Angioedema is an immunologically mediated, anatomically limited, nonpitting edema that can lead to life-threatening airway obstruction. To predict the risk of airway compromise in angioedema, we retrospectively reviewed 93 episodes in 80 patients from 1985 to 1995. Intubation or tracheotomy was necessary in 9 (9.7%) cases. Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). Voice change, hoarseness, dyspnea, and stridor were present in patients requiring airway intervention (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases. No deaths were caused by angioedema. Airway risk in angioedema may be predicted by anatomic site of presentation, allowing appropriate triage with preparation for airway intervention in selected cases.
Screening programs show promise in increasing the rate of early detection of head and neck cancers in high-risk populations. Prout et al (Otolaryngol Head Neck Surg 1997;116:201-8) examined the usefulness of a large-scale screening program for head and neck cancer in an inner city population by primary care physicians. Symptom assessment was based on the American Cancer Society's "Seven Warning Signs for Cancer," (Cancer manual. 8th ed. Boston: American Cancer Society, Massachusetts Division; 1990. p. 40-64) 4 of which are relevant to the head and neck. However, these signs may be insufficient for detection of early head and neck cancer. We analyzed these and other typical symptoms to determine their role in early detection. Coincident medical problems, tobacco abuse, and alcohol abuse were also analyzed. Our findings indicate that no symptom or symptom complex is strongly correlated with early head and neck cancer for any subsite except the glottis. Symptom duration is an unreliable indicator of the duration of disease. However, patients under medical supervision are more likely to have their cancers detected early, supporting the value of surveillance by the primary care physician. The absence of definite early warning signs for most head and neck cancers suggests the need to develop essential screening criteria. Defining the population that is at high risk for head and neck cancer and subjecting it to an aggressive screening protocol is essential.
Endoscopic epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques and the CO2 laser. Depending on the indications, the removal may be partial or complete. Indications for 51 epiglottectomies included treatment of supraglottic airway obstruction--30 cases; discovery of benign or malignant neoplasm (diagnosis and staging)--20 cases; treatment of malignant neoplasm--7 cases; glottic visualization--4 cases; and treatment of chronic inflammatory conditions--1 case. It is not unusual for a patient to have more than one indication for this procedure. Some epiglottic cancers invade the pre-epiglottic space. This crucial information may not be detectable by MRI or CT scanning techniques. Laser epiglottectomy provides a method to explore and perform a biopsy of the pre-epiglottic space and thereby stage these lesions accurately. There are no significant problems with postoperative alimentation, airway, or voice. Any form of primary or adjuvant therapy can be started without delay.
Osteopetrosis is a genetically determined bone disease resulting from malfunction of osteoclastic activity, leading to excessive deposition of immature bone. This may result in complete agenesis of the paranasal sinuses, oral complications and multiple cranial neuropathies. The case of a 12-year-old boy with osteopetrosis is presented.
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