as calcium arsenate, chromium, nickel, and arsenic compounds1). In the industrial settings, Bloomfield and Blum2) first reported nasal septum perforated ...
Short Communication
Industrial Health 2002, 40, 286–289
Nasal Septum Perforation of Welders Choong Ryeol LEE1*, Cheol In YOO1, Ji ho LEE1, and Seong Kyu KANG2 1
Department of Occupational and Environmental Medicine, Ulsan University Hospital, 290–3, Jeonha-Dong, Dong-Gu, Ulsan, 682-714, South Korea 2 Occupational Safety and Health Research Institute, Korea Occupational and Safety and Health Agency, Incheon, South Korea Received October 3, 2001 and accepted May 1, 2002
Abstract: During the periodic physical checkups in 1997–2000, the authors have found eleven cases of nasal septum perforation among 2,869 welders in Ulsan, Korea. They have not suffered from diseases and conditions that could cause septum perforation such as tuberculosis, syphilis, and longterm use of topical corticosteroids. And also they did not have trauma history and surgical experiences on their nasal septum. To investigate the cause of septum perforation we reviewed the past history of pre-employment, the results of annual working environment survey and the material safety data sheets of welding rods and steels with which they have dealt. We also analyzed the concentration of several metals of welding fume and the concentration of blood and urinary chromium. In the result, we assumed that the nasal septum perforation of welders was due to chronic exposure to low-level hexavalent chromium. Key words: Nasal septum perforation, Welders, Hexavalent chromium
Nasal septum lesions can be caused by trauma of the nose, complications during a nose operation, topical corticosteroid therapy, cocaine abuse, syphilis, and toxic substances such as calcium arsenate, chromium, nickel, and arsenic compounds1). In the industrial settings, Bloomfield and Blum2) first reported nasal septum perforated workers who exposed chromic acid more than 0.1 mg/m3 during chrome plating. After then, several investigators reported nasal septum perforation of chrome plating workers 3–5). In 1978, Jindrichova 6) reported that 35% of welders exposed to hexavalent chrome had nasal mucosa erosions. Angeler and Lehnert7) reported that stainless steel welders could be exposed to nickel compound. Matczak and Chmielnicka8) reported that the chrome concentration in the welding fumes measured at the breathing zone of stainless steel welders was between 0.005 mg/m3 and 0.995 mg/m3. Edme et al.9) reported that the chrome concentration of the stainless steel welders was 3.6 µg/L in whole blood, 3.3 µg/L in plasma, and 6.2 µg/L in urine. Lindberg and Hedenstierna10) have *To whom correspondence should be addressed.
reported that nasal septum perforation was occurred in the concentration of 0.02–0.46 mg/m3 of chromic acid. The review of the literatures shows that welders exposed to hexavalent chrome can have nasal mucosa changes such as mucosal erosion, and lots of chrome is exposed at the time of stainless steel welding. However, the reports on nasal septum perforation of welders were not until recently. We found 11 cases of nasal septum perforation at the annual health examinations of welders of a shipyard in Ulsan, Korea in 1997–2000, who have not suffered from diseases and conditions that could cause septum perforation such as tuberculosis, syphilis, and long-term use of topical corticosteroids. And also they did not have trauma history and surgical experiences on their nasal septum. Considering the size, the shape and the margin, it was assumed that the perforation has been occurred several years before. The diameters of perforation were 2–8 mm. The olfactory function was intact except one case. The position of perforation was near the Kisselbach’s area. For the purpose of investigating the cause of septum perforation we reviewed the past history of pre-employment, the results of annual working environment survey and the
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NASAL SEPTUM PERFORATION OF WELDERS Table 1. General characteristics of cases Case
Age
Entrance date
Workplace
Welding (yr)
1 2 3 4 5 6 7 8 9 10 11
43 49 39 47 51 37 43 49 39 47 51
79.12.12 75. 7.12 81. 9. 8 76. 7.12 80. 9.10 85. 7.24 79.12.22 75. 7.12 81. 9. 8 76. 7.12 80. 9.10
Minor assembly Cabin assembly Cabin assembly Shipbuilding Heavy machine Cabin assembly Minor assembly Cabin Assembly Cabin Assembly Shipbuilding Heavy machine
18 19 19 21 25 12 18 19 19 21 25
Duration of past work history Welding 1 yr (other company) Ironworker 4 yr, Agriculture 2 yr Welding in high school 3 yr Watchpin processing 1yr Welding 4 yr (other company) Elecroplating 1.5 yr Welding 1 yr (other company) Ironworker 4 yr, Agriculture 2 yr
Symptoms and signs
Epistaxis, Stuffiness Stuffiness Stuffiness, Anosmia Epistaxis, Stuffiness
Epistaxis, Stuffiness
yr: year.
