Exploring the Pathophysiology of Reinke's Edema: The Cellular Impact of Cigarette Smoke and Vibration.

OBJECTIVES: To explore the isolated or combined effects of cigarette smoke extract (CSE) and vibration on human vocal fold fibroblasts (hVFF) in an in vitro setting in order to elucidate their influence in the pathophysiology of Reinke's edema (RE). STUDY DESIGN: Immortalized hVFF were exposed to CSE or control medium under static or vibrational conditions. A phonomimetic bioreactor was used to deliver vibrational patterns to hVFF over a period of 5 days. METHODS: Cytotoxicity was quantified using a lactate dehydrogenase assay. We employed reverse transcription-quantitative polymerase chain reaction, enzyme-linked immunosorbent assay, and Magnetic Luminex(R) assays (R&D Systems, Minneapolis, MN) to assess the influence on extracellular matrix production, fibrogenesis, inflammation, and angiogenesis. RESULTS: We observed significant changes induced by CSE alone (hyaluronic acid, matrix metalloproteinase 1, Interleukin-8, cyclooxygenase [COX]1, COX2, vascular endothelial growth factor [VEGF]D), as well as settings in which only the combination of CSE and vibration led to significant changes (transforming growth factor beta 1, VEGFA, VEGFC). Also, CSE-induced levels of COX2 were only significantly reduced when vibration was applied. CONCLUSION: We were able to explore the cellular effects of CSE and vibration on hVFF by employing a phonomimetic bioreactor. Whereas cigarette smoke is generally accepted as a risk factor for RE, the role of vibration remained unclear as it is difficult to study in humans. Our data showed that some genes and proteins in the pathophysiological context of RE were only affected when CSE in combination with vibration was applied. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E547-E554, 2021.

Pathogenic Role of Reinke's Edema in Snoring and Obstructive Sleep Apnea.

OBJECTIVE: To investigate the association between vocal fold Reinke's edema, snoring, and obstructive sleep apnea. DESIGN/METHODS: Twenty-five patients diagnosed with Reinke's edema and 25 patients with normal laryngeal examination, matched according to age, gender, and body mass index were recruited for this prospective study. Demographic data included age, gender, and body mass index. All patients filled the Berlin Questionnaire, STOP-BANG Sleep Apnea Questionnaire, and the Epworth Sleepiness Questionnaire. RESULTS: Out of 25 patients with Reinke's edema, 36% had Obstructive Sleep Apnea (OSA) as evidenced by having two or more positive categories in the Berlin Questionnaire. In the control group, only 4% had OSA.The difference between the two groups was statistically significant (P value = 0.005). With respect to Epworth Sleepiness Scale and the STOP-BANG Sleep Apnea Questionnaire (P value > 0.05), there was no statistically significant difference between the two groups. CONCLUSIONS: This investigation revealed higher prevalence of snoring and obstructive sleep apnea in patients with Reinke's edema as evidenced by the Berlin Questionnaire. The caring physician should be alert to symptoms of airway obstruction for possible early intervention.

Food-induced anaphylaxis in infancy compared to preschool age: A retrospective analysis.

OBJECTIVE: Little is known regarding food anaphylaxis in infancy. We aimed to describe specificities of food anaphylaxis in infants (≤12 months) as compared to preschool children (1-6 years). METHODS: We conducted a retrospective study of all food anaphylaxis cases recorded by the Allergy Vigilance Network from 2002 to 2018, in preschool children focusing on infants. RESULTS: Of 1951 food anaphylaxis reactions, 61 (3%) occurred in infants and 386 (20%) in preschool children. Two infants had two anaphylaxis reactions; thus, we analyzed data among 59 infants (male: 51%; mean age: 6 months [SD: 2.9]); 31% had a history of atopic dermatitis, 11% of previous food allergy. The main food allergens were cow's milk (59%), hen's egg (20%), wheat (7%) and peanut (3%) in infants as compared with peanut (27%) and cashew (23%) in preschool children. Anaphylaxis occurred in 28/61 (46%) cases at the first cow's milk intake after breastfeeding discontinuation. Clinical manifestations were mainly mucocutaneous (79%), gastrointestinal (49%), respiratory (48%) and cardiovascular (21%); 25% of infants received adrenaline. Hives, hypotension and neurologic symptoms were more likely to be reported in infants than in preschool children (P = .02; P = .004; P = .002, respectively). Antihistamines and corticosteroids were more often prescribed in preschool children than in infants (P = .005; P = .025, respectively). CONCLUSION: Our study found that in infants presenting with their first food allergy, in a setting with a high rate of infant formula use, the most predominant trigger was cow's milk. As compared to older preschool children, hives, hypotonia and hypotension were more likely to be reported in infants. We believe that this represents a distinct food anaphylaxis phenotype that can further support developing the clinical anaphylaxis criteria in infants.

