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1 Anatomy of the upper airway Coronal Section of Nasal Turbinates - PDF document

Jun 15, 2023 •226 likes •391 views

Upper Airway Responses to Occupational and Environmental Exposures Disclosures: None Dennis Shusterman, MD, MPH Professor of Clinical Medicine, Emeritus UCSF Division of Occupational & Environmental Medicine Topics to be covered: Anatomy

  1. Upper Airway Responses to Occupational and Environmental Exposures Disclosures: None Dennis Shusterman, MD, MPH Professor of Clinical Medicine, Emeritus UCSF Division of Occupational & Environmental Medicine Topics to be covered: Anatomy of the upper airway  Structure & function in the upper airway  Spectrum of upper airway conditions  Inflammatory  Functional  Impact of rhinitis  Direct  Indirect 1

  2. Anatomy of the upper airway Coronal Section of Nasal Turbinates Turbinates Courtesy of Wytske Fokkens, MD Sensation Functions of the Upper Airway Ethmoidal  Sensation Olfactory N. N.  Air conditioning Infraorbital  Filtering / scrubbing N.  Communication Maxillary N. Source: Frasnelli J, Hummel T, Shusterman D. Clinical disorders of the trigeminal system. In: Welge- Luessen A & Hummel T (eds.): Management of Smell and Taste Disorders. NY: Thieme, 2014. 2

  3. Scrubbing Filtering Source: Shusterman D. Current Allergy Asthma Rep 2003;3:258 . Shusterman D: Current Allergy Asthma Rep 2003;3:258. Spectrum of upper respiratory tract health effects:  Rhinitis  Sinusitis  Pharyngitis CASE 1  Otitis media  Laryngitis 3

  4. HPI  21 y.o.m. fiberglasser / boat painter referred to Occ Med Clinic for skin complaints. • Began current job 21 mos. prior; onset within ~ 1 month of nasal congestion, rhinorrhea, nasal stuffiness. 21 y.o.m. fiberglasser / boat painter with skin rash, wheezing, nasal congestion • Gradual increase of respiratory sxs, incl. chest tightness, wheezing, cough, exertional dyspnea. & decreased sense of smell • 16 mos. post-hiring, c/o rash starting on forearms and spreading to hands. Also developed a rash on face, involving skin of the forehead & swelling of eyelids. Occ Hx HPI, cont’d  Job title: Finish fiberglasser + Boat painter  Tasks :  Saw PCP for rash: Rx’d oral and topical steroids, no w/u of resp sxs. Mixing epoxy putty & applying to defects in hulls. • Spraying epoxy primer on hulls. •  Seen again 4 mos. later, with same tx and Sanding hulls. • referral to HMC.  PPE :  On evaluation at HMC, gave neg. PHx of Skin: • allergic rhinitis or asthma Latex or nitrile gloves (visible permeation of liquids) → Respiratory: • - Half-face cartridge respirator when sanding - Full-face cartridge respirator when spraying 4

  5. Physical Exam Physical Exam  HEENT  CHEST Nares - mucosal swelling (L>R) + mucus stranding Lungs clear, no wheezing or crackles • • Mild tap tenderness bilaterally over maxillary •  SKIN sinuses. Lichenification & erythema on the dorsum of both • Prominent reddening of the external nares • hands and on the forehead Patient is observed to be nose-blowing on a frequent • basis during the examination. Screening Spirometry Presumptive diagnoses? (off work 3 days) :  Upper airway Baseline:  Rhinitis • FVC = 5.04 L (90% predicted) → Sinusitis FEV 1 = 4.14 L (89% predicted) → Conductive olfactory loss FEV 1 /FVC ratio = 0.82  Lower airway Decreased peak flow (52% predicted). Occupational asthma • Post-bronchodilator:   Skin FVC increased 1% and FEV 1 7% (i.e., < 12%). Allergic contact dermatitis • 12% increase in FEF 25-75 and 39% increase in peak expiratory flow… 5

  6. Diagnostic tests pending…  Upper airway CT of sinuses •  Lower airway Full PFT’s (w/volumes and DLco) Upper airway diagnostics • Methacholine challenge • Ambulatory peak flows •  Skin Referral for patch testing • CT of sinuses - Mild bilateral maxillary, ethmoid & sphenoid mucosal thickening. - L oseomeatal complex & area surrounding L Lower airway diagnostics turbinates completely opacified. - Imp: Poss. polyposis ORL Consult: No polyps; non-surgical case. 6

  7. PEF Log Methacholine challenge 600 500 400 PEF (L/min) 300 200 100 0 W ork days Patch testing Dermatologic diagnostics Images courtesy of Marshall Welch, MD 7

  8. Plan Confirmed diagnoses  Medical removal  Upper airway  Anti-inflammatory meds :  Rhinitis → Sinusitis • Inhaled steroids → [prob.] Conductive olfactory loss → (fluticasone 110 mcg, 4 puffs a day)  Lower airway • Nasal steroids  Occupational asthma → (fluticasone, one puff bilaterally, BID)  Skin • Topical steroids  Allergic contact dermatitis → (TAC 0.1% ointment) Serial methacholine challenges 10 5 5 2.5 1 Clinical Course PC 20 0.1 0.025 0.01 0 1 2 3 4 5 6 Months 8

