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A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18). Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other. A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.

Rigid Bronchoscopy is carried out for the diagnosis and removal of the foreign body. The post operative period may have complications like laryngobronchial spasm, laryngeal oedema, in turn may require tracheostomy and later on may lead to cardiac arrest and respiratory arrest. These post operative complications can be drastically reduced by the use of nebulization with the combination of steroids, Bronchodilators and lignocaine. Combination with lignocaine nebulization reduces rates of morbidity and mortality effectively then nebulizing only steroid and bronchodilators. Lignocaine reduces the irritative cough, reactive secretion and also hence bronchospasm and also vomiting.

Hereditary angioedema (HAE) patients experience recurrent local swelling in various parts of the body including painful swelling of the intestine and life-threatening laryngeal oedema. Most HAE literature is about attacks located in one anatomical site, though it is mentioned that HAE attacks may also involve multiple anatomical sites simultaneously. A detailed description of such multi-location attacks is currently lacking. This study investigated the occurrence, severity and clinical course of HAE attacks with multiple anatomical locations. HAE patients included in a clinical database of recombinant human C1-inhibitor (rhC1INH) studies were evaluated. Visual analog scale scores filled out by the patients for various symptoms at various locations and investigator symptoms scores during the attack were analysed. Data of 219 eligible attacks in 119 patients was analysed. Thirty-three patients (28 %) had symptoms at multiple locations in anatomically unrelated regions at the same time during their first attack. Up to five simultaneously affected locations were reported. The observation that severe HAE attacks often affect multiple sites in the body suggests that HAE symptoms result from a systemic rather than from a local process as is currently believed.

In 12 patients, ranging in age from newborn to 4 years, endotracheal intubation has been used as a substitute for tracheostomy. Using plastic tubes it was possible to maintain a good airway for periods of up to 7 weeks. Painstaking care was necessary to prevent the tubes becoming blocked or malpositioned. The tubes were tolerated well. Good laryngeal function has been regained by all 9 survivors. If permanent laryngeal changes have occurred, they show no signs of being severe. It is concluded that many cases customarily managed with tracheostomy can be equally well managed with intubation. Intubation may prove to be the preferred management in some cases of laryngeal oedema.

Patients with hereditary angio-oedema will often present to the emergency department or hospital with cutaneous swelling, abdominal pain or laryngeal oedema. This article reviews the diagnosis and acute management of patients with hereditary angio-oedema.

Laryngeal papillomata can undergo spontaneous malignant transformation without being detected histologically and, in some instances, the disease may become so advanced, before the diagnosis is confirmed, that it is beyond any form of curative treatment.Because of this limitation imposed by histopathological investigation, a study was undertaken in 17 adults with benign laryngeal papillomata, (three of whom underwent malignant transformation) to determine whether malignant transformation can be predicted from the clinical behaviour of the tumour. The following features were analysed: age, sex, patient's symptoms, frequency of excision of the papillomata, site of lesion, presence or absence of laryngeal oedema, the need for tracheostomy, vocal fold mobility and presence or absence of cervical lymph nodes.It was found that decreased vocal fold mobility, the presence of cervical lymph nodes, exuberant and rapid growth requiring very frequent excisions, oedema of the larynx with airway obstruction requiring a tracheostomy are clinical features suggestive of malignant transformation.

Patients with hereditary angioedema may present to the emergency department (ED) with subcutaneous and submucosal swellings, the most important being the development of laryngeal oedema, which can rapidly obstruct the airways and cause death. The aim of this study was to establish whether local guidelines exist for the management of such patients and to determine where the C1 inhibitor concentrate (C1 INHC) was kept in the trusts. A questionnaire survey of the availability and use of C1 INHC was sent to 35 EDs across the UK with established immunology services within their trusts. A hundred percent response was received. Thirty-three trusts had a supply of the drug C1 INHC in varying quantities. Nineteen trusts had it in their ED. Only 17 departments had any guidance with regard to their use. There is a significant lack of guidance for C1 INHC use in the EDs surveyed. A guideline was developed as a result that can be used by EDs across Europe.

