32: Angioedema

Angioedema

Angioedema is acute oral or facial swelling

Neck oedema may hazard the airway

Most cases are allergic

Emergency treatment is with intramuscular adrenaline (epinephrine)

Body and soul cannot be separated for purposes of treatment, for they are one and indivisible. Sick minds must be healed as well as sick bodies.

INTRODUCTION

This is a potentially lethal condition. Angioedema manifests with rapid development of oedematous swelling of the lip(s), tongue and oral or facial swelling (Fig. 32.1). This can be life-threatening as oedema may also involve the neck and hazard the airway. The swelling in angioedema is usually relatively transient and the skin does not scale.

Fig. 32.1 Lip swelling in angioedema

Angioedema is usually allergic (a type 1 hypersensitivity response seen mainly in those with an atopic tendency) but can rarely be drug-induced, hereditary (hereditary angio-neurotic oedema or HANE; caused by a deficiency of the complement component C1 esterase inhibitor – C1-INH) or C1-INH deficiency can be acquired.

All types of angioedema may be aggravated by the oral contraceptive pill or hormone replacement therapy.

ALLERGIC ANGIOEDEMA

INCIDENCE

Allergic angioedema is common – far more common than HANE.

Age

It occurs mainly in adults.

Gender

It is most prevalent in females.

Geographic

No known geographic incidence.

AETIOLOGY AND PATHOGENESIS

Allergic angioedema is a type 1 hypersensitivity reaction that may be induced by:

Foods: nuts are a well-known cause but many other foods (e.g. shellfish, eggs, milk) may be implicated

Drugs (Table 54.20), especially:

Other allergens – such as radiocontrast media, hepatitis B immunization, and insect bites/stings.

It is IgE mediated and causes mast cell activation and degranulation, with release of histamine and bradykinin, causing vasodilatation and increased vascular permeability. The C4 complement component is consumed and thus plasma levels fall, but the levels of C1 and C3 are usually normal.

CLINICAL FEATURES

The acute oedema, which appears < 2 h of antigen exposure, can cause pronounced itchy labial and periorbital swelling, and can involve any oral site, but when oedema involves the tongue and neck and extends to the larynx, it can cause rapidly fatal respiratory obstruction.

Acute allergic oedema usually develops along with urticaria (‘hives’) and may be associated with anaphylactic reactions.

DIAGNOSIS

Angioedema is diagnosed clinically and from a history of atopic disease and/or exposure to allergen, and sometimes by allergy testing (prick test), but only where there are appropriate resuscitation facilities and an emergency kit containing injectable adrenaline at hand. Mast cell tryptase levels may be raised. Hereditary angioedema (HANE) may need to be excluded – HANE has low C4, but normal C3 levels, and absence of C1-INH activity (Table 32.1).

Table 32.1

Aids that might be helpful in diagnosis/prognosis/management in some patients suspected of having angioedema *

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In most cases	In some cases

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Tags: Oral and Maxillofacial Medicine The Basis of Diagnosis and Treatment 3e

Jan 9, 2015 | Posted by mrzezo in Oral and Maxillofacial Pathology | Comments Off

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