubation (95% [35/37] vs 51% [19/37], p <0.001). Of the respondents who use steroids for airway edema prophylaxis, 73% (24/33) give steroids based on the air leak test.

CONCLUSIONS

The majority of surveyed pediatric critical care fellowship program directors rely on the air leak test and use corticosteroids to prevent post-extubation stridor and extubation failure. At an air leak of >or= 30 cm H(2)O most of the surveyed physicians would delay extubation and initiate glucocorticosteroids.

Management of common voice problems: Committee report

OBJECTIVE

This report provides the reader with a state-of-the-art update on a number of common voice problems that require phonosurgical intervention.

STUDY DESIGN AND SETTING

This multiauthor review is not a position statement of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) and may reflect institutional preference and/or bias. It arose from a panel discussion at the AAOHNS meeting in 2000.

RESULTS

We provide a review of the genesis and management of papillomatosis, dysplastic glottal epithelium, arytenoid granulomas, Reinke's edema, and vocal-fold paralysis.

CONCLUSIONS AND SIGNIFICANCE

In the past decade, there has been a dramatic expansion of knowledge regarding a variety of voice disorders and associated treatment. There has been a convergence of basic science investigations in anatomy, physiology, and pathology with clinical trials of treatment, both surgical and nonsurgical. This information should provide the reader with current insight into critical management issues of the aforementioned disorders.

[A case of long-term respiratory management following resection of a huge facial hemangioma]

A 49 year-old-woman was scheduled for resection of a huge hemangioma of the face and neck region. After the resection, severe edema developed on the tongue, larynx, and pharynx even leaving no space between the tracheal tube and these tissues. Prolonged respiratory management with endotracheal tube intubation was needed to maintain the upper airway for more than three weeks. Tracheostomy was performed 27 days after the operation. Two weeks later, the edema of the upper airway subsided. Thereafter her clinical course was uneventful, and she was discharged 22 days after the tracheostomy. Resection of a huge facial and neck hemangioma should be carefully managed as it can be followed by unexpected severe postoperative upper airway edema leading to suffocation.

Laryngeal oedema caused by accidental ingestion of Oil of Wintergreen

Oil of Wintergreen (methyl salicylate) is a common ingredient for liniments, ointments and essential oils used in self-treatment of musculoskeletal pain. Its pleasant smell also encourages its use to flavour confectionery. The toxic potential of this preparation is not always fully appreciated by the general public and physicians. To appreciate the danger of this oil it can be compared to aspirin tablets (325 mg dose): one teaspoon (5 ml) of Oil of Wintergreen is equivalent to approximately 7000 mg of salicylate or 21.7 adult aspirin tablets. Ingestion of as little as 4 ml in a child can be fatal. Prevention of accidental ingestion of methyl salicylate containing products can be achieved by keeping the products out of reach of children, using child resistant bottles, restricting the size of the openings of the bottles, appropriate labeling on products and reducing the salicylate content. Immediate action should be taken to treat a patient with accidental poisoning and hospitalisation is needed for monitoring and treatment. The danger of this product should be fully appreciated by both physicians and the general public. We present a case of Oil of Wintergreen poisoning with development of laryngeal oedema as a complication, general information and management issues will also be discussed.

Postextubation laryngeal edema: a review with consideration for home discharge

Respiratory complications occurring in the immediate postoperative period are well known to the seasoned postanesthesia care unit nurse. The most common adverse respiratory events originating in this setting are airway obstruction, hypoventilation, hypoxemia, and pulmonary aspiration of gastric contents. The focus of this article details airway compromise secondary to edema of the larynx and adjacent structures as a consequence of translaryngeal intubation. Postextubation laryngeal edema is a relatively rare problem; however, severe episodes may have life-threatening ramifications. A review of pertinent airway anatomy and airflow dynamics as they relate to this compromised airway condition is presented. Risk factors for the development of postextubation laryngeal edema plus contemporary patient treatment strategies will be reinforced. Patient management issues are addressed, with emphasis placed on the ambulatory patient in which discharge to a remote location is anticipated.