Background: Skin swellings are the most frequent symptoms in hereditary angio-oedema (HAE) arising out of C1-inhibitor (C1-INH) deficiency. They may be painful and impact daily activities of patients. Detailed clinical data concerning the treatment of skin swellings by C1-INH concentrate have not been reported yet. Methods: From 1976 through 2007, a total of 2104 skin-swelling attacks in 47 patients with HAE were treated with the C1-INH concentrate. Time to relief and duration of the swellings were documented during personal interviews using standardized questionnaires. The results were compared with 9046 untreated skin swellings in the same patients. Results: The first clinical sign of efficacy was a slowdown of progress of symptoms accompanied by a decreased feeling of tension and pain in the swollen area. The mean time to the first relief of symptoms was 1.1 ± 1.4 h in treated skin swellings and 50.4 ± 33 h in untreated skin swellings. Improvement of facial skin swellings took longer than swellings of the extremities, genitals or trunk. The duration of treated skin swellings was 1.7 day in treated and 3.2 day in untreated ones. In treated swellings, there was long-lasting control and no rebound within the 48 h following the drug administration and no laryngeal oedema following facial oedema were observed. No severe side-effects occurred. Conclusions: The C1-INH concentrate has proven to be highly effective and safe for treating skin swellings in patients with HAE arising out of C1-INH deficiency.

John, a 4 year old boy, has been mechanically ventilated for three days during recovery from a blunt chest trauma. According to his level of ventilator support, he is considered to be ready to be extubated. The previous patient had to be reintubated as a result of postextubation laryngeal oedema. You wonder whether corticosteroids may reduce this risk of extubation failure. In mechanically ventilated children [patient] does corticosteroid administration [intervention] reduce the chance of reintubation due to laryngeal oedema [outcome]? ### Secondary sources Cochrane Database of Systematic Reviews; 1 limited to newborn infants.1 ### PubMed clinical queries “Respiration, Artificial”[MESH] AND (Hydroxycorticosteroids)[MESH] AND systematic; 1 reference not related to the question. (“Intubation, Intratracheal”[MeSH]) AND systematic[sb] AND (Hydroxycorticosteroids)[MESH]; no references. ### PubMed (Anti-Inflammatory Agents OR Anti-Inflammatory Agents/therapeutic use OR Anti-Inflammatory Agents/therapy OR hydroxycorticosteroids) AND systematic[sb]) AND (“Intubation, Intratracheal”[MeSH] OR “Respiration, Artificial”[MeSH]); 25 references, 2 relevant studies1,2) (table 2). View this table: Table 2 Dexamethasone in …

Hereditary angio-oedema is a rare autosomal dominant disease characterized by recurrent attacks of subcutaneous oedema and caused by a deficiency of the plasma protein C1 inhibitor. Hereditary angio-oedema attacks carry a high risk of morbidity or even mortality. In literature, there are only a few publications on the treatment and follow-up of paediatric patients. We report the case of a 14-year-old male with known hereditary angio-oedema since the age of six years, revealed by a recurrent acute abdominal pain and oedema in subcutaneous tissues of extremities and face, and he was admitted once for sub mucosal oedema of larynx with suffocation, treated by fresh-frozen plasma with favourable outcome. Danazol was used for long-term prophylaxis. Clinical course improved over a follow-up of 12 months.

The case of a 30-year-old parous patient with multi-organ involvement due to systemic lupus erythematosus and severe hypertension at 33 weeks gestation is described. Despite uneventful general anaesthesia for a classical caesarean section she developed acute airway obstruction postoperatively which was attributed to pre-eclampsia induced laryngeal oedema.

Oil of Wintergreen (methyl salicylate) is a common ingredient for liniments, ointments and essential oils used in self-treatment of musculoskeletal pain. Its pleasant smell also encourages its use to flavour confectionery. The toxic potential of this preparation is not always fully appreciated by the general public and physicians. To appreciate the danger of this oil it can be compared to aspirin tablets (325 mg dose): one teaspoon (5 ml) of Oil of Wintergreen is equivalent to approximately 7000 mg of salicylate or 21.7 adult aspirin tablets. Ingestion of as little as 4 ml in a child can be fatal. Prevention of accidental ingestion of methyl salicylate containing products can be achieved by keeping the products out of reach of children, using child resistant bottles, restricting the size of the openings of the bottles, appropriate labeling on products and reducing the salicylate content. Immediate action should be taken to treat a patient with accidental poisoning and hospitalisation is needed for monitoring and treatment. The danger of this product should be fully appreciated by both physicians and the general public. We present a case of Oil of Wintergreen poisoning with development of laryngeal oedema as a complication, general information and management issues will also be discussed.

