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

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

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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

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Upper Airway Responses to Occupational and Environmental Exposures

Dennis Shusterman, MD, MPH Professor of Clinical Medicine, Emeritus UCSF Division of Occupational & Environmental Medicine

Disclosures: None Topics to be covered:

  • Structure & function in the upper airway
  • Spectrum of upper airway conditions
  • Inflammatory
  • Functional
  • Impact of rhinitis
  • Direct
  • Indirect

Anatomy of the upper airway

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Anatomy of the upper airway

Turbinates

Coronal Section of Nasal Turbinates

Courtesy of Wytske Fokkens, MD

Functions of the Upper Airway

  • Sensation
  • Air conditioning
  • Filtering / scrubbing
  • Communication

Sensation

Maxillary N. Ethmoidal N. Infraorbital 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.

Olfactory N.

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3 Filtering

Source: Shusterman D. Current Allergy Asthma Rep 2003;3:258.

Scrubbing

Shusterman D: Current Allergy Asthma Rep 2003;3:258.

Spectrum of upper respiratory tract health effects:

  • Rhinitis
  • Sinusitis
  • Pharyngitis
  • Otitis media
  • Laryngitis

CASE 1

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4

21 y.o.m. fiberglasser / boat painter with skin rash, wheezing, nasal congestion & decreased sense of smell

  • 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.

  • Gradual increase of respiratory sxs, incl. chest

tightness, wheezing, cough, exertional dyspnea.

  • 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.

HPI HPI, cont’d

  • Saw PCP for rash: Rx’d oral and topical

steroids, no w/u of resp sxs.

  • Seen again 4 mos. later, with same tx and

referral to HMC.

  • On evaluation at HMC, gave neg. PHx of

allergic rhinitis or asthma

Occ Hx

  • Job title: Finish fiberglasser + Boat painter
  • Tasks :
  • Mixing epoxy putty & applying to defects in hulls.
  • Spraying epoxy primer on hulls.
  • Sanding hulls.
  • PPE:
  • Skin:

→

Latex or nitrile gloves (visible permeation of liquids)

  • Respiratory:
  • Half-face cartridge respirator when sanding
  • Full-face cartridge respirator when spraying
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5 Physical Exam

  • HEENT
  • Nares - mucosal swelling (L>R) + mucus stranding
  • Mild tap tenderness bilaterally over maxillary

sinuses.

  • Prominent reddening of the external nares
  • Patient is observed to be nose-blowing on a frequent

basis during the examination.

Physical Exam

  • CHEST
  • Lungs clear, no wheezing or crackles
  • SKIN
  • Lichenification & erythema on the dorsum of both

hands and on the forehead

Screening Spirometry

(off work 3 days) :

  • Baseline:

FVC = 5.04 L (90% predicted)

FEV1 = 4.14 L (89% predicted) FEV1/FVC ratio = 0.82 Decreased peak flow (52% predicted).

  • Post-bronchodilator:

FVC increased 1% and FEV1 7% (i.e., < 12%). 12% increase in FEF25-75 and 39% increase in peak expiratory flow…

Presumptive diagnoses?

  • Upper airway
  • Rhinitis

→ Sinusitis → Conductive olfactory loss

  • Lower airway
  • Occupational asthma
  • Skin
  • Allergic contact dermatitis
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6 Diagnostic tests pending…

  • Upper airway
  • CT of sinuses
  • Lower airway
  • Full PFT’s (w/volumes and DLco)
  • Methacholine challenge
  • Ambulatory peak flows
  • Skin
  • Referral for patch testing

Upper airway diagnostics CT of sinuses

  • Mild bilateral maxillary,

ethmoid & sphenoid mucosal thickening.

  • L oseomeatal complex

& area surrounding L turbinates completely

  • pacified.
  • Imp: Poss. polyposis

ORL Consult: No polyps; non-surgical case.

Lower airway diagnostics

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PEF Log

100 200 300 400 500 600 PEF (L/min) W ork days

Methacholine challenge

Dermatologic diagnostics Patch testing

Images courtesy of Marshall Welch, MD

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8 Confirmed diagnoses

  • Upper airway

 Rhinitis

→ Sinusitis → [prob.] Conductive olfactory loss

  • Lower airway

 Occupational asthma

  • Skin

 Allergic contact dermatitis

Plan

  • Medical removal
  • Anti-inflammatory meds:
  • Inhaled steroids

→ (fluticasone 110 mcg, 4 puffs a day)

  • Nasal steroids

→ (fluticasone, one puff bilaterally, BID)

  • Topical steroids

→ (TAC 0.1% ointment)

Clinical Course

Serial methacholine challenges

0.025 2.5 5 5 0.01 0.1 1 10 1 2 3 4 5 6 Months PC 20

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“Take-home” points from case:

  • Nasal symptoms were the first indication that

sensitization was occurring (w/i ~ 1 month).

  • Chest symptoms occurred next (“gradual onset”),

and were neither reported nor worked up.

  • Dermal symptoms occurred last (16 mos.), and

were the first occasion for medical workup.

  • Could routine medical surveillance could have

triggered medical removal before significant impairment occurred in this case?

√

Nasal congestion  Mouth breathing  Loss of air conditioning

√

Naso-bronchial reflex

  • Cough
  • Laryngospasm
  • Bronchoconstriction

√

Aspiration of secretions

√

Immunologic signaling

√

Rhinitis associated with (and frequently precedes) asthma

Source: Widdicombe J. in: Mathew O. & Sant’Ambrogio G. (eds.): Respiratory Function of the Upper Airway. NY , Marcel Dekker, 1988.

