[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.

Transformed follicular lymphoma with laryngeal edema requiring tracheal intubation after tisagenlecleucel treatment: A case report.

RATIONALE: Cytokine release syndrome (CRS) is a common adverse event of chimeric antigen receptor T (CAR-T) cell therapy. CRS is generally a systemic inflammatory reaction, but in rare cases, it can occur in specific body areas and is referred to as "local CRS (L-CRS)." A case of laryngeal edema due to L-CRS that required tracheal intubation because of the lack of response to tocilizumab (TCZ) and dexamethasone (DEX) is reported. PATIENT CONCERNS: A 67-year-old woman with relapsed transformed follicular lymphoma was treated with CAR-T cell therapy. Although she had been given TCZ and DEX for CRS, neck swelling appeared on day 4 after infusion. DIAGNOSES: Laryngoscopy showed severe laryngeal edema, which was presumed to be due to L-CRS, since there were no other apparent triggers based on history, physical examination, and computed tomography. INTERVENTIONS: Tracheal intubation was performed because of the risk of upper airway obstruction. Ultimately, 4 doses of tocilizumab (8 mg/kg) and 6 doses of dexamethasone (10 mg/body) were required to improve the L-CRS. OUTCOMES: On day 7, laryngeal edema improved, and the patient could be extubated. LESSONS: The lessons from this case are, first, that CAR-T cell therapy may induce laryngeal edema in L-CRS. Second, TCZ alone may be ineffective in cervical L-CRS. Third, TCZ, as well as DEX, may be inadequate. In such cases, we should recognize L-CRS and manage it early because it may eventually progress to laryngeal edema that requires securing the airway.

Pediatric mumps with laryngeal edema.

Mumps virus infection primarily affects the salivary glands and may incur various complications. Laryngeal edema is such a rare complication that few adult cases have been reported. We report the first known pediatric patient with mumps with laryngeal edema. An 8-year-old boy developed dyspnea after a rapidly progressive swelling of his face and neck. Laryngoscopy revealed edematous changes in the supraglottic and subglottic regions, and computed tomography confirmed significant laryngeal edema in addition to swelling of the cervical soft tissue and the salivary glands. Laboratory findings revealed a high serum amylase level and confirmed the diagnosis of mumps. Intravenous steroid administration alleviated the dyspnea, although the patient required temporary tracheal intubation to maintain airway patency. He did not need tracheotomy and did not experience any other complications. Laryngeal edema must be regarded as a rare, potentially life-threatening complication of mumps. When mumps is diagnosed with significant swelling of the neck, an emergency airway should be established to prevent airway obstruction.

[Emergency treatment and management of anaphylaxis]. / Akuttherapie und Management der Anaphylaxie.

Anaphylaxis, the maximal manifestation of an immediate allergic reaction, is a life-threatening systemic reaction. The immediate therapy is chosen according to the clinical manifestations and new German guidelines are in preparation. Required measures include immediate removal of allergen, adequate positioning, assessment of severity and organ involvement and activation of emergency medical services. In anaphylaxis with primarily cardiovascular involvement, epinephrine is the treatment of choice and given together with volume substitution, oxygen, H(1)-antihistamines and corticosteroids. Obstruction of the airways is treated with intramuscular and inhaled epinephrine, or alternatively ß(2)-sympathicomimetics, and oxygen. Abdominal or cutaneous involvement, such as generalized urticaria, usually can be treated with intravenous H(1)-antihistamines, glucocorticoids and surveillance. In patients with anaphylaxis, the elicitor of the reaction has to be diagnosed by allergy testing. Patients with sustained risk for anaphylaxis should receive a self-medication kit and should be educated about behavioral patterns needed for prophylaxis and therapy of anaphylactic reactions. Patient educational intervention increases knowledge about anaphylaxis, and practical competence and thus, is a basis of a successful management of anaphylaxis.

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.

Pilot Study: Pneumatic Compression Garment Therapy for Postradiotherapy Laryngopharyngeal Edema.

OBJECTIVES: Pneumatic compression garment therapy (PCGT) has been established as treatment for postradiotherapy lymphedema, and its use in head and neck patients is becoming more common. Although effects on interstitial edema of the cervical soft tissues have been studied, effects on internal laryngopharyngeal edema, as well as associated symptoms of dysphagia and dysphonia, have yet to be published. METHODS: We surveyed 7 patients treated with radiation for head and neck cancer (HNC) who had also been prescribed PCGT for cervical lymphedema. Patients were asked about subjective experience with the device, and also administered the Eating Assessment Tool-10 (EAT-10) and Voice Handicap Index-10 (VHI-10) surveys regarding their symptoms after using PCGT. Laryngoscopy videos from these same periods were also reviewed and scored using a validated tool for assessing laryngopharyngeal edema. RESULTS: 85% of patients reported at least some improvement in dysphagia and dysphonia following PCGT. Average EAT-10 score after PCGT was 11.4 and average VHI-10 score after PCGT was 8.7. These compare more favorably to historical scores for the same questionnaires in similar patient populations. Laryngeal edema scores on endoscopic examination were not significantly different after at least 3 months of therapy (pre: 20.15, post: 20.21, P = .975); however, the utility of this result is limited by a low inter-rater reliability (Krippendorff α = .513). CONCLUSIONS: While we are unable to show any difference in objective assessment of laryngopharyngeal edema on endoscopic examination in this small pilot study, patients report substantial subjective improvement in postradiotherapy dysphagia and dysphonia following cervical PCGT that warrants more formal investigation.

