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Hoarseness can also be caused by neurologic conditions such as vocal cord paralysis.

This may be spontaneous or may be the result of trauma or a previous surgical procedure.

Speech therapy can be helpful in treating these patients.

A procedure to help move the vocal cord into a more natural position to achieve better voicing may also be necessary.

This can be done by injecting material into the vocal cord. This procedure is generally performed in the office without the need for general anesthesia. A patient may have other neurologic conditions such as Parkinson's disease which can lead to hoarseness. The UConn Health otolaryngologists work with their neurology colleagues in treating these patients. Speech therapy can be very helpful in improving voice quality.

This condition is called spasmodic dysphonia and can be treated with Botox injections performed in the office.

Covid-19 in Immune-Mediated Inflammatory Diseases — Case Series from New York. To the Editor: Data on Covid-19 in patients with immune-mediated inflammatory disease who have received anticytokine biologics, other immunomodulatory therapies, or both on a long-term basis are scarce.

Trials to assess the efficacy of antirheumatic therapies such as hydroxychloroquine 1 and anticytokine therapies such as interleukin-6 inhibitors 2 to improve outcomes in amoxicillin clavulanate for sinus infection patients with Covid-19 are ongoing. The rationale for their use is that worse outcomes (i.e., hospitalization, ventilation, or death) may be related to a proinflammatory cytokine storm.

Here, we report a prospective case series involving patients with known immune-mediated inflammatory disease (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, psoriasis, inflammatory bowel disease, or related conditions) who were receiving anticytokine biologics, other immunomodulatory therapies, or both when confirmed or highly suspected symptomatic Covid-19 developed.

Established patients at New York University Langone Health in New York City who had immune-mediated inflammatory disease were assessed during the period from March 3 through April 3, 2020 (average follow-up, 16 days from symptom onset).

We analyzed the demographic and clinical data on patients who had immune-mediated inflammatory disease with symptomatic Covid-19 and compared the patients for whom hospitalization was warranted (hospitalized patients) with those for whom it was not (ambulatory patients).

Baseline Characteristics of the Patients in Whom Covid-19 Was Confirmed or Highly Suspected.

We identified 86 patients with immune-mediated inflammatory disease who had either confirmed (59 patients) or highly suspected (27 patients) symptomatic Covid-19 infection ( Table 1 , and Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

Of these patients, 62 of 86 (72%) were receiving biologics or Janus kinase (JAK) inhibitors, and the overall incidence of hospitalization was 16% (14 of 86 patients). The hospitalized patients were older than the ambulatory patients.

Although the distribution of diagnoses of immune-mediated inflammatory diseases was similar in the ambulatory group and the hospitalized group, a higher percentage of admitted patients had rheumatoid arthritis. As compared with the ambulatory patients, more of the patients for whom hospitalization was warranted had coexisting hypertension, diabetes, or chronic obstructive pulmonary disease.

The percentage of patients who were receiving biologics or JAK inhibitors at baseline was higher among the ambulatory patients than among the hospitalized patients (55 of 72 patients [76%] and 7 of 14 patients [50%], respectively) ( Table 1 and Table S2), and the overall incidence of hospitalization among patients who had received these medications on a long-term basis was 11% (7 of 62 patients).

However, even after multivariate analysis, the use of oral glucocorticoids (in 4 of 14 hospitalized patients [29%] and in 4 of 72 ambulatory patients [6%]), hydroxychloroquine (in 3 of 14 patients [21%] and 5 of 72 patients [7%], respectively), and methotrexate (in 6 of 14 patients [43%] and 11 of 72 patients [15%], respectively) was higher among patients with immune-mediated inflammatory disease for whom hospitalization was warranted (Table S2). These observations were consistent when the analysis was restricted to patients with confirmed SARS-Cov-2 infection on polymerase-chain-reaction testing (Table S3).

Of the 14 patients with immune-mediated inflammatory disease who were hospitalized, 79% (11 of 14) were discharged (mean stay, 5.6 days), and 2 remain hospitalized as of April 3. Of the 2 patients with more severe disease, 1 had elevated interleukin-6 levels and received mechanical ventilation for acute respiratory distress syndrome, and the other died in the emergency department; neither patient was receiving biologic therapies on a long-term basis (Table S4). Additional data are provided in Tables S5 through S8.

A better understanding of the implications of Covid-19 in patients with immune-mediated inflammatory disease and the effects of anticytokine and other immunosuppressive therapies is urgently needed to guide clinicians in the care of patients with psoriasis, rheumatoid arthritis, psoriatic arthritis, inflammatory bowel disease, and related conditions.

Although our

analysis

These findings suggest that the baseline use of biologics is not associated with worse Covid-19 outcomes.

