Laryngeal findings in users of combination corticosteroid and bronchodilator therapy.
OBJECTIVE
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.


OBJECTIVE
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).


METHODS
Retrospective, single-subject design.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA. natasha.mizra@uphs.upenn.edu
Natasha
N
Mirza
Sandra
S
Kasper Schwartz
Danielle
D
Antin-Ozerkis
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects*; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage / Q000009:adverse effects*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000420:Albuterol / Q000008:administration & dosage / Q000009:adverse effects* / Q000031:analogs & derivatives*; D000730:Androstadienes / Q000008:administration & dosage / Q000009:adverse effects*; D001249:Asthma / Q000188:drug therapy*; D001993:Bronchodilator Agents / Q000008:administration & dosage / Q000009:adverse effects*; D004108:Dilatation, Pathologic / Q000139:chemically induced / Q000175:diagnosis; D004359:Drug Therapy, Combination; D005260:Female; D000068298:Fluticasone; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis; D006801:Humans; D007818:Laryngeal Diseases / Q000139:chemically induced* / Q000175:diagnosis; D007819:Laryngeal Edema / Q000139:chemically induced / Q000175:diagnosis; D007822:Laryngeal Neoplasms / Q000139:chemically induced / Q000175:diagnosis; D007827:Laryngitis / Q000139:chemically induced / Q000175:diagnosis; D007828:Laryngoscopy; D007830:Larynx / Q000187:drug effects* / Q000473:pathology; D007971:Leukoplakia / Q000139:chemically induced / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D011230:Precancerous Conditions / Q000139:chemically induced / Q000175:diagnosis; D000068299:Salmeterol Xinafoate; D014827:Vocal Cords / Q000187:drug effects / Q000473:pathology; D014832:Voice Disorders / Q000139:chemically induced* / Q000175:diagnosis
D000305:Adrenal Cortex Hormones; D000318:Adrenergic beta-Agonists; D000730:Androstadienes; D001993:Bronchodilator Agents; D000068299:Salmeterol Xinafoate; D000068298:Fluticasone; D000420:Albuterol