  9. Unified Airway Hypothesis “Take-home” points from case: Nasal congestion  √ Mouth breathing  Nasal symptoms were the first indication that  Loss of air conditioning sensitization was occurring (w/i ~ 1 month). Naso-bronchial reflex √ Chest symptoms occurred next (“gradual onset”), - Cough  and were neither reported nor worked up. - Laryngospasm - Bronchoconstriction Dermal symptoms occurred last (16 mos.), and  Aspiration of secretions √ were the first occasion for medical workup. Immunologic signaling √ Could routine medical surveillance could have  Rhinitis associated with (and √ triggered medical removal before significant frequently precedes) asthma impairment occurred in this case? Source: Widdicombe J. in: Mathew O. & Sant’Ambrogio G. (eds.): Respiratory Function of the Upper Airway. NY , Marcel Dekker, 1988. Classification of Work-related Rhinitis Occupational Allergens Antigen / product Occupation HMW Natural rubber latex Health care workers Psyllium Pharmacists, nurses Animal proteins Animal handlers, Vets Flour,  -amylase, mites Bakers Gum arabic Printers Mold spores Various ----------------------------------------------------------------- LMW Collophony (rosin) Solderers Western Red Cedar Sawyers Acid anhydrides Plastics workers Diisocyanates Car painters, shippers, boat building Source: Moscato et al. EAACI Task Force, Allergy 2008; 63: 969-980. 9

  10. Occupational Sinusitis  Furriers Ag  Spice workers Sinusitis  Vegetable picklers  Hemp workers Mucosal Ostial Infection Swelling Occlusion  Grain and flour workers Irritants Source: Shusterman D. Current Allergy Asthma Rep 2003;3:258 . Otitis media & second-hand smoke Ag Sinusitis Mucosal Ostial Infection Swelling Occlusion Otitis Media Irritants 10

  11. Case 2 Eustachian tube dysfunction: Occupational implications ID: 30 y.o.m. railroad switchman CC: “Choking sensation” and upper chest tightness  Aviation / aerospace  Commercial divers PI: Seen @ UW 4 mos. s/p exposure to burning rubbish in railroad car. 10-15 min. smoke exposure while moving LPG-containing  Caisson workers tank cars to avoid explosion hazard. C/o acute eye, nose & throat irritation, cough, nausea and anxiety at time of exposure. Case 2 Case 2 PI: Seen acutely in ER: PI: Seen in f/ u by pulmonologist: - VS: 124/86; 80; 18; pulse ox = 97% - Nl. PE, including chest exam - “very occasional expiratory wheeze” - Rx’d beclomethasone & fomoterol MDIs - Neg. CXR - ABGs: - Failed RTW COHb = 1% - PFTs and methacholine challenge… PO 2 = 84 (94% O 2 sat) PCO 2 = 31 HCO3 = 22 pH = 7.47 - Rx’d albuterol MDI “for cough” 11

  12. Case 2 Case 2 PI: At time of UW consult, experiencing episodic  Mechanics “choking sensation,” inspiratory dyspnea, upper FEV 1 5.28 (111%) • chest tightness, & nausea with exposure to diesel FVC 5.28 (99%) exhaust, perfumes & household cleaning prods. • Temp. disability secondary to above. Ratio 93% • FEF 25-75 7.10 (151%) • PHx: Pos. allergic rhinitis Hx. / Neg. asthma Hx. No reported GERD symptoms Smoked 1 ppd x 8 years; quit 8 years prior  Lung Volumes to incident; currently chewing tobacco. TLC 6.70 (95%) • H/o mild intermit. depression, on bupropion RV 1.79 (108%) •  DLco 32.3 (77%)  DLco/VA 5.06 (84%) Case 2 Case 2 What diagnostic test is indicated? Methacholine Challenge: PD 20 >> 8 mg/mL 12

  13. Case 2 Vocal cord dysfunction (VCD) a.k.a. “Paradoxical vocal cord motion” “Paradoxical vocal fold motion” Expiration Inspiration Source: Shusterman D. Review of the upper airway, Including olfaction, as mediator of symptoms. Environ Health Perspect 2002; 110(suppl 4):649–653. Vocal cord dysfunction (VCD) F/U: Patient underwent biofeedback training with speech pathologist and progressed to the point  Definition: Abnormal vocal cord motion that he could tolerate use of bleach solution (inappropriate adduction during inspiration) (sodium hypochlorite) with minimal symptoms.  Sxs: Inspiratory dyspnea, cough, Continued to experience episodic symptoms when Stridor (sometimes mistaken for wheeze), exposed to railroad flare smoke or second-hand smoke at work. Globus, hoarseness Obtained employment as a driver for a medical lab.  Risk factors: Post-nasal drip (2 o rhinosinusitis) • GERD • Psychological factors • Morbidity includes misdiagnosis as asthma  13

  14. Irritant-associated VCD (IVCD) Case Definition • S/p acute irritant exposure • Onset Sxs within 24 hours • No PHx VCD or other laryngeal disease • Laryngoscopy confirmed Perkner et al., JOEM 1998; Vol.: pp-pp Obstructive Sleep Apnea: Spectrum of upper respiratory tract Starling Resistor Model health effects:  Rhinitis  Sinusitis  Pharyngitis  Otitis media  Laryngitis ----------------------  VCD  Sensory irritation Source: Shusterman D et al. J Allergy Clin Immunol Pract . 2017 (In Press)  OSA 14

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