Iron Pill-Induced Chemical Laryngitis.

OBJECTIVE: To discuss the presentation and management of pill-induced chemical laryngitis by illustrating a rare case. METHODS: We report a unique case of a patient with iron pill-induced laryngitis. RESULTS: A 71-year-old male presented for evaluation of dysphonia. Five weeks prior, the patient had reportedly aspirated an iron pill. The pill was lodged in his throat for several hours before being coughed up, soft but still intact. Since that event, the patient noted complete voice loss and in clinic was found to have a very breathy and asthenic voice. Stroboscopy revealed aperiodicity with severe false fold compression and significant ulceration of the infraglottic region associated with thick exudate. Vocal folds were mobile but atrophic, with overlying crusted secretions. A sensory deficit was suspected based on scope tolerance. The patient was treated with nebulized ciprodex and humidified air with some improvement in mucosal crusting but had persistent glottic insufficiency and dysphonia, prompting bilateral hyaluronic acid injection. CONCLUSIONS: Pill-induced laryngitis is an extremely rare phenomenon. While typically associated with bisphosphonates, this condition should be considered in any patient presenting with dysphonia and history of aspiration of a pill, including iron supplements. Regardless of the inciting medication, pill-induced laryngitis may be treated with humidified air, nebulized steroids, and antibiotics. Injection augmentation of the vocal folds may be made considered when glottic insufficiency and weak cough contribute to the presentation.

The impact of iatrogenic glottic atresia due to photodynamic therapy for laryngeal cancer: A report of two cases.

Photodynamic therapy (PDT) is a minimally invasive therapy used in the treatment of premalignant and malignant diseases, including head and neck carcinomas. It can be applied before or after chemotherapy, irradiation, or surgery. Unlike irradiation and surgery, it can be repeated many times at the same site, and it is also associated with better cosmetic and functional outcomes [1]. We have treated 10 patients with laryngeal carcinomas with PDT since 1998, and herein we describe two such patients who developed vocal cord adhesion due to PDT. To our knowledge, there are no previous reports of patients with glottis atresia due to PDT, thus the cases reported herein are rare, and educationally valuable.

Inflammatory reaction to hyaluronic acid: A newly described complication in vocal fold augmentation.

OBJECTIVES/HYPOTHESIS: To establish the rate of inflammatory reaction to hyaluronic acid (HA) in vocal fold injection augmentation, determine the most common presenting signs and symptoms, and propose an etiology. STUDY DESIGN: Retrospective chart review. METHODS: Patients injected with HA over a 5-year period were reviewed to identify those who had a postoperative inflammatory reaction. Medical records were reviewed for patient demographic information, subjective complaints, Voice Handicap Index-10 (VHI-10) scores, medical intervention, and resolution time. Videolaryngostroboscopy examinations were also evaluated. RESULTS: A total of 186 patients (245 vocal folds) were injected with HA over a 5-year period, with a postoperative inflammatory reaction rate of 3.8%. The most common complaints in these patients were odynophagia, dysphonia, and dyspnea with vocal fold erythema, edema, and loss of pliability on videolaryngostroboscopy. All patients were treated with corticosteroids. Return of vocal fold vibration ranged from 3 weeks to 26 months, with VHI-10 scores normalizing in 50% of patients. CONCLUSIONS: This reaction may be a form of hypersensitivity related to small amounts of protein linked to HA. Alternatively, extravascular compression from the HA could lead to venous congestion of the vocal fold. The possibility of equipment contamination is also being investigated. Further studies are needed to determine the etiology and best treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 2016 127:445-449, 2017.

Association of alirocumab therapy with inflammatory lesions of the vocal folds: A case report.

Therapeutic monocolonal antibodies (MAbs) are a new, rapidly growing class of medications that frequently have poorly characterized side-effect profiles. We present a patient who developed inflammatory lesions of the vocal folds in temporal relation to the initiation of alirocumab. Lesions of the vocal folds represent a previously unreported adverse effect of alirocumab therapy, making it the second MAb documented with such a side effect. The potential laryngeal effects of alirocumab specifically, and of MAbs more broadly, warrant investigation. Laryngoscope, 127:1652-1654, 2017.