Angioedema and swellings of the orofacial region

OBJECTIVE

Patients may have various forms of angioedema and require dental treatment which can cause or contribute to the onset of an episode of angioedema. This paper seeks to highlight the causes and the management of this serious condition.

DESIGN

An outline of the different types of angioedema is given here, along with three case reports which illustrate treatment and management.

SUBJECTS AND METHODS

Three patients who presented to an Oral Medicine clinic with angioedema are presented to illustrate various types of angioedema and the different contributing factors that precipitated episodes of the condition.

MAIN OUTCOME MEASURES

The three patients were all investigated for biochemical and allergic factors which may have caused their disease.

RESULTS

Both drugs and dental materials were shown to be involved in the pathogenesis of angioedema in this short series of patients.

CONCLUSIONS

Dental treatment or the use of some materials may promote or contribute to the disorder. Referral to hospital for specialist care is indicated for certain groups of patients who require invasive dental treatment. The multi-disciplinary team approach in the investigation and management of patients with angioedema is emphasised.

Continuous positive airway pressure is effective in treating upper airway oedema

The case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) and upper airway oedema, is described. The patient presented with alveolar hypoventilation and obstructive apnoeas during sleep. Intravenous steroids (methylprednisolone, 160 mg.day-1) for 5 days did not reduce the oedema. However, it was rapidly reversed by the use of nasal continuous positive airway pressure (nCPAP). In addition, daytime pulmonary gas exchange was improved and sleep apnoea abolished. This beneficial effect made tracheostomy unnecessary. This case report suggests that CPAP can be a potentially useful therapeutic alternative to tracheostomy in the clinical management of upper airway oedema.

[Severe oropharyngeal angioedema caused by ACE inhibitor. A case report]

Inhibitors of angiotensin converting enzyme (ACE) are suspected of inducing angioedemas in up to 0.2% of all patients. These angioedemas are mainly localized in the upper airways and therefore can cause severe airway obstruction and even death due to suffocation. We report the case of a 64-year-old man, who underwent emergency tracheotomy because of severe angioedema of the larynx, which was refractory to pharmacological treatment. We conclude that patients with ACE inhibitor-induced angioedemas should be observed by monitoring in an intensive care unit to ensure the possibility of early intubation, because conventional antiallergic-antiedematous therapy by histamine-receptor antagonists and corticosteroids is an insufficient, unreliable form of therapy in severe cases. Especially otolaryngologists should know about this uncommon potentially life-threatening side-effect of ACE inhibitors.

Acute laryngeal oedema following carotid endarterectomy

Two cases of acute laryngeal oedema are reported following carotid endarterectomy. Although the mechanisms of development of oedema differ in each case they both illustrate a potentially lethal complication of any form of neck surgery. The requirement for careful haemostasis and airway observation of patients for the first 24 hour after neck surgery is emphasised.

[Suffocation attack]

An acute attack of suffocation is a life threatening event which may be fatal within minutes. Since the oxygen stores of the body are small, any interruption of oxygen uptake by the lungs results in immediate anoxia of tissue and in particular in perilous cerebral anoxia. The primary aims in the management of this emergency situation are: (1.) opening of the airways, clearing any obstruction, and keeping airways open; (2.) administration of oxygen and, if possible, assisted ventilation. This "reflex management" will gain time for diagnostic evaluation, for the decision about further management and, in most cases, for safe transport to the nearest emergency hospital. Further emergency measures are required in the case of upper airway obstruction due either to a foreign body or to laryngeal edema caused by local insect stings or anaphylaxis. Occasionally a foreign body obstructing the upper airways can be cleared using the Heimlich maneuver, i.e. rapid inward and upward pressure on the victim's epigastrium. Mild forms of laryngeal edema can be relieved by inhalation of epinephrine. If these methods fail, cricothyroidotomy or transtracheal ventilation must be performed. Patients with acute severe asthma must be immediately treated with inhalations of a beta-agonist, parenteral prednisolone and administration of oxygen, while emergency transport to the nearest hospital must be organized. To ensure first aid the emergency physician must be equipped with the necessary instruments such as a small oxygen cylinder, appropriate cannula with connectors and tubings for transtracheal ventilation, and a suitable bag-valve-mask device.

