Narcotic administration and stenosing lesions of the upper airway--a potentially lethal combination

Two cases are reported where significant narrowing of the upper airway in association with narcotic administration resulted in respiratory compromise and death. Case 1: A 29-year-old woman with upper airway narrowing due to tonsillar enlargement from an Epstein-Barr infection was admitted to hospital, administered morphine and left in a room on her own with the door closed. She was found dead several hours later. At autopsy there was significant narrowing of the upper airway due to tonsillomegaly with a blood morphine level of 0.16 mg/L. Case 2: A 48-year-old woman with severe narrowing of her glottic inlet from recurrent squamous cell carcinoma and an intravenous drug taking history was found dead at her home. At autopsy there was evidence of recent and remote intravenous drug administration with marked narrowing of the glottis due to a recurrent tumor with a blood morphine level of 0.48 mg/L. In both cases, death was due to the effects of severe upper airway narrowing in combination with the respiratory depressant actions of morphine. Additional exacerbating factors may have included muscle weakness, drowsiness and reduced clearance of airway secretions from the effects of morphine. Narcotic administration in individuals with compromised upper airways should be undertaken extremely circumspectly and hospital protocols should ensure constant surveillance if this has been undertaken. Individuals who self administer narcotics should also be made aware of the dangers if there is coincidental upper airway narrowing. Toxicological evaluation in fatal cases of upper airway narrowing/stenosis may be extremely useful in revealing compounding factors such as opiate administration.