bvand086/sciwritingdataset · Datasets at Hugging Face

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given nebulized albuterol, nebulized racemic epinephrine,and high-dose intravenous dexamethasone
Flexible naso-laryngoscopy revealed watery edema emanating from theinjection site and involving the arytenoid cartilage
Therewas no red discoloration or other evidence of hematoma.The patient was not on therapeutic anticoagulation, she didnot have a thrombocytopenia, nor did she have a known
history of coagulopathy
Due to the severity of edema, acute
onset of symptoms and degree of respiratory distress, thepatient was intubated for airway management and treatedwith intravenous high dose corticosteroids, 10 mg dexa-methasone every 8 hours
Positive airway pressure was notutilized prior to intubation as there was concern regardingthe rapid progression
While post-injection infection shouldalways remain on the differential in these types of cases, we
deferred use of antibiotics in this patient given the rapid
onset of symptoms with watery laryngeal edema, withoutother clinical signs of infection such as fever, leukocytosis,neck pain and erythema
On intubation day 12, the patientwas brie ﬂy extubated and displayed reduced edema on
exam ( Figure 1 ); however, the patient was re-intubated the
following day due to oxygen desaturation and tachypnea,presumably due to remaining laryngeal edema noted on
Functional Endoscopic Evaluation of Swallowing (FEES)
performed by the speech language pathology service duringa swallow evaluation after extubation
The patient thereforeunderwent tracheostomy for prolonged intubation, whichwas subsequently decannulated in a skilled nursing facilitywithin a month after discharge from the hospital
In total,the patient ’s hospital course was 33 days.
On outpatient follow up, ﬂexible nasolaryngoscopy
demonstrated resolution of th e initial swelling; however,
the right vocal fold remained immobile and a smallglottis gap present
The patient noted mild persistentdysphagia but was tolerating a regular diet without sig-niﬁcant coughing, although on formal evaluation with
modi ﬁed barium swallow study, micro aspiration was
noted
The patient ’s voice has improved from immedi-
ately post-operative, but still exhibits mild dysphonia
characterized by hoarseness
The patient is awaiting
medialization thy roplasty for de ﬁnitive treatment of
vocal fold immobility.DISCUSSION
CMC is an anionic water-soluble polymer derived fromnative cellulose and is commonly used as an excipient inpharmaceutical preparations, foods, and cosmetics.
5It is
FDA approved in these settings and is generally consideredinert
There are several reports across the scienti ﬁc literature
of hypersensitivity reactions to CMC
Recently, Hotta et alsummarized the cases published in the literature, which
include reactions to CMC in lidocaine jelly, dimethicone
drops, and corticosteroid preparations.
6
This is the ﬁrst report of a local reaction to CMC causing
airway compromise following vocal fold injection augmen-tation
Laryngeal hematoma was another diagnosis we con-sidered, however our ﬂexible laryngoscopy examinations
following the event were inconsistent with this complicationas there was no red discoloration of the vocal fold
Further-
more, this patient did not have risk factors for hematoma
formation such as coagulopathies or treatment with thera-peutic anticoagulation
This patient did not have a historyof reactivity to CMC, and as this is the ﬁrst documented
reaction for vocal fold augmentation, an explanation relieson pharmacology and dermatology literature.
It is most likely that our patient had a type one hypersen-
sitivity reaction to CMC −an immune response that
requires an initial exposure to prime the immune system to
react on re-exposure
A study done by Mori et al found that10 of 387 randomly sampled patients were positive for anti-CMC IgE in their serum.
7Of those, half displayed hista-
mine reaction on skin testing
Unfortunately, an allergenskin test for CMC has not been performed on this patient, alimitation of this report
It is most likely that this patient ’s
initial exposure occurred during previous exposure to CMC
in parenteral medications or another substance containing
the material
CMC is not digested in the gut and thereforepoorly absorbed, making immune priming via CMC-
FIGURE 1
Supraglottic edema noted on post extubation ﬂexible
nasopharyngoscopy examination.ARTICLE IN PRESS
2 Journal of Voice, Vol
&&, No.&&, 2023
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2023
For personal use only
No other uses without permission
Copyright ©2023
Elsevier Inc
All rights reserved
containing food or beverage unlikely.8However, there have
been two reports of allergic reactions to CMC in food addi-tives, demonstrating that it is possible.
8,9CMC is found in a
variety of injectable medications, including the triamcino-lone acetonide preparation Kenacort-A and the lidocainepreparation Xylocaine Viscous
This patient may have been
exposed to a CMC-containing preparation such as these or
another CMC-containing compound during her recent sur-gery.
In comparison to similar treatment options, CMC appears
to have a lower risk of allergic reaction
Hyaluronic acid(HA), another commonly used short term vocal fold augmen-tation material, has a well-documented history of reactionsfollowing vocal fold injection.
10−16One possible explanation
for these reactions is that patients are reacting to the Strepto-
coccal bacterial proteins
The bacteria is used to manufacture
HA and trace amounts of bacterial proteins have been foundin HA products used for vocal fold augmentation.
17Mean-
while, CMC is manufactured by the alkali-catalyzed reactionof cellulose with chloroacetic acid, which does not involvebacteria.
5Interestingly, there have been several reported cases
of HA hypersensitivity following COVID-19 vaccination.18
The patient presented in this case had received her third doseof the P ﬁzer COVID-19 vaccine approximately 3 weeks prior

to her reaction to CMC, raising the possibility for a similarprocess
Prior to performing inj ection laryngoplasty, we sug-
gest that providers inquire about recent vaccination status, in
addition to known medication or substance allergies.
There are several other ways in which our management of
this patient could have been improved
First, we could have

given nebulized albuterol, nebulized racemic epinephrine,and high-dose intravenous dexamethasone

