Upper Respiratory Complications of Sulfur Mustard (SM) Poisoning

  • Ramin ZojajiEmail author
  • Morteza Mazloum Farsi Baf


Various chemical agents have been used as a war weapon. Sulfur mustard (SM) due to its low cost, easy access and easy manufacture and storage are the most wildly used warfare agents in the world. It was used widely during Iraq-Iran conflict against Iranian troops. SM is a potent alkylating blistering agent that causes low mortality, but it could incapacitate a large number of soldiers in the war. SM exposure may occur in occupational or war exposure. SM can be absorbed from skin, eye, mouth and respiratory and the gastrointestinal systems. Among these organs, respiratory tract and skin are the main susceptible organs for SM intoxication and injury. Upper and lower respiratory tract may be affected by SM, however the acute and chronic effects of SM in upper respiratory tract has been less studied and most of studies have focused on lung injuries induced by SM. This study reviewed early and late clinical features and complications of SM in upper respiratory tract as well as its molecular mechanism of action and treatment.


Upper respiratory tract Sulfur mustard Poisoning Complications Inflammation Sinusitis Laryngoscopy Thyroid cancer 




The inability to produce voice. It is more severe than dysphonia


A disease in which there is permanent enlargement of parts of the airways of the lung


Sudden constriction of the muscles in the walls of the bronchi


The ability to produces cancer

Chronic bronchitis

A chronic inflammatory condition in the lungs that causes the respiratory passages to be swollen and irritated


Chemical warfare agents: a chemical substance whose toxic properties are used to kill, injure or incapacitate human beings


The quality of being toxic to cells


An impairment in the ability to produce voice sounds using the vocal organs


Shortness of breath or breathlessness is the feeling or feelings associated with impaired breathing


The condition of being subjected to something, as to infectious agents, extremes of weather, radiation, or chemical agent which may have a harmful effect.


A harsh, raspy, or strained voice caused by a variety of conditions


The area where the larynx and esophagus meet


The flow of air into an organism. In humans, it is the movement of air from the external environment, through the airways, and into the alveoli.


Relating to the act of breathing in


An abnormal state that is essentially a poisoning


An inflammation of the larynx


An exam that gives doctors a close-up view of the larynx and the throat


The ability of a chemical compound to dissolve in fats, oils, lipids, and non-polar solvents


Capable of inducing mutation or increasing its rate


A part of the pharynx lies in the upper part of the throat behind the nose


This space lies behind the oral cavity, extending from the uvula to the level of the hyoid bone

Pulmonary Alveol

An anatomical structure at the terminal ends of the respiratory tree in the lug parenchyma that has the form of a hollow cavity and is the site of gas exchange with the blood.


Sulfur mustard: a class of related cytotoxic and vesicant chemical warfare agents with the ability to form large blisters on the exposed skin and in the lungs


Direct examination of the vocal cords and surrounding structures with the use of a stroboscope


A drug or other substance capable of interfering with the development of a fetus, causing birth defects


The degree to which a substance can damage an organism

Tracheobronchial stenosis

Abnormal narrowing of the central air passage ways


A condition involving inflammation of the windpipe orbronchi


A condition characterized by flaccidity of the tracheal support cartilage which leads to tracheal collapse with condition extends further to the bronchi


A surgical procedure, which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea

Turbinate or conchae

A long, narrow and curled bone shelf that protrudes into the breathing passage of the nose

Video laryngoscopy

A form of indirect laryngoscopy in which the clinician does not directly view the larynx. Instead, visualization of the larynx is performed with a fiberoptic or digital laryngoscope inserted transnasally or transorally


