Functional Upper Airway Obstruction

Functional Upper Airway Obstruction*

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Psychogenic Pharyngeal Constriction Atsushi Nagai, M.D ., EC .C .P.; Erika Yamaguchi , M.D .; Kyoichi Sakallwto , M.D. ; and Eikoh Takahashi , M.D .

A 15-year-01d boy, \mown to have asthma, developed acute inspiratory airway obstruction with marked stridor. Spirometry indicated extrathoracic airway obstruction and a broncho6beroptic examination disclosed narrowing in the hypopharynx. After administration of sedatives, the stridor suddenly disappeared. Psychotherapy decreased the frequency of subsequent stridor attacks. It is suggested that psychogenic pharyngeal constriction may have caused the upper airway obstruction with respiratory distress. (Chest 1992; 101:14(j{)·61)

A

number of causes of inspiratory airway obstruction have been reported . I Most of them are due to organic abnormalities such as inflammation, trauma, edema and tumors. An uncommon cause of reversible airway obstruction which has been reported is abnormal motion of the vocal cords., .s The case we present here had inspiratory airflow obstruction with stridor due to pharyngeal constriction, and to our knowledge , this has never been previously reported . CASE REPORT

A I5-year-old boy, known to have asthma, was admitted to our hospital complaintng of severe shortness of breath that had started several hours before. On examination he had marked insp iratory stridor, but on auscultation rhonchi were not audible anywhere in the chest. Spirometry revealed a decreased airflow and a plateau configuration with a wave at the inspiratory portion, but a nearly normal loop at the expiratory portion, indicating extrathoraeic airway obstruction (Fig 1). During the actual stridor bronchofiberseopy was performed on the patient without anesthesia, and during the inspiratory phase considerable narrowing in the hypopharynx with an abnormally shaped (round) tremulous epiglottis was revealed (Fig 2). There was no abnormality in the glottis, vocal cords or trachea , Chest roentgenogram , ECG and routine laboratory tests were all normal. Neurologic examination including EEG and computed axial tomography were normal. Arterial blood gas value analysis revealed an acute respiratory alkalosis with a normal PaD, . lie was treated with aminophylline and steroid injection, inhalation of betaj-adrenoeeptor agonists and anticholinergic agents and gargling with atropine sulfate and lidocaine. All of these treatments were unsuccessful and the stridor did not improve. Finall y, he was given 10 mg of diazepam intramuscularly and 30 min after the injection his stridor suddenly stopped. A psychiatric evaluation suggested a depressed state. He was discharged after two days in the hospital and thereafter he required frequent emergency treatment with sedatives for stridor attacks. He is currently undergoing psychotherapy and the frequency of the stridor attacks is decreasing.

expiration FLOW liter/sec

TLC

RV liter

4

inspiration Fll;l'Iu: 1. Flow-volume loop, showing normal expiratory flows and markedly decreased inspiratory flows (indicating extrathoracic airway obstruction).

abnormally shaped epiglottis that trembled during the inspiratory phase. Upper airway obstruction is relatively rare in adolescents. The etiology of this condition may be due to inflammation, trauma, neoplasm, allergic reaction and neurologic impairment. In 1974, Patterson et al" designated such cases without organic abnormalities as Munchausen's stridor, and thereafter an increasing number of reports have been documented .. -s.r-s Most of the reported cases were found to have an abnormal (paradoxical) movement of the vocal cords. However, our case showed obvious severe narrowing in the hypopharynx with abnormal shape and movement of the epiglottis, leading to inspiratory stridor, but without abnormality in the glottis, vocal cords or trachea. And there was no evidence of vocal cord adduction during the episodes of stridor. What causes the functional (reversible) pharyngeal con-

DISCUSSION

We present a case with marked inspiratory stridor which was induced by pharyn~eal constriction associated with an *Fnnn the Department of Respiratory Medicine, Ohara Medical Center, First Department of Medicine. Tokyn Women's Medical College, Tokyo, Japan . Reprint requests : Dr. Nagai , 1st Department of Medicine, Tokyo WomenS Medical College, 8-1 Kaioadacho , Shinjuku , Tokyo, }a,)(/n

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FIGURE 2. Bronchoscopic findings during inspiration revealed narrowing in the orifice of the hvpopharyngeal area witb deformed epiglottis. Functional Upper Airway Obstruction (Nagai at at)

striction? It has been suspected that inspiratory stridor due to nonorganic airway obstruction is brought about by a psychogenic problem, and it is sometimes referred to as emotional or hysterical laryngospasm . The pharyngeal constriction as seen in our case also is most likely to have a psychogenic basis, because of the sudden onset of symptoms, their improvement with the use of sedatives and psycho therapy and the absence of organic abnormalities. Psychogenic pharyngeal constriction, leadmg to abnormal shape and movement of the epiglottis, may be an additional cause of functional upper airway obstruction with respiratory distress. REFERE:'IICES