Effect of sugarcane biopolymer in vocal fold of rabbits. Comparative study with calcium hydroxyapatite.

PURPOSE: To compare the inflammatory reaction caused by the injection of a sugarcane biopolymer (SCB) into the vocal fold of rabbits with that caused by calcium hydroxyapatite (CaH). METHODS: CaH (Radiesse(r)) and SCB gel were injected respectively into the right and left vocal cords of thirty rabbits. The rabbits were distributed into two equal groups and sacrificed at three and twelve weeks after injection. We then evaluated the intensity of the inflammatory reaction, plus levels of neovascularization, fibrogenesis and inflammatory changes in the vocal mucosa. RESULTS: The vocal cords injected with CaH had a stronger inflammatory reaction by giant cells in both study periods. The SCB group had a more intense inflammatory involvement of polymorphonuclear cells three weeks after injection. SCB caused a higher level of neovascularization compared with CaH three weeks after the procedure. CONCLUSION: Whereas calcium hydroxyapatite triggers a more intense and lasting inflammatory reaction mediated by giant cells, sugarcane biopolymer causes a greater response from polymorphonuclear leukocytes, as well as higher levels of vneoascularization three weeks after injection.

[Pediatric exposures to laundry pods or capsules: more toxic than traditional laundry products?]. / Expositions des enfants aux lessives capsules, écodoses ou pods : plus toxiques que les lessives traditionnelles ?

UNLABELLED: New concentrated laundry pods, available on the European market for approximately 10 years, are associated with more severe intoxications compared to classic laundry detergents. AIM: To compare symptoms and severity after exposure to classic laundry detergents and new laundry pods in a pediatric population. MATERIAL AND METHODS: Retrospective study conducted between 1st January 2002 and 30th June 2013 including all laundry detergent exposure patients admitted to our tertiary level pediatric emergency unit. Collected data were age, sex, date, time and location of exposure, type of product (powder, liquid, tablets, pods), estimated ingested quantity, time of admission, clinical symptoms, severity, complications, and progression. RESULTS: Descriptive analysis: eighty-nine children were included. The mean age was 2.1 ± 1.5 years (range, 36 days to 10 years), 65% of patients were aged less than 2 years. The male:female ratio was 1.5 (males, 60%). After exposure, 57% of children were symptomatic and most frequently developed digestive symptoms (75%). Comparative analysis: compared to classic laundry detergent, children exposed to laundry pods were more symptomatic (96% versus 51%, P<0.0001), had more digestive signs (P=0.003), more frequently had bronchospasm (P=0.02), had a higher risk of ocular lesions (P=0.04), and exposure was more severe (poisoning severity score grade 2, 92% versus 59%, P<0.0001). COMMENTS: Laundry pod toxicity is more severe. The chemical composition of laundry pods has a higher concentration of surfactants and ethoxylated alcohols; they have a higher viscosity and hydrotropic power. The addition of water seems to modify the alkalinity, which explains the severity of ENT, gastric, and corneal lesions. CONCLUSION: The declaration to national poison centers of these intoxications should be pursued by emergency pediatricians, physicians, and pediatric intensivists. Family physicians can encourage parents to declare adverse effects to the National Consumer Product Safety Commission. Parents need to be better informed of the risk of laundry pods and strictly keep this type of product out of the reach of children. Given that it took 7 years after the first warning by the French poison centers to obtain safety recommendations for manufacturers, it is important to maintain pressure on companies to obtain the necessary modification of the physicochemical properties and child-resistant packaging.

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.

Aquaporin changes in compound 48/80 induced inflammatory sublaryngeal edema in rat.