  1. Abell CW, Falk HL, Shimkin MB, Weisburger EK, Weisburger JH, Gubareff N (1965) Uracil mustard: a potent Inducer of lung tumors in mice. Science 147:1443–1445PubMedCrossRefGoogle Scholar
  2. Agin K (2005) Comparison of serum magnesium values among sulfur mustard induced asthma with non-chemical asthmatic in Iranian war victims. J Army Uni Med Sci Iran 9:495–499Google Scholar
  3. Akhavan A, Ajalloueyan M, Ghanei M, Moharamzad Y (2009) Late laryngeal findings in sulfur mustard poisoning. Clin Toxicol (Phila) 47:142–144CrossRefGoogle Scholar
  4. Allon N, Amir A, Manisterski E, Rabinovitz I, Dachir S, Kadar T (2009) Inhalation exposure to sulfur mustard in the guinea pig model: clinical, biochemical and histopathological characterization of respiratory injuries. Toxicol Appl Pharmacol 241:154–162PubMedCrossRefGoogle Scholar
  5. Amini F, Oghabian Z (2013) Late-onset radiologic findings of respiratory system following sulfur mustard exposure. Asia Pacific J Med Toxicol 2:58–62Google Scholar
  6. Anderson D, Yourick JJ, Moeller RB, Petralim JP, Young GD (1996) Pathologic changes in rat lungs following acute sulfur mustard inhalation. Inhal Toxicol 8:285–297CrossRefGoogle Scholar
  7. Anderson DR, Byers SL, Vesely KR (2000) Treatment of sulfur mustard (HD)-induced lung injury. J Appl Toxicol 20(Suppl 1):S129–S132PubMedGoogle Scholar
  8. Anderson D, Yourick JJ, Moeller RB, Petralim JP, Young GD (2009) Evaluation of protease inhibitors and an antioxidant for treatment of sulfur mustard-induced toxic lung injury. Toxicology 263:41–46PubMedCrossRefGoogle Scholar
  9. Andrew DJ, Lindsay CD (1998) Protection of human upper respiratory tract cell lines against sulphur mustard toxicity by hexamethylenetetramine (HMT). Hum Exp Toxicol 17:373–379PubMedCrossRefGoogle Scholar
  10. Aslani J (2000) Late Respiratory complications of sulfur mustard. In: Cheraghali AM (ed) Prevention and treatment of complications of chemical warfare agents. Chemical Warfare Research Centre, TehranGoogle Scholar
  11. ATSDR (2003) Toxicological profile for mustard gas. Draft for Public Comment. Agency for Toxic Substances and Disease Registry, AtlantaGoogle Scholar
  12. Attaran D, Mirsadraee M, Rajabian R (2007) Inhaled corticosteroids and bone density in chemical warfare patients with pulmonary complication. Tanaffos 6:25–30Google Scholar
  13. Bagheri MH, Hosseini SK, Mostafavi SH, Alavi SA (2003) High-resolution CT in chronic pulmonary changes after mustard gas exposure. Acta Radiol 44:241–245PubMedCrossRefGoogle Scholar
  14. Bakhtavar K, Sedighi N, Moradi Z (2008) Inspiratory and expiratory high-resolution computed tomography (HRCT) in patients with chemical warfare agents exposure. Inhal Toxicol 20:507–511PubMedCrossRefGoogle Scholar
  15. Balali M (1992) The evaluation of late toxic effects of sulfur mustard poisoning in 1428 Iranian veterans. In: Proceedings of the seminar on late complications of chemical warfare agents in Iranian veterans. Veteran Foundation, TehranGoogle Scholar
  16. Balali M (1984) Clinical and laboratory findings in Iranian fighters with chemical gas poisoning. Arch Belg Suppl 254–259Google Scholar
  17. Balali-Mood M, Hefazi M (2005a) The pharmacology, toxicology, and medical treatment of sulphur mustard poisoning. Fundam Clin Pharmacol 19:297–315PubMedCrossRefGoogle Scholar
  18. Balali-Mood M, Hefazi M (2005b) The clinical toxicology of sulphur mustard. Arch Iran Med 8:162–179Google Scholar
  19. Balali-Mood M, Hefazi M (2006) Comparison of early and late toxic effects of sulfur mustard in Iranian veterans. Basic Clin Pharmacol Toxicol 99:273–282PubMedCrossRefGoogle Scholar