Flexible naso-laryngoscopy revealed watery edema emanating from theinjection site and involving the arytenoid cartilage

Therewas no red discoloration or other evidence of hematoma.The patient was not on therapeutic anticoagulation, she didnot have a thrombocytopenia, nor did she have a known

history of coagulopathy

Due to the severity of edema, acute

onset of symptoms and degree of respiratory distress, thepatient was intubated for airway management and treatedwith intravenous high dose corticosteroids, 10 mg dexa-methasone every 8 hours

Positive airway pressure was notutilized prior to intubation as there was concern regardingthe rapid progression

While post-injection infection shouldalways remain on the differential in these types of cases, we

deferred use of antibiotics in this patient given the rapid

onset of symptoms with watery laryngeal edema, withoutother clinical signs of infection such as fever, leukocytosis,neck pain and erythema

On intubation day 12, the patientwas brie ﬂy extubated and displayed reduced edema on

exam ( Figure 1 ); however, the patient was re-intubated the

following day due to oxygen desaturation and tachypnea,presumably due to remaining laryngeal edema noted on

Functional Endoscopic Evaluation of Swallowing (FEES)

performed by the speech language pathology service duringa swallow evaluation after extubation

The patient thereforeunderwent tracheostomy for prolonged intubation, whichwas subsequently decannulated in a skilled nursing facilitywithin a month after discharge from the hospital

In total,the patient ’s hospital course was 33 days.

On outpatient follow up, ﬂexible nasolaryngoscopy

demonstrated resolution of th e initial swelling; however,

the right vocal fold remained immobile and a smallglottis gap present

The patient noted mild persistentdysphagia but was tolerating a regular diet without sig-niﬁcant coughing, although on formal evaluation with

modi ﬁed barium swallow study, micro aspiration was

noted

The patient ’s voice has improved from immedi-

ately post-operative, but still exhibits mild dysphonia

characterized by hoarseness

The patient is awaiting

medialization thy roplasty for de ﬁnitive treatment of

vocal fold immobility.DISCUSSION

CMC is an anionic water-soluble polymer derived fromnative cellulose and is commonly used as an excipient inpharmaceutical preparations, foods, and cosmetics.

5It is

FDA approved in these settings and is generally consideredinert

There are several reports across the scienti ﬁc literature

of hypersensitivity reactions to CMC

Recently, Hotta et alsummarized the cases published in the literature, which

include reactions to CMC in lidocaine jelly, dimethicone

drops, and corticosteroid preparations.

6

This is the ﬁrst report of a local reaction to CMC causing

airway compromise following vocal fold injection augmen-tation

Laryngeal hematoma was another diagnosis we con-sidered, however our ﬂexible laryngoscopy examinations

following the event were inconsistent with this complicationas there was no red discoloration of the vocal fold

Further-

more, this patient did not have risk factors for hematoma

formation such as coagulopathies or treatment with thera-peutic anticoagulation

This patient did not have a historyof reactivity to CMC, and as this is the ﬁrst documented

reaction for vocal fold augmentation, an explanation relieson pharmacology and dermatology literature.

It is most likely that our patient had a type one hypersen-

sitivity reaction to CMC −an immune response that

requires an initial exposure to prime the immune system to

react on re-exposure

A study done by Mori et al found that10 of 387 randomly sampled patients were positive for anti-CMC IgE in their serum.

7Of those, half displayed hista-

mine reaction on skin testing

Unfortunately, an allergenskin test for CMC has not been performed on this patient, alimitation of this report

It is most likely that this patient ’s

initial exposure occurred during previous exposure to CMC

in parenteral medications or another substance containing

the material

CMC is not digested in the gut and thereforepoorly absorbed, making immune priming via CMC-

FIGURE 1

Supraglottic edema noted on post extubation ﬂexible

nasopharyngoscopy examination.ARTICLE IN PRESS

2 Journal of Voice, Vol

&&, No.&&, 2023

Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on September 07,

2023

For personal use only

No other uses without permission

Elsevier Inc

containing food or beverage unlikely.8However, there have

been two reports of allergic reactions to CMC in food addi-tives, demonstrating that it is possible.

8,9CMC is found in a

variety of injectable medications, including the triamcino-lone acetonide preparation Kenacort-A and the lidocainepreparation Xylocaine Viscous

This patient may have been

exposed to a CMC-containing preparation such as these or

another CMC-containing compound during her recent sur-gery.

In comparison to similar treatment options, CMC appears

to have a lower risk of allergic reaction

Hyaluronic acid(HA), another commonly used short term vocal fold augmen-tation material, has a well-documented history of reactionsfollowing vocal fold injection.

10−16One possible explanation

for these reactions is that patients are reacting to the Strepto-

coccal bacterial proteins

The bacteria is used to manufacture

HA and trace amounts of bacterial proteins have been foundin HA products used for vocal fold augmentation.

17Mean-

while, CMC is manufactured by the alkali-catalyzed reactionof cellulose with chloroacetic acid, which does not involvebacteria.

5Interestingly, there have been several reported cases

of HA hypersensitivity following COVID-19 vaccination.18

The patient presented in this case had received her third doseof the P ﬁzer COVID-19 vaccine approximately 3 weeks prior

to her reaction to CMC, raising the possibility for a similarprocess

Prior to performing inj ection laryngoplasty, we sug-

gest that providers inquire about recent vaccination status, in

addition to known medication or substance allergies.

There are several other ways in which our management of

this patient could have been improved

First, we could have