Smoking cessation in chronic Reinke's oedema

In evaluating the long term results of surgical treatment of Reinke's oedema, there has been found to be a high incidence of recurrence. The recurrence rate is significantly lower amongst those patients who gave up smoking after treatment. A group of patients with chronic Reinke's oedema were followed for six months. Maximum efforts were made to help the patients to stop smoking. Twenty-nine patients entered the study, but only eight of them (28 per cent) refrained from smoking; all were women (39-70 years) and all experienced reduced discomfort, although none of the voices were restored to normal. Diffuse laryngitis disappeared completely, but the oedema did not disappear entirely in any patient. Before treatment of chronic Reinke's oedema patients must be well advised and informed, and if surgery is decided upon, they must be urged most strongly to stop smoking, if they wish to enhance the possibility of satisfactory long-term results.

Medical management of organic laryngeal disorders

Medical management of organic laryngeal disorders always involves evaluation and advice; it frequently includes reassurance and sometimes voice therapy. Occasionally medication is also necessary.

Laryngeal edema as a complication of chemical peel

Laryngeal edema is a rare complication in patients undergoing chemical face peels. Symptoms of stridor, hoarseness, and tachypnea developed within 24 hours after peeling and subsided within another 24 hours after inhalation therapy with heated aerosol mist was begun. All patients who developed this complication were heavy smokers. A possible mechanism by which this complication was produced is discussed and experience with a drug regimen to prevent its occurrence is presented.

[Otorhinolaryngologic emergencies in practice]

In practice, the most serious emergency cases may result from shortness of breath and bleeding. Some typical diseases such as subglottal laryngitis in small children and the edema of the larynx entrance are described in greater detail and emergency measures are discussed. Special attention is drawn to the aspiration of foreign bodies and the complications connected with the desensitization of allergy patients. The dominating role of cortisone, the provision of drugs for shock treatment, and possible emergency steps are discussed. A further subject is bleeding disorders in the field of otolaryngology; above all the treatment of epistaxis is discussed in greater detail. Reference is made to the various local emergency measures which in practice may become inevitable. In this context the limits of therapy outside the hospital are listed.

The significance of laryngeal edema following radiotherapy of carcinoma of the vocal cord

Laryngeal edema persisting for more than three months following radiotherapy developed in 38 of 247 (15.4%) patients irradiated for carcinoma of the vocal cord. In 17 (44.7%) of these patients, the laryngeal edema was associated with persistent or recurrent disease, although only 25.4% of the patients with uncontrolled disease had laryngeal edema. The incidence of laryngeal edema was 13.1% for T1 disease, 23.8% for T2, and 21.4% for T3 and T4 disease. It increased significantly with increase of minimum tumor dose greater than or equal to 7000 rads or with NSD greater than 1900 ret, being 46.2% with minimum tumor dose greater than or equal to 7000 rad and 13.7% with minimum tumor dose less than 7000 rad and 43% with NSD greater than 1900 ret and 17% with NSD less than or equal to 1900 ret. It also increased with increase of field size, being 13.4% with field sizes less than 6.0 x 6.0 cm2, and 24.4% with field sizes greater than or equal to 6.0 x 6.0 cm2. When laryngeal edema is progressive and unresponsive to conservative measures, multiple biopsies should be performed to establish the presence of persistent or recurrent disease before salvage surgery is attempted. However, if it is mild, stable, no visible recurrence develops, and especially if it is limited to the arytenoids, no biopsy should be attempted because of the risk of inducing laryngeal necrosis.

Laryngoscopy in space travel

The need for laryngoscopy aboard a spacecraft on a mission of one to three years is anticipated. Therefore, the inexperience of the potential endoscopists and the problems they face in the free-floating environment of space are considered. A simplified coaxial intubation technique employing a split-apart modification of a Jako-type laryngoscope is suggested.