  20. Balali-Mood M (1986) First report of delayed toxic effects of Yperite poisoning in Iranian fighters. In: Heyndrickx B (ed) Proceedings of the second world congress on new compounds in biological and chemical warfare, GhentGoogle Scholar
  21. Balali-Mood M, Farhoodi M, Panjvani FK (1986) Report of three fatal cases of war gas poisoning. In: Heyndrickx B (ed) The second world congress on new compounds in biological and chemical warfare: toxicological evaluation. Ghent University Press, GhentGoogle Scholar
  22. Balali-Mood M, Navaeian A (1986) Clinical and paraclinical findings in 233 patients with sulfur mustard poisoning. In: Heyndrickx B (ed) The second world congress on new compounds in biological and chemical warfare: toxicological evaluation. Ghent University Press, GhentGoogle Scholar
  23. Balali-Mood M, Hefazi M, Mahmoudi M, Jalali E, Attaran D, Maleki M, Razavi ME, Zare G, Tabatabaee A, Jaafari MR (2005) Long-term complications of sulphur mustard poisoning in severely intoxicated Iranian veterans. Fundam Clin Pharmacol 19:713–721PubMedCrossRefGoogle Scholar
  24. Balali-Mood M, Mousavi S, Balali-Mood B (2008) Chronic health effects of sulphur mustard exposure with special reference to Iranian veterans. Emerg Health Threats J 1:e7PubMedPubMedCentralGoogle Scholar
  25. Balali-Mood M, Afshari R, Zojaji R, Kahrom H, Kamrani M, Attaran D, Mousavi SR, Zare GA (2010) Delayed toxic effects of sulfur mustard on respiratory tract of Iranian veterans. Hum Exp Toxicol 30:1141–1149PubMedCrossRefGoogle Scholar
  26. Ball CR, Roberts JJ (1972) Estimation of interstrand DNA crosslinking resulting from mustard gas alkylation of cells. Chem Biol Interact 4:2297–2303CrossRefGoogle Scholar
  27. Bijani K, Moghadamnia AA (2002) Long-term effects of chemical weapons on respiratory tract in Iraq-Iran war victims living in Babol (North of Iran). Ecotoxicol Environ Saf 53:422–424PubMedCrossRefGoogle Scholar
  28. Blanton PL, Biggs NL (1969) Eighteen hundred years of controversy: the paranasal sinuses. Am J Ant 124:135–148CrossRefGoogle Scholar
  29. Borak J, Sidell FR (1992) Agents of chemical warfare: sulfur mustard. Ann Emerg Med 21:303–308PubMedCrossRefGoogle Scholar
  30. Bürkle A (2001) Physiology and pathophysiology of poly(ADPribosyl) ation. Bioessays 23:795–806PubMedCrossRefGoogle Scholar
  31. Callaway S, Pearce KA (1958) Protection against systemic poisoning by mustard gas, di(2-chloroethyl) sulphide, by sodium thiosulphate and thiocit in the albino rat. Br J Pharmacol Chemother 13:395–398PubMedPubMedCentralCrossRefGoogle Scholar
  32. Capacio BR, Smith JR, Lawrence RJ, Boyd BL, Witriol AM, Conti ML, Collins JL, Sciuto AM (2008) Gas chromatographic-mass spectrometric analysis of sulfur mustard-plasma protein adducts: validation and use in a rat inhalation model. J Anal Toxicol 32:37–43PubMedCrossRefGoogle Scholar
  33. Clemedson CJ, Kristoffersson H, Soerbo B, Ullberg S (1963) Whole body autoradiographic studies of the distribution of sulphur 35-labelled mustard gas in mice. Acta Radiol Ther 1:314–320CrossRefGoogle Scholar
  34. Connors TA (1966) Protection against the toxicity of alkylating agents by thiols: the mechanism of protection and its relevance to cancer chemotherapy. A review. Eur J Cancer 2:293–305PubMedCrossRefGoogle Scholar
  35. Dacre JC, Goldman M (1996) Toxicology and pharmacology of the chemical warfare agent sulfur mustard. Pharmacol Rev 48:289–326PubMedGoogle Scholar
  36. Despretz (1822) Sulphur mustard preparation and propertie. Annales de Chimie et de Physique 21:428Google Scholar
