TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.
Background
Angioedema is defined as acute onset subcutaneous nonpitting or watery edema commonly localizing to the airway structures. Angioedema can be hereditary (C1 esterase deficiency) or acquired (angiotensin-converting enzyme inhibitors [ACEI], allergic reactions, and idiopathic etiologies). Regardless of etiology, the clinical presentation is similar but will vary in severity. In the head and neck, the face, lips, palate, and tongue are the most commonly involved subsites, with laryngeal involvement occurring less frequently (Laryngoscope. 2000;110:2016–2019). Depending on the sites of involvement and symptoms, patients can be stratified and managed accordingly.
Flexible laryngoscopy (FL) is a critical part of the angioedema workup because it localizes and qualifies the extent of airway involvement. Ideally, it would be used in cases that are suspicious for airway involvement. In practice, however, it is common to find that every patient presenting with angioedema will undergo FL, even when edema is limited to one facial subsite without airway symptoms. FL is generally a safe and efficient way to quickly evaluate the airway structures, so it is vulnerable to overuse. Theoretical complications associated with FL include epistaxis, emesis, aspiration, lacerations, ecchymoses, and perforations. These complications are rare and do not typically warrant deferral of the procedure. Patients more commonly report pain in the nose and throat, as well as discomfort in the forms of gagging sensation and/or transient dyspnea. Alternative forms of imaging used to evaluate the function of the larynx and vocal fold mobility include computed tomography scans and magnetic resonance imaging. However, they are not as useful in cases of angioedema, because they are not feasible as modalities of point-of-care testing. They take longer to perform, require nonportable advanced equipment, and tend to be more expensive than FL. The purpose of this review was to query the literature in an attempt to stratify patients who present with angioedema of any etiology of the head and neck into groups that do or do not need an endoscopic airway evaluation.
Best Practice
Patients with isolated face and lip angioedema, with no signs/symptoms of laryngeal and pharyngeal involvement, can be individually assessed for the need of FL. Symptomatic patients or those with multiple subsite involvement or oropharyngeal involvement require FL.