Effects of postnatal environmental tobacco smoke on non-nutritive swallowing-breathing coordination in newborn lambs

While prenatal environmental tobacco smoke (ETS) exposure is a well-known risk factor for sudden infant death syndrome, the effect of postnatal ETS exposure is less clear. The objective of this study was to investigate the effect of postnatal ETS exposure on non-nutritive swallowing (NNS) and NNS-breathing coordination, which are crucial to prevent aspiration related-cardiorespiratory events. Eighteen newborn lambs (6 per group) were randomly exposed to either 10 cigarettes/day, 20 cigarettes/day or room air for 15 days. Lambs were instrumented for recording states of alertness, swallowing, electrocardiogram and breathing; recordings were performed in non-sedated lambs at the end of ETS exposure. Urinary cotinine/creatinine ratio confirmed relevant real-life exposure. Postnatal ETS exposure had no effect on NNS frequency but tended to decrease inspiratory NNS (p=0.07) during quiet sleep. No effect on respiratory or heart rate (p>0.6), apnea index (p=0.2) or sleep states (p=0.3) was observed. In conclusion, postnatal ETS exposure in lambs had only mild effects on NNS-breathing coordination.

Methyl methacrylate and respiratory sensitization: a critical review

Methyl methacrylate (MMA) is a respiratory irritant and dermal sensitizer that has been associated with occupational asthma in a small number of case reports. Those reports have raised concern that it might be a respiratory sensitizer. To better understand that possibility, we reviewed the in silico, in chemico, in vitro, and in vivo toxicology literature, and also epidemiologic and occupational medicine reports related to the respiratory effects of MMA. Numerous in silico and in chemico studies indicate that MMA is unlikely to be a respiratory sensitizer. The few in vitro studies suggest that MMA has generally weak effects. In vivo studies have documented contact skin sensitization, nonspecific cytotoxicity, and weakly positive responses on local lymph node assay; guinea pig and mouse inhalation sensitization tests have not been performed. Cohort and cross-sectional worker studies reported irritation of eyes, nose, and upper respiratory tract associated with short-term peaks exposures, but little evidence for respiratory sensitization or asthma. Nineteen case reports described asthma, laryngitis, or hypersensitivity pneumonitis in MMA-exposed workers; however, exposures were either not well described or involved mixtures containing more reactive respiratory sensitizers and irritants. The weight of evidence, both experimental and observational, argues that MMA is not a respiratory sensitizer.

Severe laryngitis following chronic anabolic steroid abuse

The effects of anabolic steroids on the quality of voice have been well documented; however, no study has established significant structural changes in the larynx as a direct result of anabolic steroid use. We report a unique case of a 47-year-old male smoker and professional body builder who presented with progressive stridor and hoarseness following abuse of anabolic steroids over a period of two years. Conservative management failed to resolve his symptoms and a planned tracheostomy was performed to secure his airway. Subsequently he was treated with multiple laser resections and eventually decannulated. No case of severe laryngitis in association with anabolic steroid usage has been reported previously in the literature.

Alendronate-induced chemical laryngitis

Alendronate is a bisphosphonate used in treating osteoporosis. Its recognized side-effects include oesophageal irritation and ulceration. The authors describe a case of laryngitis induced by transient contact of this medication with the laryngeal mucosa. Successful management of this case is also detailed.

[Chronic hyperplastic laryngitis following treatment of hypertension with angiotensin converting enzyme-inhibitor]

We report the case of a 42 year old patient who developed chronic hyperplastic laryngitis during treatment with the angiotensin converting enzyme-inhibitor Cibacen 10. A severe cough and vocal restrictions with hoarseness were only incompletely cured after changing this anti-hypertensive medication to a adrenergic blocker, combined with a vocal rest and anti-inflammatory inhalation. Therefore we performed a laryngoscopy under general anesthesia and excised the swelling of the vocal cords. Additionally, voice therapy was prescribed and complete restitution achieved. Although hoarseness is documented as a potential side effect of angiotensin converting enzyme-inhibitors, morphological alterations in the vocal cords have not been linked to this type of drug. In our case, prolonged medication with Cibacen 10 led to chronic hyperplastic laryngitis. Initial coughing might have induced the trauma of the epithelium of the vocal cords. Due to the morphological alterations to the vocal cords the patient developed additional functional dysphonia.