  37. Drasch G, Kretschmer E, Kauert G, von Meyer L (1987) Concentrations of mustard gas [bis(2-chloroethyl)sulfide] in the tissues of a victim of a vesicant exposure. J Forensic Sci 32:1788–1793PubMedCrossRefGoogle Scholar
  38. Easton DF, Peto J, Doll R (1988) Cancers of the respiratory tract in mustard gas workers. Br J Ind Med 45:652–659PubMedPubMedCentralGoogle Scholar
  39. Eklow L, Moldéus P, Orrenius S (2004) Oxidation of glutathione during hydroperoxide metabolism: a study using isolated hepatocytes and glutathione reductase inhibitor 1, 3-bis(2-chloroethyl)-1- nitrosurea. Eur J Biochem 138:459–463CrossRefGoogle Scholar
  40. Elsayed NM, Omaye ST (2004) Biochemical changes in mouse lung after subcutaneous injection of the sulfur mustard 2-chloroethyl 4-chlorobutyl sulfide. Toxicology 199:195–206PubMedCrossRefGoogle Scholar
  41. Emad A, Rezaian GR (1997) The diversity of the effects of sulfur mustard gas inhalation on respiratory system 10 years after a single, heavy exposure: analysis of 197 cases. Chest 112:734–738PubMedCrossRefGoogle Scholar
  42. Etezad-Razavi M, Mahmoudi M, Hefazi M, Balali-Mood M (2006) Delayed ocular complications of mustard gas poisoning and the relationship with respiratory and cutaneous complications. Clin Experiment Ophthalmol 34:342–346PubMedCrossRefGoogle Scholar
  43. Fairhall SJ, Brown RF, Jugg BJ, Smith AJ, Mann TM, Jenner J, Sciuto AM (2008) Preliminary studies of sulphur mustard-induced lung injury in the terminally anesthetized pig: exposure system and methodology. Toxicol Mech Methods 18:355–362PubMedCrossRefGoogle Scholar
  44. Foster JH, Lewis MR, Jacobs JK (1962) Thiosulfate protection against the toxic effects of nitrogen mustard in perfusion of the liver. Am Surg 28:461–464PubMedGoogle Scholar
  45. Freitag L, Firusian N, Stamatis G, Greschuchna D (1991) The role of bronchoscopy in pulmonary complications due to mustard gas inhalation. Chest 100:1436–1441PubMedCrossRefGoogle Scholar
  46. Gaga M, Vignola AM, Chanez P (2001) Upper and lower airways: similarities and differences. Eur Respir Mon 6:1–15Google Scholar
  47. Ghanei M, Harandi AA (2007) Long term consequences from exposure to sulfur mustard: a review. Inhal Toxicol 19:451–456PubMedCrossRefGoogle Scholar
  48. Ghanei M, Vosoghi AA (2002) An epidemiologic study to screen for chronic myelocytic leukemia in war victims exposed to mustard gas. Environ Health Perspect 110:519–521PubMedPubMedCentralCrossRefGoogle Scholar
  49. Ghanei M, Akhlaghpoor S, Mohammad MM, Aslani J (2004a) Tracheobronchial stenosis following mustard gas inhalation. Inhal Toxicol 16:845–849PubMedCrossRefGoogle Scholar
  50. Ghanei M, Fathi H, Mohammad MM, Aslani J, Nematizadeh F (2004b) Long-term respiratory disorders of claimers with subclinical exposure to chemical warfare agents. Inhal Toxicol 16:491–495PubMedCrossRefGoogle Scholar
  51. Ghanei M, Hosseini AR, Arabbaferani Z, Shahkarami E (2005) Evaluation of chronic cough in chemical chronic bronchitis patients. Environ Toxicol Pharmacol 20:6–10PubMedCrossRefGoogle Scholar
  52. Ghanei M, Akbari Moqadam F, Mohammad MM, Aslani J (2006a) Tracheobronchomalacia and air trapping after mustard gas exposure. Am J Respir Crit Care Med 173:304–309PubMedCrossRefGoogle Scholar
  53. Ghanei M, Harandi AA, Rezaei F, Vasei A (2006b) Sinus CT scan findings in patients with chronic cough following sulfur mustard inhalation: a case-control study. Inhal Toxicol 18:1135–1138PubMedCrossRefGoogle Scholar
  54. Ghanei M, Panahi Y, Mojtahedzadeh M, Khalili AR, Aslani J (2006c) Effect of gamma interferon on lung function of mustard gas exposed patients, after 15 years. Pulm Pharmacol Ther 19:148–153PubMedCrossRefGoogle Scholar