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Harvey AM. Johns RJ. Owens All , Ross RS. The principle and practice of medicine. New \(lrk : Appleton-Century-Crofts , 1972 Rogers JII , Stell PM. Paradoxical movement of the vocal cords as a cause of stridor. J Laryngol Oto11978; 92:157-58 Kellmann RM, Leopold DA. Paradoxical cord motion : an important cause of stridor, Laryngoscope 1982; 92 :58-60 Appelblatt NIl , Baker SR. Functlonal upper airway obstruction: a new syndrome . Arch Otolaryn~oI1981 ; 107;305-06 Ophir D . Katz Y, Tavori I, Aladjen M. Functional upper airway obstruction in adolescents. Arch Otolaryngol lIead Neck Surg 1990; 116:1208-09 Patterson R, Schatz M. Horton M. Munchausens stridor; nonorganic laryngeal obstruction. Cl in Aller~ ' 1974; 4:307-10 Cormier YR. Camus P. Desmeules MJ. Non -organic acut e upper airway obstruction : description and a dlagnostic approach . Am Rev Respir Dis 1980; 121:147-50 Kattan M. Ben-Zvi Z. Stridor caused by vocal cord malfunction associated with emotional factors . Clin Pediatr 1911.'5; 24:158-60 Christopher KL. W'H>d RP. Eckert C , Blager FR , Raney RA. Souhrada JF. \ hcal cord dysfunction presenting as asthma. N En~1 J Med 1983; 308 :1566-70

Rapid Evolution of Cardiac Tamponade due to Bacterial Pericarditis in Two Patients With HIV-1 Infection*

one documented case of purulent pericarditis in such patients.' In this report, we describe two Hlv-seropositive subjects in whom contiguous spread of pneumococcal infection from the left pleural space caused pericarditis and rapid evolution of cardiac tamponade . CASE REPORTS C.~SE

1

A 32-year-old woman was adm itted with fever. cough productive of yellow sputum. and left -sided pleuritic pain for three days. Two years prior to this adm ission. she was treated with chemotherapy for malignant lymphoma of intermediate ~rad, ' involvirut the central nervous system , Simultaneously, pulmonary tuberculosis was diagnosed . The lymphoma and TB remitted with therapy. The patient was found to have antibodies to lilY-I hy \\btern blot . The only risk factor for 1I1V-l infection was a history of sexual promiscuity. One year prior to admission. th e patient was treated with penicillin. oxacillin. and thoracentesis for a right middle lohe pneumonia with empyema: Gram stain of the pleural Huid documented Gram-positive cocci in pairs and dusters. Spin al Auid examination and a lymph node biopsy at that time showed no evidence of lymphoma. On admission, the temperature was 39°(;: the heart rat e . 140 heats per minute: and th e hl'HKI pressure, 1101H0 mm II~ without pulsus paradoxus. The patient appeared toxic and had ~eneralized lymphadenopathy. In th e left posterior hemithorax , tactile fremitus was reduced . and percussion note was dull . breath sounds were absent , and e ~op h o n y was evident. Chest roentgenogram showed left pleural effusion . hilateral retieulonodular infiltrates. and med iasttnal Iymphadenopathy: the infiltrates and lymphadenopathy had been stable filr the previous two years . In the pleural Huid. pll was 7.05 : protein, 76 WL; glucose, 1.11mmoVL (20 mg/dl) . LDII , 2661 lUlL : and WBC, 22,000/cu mm with 42 percent polymorphonuclear leukocytes. Gram stains of the sputum and pleural Auid showed Gram-positive d iplococci and Cram-negattve coccobacilli. A ZiehlNeelsen stain was negative . A chest tube was inserted in the I"ft hemithorax. and intravenous penicillin G (4 million units every 4 h) and cefotaxirne (2 ~ every 8 h) were prescribed. With this treatment , the patient deferveseed within 48 h . Cultures of the pleural Auid

Milind M . Karoe, M .D.;t Mandakolathur R. Murali , M .D.;+ Hemant M . Shah . M .D. , F.C .C.P.:t and Kenneth R. Phelps. M .D .§

We describe two HIV-seropositive patients with acute pneumococcal empyema and pericarditis. Cardiac tamponade evolved rapidly in each patient and was reversed with prompt surgical intervention. In each case, immunologic abnormalities were detected which could have facilitated local spread of infection and progression to tamponade. Pericarditis, an otherwise rare manifestation of pneumococcal infection in the antibiotic era, should be anticipated in HIV-seropositive patients with pneumococcal empyema, (Chest 1992; 101:1461-63)

A lthough echocardiograms of patients infected with HIV-

1'1

1 commonly show pericardia] fluid ,' we can find only

·From the Department of Medicine. Kings County Hospital Center and The State Universltv of New \(lrk Health Science Center at Brooklvn, . tClinic;il Assistant Instructor, +Assistant Professor of Medicine . §Associate Professor of Clinical Medicine. Reprint requests: Dr. Murali, Dirision of Allergy and Clinical Immunolo/{y. -ISO Clarkson AI)('nut ', Box .50, Brooklyn 11203-2098

FllarllE 1. Chest rot 'nt~"no~ram of patient 1. A lar~t' cardiae silhouett« and a left pleural effusion an' evident. An echocurdiogrum confirmed the presence of a pericardial effusion and cardiac tamponade. CHEST I 101 I 5 I MAY, 1992

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