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Adult supraglottitis subsequent to smoking crack cocaine. (Original Article).

Abstract

Supraglottitis is one possible complication of smoking crack cocaine. From 1992 through 2001, our institution treated nine patients for thermal supraglottitis secondary to crack cocaine inhalation. In this article, we describe two of these cases, and we briefly review what is known about this entity and the mechanism of injury. We also provide our recommendations for management.

Introduction

Once considered to be a problem unique to particular subpopulations, the abuse of illicit substances is clearly now a worldwide epidemic. An association between smoking crack cocaine and thermal supraglottitis has been previously reported in the literature. (1-4) In most cases, the inflammation occurs as a result of the inhalation of crack cocaine vapors or heated particles from the smoking paraphernalia. Crack cocaine-induced thermal supraglottitis can also occur when a foreign body is not inhaled.

From 1992 through 2001, our institution treated nine patients for thermal supraglottitis subsequent to crack cocaine inhalation. In this article, we describe two of these cases, and we briefly review what is known about this entity and its mechanism of injury. We also provide our recommendations for management.

Case reports

Patient 1. A 37-year-old man complained of a 12-hour history of progressive dysphagia, odynophagia, and dysphonia. The patient also reported difficulty breathing while he was in the supine position. He was noted to be drooling. The patient said his symptoms had begun shortly after he had smoked crack cocaine at a concert.

On admission, the patient's temperature was 99.6[degrees] F and his white blood cell count was 14,400/[mm.sup.3]. Lateral neck radiography and fiberoptic laryngoscopy revealed extensive edema and erythema involving the epiglottis, aryepiglottic folds, and false vocal folds; the edema obstructed more than 50% of the glottic aperture (figure 1).

The patient was started on an intravenous steroid and taken to the operating room for endotracheal intubation. Intraoperative cultures of the supraglottic region grew no pathogenic organisms. The patient responded to the IV steroid and was extubated on hospital day 3. He was discharged on day 6 with a complete resolution of his supraglottitis.

Patient 2. A 39-year-old man was evaluated for a 3-day history of progressive dysphagia, odynophagia, dysphonia, and shortness of breath. His symptoms had begun immediately after he had smoked crack cocaine. On admission, his temperature was 102.8[degrees] F and his white blood cell count was 20,300/[mm.sup.3]. Fiberoptic examination of the larynx revealed an erythematous and edematous epiglottis that was hooding over the glottis (figure 2). The patient's aryepiglottic and false vocal folds were also enlarged, obstructing more than 60% of his glottic aperture. He was intubated and started on IV dexamethasone. In less than 48 hours, his supraglottic edema resolved and he was extubated. Final cultures of the supraglottic region were negative.

Discussion

Supraglottitis is characterized as an inflammation of the supraglottic soft-tissue structures, including the aryepiglottic folds, epiglottis, false vocal folds, and arytenoid mucosa. This condition was first described by Mainwaring in 1791. The most commonly identified bacteriologic agent in supraglottitis is Hemophilus influenzae type B (HiB), and for many years, supraglottitis was regarded as primarily a disease of infancy and childhood. But since the advent of effective pediatric prophylaxis with the HiB vaccine, supraglottitis is now more common in adults. The ratio of affected children to adults has declined from 2.6:1 in 1980 to 0.4:1 in 1993. (5)

In the adult population, symptoms of dysphagia, odynophagia, and labored respiration are present, but they are less pronounced than they are in children. Because clinicians are frequently unable to isolate a causative organism and because the manifestation of supraglottitis in adults is often subacute, some authors have suggested that the disease has a viral etiology. The herpes simplex virus is the only virus that has been positively identified in conjunction with adult supraglottitis. (5)

Thermal supraglottitis secondary to smoking illicit drugs has been recognized as an uncommon cause of acute adult supraglottitis. The smoking of crack cocaine causes thermal injuries to the supraglottis because the cocaine converts to vapor at extremely high temperatures. (4) In 1988, Bezmalinovic et al reported that oropharyngeal thermal injury was most likely caused by hot vapors inhaled while smoking crack cocaine. (1) In addition to vapors, the inhalation of particles from wire screens used in cocaine pipes can also cause thermal supraglottitis. Mayo-Smith and Spinale reported just such a cause in four of more than 400 cases (~1%) of supraglottitis that they studied. (3) All four of these cases were secondary to inhalation of heated particles from the smoking apparatus; in one case, a small portion of a marijuana cigarette was found on direct laryngoscopy. The other three cases were attributed to the inhalation of metal particles from the smoking apparatus. In all four cases, the patients were aware that they had inhaled the offending foreign bodies.