Reinke's Edema.

Reinke's edema (RE) is the polypoid degeneration of one or both vocal folds within Reinke's space. The viscoelastic properties of the mucosal folds are characteristically altered by the expansion of the subepithelial space. Most frequently, patients present with dysphonia, with women being more affected than men. The primary risk factor is tobacco use. Voice overuse and laryngopharyngeal reflux are also considered to be contributory. Although RE shares the same primary risk factor as malignancy, the risk of malignancy is low, and dysplasia is found only in 0% to 3% of cases. Treatment is focused on decrease of risk factors, such as implementation of smoking cessation, voice therapy, and reflux control. Surgical techniques aim to decrease redundant polypoid mucosa in order to improve voice and restore the glottic airway. Recurrence of RE is high.

Cigarette Smoke Exposure to Pig Larynx in an Inhalation Chamber.

OBJECTIVES: This study investigated the effects of cigarette smoke exposure on the pig larynx using an inhalation chamber. Specifically, we compared the effects of cigarette smoke exposure from either 3 cigarettes per day (3cd) or 15 cigarettes per day (15cd) for 20 days. STUDY DESIGN: In vivo prospective design. METHODS: Female pigs were exposed via an inhalation chamber to cigarette smoke (3R4F research cigarettes) from 3cd (n = 6) or 15cd (n = 6) for 20 days. Outcomes included histopathology of vocal fold and airway tissues; gene expression of interleukins, TNF-α, and VEGF; protein levels of TNF-α and IL-6; and number of coughs recorded in the chamber. RESULTS: Pigs exposed to cigarette smoke from 15cd exhibited mild vocal fold edema as compared to the 3cd group on histopathological evaluation. There was also minimal inflammation of nasal and tracheal tissue characterized by presence of more granulocytes in the 15cd group compared to the 3cd group. Cough frequency was significantly greater for the 15cd group compared to the 3cd group. CONCLUSIONS: A custom-designed large animal inhalation chamber successfully challenged pigs repeatedly, to varying levels of cigarette smoke. Future studies will combine such low levels of smoke exposure with other common challenges such as acid reflux to understand the multifactorial causation of laryngeal pathologies.

Inhalational injury and the larynx: A review.

OBJECTIVE: To review and discuss the existing research on the pathophysiology, impact and management of inhalational injury on the larynx and lower respiratory tract. DATA SOURCES: A literature search was conducted on the PubMed, MedLine, Embase, Web of Science and Google Scholar databases based on the keywords "airway burn", "inhalational injury" and "larynx". REVIEW METHODS: Inclusion criteria included English language studies containing original and review data on airway injury. Data was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. CONCLUSIONS: Abnormal laryngeal and lower airway findings are common in burns patients and the incidence tends to increase with severity of the burns. Most patients with abnormal findings remain dysphonic decades after the initial injury. Larynx, the inlet to the airway, is exposed to the most intense thermal damage and highest concentration of chemical in inhalational injury. Airway injury is common and may result in long term morbidity. Healing of this tissue architecture is prolonged and different from cutaneous burn. Many patients receive prolonged intubation for medical complications that arise due to the burn injury. The degree of subglottic damage, however, is more extensive and occurs sooner compared with those without inhalational injuries. IMPLICATIONS FOR PRACTICE: With advances in acute medical and surgical management of burn and inhalational injury, airway injury is an important secondary outcome with lasting impact. Awareness of these potential complications and early involvement of medical and allied health team are important steps in improving patient care. A multi-disciplinary approach to management will optimise the short and long-term morbidity management and ultimately our patients' quality of life.