  55. Ghanei M, Shohrati M, Harandi AA, Eshraghi M, Aslani J, Alaeddini F, Manzoori H (2007) Inhaled corticosteroids and long-acting beta 2-agonists in treatment of patients with chronic bronchiolitis following exposure to sulfur mustard. Inhal Toxicol 19:889–894PubMedCrossRefGoogle Scholar
  56. Ghasemi Boroumand M, Aslani J, Emadi SN (2008) Delayed ocular, pulmonary, and cutaneous complications of mustard in patients in the city of Sardasht, Iran. Cutan Ocul Toxicol 27:295–305CrossRefGoogle Scholar
  57. Ghasemi Broumand M, Karamy G, Pourfarzam S, Emadi SN, Ghasemi H (2007) Late concurrent ophthalmic, respiratory, cutaneous and psychiatric complications of chemical weapons exposure in 479 war patients. Daneshvar Med 70:81–90Google Scholar
  58. Gilasi HR, Holakouie NK, Zafarghandi MR, Mahmoudi M, Ghanei M, Soroush MR, Dowlatyari A, Ardalan A (2006) Relationship between mustard gas and cancer in Iranian soldiers of imposed war in Isfahan Province: a pilot study. J School Publ Hlth Inst Publ Hlth Res 4:15–24Google Scholar
  59. Graham JS, Schoneboom B (2013) Historical perspective on effects and treatment of sulfur mustard injuries. Chem Biol Interact 206:512–522PubMedCrossRefGoogle Scholar
  60. Graham JS, Chilcott R, Rice P, Milner SM, Hurst CG, Maliner BI (2005) Wound healing of cutaneous sulfur mustard injuries: strategies for the development of improved therapies. J Burn Wounds 4:1–45Google Scholar
  61. Graham JS, Stevenson RS, Mitcheltree LW, Hamilton TA, Deckert RR, Lee RB, Schiavetta AM (2009) Medical management of cutaneous sulfur mustard injuries. Toxicology 263:47–58PubMedCrossRefGoogle Scholar
  62. Gross C, Innace JK, Hovatter RC, Meier HL, Smith WJ (1993) Biochemical manipulation of intracellular glutathione levels influences cytotoxicity to isolated human lymphocytes by sulfur mustard. Cell Biol Toxicol 9:259–267PubMedCrossRefGoogle Scholar
  63. Guthrie F (1860) Ueber einige Derivate der Kohlenwasserstoffe CnHn. Ann Chem Pharm 113:266–288CrossRefGoogle Scholar
  64. Haber L (1986) The poisonous cloud. Clarendon Press, OxfordGoogle Scholar
  65. Hasanzadeh R (2012) Video laryngoscopic findings in dysphonic war chemical agent victims. In: Otolaryngology. Islamic Azad University, Mashhad Branch, MashhadGoogle Scholar
  66. Hefazi M, Attaran D, Mahmoudi M, Balali-Mood M (2005) Late respiratory complications of mustard gas poisoning in Iranian veterans. Inhal Toxicol 17:587–592PubMedCrossRefGoogle Scholar
  67. Heston WE (1949) Induction of pulmonary tumors in strain A mice with methyl-bis(beta-chloroethyl) amine hydrochloride. J Natl Cancer Inst 10:125–130PubMedGoogle Scholar
  68. Heston W (1950) Carcinogenic action of the mustard. J Natl Cancer Inst 11:415–423PubMedGoogle Scholar
  69. Heston WE, Lorenz E, Deringer MK (1953) Occurrence of pulmonary tumors in strain A mice following total-body X-radiation and injection of nitrogen mustard. Cancer Res 13:573–577PubMedGoogle Scholar
  70. Heydari F, Ghanei M (2011) Effects of exposure to sulfur mustard on speech aerodynamics. J Commun Disord 44:331–335PubMedCrossRefGoogle Scholar
  71. Hosseini-Khalili A, Haines DD, Modirian E, Soroush M, Khateri S, Joshi R, Zendehdel K, Ghanei M, Giardina C (2009) Mustard gas exposure and carcinogenesis of lung. Mutat Res 678:1–6PubMedPubMedCentralCrossRefGoogle Scholar
  72. International Agency for Research on Cancer (ed) (1992) Occupational exposures to mists and vapors from strong inorganic acids; and other industrial chemicals. IARC, IARC Monogr Eval Carcinog Risks Humans, LyonGoogle Scholar