Hereditary angioedema: a case of near fatal laryngeal swelling in a 41-year-old woman.

Hereditary angioedema (HAE) is characterized by nonpitting, nonpruritic subcutaneous, or submucosal edema that may be accompanied by a nonpruritic serpentine erythematous rash. The swelling in this autosomal dominantly inherited disorder is mediated by uncontrolled localized bradykinin production. The extremities, face, gastrointestinal tract, genitalia, larynx, and trunk are commonly involved. Nearly one-third of patients who are not treated may suffer asphyxiation from a laryngeal attack. HAE symptoms overlap with other conditions that cause swelling. An accurate diagnosis is therefore crucial when considering therapy. Recently approved treatments for HAE swelling attacks include C1 esterase inhibitor concentrate and ecallantide. This case describes a 41-year-old woman who was treated ineffectively for more than 20 years, was switched to an effective therapy, but suffered near fatal laryngeal edema due to a missed dose of the effective therapy. The case underscores the need for increased awareness of HAE among clinicians and the importance of good compliance to therapy among patients with HAE.

[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.

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.

Current status of the management of hereditary angioedema in China: a patient-based, cross-sectional survey.

BACKGROUND: Hereditary angioedema (HAE) is a rare, inherited disorder characterized by unpredictable and recurrent cutaneous and mucosal oedema. OBJECTIVES: This study aimed to identify the current status of HAE management in China. MATERIALS AND METHODS: An internet-based survey was sent to 129 patients with type 1 and 2 HAE diagnosed between 1983 and 2017; a total of 107 patients provided complete disease management information. RESULTS: The survey response rate was 82.9% (107 responders). Ten patients reported 18 fresh frozen plasma (FFP) transfusions for the main purpose of treating lethal laryngeal oedema. Two patients reported adverse events. Eighty-nine (83.2%) patients had taken danazol for long-term prophylaxis, and 74 (69.2%) were on long-term danazol prophylaxis. Among patients on long-term prophylaxis, 56 (75.7%) patients reported a decrease in their annual attack frequency after taking danazol. Twenty-five (33.8%) patients had an attack frequency of no more than once per year. The most common side effects were menstrual disorders, weight gain, osteoarticular pain, acne, and sebaceous hypersecretion. Patients with higher education levels, positive family histories, and laryngeal oedema attacks before medication tended to show better adherence. Patients maintaining high or medium adherence showed better control of laryngeal and gastrointestinal involvement than patients with low adherence. Four (3.7%) patients reported current or past use of tranexamic acid. CONCLUSION: Attenuated androgen and FFP transfusions remain the mainstay in China, where specifically targeted drugs are currently lacking. Maintaining good medication adherence should be recommended to achieve improved disease control.

Acute laryngeal and bronchial obstruction after CS (o-chlorobenzylidenemalononitrile) gas inhalation.

CS gas (o-chlorobenzylidenemalononitrile) is one of the most commonly used riot agents. It can create excessive tearing, conjunctivitis, uncontrolled blinking (blepharospasm) and a sensation of burning and pain at initial exposure. Pulmonary edema (ARDS) and/or diffuse airway lesions on human would be lethal after CS inhalation. We report a case with acute laryngeal and bronchial obstruction due to vocal cord edema and extensive crusting at glottic level, trachea and bronchi. The CS gas was sprayed in a 6 x 6 m(2) closed room, and she was exposed to increased concentration of the gas for 10 s. Surprisingly, her initial symptoms were raised 21 days after CS spray exposure.

Immediate postoperative airway obstruction secondary to airway edema following tumor excision from the neck.

A 46-year-old woman was scheduled for excision of a malignant peripheral nerve sheath tumor from the neck. The tumor had caused deviation of the trachea to the left and partial obstruction of the superior vena cava. Her upper airway at laryngoscopy after induction of anesthesia was normal. During tumor resection there were transient phases characterized by the complete disappearance of the peripheral oxygen saturation (Sp(O2)) and radial artery tracings. At the end of the operation, the trachea was extubated after ensuring adequate antagonization of neuromuscular blockade. However, immediately post-extubation, she showed signs of acute airway obstruction that necessitated reintubation of the trachea. Laryngoscopy revealed significant edema of the upper airway and vocal cords, requiring a smaller size tracheal tube. Many reports suggest the development of significant airway edema 24 h after such surgery. Our report highlights the fact that this can happen in the immediate postoperative period also. Some authors suggest that, in such surgery, extubation should routinely be done over pediatric tube exchangers. Routine leak testing and direct laryngoscopic/fiberoptic evaluation of the upper airway prior to extubation may also help. While our report reaffirms these points, it also stresses the importance of intraoperative monitoring for the compression of the great vessels, which may serve as a useful indicator of the early development of airway edema.

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.

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.

Emergency percutaneous transtracheal jet ventilation in a hypoxic cardiopulmonary resuscitation setting: a life-saving rescue technique.

(Un)anticipated difficult airway remains a challenge in anaesthesia. Percutaneous transtracheal jet ventilation has been shown to be an adequate technique for temporary oxygenation and ventilation and has been described as an acknowledged method in emergency settings of an unanticipated difficult airway. These emergency settings can be considered as low incidence high-risk situations. Both technical and non-technical skills should be trained regularly as education and simulation continues to play an important factor in patient safety. Furthermore, postoperative laryngeal oedema due to altered lymphatic drainage patterns must be considered as a possible mechanism of an upper airway obstruction in combination with a history of neck dissection and radiotherapy.

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.