Evaluation of upper esophageal sphincter in benign vocal lesions.

PURPOSE: To evaluate upper esophageal sphincter (UES) activity in patients with benign glottic lesions. METHODS: Twenty-three patients with benign vocal fold (VF) lesions scheduled for manometric evaluation were enrolled as the study group (SG); 20 healthy subjects without vocal pathology or dysphagia were included as the control group (CG). UES residual, basal, relaxation time and peak pharyngeal pressures were evaluated by manometry. The reflux symptom index (RSI) and reflux finding score (RFS) were used to estimate the clinical findings of laryngopharyngeal reflux, and the voice handicap index (VHI) was measured in both groups. The patients' data were compared using the Mann-Whitney test and t test. RESULTS: The diagnoses in the SG were vocal nodules, vocal polyps, vocal cysts, sulcus vocalis, or Reinke's edema. The evaluation scores (RSI, RFS, and VHI) were significantly higher in the SG than in the CG (P < 0.05). UES basal and relaxation pressures, relaxation time, and peak pharyngeal pressures did not differ between the SG and the CG (P > 0.05). CONCLUSION: UES manometric pressure was similar in patients with VF mucosal lesions and controls. Studies involving larger populations are necessary to confirm the manometric changes in the UES and to elucidate the pathogenesis of benign VF lesions.

Permeability and Weibel-Palade Bodies of the Blood Vessels in the Human Vocal Fold Mucosa.

OBJECTIVES: Transendothelial exchange and permeability of the capillaries in Reinke space (the superficial layer of the lamina propria) of the vocal fold mucosa affect physiological and pathological conditions of the human vocal fold mucosa. The mechanism of permeability and Weibel-Palade bodies of the blood vessels in the human vocal fold mucosa were investigated using electron microscopy. STUDY DESIGN: Histologic analysis of the human vocal fold. METHODS: Six normal human vocal folds (three adults and three newborns) obtained from autopsy cases and three human vocal folds with Reinke edema from surgical specimens were investigated under transmission electron microscopy. RESULTS: There were three possible capillary wall transport systems related to the permeability of the blood vessels in the vocal fold mucosa: 1) Fenestra transport, plasma exuded from the capillaries into surrounding tissue via the fenestration with or without a diaphragm; 2) vesicular transport (transcellular transport via vesicles), the use of vesicles to ferry fluid and solutes across endothelial cells; and 3) junctional transport (intercellular transport), molecules passed through intercellular gaps between endothelial cells. Weibel-Palade bodies were present in the cytoplasm of endothelial cells both in adults and newborns. They were present in high numbers in the cytoplasm of endothelial cells, with intercellular transport in the vocal folds with Reinke edema. CONCLUSION: There were three types of mechanisms for the permeability of the blood vessels in the human vocal fold mucosa. Some physiologically active substances, such as histamine produced by Weibel-Palade bodies, may adversely influence the permeability of the blood vessels. LEVEL OF EVIDENCE: NA. Laryngoscope, 2588-2592, 2018.

[The clinical and functional condition of the larynx in the patients of the elder age group presenting with chronic oedematous polypoidal laryngitis]. / Kliniko-funktsional'noe sostoianie gortani u patsientov starshei vozrastnoi gruppy s khronicheskim otechno-polipoznym laringitom.

This article was designed to report the results of the evaluation of the clinical and functional condition of the larynx in the patients of the elder age group presenting with chronic oedematous polypoidal laryngitis before and after their surgical treatment. A total of 60 patients at the age from 60 to 72 years were available for the examination; all of them had a concomitant somatic or ENT pathology. The clinical and functional conditions of the larynx in the patients of the elder age group were studied, with special reference to those suffering from chronic oedematous polypoidal laryngitis before the surgical intervention, that determined the overall clinical picture of the disease characterized in the first place by the predominance of the severe polypoid process with the combination of the organic and functional laryngeal pathology. The specific clinical and functional features of the larynx were identified after the surgical treatment that exerted the appreciable influence on the postoperative course of the disease and the duration of dysphonia. The peculiarities of postoperative laryngitis are described. Its catarrhal form was diagnosed in 42% of the patients. The strong inflammatory reaction with exudation and formation of fibrin films was documented in 58% of the patients while 83% of them exhibited formation of the functional component of dysphonia that required the application of the additional therapeutic measures for the complete restoration of the vocal function taking into consideration the age-related alteration of the larynx together with the long-term postoperative observation of the patients.

