Supraglottic oedema and cocaine crack abuse
Editor—Many serious medical complications1 2 and anaesthetic considerations3 have been described in cocaine abuse. Several cases of burn injuries of the larynx have been reported, presenting usually with acute laryngeal symptoms.4 We report a case of supraglottic oedema without the specific symptoms of acute laryngeal distress, discovered incidentally in a crack cocaine addict patient during assessment for general anaesthesia before lung cancer surgery.A 70-yr-old man was admitted with a 2 week history of haemoptysis, without dyspnoea or stridor. He was an alcoholic and a heavy smoker with overt signs of chronic obstructive pulmonary disease. Investigations revealed a right lung carcinoma. During fibreoptic bronchoscopy, a supraglottic oedema was noted. The patient was undergoing right pulmonary resection. During the preoperative anaesthesia assessment, he admitted smoking and sniffing large quantities of crack cocaine for the past 18 yr, most recently 2 days ago. He denied having any history of pharyngeal or laryngeal symptoms. He noted having a few episodes of chest pain, within hours of a large dose of crack, which resolved after sublingual nitroglycerin. He never had general anaesthesia before. His physical examination revealed no evidence of respiratory distress, pain, or injury to the tongue, palate or oral surfaces. Preoperative investigations were all within the normal range. The supraglottic oedema prompted us to perform a fibreoptic laryngoscopy immediately before induction of anaesthesia. It revealed atrophy of the nasal mucosa and perforation of the nasal septum. The oral mucosa appeared normal. A supraglottic oedema with mucosal thickening was noted, involving the epiglottis as well as the aryepiglottic, arytenoid and false vocal folds, causing marked impairment of the mobility of both vocal cords. The otolaryngologist was confident however, that a tracheal tube could be inserted. After i.v. administration of propofol 200 mg, fentanyl 100 µg and suxamethonium 100 mg, the trachea was smoothly intubated under direct laryngoscopy with a 6.0 mm cuffed microlaryngeal tube. The supraglottic area was exposed again for biopsies and bacteriology swabs. Frozen section revealed oedematous changes without evidence of malignancy. We decided that a tracheostomy should be done before lung surgery because: (i) the insertion of a double-lumen endobronchial tube (DLET) in an oedematous larynx could be traumatic; (ii) the airway may be compromised following extubation; and (iii) impaired mobility of the vocal cords could interfere with coughing and clearing of bronchial secretions after operation. Following insertion of a short left DLET, right lung resection was performed with one lung ventilation, with invasive monitoring, under general anaesthesia and thoracic epidural analgesia. Antibiotics and i.v. steroids were given. The perioperative period was uneventful. Pathology of the laryngeal biopsies revealed fibrosis with non-specific oedematous changes. Fibreoptic laryngoscopy 4 days later showed marked improvement of the upper airway oedema allowing successful removal of the tracheostomy tube.
To our knowledge, this is the first incidentally discovered case of cocaine-related supraglottic oedema in a crack addict patient. Cocaine burns of the upper airway have been reported in 22 cases, with various and sometimes puzzling clinical manifestations, but with related symptoms such as hoarseness, dysphonia, odynophagia, dysphagia or stridor.4 5 In our opinion, the anaesthetic management helped in the uneventful course of the surgery. Recommendations concerning acute laryngeal oedema are controversial and range from observation in the ICU, with or without local anaesthetics, steroids and antibiotics, to intubation or tracheostomy.6 7
The fortuitous discovery of this patient's laryngitis adds another insidious clinical presentation that anaesthetists should be aware of in any patient with a history of drug abuse. Even in the absence of evident laryngeal symptoms or respiratory distress, we recommend careful history and discussion between the anaesthetist and otolaryngologist for adequate airway management before surgery.
Beirut, Lebanon
*E-mail: fflhlb{at}yahoo.com
References
1 Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med 1990; 88:325–31[CrossRef][ISI][Medline]
2 Cregler LL and Mark H. Medical complications of cocaine abuse. N Engl J Med 1886; 315:1495–500
3 Kuczkowski KM. The cocaine abusing parturient: a review of anesthetic considerations. Can J Anesth 2004; 51:145–54
4 Osborne R, Avitia S, Zandifar H, Brown J. Adult supraglottitis subsequent to smoking crack cocaine. Ear Nose Throat J 2003; 82:53–5[Medline]
5 Snyderman C, Weissmann J, Tabor E, Curtin H. Crack cocaine burns of the larynx. Arch Otolaryngol Head Neck Surg 1991; 117:792–5[Abstract]
6 Savitt DL and Colagiovanni S. Crack cocaine-related epiglottitis. Ann Emerg Med 1991; 20:322–3[ISI][Medline]
7 Silverman RS, Lee-chiong TL, Sherter CB. Stridor from edema of the arytenoids, epiglottis, and vocal cords after use of free-base cocaine. Chest 1995; 108:1477–8
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