Direct laryngoscopy with provocation: A useful method to distinguish acute laryngeal edema from nonorganic disease

Background: Acute laryngeal edema is a manifestation of anaphylaxis, is frequently sudden in onset and requires immediate treatment to prevent further airway compromise. Nonorganic disease such as globus hystericus may present with symptoms similar to acute laryngeal edema. Distinguishing life- threatening acute laryngeal edema from non-life-threatening disease may be difficult. Objective: We present a patient in which direct laryngoscopy was used to distinguish acute laryngeal edema from nonorganic disease. Methods: A case report of a woman who had presented to numerous emergency rooms with symptoms of cough, sensation of throat closing, and hoarseness when exposed to odors such as nail polish remover and musk cologne. She was treated repeatedly with subcutaneous epinephrine, oral diphenhydramine and intravenous methylprednisolone. Her history was not classic for IgE-mediated anaphylaxis and we challenged her with nail polish remover while visualizing her vocal cords with direct laryngoscopy. Results: Upon challenge with an offending agent, her symptoms were again suggestive of life-threatening laryngeal edema. Direct laryngoscopy, however, revealed no objective evidence of airway obstruction. Conclusion: Direct laryngoscopy with provocation is useful in distinguishing acute laryngeal edema from nonorganic disease.