Eucalyptus as a specific irritant causing vocal cord dysfunction

BACKGROUND

Vocal cord dysfunction (VCD) is a well-recognized clinical entity that frequently mimics asthma and is characterized by inappropriate adduction of the vocal cords during inspiration. The pathogenesis of VCD has not yet been defined. The only previous report suggested that respiratory irritants may trigger paradoxical motion of the vocal cords.

OBJECTIVE

To report the case of a 46-year-old woman with VCD precipitated by eucalyptus exposure.

METHODS

A masked flexible fiberoptic nasolaryngoscopy was performed to confirm whether VCD occurred with eucalyptus and not with other known respiratory irritants. The patient underwent inhalation challenges consisting of water, ammonia, pine oil, and a combination of eucalyptus (dried leaves) and ammonia. Two independent observers before patient challenge could not identify eucalyptus.

RESULTS

Vocal cord dysfunction occurred within minutes of exposure to eucalyptus. This is the first report to prospectively document that a specific irritant, eucalyptus, can precipitate VCD. Negative skin prick test results, total IgE level, and negative IgE eucalyptus-specific antibodies support a nonimmunologic mechanism.

CONCLUSIONS

A new pathogenic mechanism for this clinical entity is supported by our observations. Furthermore, a nonimmunologic mechanism in which respiratory irritants may induce VCD is suspected. Future studies to elucidate this mechanism need to be performed in individuals with irritant-specific VCD.

Laryngeal findings in users of combination corticosteroid and bronchodilator therapy

EDUCATIONAL OBJECTIVE

At the conclusion of this article, the readers should be able to 1) describe the laryngeal findings in patients who use combination therapy for asthma, 2) discuss the mechanism of laryngeal irritation from the use of inhalers, and 3) describe possible mechanisms for reducing laryngeal irritation and secondary dysphonia from the use of inhalers.

OBJECTIVES

To describe voice changes and laryngeal findings in patients who are started on combination corticosteroid and bronchodilator therapy in the form of a dry powder inhaler (DPI).

STUDY DESIGN

Retrospective, single-subject design.

METHODS

Retrospective review of 10 consecutive patients meeting inclusion criteria, who presented at the voice center with more than 4 weeks of dysphonia after being started on a combination form of asthma medication for control and maintenance therapy. All patients were nonsmokers and without history of previous identification or excision of vocal pathology. All patients were treated previously with a proton pump inhibitor for gastroesophageal reflux. Laryngeal videostroboscopic evaluations were performed on all patients. Patients were asked to complete a questionnaire regarding their perceived voice change and history of medical maintenance therapy for asthma.

RESULTS

Dysphonia was present in the patients selected for greater than 4 weeks. Patients had been switched to combination therapy after previously using traditional two-drug asthma regimens. In eight of nine patients, the vocal folds demonstrated areas of hyperemia, with plaque-like changes on the surface mucosa. Reduced amplitude of vibration and a reduction in mucosal wave propagation were present on videostroboscopy. Questionnaires revealed that all patients were initiated on combination DPI treatment within the last 6 months.

CONCLUSIONS

Dysphonia caused by a change in the surface mucosa is a side effect from the use of DPI therapy for asthma. The high-impact force during inhalation of the medication and carrier leads to deposition of particles in the upper airway. We believe the extent of mucosal irritation can be minimized by patient education in the proper delivery of DPI. In some cases, however, return of the two medications delivered separately was necessary. The irritation of the laryngeal mucosa and return of normal vibratory parameters occurred in all patients.