Hyaluronidase Injection in the Vocal Folds for Vocal Hemorrhage, Reinke Edema, and Hyaluronic Acid Overinjection: A Novel Application in the Larynx.

Hyaluronidase (HAase) injection into the vocal folds is an off-label use of an enzyme for liquefaction of hyaluronic acid (HA). HAase injection was performed in 14 cases in 13 patients. Office and operative injections of HAase were performed. The indications were five cases of overinjection of HA, six cases of Reinke edema and polypoid corditis, and three cases of acute vocal hemorrhage with early fusiform polyp formation. All the patients tolerated the HAase without complications. Significant voice improvements were noted between pre- and postinjection procedures as evaluated by a self-rating of voice by the Voice Handicap Index-10. A marked decrement in the mass on the side of the injection of HAase was noted in all groups successfully injected upon viewing by videostroboscopy. HAase prevented an additional operative phonosurgery in 10 patients. In conclusion, HAase injection can be used in the vocal folds with good effect in patients. The indications are polypoid corditis with overproduction of HA, acute vocal hemorrhage, and correction of iatrogenic HA overinjection.

"Cold-Steel" Phonosurgery of Reinke Edema Evaluated by the Multidimensional Voice Program.

OBJECTIVES: "Cold-steel" phonosurgery (PS) of Reinke edema is challenging, as the delicate structures of the vocal folds are difficult to preserve. This study aimed to evaluate the results of PS using the Multidimensional Voice Program (MDVP) . MATERIALS AND METHODS: From 2003 to 2007, 76 consecutive patients with Reinke edema were treated with PS for the first time. Reliable MDVP data were available in 37 female patients with both pre- and postoperative values in 14 patients. Voice quality and outcome after PS were evaluated by jitter, shimmer, soft phonation index, and fundamental frequency (f0) using MDVP, videostroboscopy, and a five-step voice outcome score. RESULTS: In the 14 patients, the mean f0 increased from 172 to 222 (P = 0.01), and jitter decreased from 2.03 to 1.17 (P = 0.04) 3 months postoperatively. Vocal fold grading based on videostroboscopy correlated significantly with jitter (P = 0.01). Patients with high preoperative values of jitter, shimmer, or soft phonation index had larger reductions than those with normal values. All had a postoperative reduction of the edemas. The mean voice outcome score increased postoperatively. None of the 37 patients reported complications, but seven patients were reoperated. Preoperatively, 95% of the 37 patients were smokers and only 9 (24%) changed smoking habits. Pre- or postoperative voice therapy was used in 23 (62%) patients. CONCLUSIONS: f0 and jitter by MDVP adequately reflected the postoperative voice improvement and reduction of the edema. Removal of large amounts of edematous tissue, many years of vocal abuse, and unchanged smoking habits may prevent optimal results.