material safety data sheets of welding rods and steels with which they have dealt. We also analyzed the chrome concentration of welding fume and the concentration of blood and urinary chromium. For personal breathing zone air sampling, trained industrial hygienists selected 31 workers of 6 workplaces where cases were working. Airborne particulate sampling was performed on cellulose ester membrane filter (0.8 µm pore size, 37 mm diameter) in Millipore filter holders according to the NIOSH method 702411). The filter holder was placed inside the welding helmet in the breathing zone of the welder. The analysis was executed in the laboratory of Occupational Safety and Health Research Institute of Korea Occupational and Safety and Health Agency that was designated as the reference laboratory of analyzing some ambient heavy metals samples including chrome by the Korean government. This laboratory has participated in a national quality control program 12) applied to all Korean industrial hygiene laboratories. This reference laboratory has participated in the American Industrial Hygiene Association Proficiency analytical testing program and has performed internal quality control program. According to the NIOSH method 760011) the water soluble chromium species were analyzed by visible absorption spectrometry (UV-265, Shimadzu, Japan) for hexavalent chromium and by inductively coupled plasma spectrometry (ICP, JY 70C, Jobzn Yuon, France) for total chromium. The insoluble chromium analyzed after dissolution of the residue by ICP. Ambient nickel was sampling on was cellulose ester membrane filter (0.8 µm pore size, 37 mm diameter) in Millipore filter holders and analyzed by ICP according to the NIOSH method 730011). For biological monitoring plasma and urine were diluted using 0.1% Triton X-100 solution, and analyzed by atomic
absorption spectrometry (Spectra AA 110/200, Varian, Australia) using standard addition method13). A three-step temperature program was used (90°C, 110°C, 1100°C) for the mineralization of the biological matrix. Detection limit of blood chrome concentrations was 0.08721 µg/dl, and that of urine chrome concentrations was 1.0081 µg/dl. Every sample was analyzed in triplicate and the average was calculated. General characteristics of cases were listed in Table 1. As shown in the table, age was 37–51, and the duration of welding was 12–25 years. Except one case, there was not any job experience that could induce nasal septum perforation such as chrome plating. In five cases they complained nasal stuffiness and/or epistaxis, in only one case complained of anosmia, but in six cases there were not any special symptoms. In all cases there was not any past history of tuberculosis, syphilis, operation that could induce nasal septum perforation. Blood chrome concentrations of cases were below the detection limit, and urine chrome concentrations of cases were also below the detection limit. According to the material safety data sheets, the constituents of welding rod mainly consisted of iron, but have small amounts of SiO2, aluminum, titanium, manganese, nickel, magnesium, zinc, lead, copper and so on. On the contrary, the proportions of constituents of welding rod used in the stainless steel welding comprised of 18–23% chromium, 8–13% nickel, 3–5% titanium, 1–3% manganese, and 55–75% iron. The constituents of base steel also mainly consisted of iron, but have small amounts of SiO2, aluminum, manganese, nickel, copper, sulfur, phosphorus and so on. The proportions of constituents of base steel used in the stainless steel welding comprised of 17.6–18.1% chromium, 8.25–10.63% nickel, 3–5% titanium, 0.78–0.79% manganese,
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Table 2. Mean concentrations of metals in the ambient air of workplace on the annual working environment survey [mean (minimummaximum), unit:mg/m3] Metal Yr (No) 1991 (111) 1992 (52) 1993 (64) 1994 (53) 1995 (53) 1996 (53) 1997 (21) 1998 (56) 1999 (54) 2000 (53)
Al
Cr
Cu
Fe
Mn
Ni
Pb
Zn
–
0.019 (ND–0.509) 0.002 (ND–0.010) 0.013 (ND–0.024) 0.019 (ND–0.286) 0.023 (ND–0.176) 0.011 (ND–0.049) 0.025 (ND–0.153) 0.015 (0.010–0.100) 0.002 (ND–0.007) 0.018 (ND–0.752)
0.012 (ND–0.066) 0.004 (ND–0.015) 0.017 (ND–0.064) 0.009 (ND–0.046) 0.023 (ND–0.330) 0.016 (ND–0.106) 1.946 (ND–15.000) 0.005 (ND–0.071) 0.005 (ND–0.013) 0.006 (ND–0.015)
6.556 (0.710–34.838) 3.384 (0.707–7.850) 6.833 (1.540–28.590) 4.788 (1.750–20.600) 4.600 (1.180–10.970) 3.790 (1.185–10.370) 4.829 (1.260–20.700) 1.298 (0.176–3.126) 2.598 (0.178–7.526) 3.012 (1.021–0.583)
0.134 (0.007–0.977) –
0.004 (ND–0.007) –
0.824 (0.020–3.820) 0.810 (0.107–1.570) 0.950 (0.014–4.260) 0.694 (0.040–3.399) 0.819 (0.010–2.380) 0.390 (0.010–0.995) 0.695 (0.045–2.106) 0.726 (0.010–1.969)
–
0.008 (ND–0.123) 0.002 (ND–0.003) 0.044 (ND–0.330) 0.003 (ND–0.380) 0.043 (ND–0.130) 0.014 (ND–0.027) 0.026 (ND–0.050) 0.005 (ND–0.018) 0.004 (ND–0.033) 0.005 (ND–0.041)
0.021 (ND–0.350) 0.143 (0.005–0.422) 5.296 (0.310–24.100) 1.427 (0.018–4.690) 1.998 (0.052–8.940) 2.275 (0.480–8.873) 1.780 (0.380–4.120) 0.867 (0.026–2.048) 1.509 (0.077–3.226) 1.426 (0.008–2.899)
– – – – 0.530 (0.026–3.466) 0.709 (ND–1.980) 0.019 (0.010–0.1000) 0.012 (ND–0.202) 0.015 (ND–0.925)
– – – 0.023 (ND–0.040) 0.001 (ND–0.010) 0.001 (ND–0.011) 0.001 (ND–0.011)
–: Not measured or not detected, ND: Not–detected, Yr: year, No: number of samples.