OBJECTIVES/HYPOTHESIS: Laryngeal edema is a common clinical condition. However, the underlying molecular mechanisms remain elusive. Aquaporins (AQPs) are small integral plasma membrane proteins that transport water across the plasma membrane. In this study, we explore the relationship between inflammatory laryngeal edema induced by compound 48/80 and the expression of AQPs. STUDY DESIGN: Prospective, controlled, experimental animal study. METHODS: Healthy adult male SD rats were injected with either sterile water, compound 48/80 (2 mg/kg), or compound 48/80 plus dexamethasone (3 mg/kg) via the tail vein. The larynxes were harvested 10, 30 minutes, and 1 hour after the injection for the measurement of sublaryngeal water content and histological and molecular evaluations. RESULTS: Ten and 30 minutes after the compound 48/80 injection compared with the sterile water injection control groups, the water content in subglottic larynx increased significantly and the tissues were markedly swollen accompanied with inflammatory cell infiltration. AQP1 and AQP5 mRNA decreased significantly. One hour after the compound 48/80 injection, the edema was diminished, but the inflammatory cell infiltration remained. AQP1 was elevated but AQP5 was still lower than controls. Dexamethasone did not significantly reduce laryngeal edema, but significantly reduced inflammatory cells infiltration induced by compound 48/80 injection. Dexamethasone increased the AQP5 level but not AQP1. CONCLUSIONS: AQP1 and AQP5 might play key roles in inflammatory subglottic edema caused by compound 48/80 in rats. AQP1 and AQP5 might be useful molecular targets of clinical treatment of inflammatory laryngeal edema.

Effects of simulated reflux laryngitis on laryngeal chemoreflexes in newborn lambs.

It has been suggested that reflux laryngitis (RL) is involved in apneas-bradycardias of the newborn. The aim of the present study was to develop a unique RL model in newborn lambs to test the hypothesis that RL enhances the cardiorespiratory components of the laryngeal chemoreflexes (LCR) in the neonatal period. Gastric juice surrogate (2 ml of normal saline solution with HCl pH 2 + pepsin 300 U/ml) (RL group, n = 6) or normal saline (control group, n = 6) was repeatedly injected onto the posterior aspect of the larynx, 3 times a day for 6 consecutive days, via a retrograde catheter introduced into the cervical esophagus. Lambs instilled with gastric juice surrogate presented clinical signs of RL, as well as moderate laryngitis on histological observation. Laryngeal chemoreflexes were thereafter induced during sleep by injection of 0.5 ml of HCl (pH 2), ewe's milk, distilled water or saline into the laryngeal vestibule via a chronic, transcutaneous supraglottal catheter. Overall, RL led to a significantly greater respiratory inhibition compared with the control group during LCR, including longer apnea duration (P = 0.01), lower minimal respiratory rate (P = 0.002), and a more prominent decrease in arterial hemoglobin saturation (SpO(2)) (P = 0.03). No effects were observed on cardiac variables. In conclusion, 1) our unique neonatal ovine model presents clinical and histological characteristics of RL; and 2) the presence of RL in newborn lambs increases the respiratory inhibition observed with LCR, at times leading to severe apneas and desaturations.

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.

Acute glutaraldehyde mucosal injury of the upper aerodigestive tract due to damage to the working channel of an endoscope.

OBJECTIVES: Glutaraldehyde (Cidex) is a commonly used agent for cold sterilization of endoscopes despite its known irritative, allergic, and carcinogenic potential. This report details the clinical course of 2 patients who suffered acute glutaraldehyde exposure during office injection procedures. METHODS: Clinical records of 2 outpatients undergoing office injection procedures were reviewed. One patient underwent bilateral injections of hydroxyapatite, and 1 underwent voice gel injection. RESULTS: Both patients developed acute mucosal injury in the form of supraglottitis and laryngitis. Both patients required inpatient admission with airway monitoring (1 requiring admission to the intensive care unit) and were treated with steroids and antibiotics. The same channel endoscope was used for both procedures and was noted after careful examination to have retained glutaraldehyde inside the scope due to a perforation of the lining of the working channel. CONCLUSIONS: Glutaraldehyde can cause acute mucosal injury to supraglottic and glottic structures, and diligent procedures must be maintained for flushing the channels and monitoring glutaraldehyde retention in the channels. Great care should be taken to avoid damage to the lining of working channels from instrumentation.

[The effect of hormonal agents on the development of chronic laryngitis and tumor disease. Report of two cases]. / Chronische Laryngitis und Tumorerkrankung unter dem Einfluss von hormonell wirksamen Substanzen. Zwei Kasuistiken.