Edema de Reinke obstructivo / Obstructive Reinke edema

Introducción: el edema de Reinke es la acumulación de fluidos en la capa externa de la lámina propia de las cuerdas vocales. Produce disfonía y raras veces obstrucción respiratoria. Las etiologías más frecuentes son el tabaquismo, el reflujo gastroesofágico y el mal uso y abuso vocal. Objetivos: determinar, mediante tratamiento quirúrgico, la tasa de resolución de la disnea inspiratoria severa provocada por edema de Reinke bilateral de cuerdas vocales. Diseño: estudio descriptivo y retrospectivo. Material y métodos: revisión de las historias clínicas electrónicas de todos los pacientes que consultaron y fueron tratados por disnea inspiratoria severa provocada por edema de Reinke bilateral de las cuerdas vocales, en el servicio de Otorrinolaringología del Hospital Italiano de Buenos Aires, entre febrero de 2007 y abril de 2015. Resultados: fueron tratados 4 pacientes de sexo femenino que consultaron por disnea inspiratoria severa. Fumaban más de 30 cigarrillos por día. La técnica quirúrgica consistió en resecar todo el edema polipoideo en forma bilateral, preservando el borde libre de las cuerdas vocales. Conclusiones: el edema de Reinke obstructivo es una patología infrecuente. La tasa de resolución de la disnea inspiratoria severa en las cuatro enfermas tratadas fue del100%. La resección total del edema y de la mucosa excedente, preservando un pequeño sector para que recubra el borde libre de la cuerda vocal (cordectomía vs. cordotomía), fue la técnica quirúrgica preferida. (AU)

Introduction: the Reinke edema is an accumulation of fluid in the outer layer of the lamina propria of the vocal cords. Causes dysphonia and rarely produces respiratory obstruction. Objectives: to determine the rate of resolution of the severe inspiratory dyspnea caused by bilateral Reinke edema of vocal cords with surgical treatment. Design: descriptive and retrospective study. Material and methods: review of the electronic medical records of all patients who consulted and were treated for severe inspiratory dyspnea caused by bilateral Reinke edema of the vocal chords in the Hospital Italiano de Buenos Aires between February 2007 and April 2015. Results: four women were treated, consulted for severe inspiratory dyspnea. Smoked more than 30 cigarettes per day. The surgical technique consisted in to resect all the bilateral polypoid edema, while preserving the free edge of the vocal cords. Conclusions: the obstructive Reinke edema is an infrequent pathology. The rate of resolution of the severe inspiratory dyspnea in the four patients treated was 100%. The total resection of the edema and mucosa excess, preserving a small sector to cover the free edge of the vocal cord (cordectomy vs cordotomy) was the preferred surgical technique. (AU)

Vocal-fold vibration of patients with Reinke's edema observed using high-speed digital imaging.

OBJECTIVE: We aimed to assess the vocal-fold vibration of patients with moderate-to-severe Reinke's edema using high-speed digital imaging (HSDI) and videostroboscopy and to confirm HSDI usefulness in examining the vocal folds with Reinke's edema. METHODS: We examined the vocal folds of seven patients (six severe and one moderate; six females and one male; aged 55-74 years; mean 64.7 years) with Reinke's edema using HSDI and videostroboscopy. The following characteristics were analyzed: glottic closure, mucosal-wave propagation, left-right asymmetry, phase shift, frequency difference, periodicity, and contact of the true vocal fold with the false vocal fold. RESULTS: HSDI revealed complete glottic closure, anterior-posterior phase shift, and obvious contact of at least one side of the edematous true vocal fold with the ipsilateral false vocal fold in all patients. Mucosal-wave propagation increased in six patients and decreased in one. Left-right asymmetry was observed in six patients. Left-right phase shifts and left-right frequency differences were observed in four and two patients, respectively. The vibration was periodic in four patients, quasi-periodic in three, and aperiodic in none. Anterior-posterior frequency differences were not observed for any patient. The vocal-fold vibration always synchronized with strobolights in two patients, while the vibration occasionally and never synchronized in two and three patients, respectively. In one patient whose vibration occasionally synchronized, videostroboscopy could not reveal the slight left-right frequency difference of the vibration. CONCLUSION: It was often difficult to observe vocal-fold vibration correctly in patients with severe Reinke's edema using videostroboscopy. However, HSDI was useful for examining these patients. Our results suggest that HSDI can be very useful for examining the vocal folds of patients with severe Reinke's edema.

Normative Values and Interrelationship of MDVP Voice Analysis Parameters Before and After Endotracheal Intubation.

