Steroid Inhalers for Asthma Can Cause Fungal Laryngitis

It is a big bummer to be an asthmatic. Not only is breathing a problem, but even the treatment for asthma can cause problems.

Take for example steroid inhalers like advair, symbicort, fluticasone, etc.

All asthma patients know to rinse their mouth out after inhaler use due to risk of oral thrush, but what about from the back of the mouth down to the vocal cords??? This nether region can't be gargled very easily. One can swallow water to rinse this area out, but the vocal cord region would still not be addressed (otherwise aspiration would occur).

And that leads to potential vocal problems... like fungal laryngitis (or thrush of the voicebox). Here's a picture of what that looks like. To compare, normal is shown in the smaller picture.

Note the white patches indicative of fungal growth. This fungal infection can lead to symptoms of a mild (if any) sore throat, but most patients complain of hoarseness as their only symptom.

Treatment is ideally to stop the steroid inhaler triggering the infection, but if an asthmatic needs it... than they need it. As I often tell patients, breathing is more important than voice. Often, anti-fungal medications like diflucan and nystatin can eliminate the fungal laryngitis, but problem is, as long as steroid inhalers are used, it comes right back. And repetitive anti-fungal treatment can place the patient at risk for a drug-resistant fungal infection.

So what to do???

There is one type of little-known (unpleasant) treatment an asthmatic patient can perform to minimize risk of fungal laryngitis while still maintaining steroid inhaler use.

It's called laryngeal washes and it takes a lot of time, patience, and period of discomfort. Think of it as gargling of the voicebox.

The patient takes a curved luer-lock cannula (picture shown) attached to a syringe filled with salt-water. While opening the mouth and sticking the tongue out, the curved end of the cannula is directed such that the end is pointed straight down into the throat. After taking a deep breath in, while saying "ah", salt-water is dripped down into the throat thereby "gargling" the voicebox. Coughing may be inevitable after performing.

This needs to be done after every steroid inhaler use. Or during an active fungal infection, at least 4 times per day.

Gagging is the biggest problem preventing correct usage of this technique. Coordinating the injection while saying "ah" is another issue since if it is incorrectly performed, can lead to aspiration and severe coughing. As such, it is not for everyone.

One can purchase such "luer-lock laryngeal cannulas" from any ENT medical supply company.

Itchy Ears

A common complaint we often see patients for are itchy ears. The don't hurt or drain... They just itch... a lot...

There are a few common causes of such itchy ears including earwax and a piece of hair in the ear canal. However, there are a few other etiologies which are not often considered.

Ear Canal Dermatitis

Yes... the skin of your ear canal can become dry and irritated (just like the hands after washing your hands too often). People sometimes complain of very dry flaky earwax with this condition, similar to the dry flaky skin of psoriasis.

Treatment is easy... steroids! Whether it be in cream form (elicon, triamcinolone) or drops (dermotic). For those a bit wary of using steroids, one can try facial lotion.

Fungal Otitis Externa

Also known as thrush of the ears. This often happens when antibiotics are given repeatedly over time for an "ear infection" whether in ear drop or oral pill form. Pain may be present, but even with pain, the adjective itchy is always included.

Treatment is also a snap... anti-fungal cream! We like to use lotrisone for this condition. However, the other key to successful treatment is complete debridement of the ear canal prior to cream insertion. Also, when the cream is used, one needs to completely fill the ear canal from eardrum to ear canal entrance.

Often, one single treatment is all that is required!