Table 3. Concentrations of hexavalent chromium and nickel in the ambient air of workplace
Division A shop B shop C shop D shop E shop F shop
No of Samples 9 2 5 7 5 3
Concentrations of hexavalent chromium (8 hour-TWA), mg/m3 Mean ± standard deviation 0.0020 ± 0.0010 0.0012 ± 0.00013 0.0014 ± 0.0013 0.0020 ± 0.0017 0.0028 ± 0.0012 0.22 ± 0.16
Minimum
Maximum
Welding method and shop cases belong in
0.00078 0.0011 0.00037 0.00035 0.0016 0.044
0.0038 0.0013 0.0025 0.0050 0.0041 0.34
CO2 welding, case 1, 7 CO2 welding, case 2, 3 CO2 welding, case 6, 8, 9 CO2 welding, case 4, 10 CO2 welding, case 5, 11 Stainless steel welding
*Nickel was detected except F shop, where the mean concentration of nickel was 0.60 mg/m3 (not detected–1.23 mg/m3).
and 65–70% iron. Table 2 shows the mean concentrations of metals in the ambient air of workplace revealed on the annual working environment survey, and we could acquire the reports of working environment survey14) after 1991 from the company where cases were working. According to these data, although the concentration was different depending on the measuring year, iron, manganese, zinc, lead, and copper have been detected, but chrome and nickel were either not detected or detected very little. The total chrome concentration in the ambient air of workplace 0.002–0.025 mg/m3, and the maximum concentration was 0.010–0.509 mg/m3. We could
not obtain the concentration of hexavalent chromium and the total chrome concentration in the ambient air of stainless steel welding workplace. On the whole, even the total chrome concentration in the workplace was lower than that of hexavalent chrome that could perforate the nasal septum. Table 3 shows the results of concentration of hexavalent chromium and nickel in the ambient air of 1 stainless steel welding shop (F shop) and 5 working sites (A-E shop) in where cases are currently working. The concentration of hexavalent chrome in the welding fume was 0.0012 mg/ m3–0.22 mg/m3. Although the concentration were different from site to site, the maximum concentration of 0.34 mg/
Industrial Health 2002, 40, 286–289
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NASAL SEPTUM PERFORATION OF WELDERS m3 was measured in F shop in where they have done stainless steel welding. We think that the concentration at the stainless steel welding shop could be enough to perforate the nasal septum of worker if the duration of exposure were satisfactory. We think that nickel is not the main cause of nasal septum perforation of welders, because most cases did not work in the F shop in recent years and ambient nickel was not detected except in F shop, where the mean concentration of nickel in the air was 0.60 mg/m3 (not dectected-1.23 mg/m3). According to the documents of the company, protective equipment began to be provided after 1984, but its regular use was done after 1990 by the statements of workers who had perforated nasal septum. The authors presume that the cause of the nasal septum perforation was the long-term exposure to the low-levels of hexavalent chromium during welding on the basis of the following evidences. Firstly, fumes that contain hexavalent chromium that can induce nasal septum perforation are produced during welding, and as in the case of stainless steel welding welders can be exposed in considerable amount. Secondly, judging from the result of working environment measurement after 1991, the recent exposure to noxious substances is little, but before 1990 it is estimated that the working environment was much worse than now and the exposure amount of welding fumes containing chrome was not little. Thirdly, as nasal septum perforation is not known to be the naturally occurring disease with aging process, the nasal septum perforation of the welders are presumed to be due to toxic substances during welding. Fourthly, there were no other causes of nasal septum perforation, such as the operation within the nasal cavity, tuberculosis or syphilis. Fifthly, in a considerable number of welders (51 out of 2,858 workers), the change such as nasal septum erosion, which can be seen as the prior step of nasal septum perforation, was confirmed. Finally, according to Cohen et al.15), the fingers contaminated with the hexavalent chrome during welding can irritate the nasal septum directly despite the low concentration of hexavalent chrome in the air, even through the nasal septum perforation can not be induced by hexavalent chrome itself in the air. In conclusion, we assumed that the nasal septum perforation of welders was due to chronic exposure to lowlevel hexavalent chromium, careful inspection of nasal cavity in welders is necessary in the physical examination of welders.
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