Unlike the patients described by Mayo-Smith and Spinale, none of our nine patients recalled having inhaled any foreign body or experiencing a burning sensation, and no evidence of foreign bodies or bums were identified by direct laryngoscopy. However, it has been postulated that patients might not be aware of foreign-body inhalation in light of their drug-induced diminished sensation (topical anesthesia) and altered sensorium. (2) Alternatively, the injuries to our patients might have been caused by the extreme heat of the vapors, as happened in the patient reported by Bezmalinovic et al. (1)

Management of adults with supraglottitis is controversial. Recommendations range from intubation of all patients to observation in the intensive care unit. Some authors also recommend airway intervention based on symptoms such as tachycardia, an elevated white blood cell count, and a history of rapidly progressive odynophagia associated with respiratory difficulty. (5) Because of their severe airway compromise, the patients at our institution were managed with intubation for a maximum of 72 hours. At that point, fiberoptic laryngoscopy showed that all of these patients had experienced a complete resolution of their supraglottitis in response to IV steroids alone.

Based on our experience and that of the authors of similar case reports, we have developed recommendations for the management of crack cocaine-induced supraglottitis:

* The presence of heated inhaled foreign bodies should be excluded by direct laryngoscopy.

* The decision whether to observe or intubate should be guided by the overall status of the patient, keeping in mind that adults have a larger pulmonary reserve than do children. Most adult airways can be managed expectantly; intubation can be used as a final resort to stabilize the airway.

* Although the efficacy of steroids is controversial, we feel they accelerated the clinical response in our patients.

* Routine epiglottic cultures should be obtained to rule out any concomitant infection. Prophylactic antibiotics should be administered until negative cultures are obtained.

* If a foreign body is not identified, an infectious component cannot be ruled out. Therefore, coverage with empiric antibiotics is warranted.

In conclusion, the abuse of crack cocaine is a growing problem, and the incidence of cocaine-induced supraglottitis will more than likely increase. Even so, patients do not always readily admit to drug abuse, even when they are faced with life-threatening complications such as airway compromise. Clinicians who encounter adults with suspected supraglottitis should consider cocaine as a possible causative agent, especially in urban communities. In addition to standard blood chemistries and cultures, toxicology screening might play a role in defining the etiology of adult supraglottitis.

References

(1.) Bezmalinovic Z, Gonzalez M, Farr C. Oropharyngeal injury possibly due to free-base cocaine. N Engl J Med 1988;319:1420-1.

(2.) Ginsberg GG, Lipman TO. Endoscopic diagnosis of thermal injury to the laryngopharynx after crack cocaine ingestion. Gastrointest Endosc 1993;39:838-9.

(3.) Mayo-Smith MF, Spinale J. Thermal epiglottitis in adults: A new complication of illicit drug use. J Emerg Med 1997;15:483-5.

(4.) Reino AJ, Lawson W. Upper airway distress in crack-cocaine users. Otolaryngol Head Neck Surg 1993;109:937-40.

(5.) Carey MJ. Epiglottitis in adults. Am J Emerg Med 1996;14:421-4.

From the Department of Otolaryngology-Head and Neck Surgery, Charles R. Drew University of Medicine and Science, Los Angeles.

Reprint requests: Ryan Osborne, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Martin Luther King Jr./Charles R. Drew Medical Center, 12021 S. Wilmington Ave., Los Angeles, CA 90059-3019. Phone: (310) 668-4536; fax: (310) 337-0131; e-mail: rfozborne@aol.com.
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Article Details
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Author:Brown, Jimmy
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Jan 1, 2003
Words:1381
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