  73. International Agency for Research on Cancer (ed) (1975) Some Aziridenes, N-, S-, and O-mustards and Selenium. IARC, IARCMonogr Eval Carcinog Risks Humans, LyonGoogle Scholar
  74. Ivarsson U, Nilsson H, Santesson J (eds) (1992) A FOA briefing book on chemical weapons: threat, effects, and protection. National Defence Research Establishment, UmeåGoogle Scholar
  75. Iwaszkiewicz J (1966) Burns of the upper respiratory tract caused by mustard gas. Pol Med J 5:706–709PubMedGoogle Scholar
  76. Iwaszkiewicz J (1996) Burns of the respiratory tract due to mustard gas. Otolaryngol Pol 20:237–247Google Scholar
  77. Kehe K, Szinicz L (2005) Medical aspects of sulphur mustard poisoning. Toxicology 214:198–209PubMedCrossRefGoogle Scholar
  78. Kehe K, Reisinger H, Szinicz L (2000) Sulfur mustard induces apoptosis and necrosis in SCL II cells in vitro. J Appl Toxicol 20(Suppl 1):S81–S86PubMedGoogle Scholar
  79. Kehe K, Worek F, Thiermann H (2008) Medical aspects of chemical warfare agents. In: Richardt A, Blum M (eds) Decontamination of warfare agents, 1st edn. Wiley-VCH, WeinheimGoogle Scholar
  80. Kehe K, Thiermann H, Balszuweit F, Eyer F, Steinritz D, Zilker T (2009) Acute effects of sulfur mustard injury–Munich experiences. Toxicology 263:3–8PubMedCrossRefGoogle Scholar
  81. Ketabchi A (1998) Urogenital and fertility complications in victims of chemical war residing in Kerman province. J Kerman Univ Med Sci 5:72–77Google Scholar
  82. Khateri S, Ghanei M, Keshavarz S, Soroush M, Haines D (2003) Incidence of lung, eye, and skin lesions as late complications in 34,000 Iranians with wartime exposure to mustard agent. J Occup Environ Med 45:1136–1143PubMedCrossRefGoogle Scholar
  83. Kim YB, Lee Y, Choi DS, Cha SH, Sok DE (1996) Change in glutathione S-transferase and glyceraldehyde-3-phosphate dehydrogenase activities in the organs of mice treated with 2-chloroethyl ethyl sulfide or its oxidation products. Food Chem Toxicol 34:259–265PubMedCrossRefGoogle Scholar
  84. Kimoff RJ (2005) Physiology of the upper airways and upper airway obstruction in disease. In: Hamid Q, Martin J, Shannon J (eds) Physiological basis of respiratory disease. Decker Inc., HamiltonGoogle Scholar
  85. Leikin JB, McFee R (2007) Handbook of nuclear, biological and chemical agent exposures. CRC Press, Taylor & Francis Group, Boca RatonCrossRefGoogle Scholar
  86. Malhotra RC, Ganesan K, Sugendran K, Swamy RV (1999) Chemistry and toxicology of sulphur mustard: a review. Defence Sci J 49:97–116CrossRefGoogle Scholar
  87. Manning KP, Skegg DC, Stell PM, Doll R (1981) Cancer of the larynx and other occupational hazards of mustard gas workers. Clin Otolaryngol Allied Sci 6:165–170PubMedCrossRefGoogle Scholar
  88. Marshall V (1987) Case histories of toxic releases. In: Marshall VC (ed) Major chemical hazards. Ellis Horwood, ChichesterGoogle Scholar
  89. Maynard R (2007) Mustard gas. In: Maynard RL, Marrs T, Sidell FR (eds) Agents: toxicology and treatment, 2nd edn. Wiley, ChichesterGoogle Scholar
  90. Maynard RL, Meredith T, Marrs TC, Vale JA (1991) Management of war injuries. Lancet 337:122CrossRefGoogle Scholar
  91. McClintock SD, Hoesel LM, Das SK, Till GO, Neff T, Kunkel RG, Smith MG, Ward PA (2006) Attenuation of half sulfur mustard gas-induced acute lung injury in rats. J Appl Toxicol 26:126–131PubMedCrossRefGoogle Scholar
  92. McNamara B, Owens EJ, Christensen MK, Vocci FJ, Ford DF, Rozimarek H (eds) (1975) Toxicological basis for controlling levels of mustard in the environment. Edgewood Arsenal, MarylandGoogle Scholar
  93. Miller K, Chang A (2003) Acute inhalation injury. Emerg Med Clin North Am 21:533–557PubMedCrossRefGoogle Scholar