Allergic conjunctivitis usually causes mild to moderate symptoms, including redness, which respond to non-medicated treatment.

However, sometimes symptoms can be extremely severe and debilitating with swelling of the eyelids, conjunctivae and a sensation of grittiness and burning.

Unlike conjunctivitis that is caused by bacterial infection, allergic conjunctivitis is not contagious, so it cannot be transferred from one person to another. Red eye is one of the most common eye problems for which people visit a doctor.

A description of symptoms and an eye examination by the doctor will usually suggest the cause: Pus containing discharge usually indicates that there is bacterial infection. Clear discharge suggests a viral or allergic cause. Itch and clear discharge suggests an allergic cause, possibly allergic conjunctivitis. Mild discomfort or burning often with excess watering may be due to dry eye. Vision loss, discomfort in bright sunlight (photophobia) and pain suggest more serious conditions, which should be investigated by an eye specialist (ophthalmologist).

A gritty sensation is common in conjunctivitis, but the presence of a foreign body must be excluded, particularly if only one eye is affected.

The conjunctiva is a layer of tissue which lines the front part of the eyeball (the white part of the eye) and the inside of the eyelids, but does not cover the cornea (the coloured looking part of the eye).

It helps to protect the eye from insults such as smoke, bacteria and allergens in the air, as well as the damaging effects of sun and wind. The eye is also protected by the eyelids, tears and cornea.

Conjunctivitis is an inflammation of the conjunctiva of the eye, which becomes red, swollen and produces discharge, in response to these insults. It can be caused by infection by bacteria or viruses, allergy and physical or chemical irritation. Treatment depends on identifying the cause and severity of the condition. There are several signs of allergic conjunctivitis.

Typical signs and symptoms of allergic conjunctivitis include: Redness in both eyes.

Itching and burning of both the eye and surrounding tissues.

Watery discharge, often accompanied by acute discomfort in bright sunlight light (photophobia). The conjunctiva itself may become very swollen and look light purple, and this may interfere with clarity of vision. Eyelids may also be affected by an allergic reaction, causing the loose tissues of the lid to become swollen with subsequent drooping of the eyelid. In cases of severe swelling, the lids cannot open and the gap between the upper and lower lids becomes slit like. It is important to note that blurred vision or corneal haze require urgent referral to an eye specialist. Allergic conjunctivitis symptoms may be: Perennial (all year round) due to exposure to dust mite, animal dander, indoor and outdoor mould spores and occasionally foods or food additives. Seasonal due to airborne allergens such as pollen of grasses, trees and weeds.

Pollen allergy symptoms vary from day to day, depending on the weather, improving in wet weather and worsening on hot windy days or after thunderstorms. There are also seasonal variations in some airborne mould spores, which may cause seasonal symptoms.

Treatment depends on severity and cause of symptoms. Identifying and removing the cause of allergic conjunctivitis, where possible, is ideal when an allergic cause has been confirmed from allergy testing.

For example: House dust mite minimisation measures in the bedroom (removing carpet, using barrier encasing of pillows and mattress, washing bedding in hot water).

Removing the cat from the house in sensitive individuals.

It is also important to exclude the presence of a foreign body such as dust, wood chip or an insect/s. Symptoms of allergic conjunctivitis are generally mild to moderate and respond to bathing eyes with cold water, ice packs and cold water compresses.

Topical lubricants can also help flush allergens from the tear film.

However, symptoms can sometimes be extremely severe and debilitating and require medication. Treatment options include: Topical medications (eye drops) Antihistamine eye drops are effective but should not be used for longer than 6 weeks without medical advice.

Antihistamine eye drops in conjunction with a vasoconstrictor minimise itch and remove redness, but should not be used for longer than 14 days without medical advice.

Topical vasoconstrictor eye medications twice daily have minimal side effects, unlike nasal vasoconstrictor medications, but rebound vasodilation encourages overuse. Mast cell stabilisers are generally well tolerated, however, as they can take three to seven days to show an effect, they should be used to prevent symptoms before they occur and can be used as long as necessary. Mast cell stabilisers/antihistamines are fast acting, effective and generally well tolerated. Steroid eye drops i need a prescription for amoxicillin - are effective quickly in relieving symptoms, but are associated with cataract formation, glaucoma and bacterial and viral infections of the cornea and conjunctiva. They should only be used short term, only under medical supervision and never in the presence of herpes infections. Oral antihistamines (tablets) Help some people when avoidance measures are difficult.

However, they may dry the eyes, nose and mouth, and may cause blurred vision.

Antihistamines are usually contraindicated in glaucoma and advice should be sought from an eye specialist.