PURPOSE: The Multi-Dimensional Voice Program (MDVP) is used for assessment of voice quality. A simple procedure for MDVP recordings was used in a randomized clinical trial (RCT) on induced vocal fold trauma due to intubation. This secondary study compares the common MDVP parameters with other normative values for adults and investigates the correlation between these MDVP parameters in relation to the "standardized" trauma of endotracheal intubation. METHODS: Preoperative and postoperative assessments of vocal fold pathology with flexible videolaryngoscopy and voice analysis with MDVP using the best-of-three standardized recording were performed in 121 patients with normal voices included consecutively in the RCT. The procedures of anesthesia were standardized. RESULTS: The normative MDVP values of this study are consistently lower compared with most normative values presented in other studies. The preoperative to postoperative differences in jitter values (jitter and relative average perturbation) were closely correlated to the shimmer values for patients with postoperative vocal fold edemas. In the patients with edema, the preoperative to postoperative differences in jitter had a correlation coefficient of 0.95 (P < 0.0001) to the difference in shimmer, compared with a correlation coefficient of 0.39 (P < 0.0001) in the patients without edema. CONCLUSIONS: This study supports the use of the "Best-of-Three" procedures for precise and relevant MDVP parameter calculations. The MDVP parameters, with closely correlated changes in jitter and shimmer values, accurately reflect the induced vocal fold edema when using the preoperative to postoperative changes.

Laryngeal Side Effects of Tyrosine Kinase Inhibitors.

OBJECTIVES: Tyrosine kinase inhibitors (TKIs) are common targeted drugs, used in the treatment of hematological and solid malignancies. These drugs present a multitude of potential adverse effects. Laryngeal manifestations, including laryngeal edema, secondary to TKIs treatment have not been well studied, despite their potential lethality. METHODS: This cross-sectional study included adult patients (>18 years) treated with TKIs who were followed in a secondary medical center and underwent a voluntary otolaryngological examination, which included laryngeal fiber-optic laryngoscopy (FOL). FOL was independently performed by two senior otolaryngologists, and results were recorded and evaluated by two grading systems, to assess the degree of laryngeal edema. In addition, medical files were reviewed, and data collected included past medical history, signs and symptoms, physical examination, laboratory results, treatment type, and duration. RESULTS: Sixteen patients, aged 68.2 ± 13.6 years, were examined during October 2014 to December 2014. Of them, three (19%) were males. Eleven (68%) patients presented with varying degrees of laryngeal edema. A significant correlation was found between gastroesophageal reflux symptoms and laryngeal edema (P = 0.02). TKI treatment was stopped in one patient, because of symptomatic laryngeal edema, which completely resolved within 2 weeks. CONCLUSIONS: Laryngeal edema was common in our study group. This edema was most often not life threatening. Yet, because of the potential severity of this side effect, we propose a routine FOL examination of patients before commencing TKI treatment and a reevaluation performed during treatment.

Two rare cases of laryngeal intralymphatic histiocytosis.

We report two rare cases of intralymphatic histiocytosis causing, respectively, recurrent and persistent episodes of upper airway swelling and breathing difficulties. Case 1 was a 39-year-old man who was referred with recurrent upper airway swelling causing difficulty in breathing. A direct laryngoscopy was performed under general anesthesia due to minimal effect from treatment with antibiotics and anti-oedema medication. On examination, the larynx was found to be swollen and oedematous but not inflamed. Biopsies from the aryepiglottic folds showed intralymphatic histiocytosis. The patient was extensively examined but the only abnormal finding was a low CD4 count. The breathing difficulties fluctuated during the diagnostic process and settled after a year. Case 2 was a 35-year-old man who presented with persistent laryngeal swelling. Biopsies from the epiglottis showed intralymphatic histiocytosis. Extensive investigations were performed but discovered no abnormal findings. He received CO2 laser treatment twice and the swelling decreased. Intralymphatic histiocytosis is extremely rare in upper airway pathology. It is an important differential diagnosis in patients with recurrent and chronic laryngeal swelling and dyspnoea.

Analysis of Potassium Titanyl Phosphate Laser Settings and Voice Outcomes in the Treatment of Reinke's Edema.

