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
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
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
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
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
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
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
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
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
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
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
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
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
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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