A 27-year-old Bangladeshi complained of fever (39.2°C) and tenderness of the neck. He was admitted to our hospital. A fiberoptic laryngoscopy revealed oedema of the right side of the epiglottis. A CT scan showed a swelling of the bilateral parotid glands, submandibular glands and the right side of the epiglottis, and the neck and anterior thoracic wall showed phlegmonous inflammation (figure 1). Laboratory tests showed a …

SUMMARY A total of 145 patients with early carcinoma of the vocal cords (T1,2N0) were treated by radiotherapy from 1979 to 1989. Survival and local control data were available for 135 and 127 patients, respectively. The respective 5 and 10 year results for overall survival were 75 and 68%. The 5 and 10 year probabilities of local control by radiotherapy were 89 and 86%, respectively, for T1 tumours and 70% at both time intervals for T2 tumours. Tumour recurrence following radiotherapy was documented in 18 of 127 patients. Tumour stage predicted significantly for local control, with recurrence rates for T1 and T2 tumours of 11 and 27%, respectively (P= 0.02). There was a higher proportion of recurrences for total radiation doses ≦ 6200 cGy (17%) compared with >6200 cGy (8%), but the difference was not statistically significant. Increasing duration of treatment was related significantly to increased recurrence for T2 (P= 0.01), but not T1, tumours. Most recurrences (60%) were salvaged successfully by laryngectomy. Three patients required laryngectomy for laryngeal oedema without recurrent tumour; all had been treated using a large field size (7 × 6 cm). There were 20 metachronous tumours, including five lung and two head and neck tumours. These results are similar to previous reports and confirm that radiotherapy is very effective for early glottic cancer, with high local control rates and effective salvage if local recurrences are recognized early.

Acute onset stridor in a neonate following general anaesthesia is commonly attributed to laryngeal oedema secondary to anaesthetic airway trauma. The authors present a case of recurrent laryngeal nerve injury resulting in vocal cord paralysis causing stridor following central venous catheterisation under general anaesthesia in a neonate. This was managed expectantly and resolved spontaneously over a period of 6 months.

We report the first case of oro-facial granulomatosis (OFG) presenting in pregnancy with laryngeal manifestations.

I WISH to share with colleagues my concern regarding probable laryngeal oedema following the use of Xylocaine spray (AstraZeneca) when intubating a cat. Adverse reaction to the use of this product in cats has previously been reported ([Taylor 1992][1]). Having contacted the Veterinary Medicines

Preservation of the larynx in patients with glottic carcinoma by means of radiotherapy is a relatively recent development. In 1955, at a leading cancer treatment centre, 90% of glottic cancer patients were being treated surgically and only a few by radiation therapy (Hawkins 1975). Since then, the policy at this centre and elsewhere increasingly has become that of conserving the larynx wherever possible while minimizing morbidity. With early glottic cancer, radiation therapy has become the initial treatment choice, with surgery being reserved for radiation failure (Hawkins 1975, Harwood and Tierei 1979, Dicknes et al. 1983). Hawkins (1975) reported that complications arising in 673 patients treated by radiation for cure were low; transient dysphagia and an increase in huskiness during and immediately after treatments was usual; laryngeal oedema, the most troublesome feature, usually subsided but occasionally persisted, particularly following the successful treatment of extensive tumours.

An unusual cmomplication is presented following a tempormomandibular arthroscopy carried out under general anaesthesia. Severe cervicofacial oedema occurred immediately after surgery which required prolonged endotracheal intubation. Retrospective analysis revealed a massive fluid escape in the surrounding tissues leading to laryngeal oedema.