The local side effects of inhaled corticosteroids: current understanding and review of the literature

The frequent use of inhaled corticosteroids (ICSs), especially at higher doses, has been accompanied by concern about both systemic and local side effects. The systemic complications of ICSs have been extensively studied and are well-documented in the literature. There are comparatively few studies reporting on the local complications of ICSs. Compared with systemic side effects, the local side effects of ICSs are considered to constitute infrequent and minor problems. However, while not usually serious, these local side effects are of clinical importance. They may hamper compliance with therapy and the symptoms produced may mimic more sinister pathology. This review considers the prevalence of local side effects, their clinical features, the potential causes, the role of inhaler devices, and current measures that have been suggested to avoid the problem.

Activated charcoal laryngitis in an intubated patient

Activated charcoal is useful in the management of poisonings, but it is not harmless. We report the case of a patient who developed obstructive laryngitis secondary to aspiration of activated charcoal with a protected airway.

CASE

A 2-year-old girl presented acute mental alteration secondary to presumed poisoning. Mechanical ventilation was initiated, and a single dose of activated charcoal was administered. She had an episode of vomiting during the respiratory weaning. Black-tinted tracheal secretions were suctioned through the tube immediately. Pulmonary auscultation and radiologic examination were normal. When she was extubed, she developed obstructive laryngitis. Fiberbronchoscopy was performed and showed edema and a significant amount of charcoal particles on the epiglottis, arytenoids, and arytenoepiglottic folds. Charcoal particles were removed by bronchoscopy successfully. Later evolution was normal, and no symptoms were present when she was discharged at home.

COMMENTS

Obstructive laryngitis is a new major complication of activated charcoals use in upper airway. It is remarkable that this complication occurred in a protected airway. Charcoal is not an innocuous agent. This case shows that nasogastric administration of activated charcoals presents a significant degree of risk.

Steroid inhaler laryngitis: dysphonia caused by inhaled fluticasone therapy

OBJECTIVE

To describe a condition that is referred to as steroid inhaler laryngitis, a clinical entity that is caused by the use of inhaled fluticasone propionate and manifested by dysphonia, throat clearing, and fullness.

DESIGN

Case series.

SETTING

An outpatient clinic of an academic referral center.

PATIENTS

The study population consisted of 20 patients with reactive airway disease and dysphonia who were receiving inhaled fluticasone therapy and who were diagnosed as having steroid inhaler laryngitis during the period from January 1998 to June 2000.

INTERVENTION

Cessation of inhaled fluticasone therapy when possible, as well as treatment of other underlying causes of dysphonia, such as laryngopharyngeal reflux and infectious processes.

MAIN OUTCOME MEASURE

The resolution of dysphonia with cessation of inhaled fluticasone therapy.

RESULTS

Patients with steroid inhaler laryngitis were found to have laryngeal findings ranging from mucosal edema, erythema, and thickening to leukoplakia, granulation, and candidiasis. Patients with more severe mucosal findings were more likely to have laryngopharyngeal reflux as well. Resolution of dysphonia occurred only after discontinuation of the inhaled fluticasone therapy.

CONCLUSIONS

Steroid inhaler laryngitis is a form of chemical laryngopharyngitis induced by topical steroid administration. Symptoms and physical findings mimic laryngopharyngeal reflux, but only respond completely to discontinuation of the inhaled steroid therapy. The otolaryngologist should be familiar with this cause of dysphonia.

[Comparison of iodixanol (Visipaque) and ioxaglate (Hexabrix) in coronary angiography and ventriculography: a double-blind randomized study]

OBJECTIVE

To evaluate and compare in a double-blinded and prospective study the incidence of adverse reactions between two contrast agents used for coronary angiography and ventriculography. The first agent was the non-ionic, dimeric, isotonic contrast medium iodixanol (Visipaque), the other was the ionic dimeric contrast medium ioxaglate (Hexabrix).

METHODS

A total of 110 consecutive patients were randomized and received either iodixanol 320 mgl/ml or ioxaglate 320 mgl/ml. The efficacy, safety, tolerability and specific cardiovascular effects were evaluated. Adverse reactions were recorded during the procedure and during the first 24 hours after the examination. Hemodynamic and electrophysiological parameters were recorded before and after the ventricular injection and the first injections into the left and right coronary artery, respectively.