Unified Airway Hypothesis

Occupational Allergens

Antigen / product Occupation Natural rubber latex Health care workers Psyllium Pharmacists, nurses Animal proteins Animal handlers, Vets Flour, -amylase, mites Bakers Gum arabic Printers Mold spores Various

  • Collophony (rosin)

Solderers Western Red Cedar Sawyers Acid anhydrides Plastics workers Diisocyanates Car painters, shippers, boat building HMW LMW

Source: Moscato et al. EAACI Task Force, Allergy 2008; 63: 969-980.

Classification of Work-related Rhinitis

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Mucosal Swelling Ostial Occlusion Ag Infection Irritants Sinusitis

Occupational Sinusitis

  • Furriers
  • Spice workers
  • Vegetable picklers
  • Hemp workers
  • Grain and flour workers

Source: Shusterman D. Current Allergy Asthma Rep 2003;3:258.

Mucosal Swelling Ostial Occlusion Ag Infection Irritants Otitis Media Sinusitis

Otitis media & second-hand smoke

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Eustachian tube dysfunction: Occupational implications

  • Aviation / aerospace
  • Commercial divers
  • Caisson workers

ID: 30 y.o.m. railroad switchman CC: “Choking sensation” and upper chest tightness PI: Seen @ UW 4 mos. s/p exposure to burning rubbish in railroad car. 10-15 min. smoke exposure while moving LPG-containing tank cars to avoid explosion hazard. C/o acute eye, nose & throat irritation, cough, nausea and anxiety at time of exposure.

Case 2

PI: Seen acutely in ER:

  • VS: 124/86; 80; 18; pulse ox = 97%
  • “very occasional expiratory wheeze”
  • Neg. CXR
  • ABGs:

COHb = 1% PO2 = 84 (94% O2 sat) PCO2 = 31 HCO3 = 22 pH = 7.47

  • Rx’d albuterol MDI “for cough”

Case 2

PI: Seen in f/ u by pulmonologist:

  • Nl. PE, including chest exam
  • Rx’d beclomethasone & fomoterol MDIs
  • Failed RTW
  • PFTs and methacholine challenge…

Case 2

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12 Case 2

PI: At time of UW consult, experiencing episodic “choking sensation,” inspiratory dyspnea, upper chest tightness, & nausea with exposure to diesel exhaust, perfumes & household cleaning prods.

  • Temp. disability secondary to above.

PHx:

  • Pos. allergic rhinitis Hx. / Neg. asthma Hx.

No reported GERD symptoms Smoked 1 ppd x 8 years; quit 8 years prior to incident; currently chewing tobacco. H/o mild intermit. depression, on bupropion

  • Mechanics
  • FEV1

5.28 (111%)

  • FVC

5.28 (99%)

  • Ratio

93%

  • FEF25-75 7.10

(151%)

  • Lung Volumes
  • TLC

6.70 (95%)

  • RV

1.79 (108%)

  • DLco

32.3 (77%)

  • DLco/VA

5.06 (84%)

Case 2

Methacholine Challenge: PD20 >> 8 mg/mL

Case 2

What diagnostic test is indicated?

Case 2

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Inspiration Expiration

Case 2

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) a.k.a. “Paradoxical vocal cord motion” “Paradoxical vocal fold motion”

Vocal cord dysfunction (VCD)

  • Definition: Abnormal vocal cord motion

(inappropriate adduction during inspiration)

  • Sxs: Inspiratory dyspnea, cough,

Stridor (sometimes mistaken for wheeze), Globus, hoarseness

  • Risk factors:
  • Post-nasal drip (2o rhinosinusitis)
  • GERD
  • Psychological factors
  • Morbidity includes misdiagnosis as asthma

F/U: Patient underwent biofeedback training with speech pathologist and progressed to the point that he could tolerate use of bleach solution (sodium hypochlorite) with minimal symptoms. Continued to experience episodic symptoms when exposed to railroad flare smoke or second-hand smoke at work. Obtained employment as a driver for a medical lab.

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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: Starling Resistor Model

Source: Shusterman D et al. J Allergy Clin Immunol Pract. 2017 (In Press)

Spectrum of upper respiratory tract health effects:

  • Rhinitis
  • Sinusitis
  • Pharyngitis
  • Otitis media
  • Laryngitis
  • VCD
  • Sensory irritation
  • OSA
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15 Why is rhinitis important?

  • Prevalence & Cost
  • Quality-of-life (QOL)
  • Upper airway sequelae
  • Sinusitis
  • Olfactory loss (safety)
  • Eustachian tube dysfunction
  • VCD risk factor (PND)
  • OSA risk factor (obstruction)
  • Lower airway sequelae (“unified airway”)
  • Asthma

Q.1. Which one of the following symptoms is typically shared between asthma and VCD?

A.

Episodic dyspnea

B.

Stridor

C.

Hoarseness

  • D. Globus sensation

Q.2. Hyperreactivity in the upper & lower airways may be linked by all of the following except…

A.

Aspiration of sino-nasal secretions

B.

Naso-bronchial (neural) reflexes

C.

Shared cell signaling molecules in nose & lung

  • D. Local antibody production

Q.3. The Starling resistor model may help explain the link between rhinitis and:

A.

Asthma

B.

Pulmonary hypertension

C.

Obstructive sleep apnea (OSA)

  • D. Sinusitis