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Endgames Case Report

A case of airway compromise

BMJ 2010; 341 doi: (Published 29 September 2010) Cite this as: BMJ 2010;341:c3822
  1. Nehal Hussain, teaching and research registrar in cardiology1,
  2. Noweed Ahmed, ear, nose, and throat registrar1,
  3. Sheila Ramjug, core medical trainee 2
  1. 1South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough TS4 3BW
  2. 2Central Manchester University Hospitals NHS Foundation Trust, Manchester Royal Infirmary, Manchester M13 9WL
  1. Correspondence to: N Hussain doc-on-call{at}

A 75 year old white man presented to the accident and emergency department because of sudden onset neck swelling of one hour’s duration, with difficulty in speaking and swallowing. He had no history of recent fever or antibiotic use.

His medical history included ischaemic heart disease with impaired left ventricular function. His drugs had remained unchanged for the past year and included atorvastatin, bisoprolol, bendroflumethiazide, lisinopril, and aspirin. He had no known allergies and was an ex-smoker.

On examination he was haemodynamically stable with a respiratory rate of 25 breaths/min and saturations of 100% on high flow oxygen. Initially he had no urticaria or wheeze, but direct observation of the throat showed a swollen uvula and soft palate. Fibreoptic nasolaryngoscopy by the ear, nose, and throat surgeons showed oedema of the vallecula and arytenoid, partially covering the airway. Later his eyes and lips became swollen.

We started emergency management and admitted him to hospital. Concentrations of mast cell tryptase, total IgE, and C1 esterase were normal.


  • 1 What was the cause of our patient’s presentation?

  • 2 What should the initial management be?

  • 3 What should be done to prevent this from happening again?


1 What was the cause of our patient’s presentation?

Short answer

Angio-oedema secondary to use of an angiotensin converting enzyme (ACE) inhibitor (lisinopril).

Long answer

Angio-oedema is a self limiting localised swelling that affects mucosal tissues of the face, larynx, and bowel, as well as the skin and extremities. It is characterised by non-pitting asymmetric swelling, which is not pruritic. Angio-oedema develops over minutes …

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