OBJECTIVE: Despite increased clinical utility of the 532-nm potassium titanyl phosphate (KTP) laser, no studies have examined outcomes for Reinke's edema (RE) as a function of laser parameters and initial treatment effects. Variability in delivery parameters, fiber-to-tissue distance, and immediate end-tissue effects limits universal application of existing study outcomes. We examine voice outcomes using standardized treatment classification, providing justification for laser parameter selection and immediate tissue effect in clinical use. METHODS: Retrospective review of 9 patients who underwent KTP laser treatment for RE. Demographics, RE severity, laser settings, total laser energy, and immediate tissue effects were correlated with quantified voice outcomes. RESULTS: An average of 157 joules (6-640 J) was delivered over a 0.369-second exposure time (0.1-0.9 seconds). Immediate tissue effects varied from nonablative treatment (type I and type II) to ablation without tissue removal (type III). Overall, Voice Handicap Index-10 (VHI-10) decreased by 8.23; improvement was most pronounced with type II treatments (delta VHI-10=12). No complications were encountered. CONCLUSION: Potassium titanyl phosphate laser can be safely and effectively used to improve voice in RE patients regardless of severity. This is the first study to provide detailed information on laser settings, energy delivery, and treatment effect in RE management; these results may guide clinical use of this modality, especially for novice laser surgeons.

Angiotensin converting enzyme inhibitor-related angioedema: onset, presentation, and management.

OBJECTIVE: This study aimed to determine the duration of use, presentation, and management of angiotensin converting enzyme (ACE) inhibitor-related angioedema patients at an urban academic medical center. METHODS: Retrospective chart review. RESULTS: Eighty-eight patients who presented with ACE inhibitor-related angioedema between January 1, 2012, and December 31, 2012, were identified. They presented anywhere from 1 day to 20 years after starting an ACE inhibitor. About half the patients (50.7%) presented after taking an ACE inhibitor for at least 1 year. Fifty-five patients were female (62.5%). Twenty-eight patients (31.8%) had an airway intervention with 27 intubated and 1 requiring cricothyroidotomy. Six patients were intubated after more than 1 flexible laryngoscopy. The percentage of patients with involvement of the face, lips, tongue, floor of mouth, soft palate/uvula, and larynx were 12.5%, 60.2%, 39.7%, 6.8%, 17.0%, and 29.5%, respectively. Sixty-eight percent of patients with laryngeal edema were intubated. The majority of patients were treated with a corticosteroid and H1 and H2 receptor antagonists. CONCLUSION: Angioedema can occur at any time after starting ACE inhibitor use, with nearly half occurring after 1 year of use. Laryngeal involvement occurred in a minority of patients, but most of these patients were felt to require airway protection.

Permeability of canine vocal fold lamina propria.

OBJECTIVES/HYPOTHESIS: Determine the permeability of excised canine vocal fold lamina propria. STUDY DESIGN: Basic science. METHODS: Vocal folds were excised from canine larynges and mounted within a device to measure the flow of 0.9% saline through the tissue over time. The resultant fluid volume displaced over time was then used in a variation of Darcy's law to calculate the permeability of the tissue. Permeability was found through each anatomical plane of the vocal fold, with five samples per plane. Permeability was also found for lamina propria stretched to 10%, 20%, and 30% of its initial length to determine the effects of tensile strain on permeability, with five samples per level of strain. RESULTS: Permeability was found to be 1.40 × 10(-13) m(3) s/kg through the sagittal plane, 1.00 × 10(-13) m(3) s/kg through the coronal plane, and 4.02 × 10(-13) m(3) s/kg through the axial plane. It was significantly greater through the axial plane than both the sagittal (P = .025) and coronal (P = .009) planes. Permeability under strain through the sagittal plane was found to be 1.94 × 10(-13) m(3) s/kg under 10% strain, 3.35 × 10(-13) m(3) s/kg under 20% strain, and 4.80 × 10(-13) m(3) s/kg under 30% strain. The permeability significantly increased after 20% strain (P < .05). CONCLUSIONS: Permeability in canine vocal fold lamina propria was found to be increased along the anterior-posterior axis, following the length of the vocal folds. This may influence fluid distribution within the lamina propria during and after vibration. Similarly, permeability increased after 20% strain was imposed on the lamina propria, and may influence vocal fold dynamics during certain phonation tasks. LEVEL OF EVIDENCE: NA Laryngoscope, 125:941-945, 2015.

[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.