An Extubation Protocol for Angioedema.

Angioedema-nonpitting edema of the mucous membranes and skin-most commonly occurs as a complication from the use of angiotensin-converting enzyme inhibitors. At our institution, the otolaryngology department has incorporated the use of the endotracheal tube cuff-leak test and bedside direct laryngoscopy to aid in timing for extubation of angioedema patients. Prospective data collection of patients presenting to the emergency department with angioedema was performed. Of 76 patients with angioedema, 9 required fiberoptic intubation. Intubation was performed at a median of 73 hours (range, 44-118). An endotracheal tube cuff-leak test was performed in 7 patients prior to extubation, and bedside direct laryngoscopy was also performed in 3 of these 7 patients to document resolution of laryngeal edema. The use of the endotracheal tube cuff-leak test and bedside direct laryngoscopy is an easy and inexpensive method to help determine eligibility for extubation in patients intubated for angioedema.

The subalar graft and its role in nasal tip medialization and improved nostril symmetry.

OBJECTIVES: Relationships between nasal axis deviation and lower midfacial asymmetry or hypoplasia have been established in prior studies. We describe our experience with the subalar grafting technique in addressing nasal tip deviation associated with facial asymmetry. Indications in using this graft in isolation or in conjunction with other tip modification techniques are also investigated. STUDY DESIGN: Retrospective case series. SETTING: Academic medical center. SUBJECTS AND METHODS: Thirty-seven consecutive patients from a single surgeon (R.W.W.) treated using subalar grafting are evaluated for correction. Various measurements from preoperative and postoperative photographs are analyzed to determine the effectiveness of this intervention. RESULTS: Statistically significant correlations between improvement in nasal axis and alar-facial angle on base view (AFAB) (P < .001) and between alar-facial angle on frontal view (AFAF) (P = .017) were observed. In addition, a significant correlation between AFAB improvement and AFAF normalization was observed (P < .001). The improved nostril symmetry was significantly correlated with base view correction and was not the result of general improvements in nasal deviation. CONCLUSION: While measuring the independent effects of subalar grafting is limited due to contaminant procedures, it can be recognized as a foundation rhinoplasty technique that, in conjunction with septoplasty, provides medialization of the tip in patients with facial asymmetry. Furthermore, aesthetic correction of nostril horizontal dystopia and/or nostril "show" is achieved with the proper application of this technique. This correction represents a unique intervention in rhinoplasty and should be considered a second indication for its use.

Association between otitis media and gastroesophageal reflux: a systematic review.

OBJECTIVE: To systematically review the association between otitis media and gastroesophageal/laryngopharyngeal reflux in children. DATA SOURCES: Cochrane library, MEDLINE (1966-September 2011), EMBASE (1974-September 2011), proceedings of International Symposia on Recent Advances in Otitis Media, and reference lists of relevant selected articles. REVIEW METHODS: Studies with planned data collection, in children with chronic otitis media with effusion/recurrent acute otitis media, assessing gastroesophageal/laryngopharyngeal reflux, pepsin/pepsinogen in middle ear, or antireflux therapy, were included. RESULTS: Of 242 initial studies, 15 met inclusion criteria. The authors found a mean prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion of 48.4% (range, 17.6%-64%) and in children with recurrent acute otitis media of 62.9% (range, 61.5%-64.3%). A mean prevalence of laryngopharyngeal reflux of 48.6% (range, 27.3%-70.6%) was found in children with otitis media. Mean pepsin/pepsinogen presence in otitis media was 85.3% (range, 60%-100%) and of enzymatic activity was 34.2% (range, 14.5%-73%). Two randomized trials could not find benefit after antireflux treatment for 3 months, with an absolute rate difference (95% confidence interval) of 0.23 (0.023-0.42) and 0.13 (-0.086 to 0.34), respectively. Reporting of adverse events was limited, or absent, in most studies. CONCLUSION: The prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion/recurrent acute otitis media may be higher than the overall prevalence for children. Presence of pepsin/pepsinogen in the middle ear could be related to physiologic reflux. A cause-effect relationship between pepsin/pepsinogen in the middle ear and otitis media is unclear. Antireflux therapy for otitis media cannot be endorsed based on existing research.

Angioedema: a review of 367 episodes presenting to three tertiary care hospitals.

OBJECTIVES: We evaluated the clinical characteristics of patients treated for angioedema, and determined the factors associated with the clinical course. METHODS: We performed a chart review of 367 episodes presenting from 1997 through 2008. RESULTS: The mean (+/-SD) age was 51.8 +/- 20.1 years; 65.7% of the episodes occurred in female patients; 62.4% of the episodes were in African American patients. The patients were on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for 49.1% of the episodes, and an inciting factor (diet change, minor trauma, or exposure to fumes) was present for 21.5%. We found that 75.7% of the episodes were type 1 angioedema, 5.7% were type 2, 1.4% were type 3, and 17.2% involved multiple sites; 58% of the episodes required admission. For 3.3% of the episodes, the patients were intubated, and in 0.3% of the episodes, the patients required a tracheostomy. Logistic regression identified non-African American race, allergies, alcohol use, use of ACE inhibitors or ARBs, multiple sites, and age as associated with the need for admission. Bivariate analysis identified age, multiple affected sites, stridor, hoarseness, dysphagia, and drooling as associated with intubation or tracheostomy. CONCLUSIONS: The novel findings of this study are lower rates of airway intervention than reported previously and the fact that multiple affected sites were associated with admission and intubation or tracheostomy, particularly when the edema involved the larynx or hypopharynx.