fluticasone and Laryngitis

Inhaled corticosteroids (ICS) have become the prevalent treatment in asthmatics. Hazards to voice are under-recognized. A total of 38 patients with voice complaints associated with the use of ICS were assessed by 79 strobovideolaryngoscopy (SVL) examinations, 24 single and 14 multiple SVL. Hoarseness and dysphonia were the primary reasons for referral. The ICS initially used most frequently was Advair Diskus (fluticasone propionate and salmeterol-inhalation powder-[IP]) in 22 patients, followed by Flovent (fluticasone propionate inhalation aerosol-pressurized metered-dose inhaler-[PMDI]) in 11. Duration of ICS usage varied from 2 weeks to 4-5 years. Higher dosage and frequency of use exacerbated problems. Hazards to voice previously unrecognized by real-time indirect mirror or fiberoptic laryngoscopy were identified by meticulous attention to SVL abnormalities. There was essentially no difference in occurrence of abnormalities whether analyzed from the perspective of the initial 38 or all 79 examinations. These included abnormal mucosal wave symmetry/periodicity (76-63%), phase closure (74-63%), glottic closure (63-59%), mucosal wave amplitude/magnitude (50-35%), supraglottic hyperactivity (39-25%), mucosal quality (34-34%), and glottic plane (10-5%). Candidiasis of the larynx was infrequently observed. Fluticasone ICS were a cause of steroid inhaler laryngitis, and the best treatment was their avoidance or cessation. Further prospective studies ideally might include SVL documented as a pretherapy baseline and then repeated in each ICS patient who developed hoarseness/dysphonia.

Topics: Administration, Inhalation; Adolescent; Adrenal Cortex Hormones; Adult; Aged; Aged, 80 and over; Androstadienes; Female; Fluticasone; Glottis; Hazardous Substances; Hoarseness; Humans; Laryngitis; Laryngoscopy; Male; Metered Dose Inhalers; Middle Aged; Severity of Illness Index; Voice

At the conclusion of this article, the readers should be able to 1) describe the laryngeal findings in patients who use combination therapy for asthma, 2) discuss the mechanism of laryngeal irritation from the use of inhalers, and 3) describe possible mechanisms for reducing laryngeal irritation and secondary dysphonia from the use of inhalers.. To describe voice changes and laryngeal findings in patients who are started on combination corticosteroid and bronchodilator therapy in the form of a dry powder inhaler (DPI).. Retrospective, single-subject design.. Retrospective review of 10 consecutive patients meeting inclusion criteria, who presented at the voice center with more than 4 weeks of dysphonia after being started on a combination form of asthma medication for control and maintenance therapy. All patients were nonsmokers and without history of previous identification or excision of vocal pathology. All patients were treated previously with a proton pump inhibitor for gastroesophageal reflux. Laryngeal videostroboscopic evaluations were performed on all patients. Patients were asked to complete a questionnaire regarding their perceived voice change and history of medical maintenance therapy for asthma.. Dysphonia was present in the patients selected for greater than 4 weeks. Patients had been switched to combination therapy after previously using traditional two-drug asthma regimens. In eight of nine patients, the vocal folds demonstrated areas of hyperemia, with plaque-like changes on the surface mucosa. Reduced amplitude of vibration and a reduction in mucosal wave propagation were present on videostroboscopy. Questionnaires revealed that all patients were initiated on combination DPI treatment within the last 6 months.. Dysphonia caused by a change in the surface mucosa is a side effect from the use of DPI therapy for asthma. The high-impact force during inhalation of the medication and carrier leads to deposition of particles in the upper airway. We believe the extent of mucosal irritation can be minimized by patient education in the proper delivery of DPI. In some cases, however, return of the two medications delivered separately was necessary. The irritation of the laryngeal mucosa and return of normal vibratory parameters occurred in all patients.

Topics: Adrenal Cortex Hormones; Adrenergic beta-Agonists; Adult; Aged; Aged, 80 and over; Albuterol; Androstadienes; Asthma; Bronchodilator Agents; Dilatation, Pathologic; Drug Therapy, Combination; Female; Fluticasone; Hemorrhage; Humans; Laryngeal Diseases; Laryngeal Edema; Laryngeal Neoplasms; Laryngitis; Laryngoscopy; Larynx; Leukoplakia; Male; Middle Aged; Precancerous Conditions; Salmeterol Xinafoate; Vocal Cords; Voice Disorders

To describe a condition that is referred to as steroid inhaler laryngitis, a clinical entity that is caused by the use of inhaled fluticasone propionate and manifested by dysphonia, throat clearing, and fullness.. Case series.. An outpatient clinic of an academic referral center.. The study population consisted of 20 patients with reactive airway disease and dysphonia who were receiving inhaled fluticasone therapy and who were diagnosed as having steroid inhaler laryngitis during the period from January 1998 to June 2000.. Cessation of inhaled fluticasone therapy when possible, as well as treatment of other underlying causes of dysphonia, such as laryngopharyngeal reflux and infectious processes.. The resolution of dysphonia with cessation of inhaled fluticasone therapy.. Patients with steroid inhaler laryngitis were found to have laryngeal findings ranging from mucosal edema, erythema, and thickening to leukoplakia, granulation, and candidiasis. Patients with more severe mucosal findings were more likely to have laryngopharyngeal reflux as well. Resolution of dysphonia occurred only after discontinuation of the inhaled fluticasone therapy.. Steroid inhaler laryngitis is a form of chemical laryngopharyngitis induced by topical steroid administration. Symptoms and physical findings mimic laryngopharyngeal reflux, but only respond completely to discontinuation of the inhaled steroid therapy. The otolaryngologist should be familiar with this cause of dysphonia.

Topics: Administration, Inhalation; Adult; Androstadienes; Anti-Inflammatory Agents; Female; Fluticasone; Humans; Laryngitis; Laryngoscopy; Male; Middle Aged; Voice Disorders