The six trials in the meta-analysis of prophylactic parenteral steroid use to prevent laryngeal oedema after extubation, and subsequent reintubation, use different agents and non-equivalent doses.1 Biological half lives vary considerably, hydrocortisone being shortest acting, …

From 1975 to 1985, 161 patients affected by head and neck cancer (58 oropharynx, 67 oral cavity, 36 paranasal sinuses) were treated with radiotherapy using an accelerated fractionation (AF) schedule at the University and Hospital Radiotherapy Departments of Florence. Most cases, classified with U.I.C.C. and A.J.C. TNM 1978 were advanced ( 137 161 = 85% ). Five-year actuarial local control and survival was 38% for the oropharynx, 18% and 20% for the oral cavity, and 38% and 31% for the paranasal sinuses. Results were analysed according to T and N stage as well. Severe late sequelae were evaluated in 53 patients without local disease and with a minimum follow-up of one year: 8 patients developed osteonecrosis; there were 3 cases of trismus, 2 cases of laryngeal oedema, one case of blindness and one case of ophthalmitis.

1 Dickstein K, Kjekshus J; OPTIMAAL Steering Committee of the OPTIMAAL Study Group. Eff ects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet 2002; 360: 752–60. 2 Pfeff er MA, McMurray JJ, Velazquez EJ, et al; Valsartan in Acute Myocardial Infarction Trial Investigators. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003; 349: 1893–906. 3 Demers C, McMurray JJ, Swedberg K, et al; CHARM Investigators. Impact of candesartan on nonfatal myocardial infarction and cardiovascular death in patients with heart failure. JAMA 2005; 294: 1794–98. 4 Pourdjabbar A, Lapointe N, Rouleau JL. Angiotensin receptor blockers: powerful evidence with cardiovascular outcomes? Can J Cardiol 2002; 18 (suppl A): 7A–14A.

OEDEMA denotes expansion of the interstitial fluid to produce either subcutaneous swelling or accumulations of fluid in the lungs, thoracic cavity, abdomen (ascites), and so on. General tissue oedema is unsightly and uncomfortable, but seldom life-threatening. Other forms of oedema are of greater clinical significance. If extensive, gut oedema causes severe disturbances, and pulmonary and laryngeal oedema are potentially lethal; so, eventually, is ascites or hydrothorax because of the interference with respiratory movements.

Drs T SILFVAST (Helsinki University Central Hospital, 002900 Helsinki, Finland), A KINNUNEN (Helsinki Area Emergency Medical Air Service, 01530 Vantaa, Finland), T VARPULA (Jorvi Hospital, 02740 Espoo, Finland) write: Emergency staff found a 65 year old woman who had suddenly collapsed lying unconscious on the floor. Babinski's sign was bilaterally positive and her blood pressure was 220/130 mm Hg. She was breathing without difficulty. Two sprays of …

Laryngeal tuberculosis is one of the rarer forms of extrapulmonary tuberculosis. A retrospective analysis of 26 patients seen in the last nine years in our hospital was conducted to illustrate the various modes of clinical presentation. Of the 26 patients, twenty were male and six female. The average age of presentation was 47 years with an age range of 15 months to 71 years. Hoarseness (92.3 per cent) was the commonest symptom. The laryngoscopic appearances often simulated malignancy. Most patients (69.2 per cent) had lesions involving the anterior two-thirds of the true vocal cords. Hypertrophic lesions (69.2 per cent) out-numbered ulcerative ones (38.5 per cent). Laryngeal oedema was infrequent (7.7 per cent). Diagnosis was based on a laryngeal biopsy in 18 patients and on evidence of associated pulmonary tuberculosis and response to anti-tuberculous therapy in eight. Chest X-rays showed apical cavitation and infiltration as the commonest findings. Three patients had miliary tuberculosis and one had no pulmonary lesion. Diabetes mellitus was present in seven (26.9 per cent) patients. Four illustrative cases are described. The problems in diagnosis and management of laryngeal tuberculosis are discussed.

Nine patients with advanced head and neck cancer have been treated by irradiation consisting of three fractions a day of 180 rad administered with intervals of 4 h. The total dose was 4860--5400 rad in an overall time of 11--12 days. The acute mucosal reactions produced by this multifractionated schedule were similar to those observed with conventional fractionation. The acute skin reactions were minimal. The period of acute reactions were shorter than is generally observed with conventional fractionation. In six patients with a follow-up time of six months or longer no late reactions have been detected with the exception of one patient requiring permanent tracheostomy because of laryngeal oedema. In the whole group of patients loco-regional control of the disease has been achieved. Six patients have maintained the full response for six months or longer. The results so far obtained with this multiple fractions a day schedule are encouraging. More patients have to be entered in this study in order to draw definitive conclusions.