BACKGROUND: In the literature the potential effect of sexual steroids on the development and growth of laryngeal carcinomas, and even other tumor entities of the upper aerodigestive tract, within the context of multifactorial carcinogenesis has been the subject of controversial discussion. Experimental cell studies have provided evidence for the differentiated effects of these agents. Apart from the male preponderance in tumor formation, the high incidence at an age characterized by decreased peripheral androgenic signalling should be noted. PATIENTS AND METHODS: Two patients with chronic symptoms and abnormal hormone levels are reported who underwent a hormonal trial regimen. The course of their disease was followed up for a period of more than 10 years. RESULTS: In the first case of a patient suffering from chronic hyperplastic laryngitis for 17 years, a close correlation was found between the treatment with the 5alpha-reductase inhibitor Finasteride, the drop in serum levels of dihydrotestosterone (DHT), and the appearance of an invasive squamous cell carcinoma of the vocal cord. During the postoperative 7-year follow-up without recurrence the androgen serum levels were within normal range. The laryngeal mucosa did not display any further dysplastic changes. Retrospective studies of the biopsies demonstrated a significant degree of epidermal growth factor receptor (EGFR) expression, the characteristic high degree of EGFR activity in all of the tumor tissue, and a significantly lower degree of activity in the subsequent excision biopsies. In the second patient, who had undergone previous surgery for mesopharyngeal cancer at another site before the present tumor operation, rapid recurrence was seen within 2 years. Despite radical revision surgery and subsequent irradiation the patient insisted on carrying on with his work. He complained about a general lack of stamina and libido. His androgen serum levels were at the low-end of the normal range and even below that. The daily administration of 25 mg dehydroepiandrosterone (DHEA) resulted in normal androgen serum levels and improved his wellbeing. He has been free of recurrence for 10 years. DISCUSSION: Occasional long-term follow-up of patients supports the circumstantial evidence of previous experimental cellular studies that a dysbalanced androgen metabolism appears to act as cofactor in the genesis and development of malignant tumors of the upper aerodigestive tract.

Uso de carbonos pirolíticos (Durasphere) no tratamento da insuficiência glótica: estudo experimental em cães / Use of pyrolytic carbon coated beads (Durasphere) to treat glottic failure: an experimental study in dogs

Nenhum tecido ou substância ideal foi encontrado para a injeção em pregas vocais. O objetivo deste estudo prospectivo foi avaliar o uso do Durasphere como substância de injeção na prega vocal canina. Materiais e métodos: Em seis cães adultos foram injetados 0,3mL de Durasphere no terço médio da prega vocal direita no músculo tireoaritenoideo e 0,3mL de soro fisiológico na prega contralateral. Os animais foram sacrificados após 7 dias (três cães) e 90 dias (três cães). Analisamos os processos inflamatórios no músculo vocal e na lâmina própria das pregas vocais. Resultados: No músculo vocal com Durasphere havia uma inflamação significativamente maior que no músculo controle, formouse um infiltrado linfomononuclear moderado após 7 dias e leve após 90 dias. Não observamos formação de corpos estranhos ou granulomas. Já na lâmina própria houve um processo inflamatório leve nos dois grupos, sem diferença entre eles. Conclusão: Trata-se de uma substância com biocompatibilidade comprovada em humanos, com resultados preliminares e inéditos de sua injeção em pregas vocais caninas que causou um processo inflamatório moderado no músculo vocal após 7 dias e leve após 90 dias, sem formação de corpos estranhos ou granulomas.

There is no ideal tissue or substance to be injected in the vocal folds. The objective of the present study was to assess the use of Durasphere in canine vocal fold injection. Materials and methods: in six adult dogs we injected 0.3 mL of Durasphere in the middle third of the thyroarytenoid muscle and 0.3 mL of saline solution in the contralateral vocal fold. The animals were slaughtered after seven days (three dogs) and after 90 days (three dogs). We analyzed the inflammatory process in the vocal fold and in the lamina propria of the vocal folds. Results: in the vocal muscle which received Durasphere there was a significantly more intense inflammation when compared to the control muscle - there was a moderate lymphomodular infiltrate after seven days and mild after 90 days. We did not observe foreign bodies nor granulomas. On the lamina propria there was a mild inflammatory process in the two groups, without difference between them. Conclusion: this is a substance of proven biocompatibility in humans, with preliminary and unprecedented results and its injection in canine vocal folds caused a moderate inflammatory process after seven days and mild after 90 days, without foreign bodies or granuloma formation.