RESULTS

The incidence of clinical adverse reactions was significantly different between iodixanol and ioxaglate (3% vs 28%, p = 0.0004). 24 patients (16 iodixanol; 8 ioxaglate) experienced no discomfort (sensation of warmth, coldness or pain), and the intensity of discomfort experienced by the remainder was similar for the two groups. No patient reported pain. During the 3 minutes after injection of contrast medium, the LV end-diastolic pressure increased but, apart from one reading, the increases with iodixanol were always significantly different (p < 0.05), and less than those for ioxaglate. During the same time period, heart rate was increased to a greater extent by ioxaglate (p < 0.05). QT interval was significantly (p < 0.05) prolonged with both ioxaglate and iodixanol, but the changes were less marked after iodixanol. The angiographic studies were of diagnostic quality for all patients and optimal diagnostic information was achieved in 92% of both groups.

CONCLUSION

This randomized study shows that iodixanol and ioxaglate are of comparable diagnostic efficacy in coronary angiography and ventriculography, but that iodixanol is better tolerated by patients and results in less marked hemodynamic and eletrophysiological changes than does ioxaglate.

Occupational laryngitis caused by formaldehyde: a case report

Formaldehyde is commonly accepted to be an allergen and irritant. However, specifically diagnosed occupational respiratory diseases caused by formaldehyde are relatively rare. Occupational laryngitis was diagnosed in a 47-year-old dairy foreman. He had been exposed for 9 years to formaldehyde emitted from a milk-packing machine situated underneath his office. His exposure level varied considerably. Under normal process conditions, the measured formaldehyde level was 0.03 mg/m3. The patient was examined by different specialists over 1 1/2 years. It was concluded that he had psychogenic dysphonia. However, a specific laryngeal provocation test with formaldehyde carried out at the Finnish Institute of Occupational Health was positive. His laryngitis was so serious that he was pensioned. During the 3 years of follow-up his condition gradually worsened. He now reacts especially to tobacco smoke and other air impurities known to contain formaldehyde.

Radiation recall supraglottitis. A hazard in head and neck chemotherapy

The enhanced effects of chemotherapy on previously irradiated tissue have been well demonstrated. When chemotherapy is given some time after irradiation and elicits a tissue reaction in the radiation field, the reaction is termed radiation recall. We review known interactions between chemotherapy and radiotherapy and report, to our knowledge, the first case of a supraglottitis radiation recall reaction. Familiarity with this phenomenon and potential complications of chemotherapy following head and neck irradiation may expedite early diagnosis and appropriate lifesaving treatment.

Hydralazine-induced relapsing polychondritis-like syndrome. Report of a case with severe chronic laryngeal complications

Relapsing polychondritis is a rare disease of uncertain etiology, characterized by inflammation of cartilage. Cartilage of the respiratory tract is engaged in more than half of all cases. Hydralazine-induced systemic lupus erythematosis (SLE) is a well known disease. Females who are slow acetylators and are HLA-DR4 positive when treated with hydralazine are at serious risk of contracting SLE syndrome. We describe here a woman, treated for 10 years with hydralazine, who was a slow acetylator and was HLA-DR4 positive and who presented with a relapsing polychondritis and ultimately required a permanent tracheostoma. To our knowledge, this is the first published case of relapsing polychondritis induced by hydralazine.

Toxicity of aerosols of sodium reaction products

Sodium is used as the heat transfer medium in several new energy technologies such as liquid-metal fast-breeder reactors and solar-thermal collection systems. Because sodium burns in air and reacts violently with water, the potential exists for an airborne release of sodium combustion products and subsequent human exposure. To help evaluate the potential short-term hazard from an accidental sodium fire, male juvenile or adult Wistar rats were exposed to sodium aerosols for 2 hours to determine the dose at which 50 percent of the animals were affected (ED50) for each age group. The estimated ED50 of 510 microgram/l for adults was not significantly different from the estimated ED50 of 489 microgram/l for juveniles. The incidence of acute laryngitis, attributed to exposure, was three times higher for juvenile rats than for adults, and the degree of severity of this lesion was significantly (P less than 0.05) higher for juveniles.