EDITORIAL

Emergency treatment of upper airway angio-oedema after a routine extraction in a patient with C1 esterase deficiency

Not long ago I had a patient – a colleague, gynecologist – saying he had a hereditary angio-oedema, demanding I extract one of his teeth. I refused and asked for a consultation with a clinical immunologist, he was rather impertinent, said “we will not argue about it“, because he was a doctor, he had toothache and wanted me to extract his tooth immediately. We did not “argue” – he had to go and see a clinical immunologist. He returned the same day and asked for my help pretty meekly. The clinical immunologist demanded his hospitalization, a dose of concentrated C1-esterase inhibitors, and an anesthesiologist stand-by.
The authors of the article Rice S, Cochrane TJ, Millwaters M, Ali NT. Emergency management of upper airway angio-oedema after routine dental extraction in a patient with C1 esterase deficiency. Br J Oral Maxillofac Surg 2008;46/5:394-6., describe a patient admitted to emergency ward due to stridor, impaired breathing, orofacial swelling and saliva excretion from the mouth. Some hours earlier a dentist had extracted a lower molar, and the extraction resulted in lip and tongue edema and impaired breathing. After being admitted, she received oxygen, adrenaline and corticosteroid drugs intravenously, but there was no improvement. The oral surgeon excluded infection, and the history revealed that she has irregular swellings of arms and legs, with five members of her family died from angio-oedema. After and emergency consultation with a clinical immunologist, she received 1000 IU of C1 inhibitors. She was admitted to intensive care and there was rapid recovery.
Hereditary angio-oedema is a rare, but life-threatening, autosomal dominant inheriting condition that is characterized by repeating episodes of perioral or laryngeal edema. Frequency is estimated at 1/50,000, and the cause is lack of C1 esterase inhibitor. A trigger can be psychological stress or local trauma, and dental treatment is stressed as a trigger that lead to life-threatening condition in half of the described cases. Antihistaminic therapy is not efficient, since it is not a histaminic reaction.
Based on my own experience, I considered it important to describe this case in order to warn the colleagues about this life-threatening condition. They should not be “talked into” the treatment even when they are treating fellow colleagues.

                                                                

Darko Macan
darkom@kbd.hr

  

Acta Stomatol Croat. 2009;43(2):76.

  

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REVIEW

 

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Guidelines for Assessment, Diagnosis, and Management - The American Academy of Orofacial Pain

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