Late laryngeal findings in sulfur mustard poisoning.

INTRODUCTION: Sulfur mustard is an alkylating warfare agent and its inhalation results in early and late toxic effects. This agent was used widely against both military and civilian population by Iraqi forces in the Iran-Iraq war (1983-88). The purpose of the study was to describe abnormal laryngeal findings in a group of chemical war injury patients (soldiers) 20 years after an acute exposure to sulfur mustard. METHODS: In this observational case series study, 50 male patients who were suffering from chronic respiratory symptoms and because of exacerbation of these problems, were consecutively selected and clinically examined for dysphonia by a speech-language pathologist, and then underwent fiberoptic laryngobronchoscopy to describe anatomical and functional pathologic findings of the larynx. RESULTS: In objective speech evaluation, different degrees of dysphonia including harshness and hoarseness were observed in 46% of patients. Inflammation was present in supraglottic and subglottic regions of 9 (18%) and 3 (6%) patients, respectively. Hyperfunction of the false vocal cords was observed in 24 (48%) patients. CONCLUSION: Chronic laryngitis was seen in a considerable number of exposed victims nearly 20 years after exposure, in spite of different treatments received.

Histological behavior of the vocal fold after hyaluronic acid injection.

The vocal fold is formed by tissues with abundant cells surrounded by an extracellular matrix. One of the most important components of the extracellular matrix is hyaluronic acid (HA). This study evaluated the inflammatory response of the vocal folds of rabbits submitted to local injection of Restylane HA. We performed a prospective, experimental, and controlled study in 22 New Zealand rabbits with injection in vocal fold. The 22 adult male rabbits underwent a 0.1-ml injection of Restylane HA in one vocal fold and a 0.1-ml injection of saline solution in the other vocal fold, at random. The animals were then subdivided in two distinct groups. One group was sacrificed after a 1-week follow-up and the other group after 3 months. Slides were then stained with hematoxylin-eosin (HE), Masson's trichrome, and toluidine blue. HA was found microscopically in all specimens of both groups. Using the stain (HE), it was easily distinguished. We have measured the inflammatory reaction by histopathology conducted by a pathologist. An increase in connective tissue was found surrounding the HA, and was always associated with a mild inflammatory response. The extended time of exposure did not increase the intensity of the inflammatory reaction. Tissue necrosis and foreign body inflammatory reaction were not observed in either group. The current study suggests that HA is a good alternative for a filling material of the vocal folds when treating glottal insufficiency.

Use of pyrolytic carbon coated beads (Durasphere) to treat glottic failure: an experimental study in dogs.

UNLABELLED: There is no ideal tissue or substance to be injected in the vocal folds. The objective of the present study was to assess the use of Durasphere in canine vocal fold injection. MATERIALS AND METHODS: in six adult dogs we injected 0.3 mL of Durasphere in the middle third of the thyroarytenoid muscle and 0.3 mL of saline solution in the contralateral vocal fold. The animals were slaughtered after seven days (three dogs) and after 90 days (three dogs). We analyzed the inflammatory process in the vocal fold and in the lamina propria of the vocal folds. RESULTS: in the vocal muscle which received Durasphere there was a significantly more intense inflammation when compared to the control muscle--there was a moderate lymphomodular infiltrate after seven days and mild after 90 days. We did not observe foreign bodies nor granulomas. On the lamina propria there was a mild inflammatory process in the two groups, without difference between them. CONCLUSION: this is a substance of proven biocompatibility in humans, with preliminary and unprecedented results and its injection in canine vocal folds caused a moderate inflammatory process after seven days and mild after 90 days, without foreign bodies or granuloma formation.