A case is described in which recurrent laryngeal oedema was the presenting feature of thyroid lymphoma. Conventional isotope scanning was of no value in reaching the diagnosis.

I have attempted to deal with the complications of endotracheal anaesthesia, stressing some and of necessity dealing briefly with others. These sequelae include injuries and infections of the supraglottic, glottic, and infraglottic areas. Special mention has been given to such entities as laryngeal oedema, laryngeal granu-loma, subglottic membrane, and laryngotracheitis. The more unusual complications connected chiefly with mechanical difficulties have been considered. In most instances recommendations for their prevention or treatment have been outlined.

BackgroundThe AIR-Q Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical) is a supraglottic device present in the market since 2004. It has different sizes for pediatric and adult use. This device proved to be of utmost importance in the management of difficult airway [1]. The study evaluates the different adult sizes of the Air Q when used for intubation regarding the ease of insertion, the laryngeal view grade, their efficacy as conduit for standard cuffed endotracheal tubes using fiberoptic bronchoscope. The study also records the time of intubation, the ease and time of removal of the AIRQ over a removal stylet without dislodgement of the tube from trachea. Any complications related to the use of AIRQ were also recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.MethodsSixty adult patients aged 20–50years, ASA I, II undergoing elective surgeries requiring general anesthesia, were enrolled in the study. The patients were divided into 2 equal groups according to their body weight. The body weight of the first group ranged from 50 to 70kg and used the Air Q 3.5 for intubation with an endotracheal tube (ETT) 7mm ID, while the body weight of the second group ranges from 70 to 100kg and used the Air Q 4.5 for intubation with a tube 7.5mm ID. The number of attempts of insertion, the seal pressure, the laryngeal view grade, the time and the number of attempts of intubation, time of removal of the AIRQ over the tube without dislodgement, and any complications related to the use of AIRQ were recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.ResultsThe insertion and removal of the AIRQ were easy and successful in all patients of both groups. The endotracheal intubation by fiberoptic bronchoscope through the Air Q was successful and easy in both groups. Grade 5 laryngeal view was seen with AIRQ 4.5 in some patients with higher body weight.ConclusionThe insertion of AIRQ in adult patients is easy and provides an effective conduit for the standard cuffed endotracheal tubes using fiberoptic bronchoscope. The removal of the AIRQ over the removal stylet is easy without dislodgement of the tube. Because of higher incidence of down folding of the epiglottis in some obese patients, they are better intubated under direct vision with the use of fiberoptic bronchoscope.

Failure to intubate the trachea continues to claim the lives of women undergoing caesarian section. Obstetric anaesthetists have been advised to desist from prolonged attempts to intubate, and to provide either inhalational anaesthesia via a face mask, or regional anaesthesia. A case is described in which neither of these options was considered appropriate.

Ľosdeme angioneurotique hereditaire (HANE) presents le danger ďaedeme larynge qui peut, parmi ďautres causes, etre declenche par ľanesthesiste manipulant les voies aeriennes. Ľanesthesie locale et regionale sont souvent recommandes. Cette histoire de cas concerne un patient qui tolera avec succes ľanesthesie generate endotracheal et dont la conduite compre-nait un pre-traitement prophylactique avec le danazol ainsi que des plasmas pre congeles.

Pre-eclamptic toxaemia is a common complication of late pregnancy. However, the occurrence of clinically unsuspected laryngeal oedema has not, to the authors' knowledge, been described previously. Experience of such a case leads them to recommend that a selection of tracheal tubes ranging from 8 to 4-5 mm, be available when anaesthesia is undertaken in patients who have oedema associated with pre-eclamptic toxaemia.

A 17-year-old black female with pregnancy-induced hypertension (PIH) suffered cardiorespiratory arrest on arrival in the recovery room after Caesarean section under general endotracheal anaesthesia. Successful resuscitation included orotracheal intubation, complicated by severe laryngeal oedema. Causative mechanisms are discussed.

Emergencies can arise if a patient is allergic to a drug, particularly if he has received it by injection. Anaphylactic collapse resembles a faint with a precipitous fall in blood pressure, bronchoconstriction and sometimes laryngeal oedema. The collapse can occur immediately after an intravenous injection or within an hour of an intramuscular injection.