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