  94. Mx D (2003) A case report of a patient with damages of the respiratory system after severe sulfur mustard exposure. Med J Chin PLA 28:1134Google Scholar
  95. Mygind N, Bisgaard H (1990) Applied anatomy of the airways. In: Mygind N, Pipkorn U, Dahl R (eds) Rhinitis and asthma: similarities and differences. Munksgaard, CopenhagenGoogle Scholar
  96. Namazi S, Niknahad H, Razmkhah H (2009) Long-term complications of sulphur mustard poisoning in intoxicated Iranian veterans. J Med Toxicol 5:191–195PubMedPubMedCentralCrossRefGoogle Scholar
  97. Niemann A (1860) Ueber die Einwirkung des braunen Chlorschwefels auf Elaylgas. Ann Chem Pharm 113:288–292CrossRefGoogle Scholar
  98. Nishimoto Y, Yamakido M, Ishioka S, Shigenobu T, Yukutake M (1988) Epidemiologic studies of lung cancer in Japanese mustard gas workers. In: Miller R (ed) Unusual occurrences as clues to cancer etiology. Taylor and Francis, Ltd., TokyoGoogle Scholar
  99. Nishimoto Y, Yamakido M, Ishioka S, Shigenobu T, Yukutake M (1998) Epidemiologic studies of lung cancer in Japanese mustard gas workers. In: Miller R (ed) Unusual occurrences as clues to cancer etiology. Taylor and Francis, Ltd., TokyoGoogle Scholar
  100. Norman JE Jr (1975) Lung cancer mortality in World War I veterans with mustard-gas injury: 1919–1965. J Natl Cancer Inst 54:311–317PubMedCrossRefGoogle Scholar
  101. Pant SC, Vijayaraghavan R (1999) Histomorphological and histochemical alterations following short-term inhalation exposure to sulfur mustard on visceral organs of mice. Biomed Environ Sci 12:201–213PubMedGoogle Scholar
  102. Papirmeister B, Gross C, Petrali JP, Meier HL (1984) Pathology produced by sulfur mustard in human skin grafts on athymic nude mice. II. Ultrastructural changes. J Toxicol Cutaneous Ocul Toxicology 3:393–408CrossRefGoogle Scholar
  103. Papirmeister B, Fiester A, Robinson SI, Ford RD (1991) Medical defense against mustard gas: toxic mechanisms and pharmacological implications. CRC Press, BostonGoogle Scholar
  104. Paromov V, Qui M, Yang H, Smith M, Stone WL (2008) The influence of N-acetyl-L-cysteine on oxidative stress and nitric oxide synthesis in stimulated macrophages treated with a mustard gas analogue. BMC Cell Biol 9:33PubMedPubMedCentralCrossRefGoogle Scholar
  105. Pechura CM, Rall DP (eds) (1993) Veteran at risk: the health effects of mustard gas and lewisite. National Academy Press, Washington, DCGoogle Scholar
  106. Perchura CM, Rall DP (eds) (1993) Veterans at risk: the health effects of mustard gas and lewisite. Institute of Medicine, Washington, DCGoogle Scholar
  107. Pore SG, Reed KL (eds) (1997) Quick reference to speech-language pathology. Aspen Publishers Inc, GaithersburgGoogle Scholar
  108. Prentiss A (ed) (1937) Chemicals in war. McGraw-Hill Book Company Inc, New YorkGoogle Scholar
  109. Rankin PW, Jacobson MK, Mitchell VR, Busbee DL (1980) Reduction of nicotinamide adenine dinucleotide levels by ultimate carcinogens in human lymphocytes. Cancer Res 40:1803–1807PubMedGoogle Scholar
  110. Razavi SM, Ghanei M, Salamati P, Safiabadi M (2013) Long-term effects of mustard gas on respiratory system of Iranian veterans after Iraq-Iran war: a review. Chin J Traumatol 16:163–168PubMedGoogle Scholar
  111. Rhys Evans P (1987) Anatomy of the nose and paranasal sinuses. In: Kerr AG, Groves J, Scott Brown WG (eds) Scott-Brown’s otolaryngology. Butterworth, LondonGoogle Scholar
  112. Rosemond ZA, Beblo D, Amata R (2003) Toxicological profile for sulphur mustard. U.S. Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease RegistryGoogle Scholar
  113. Rowell M, Kehe K, Balszuweit F, Thiermann H (2009) The chronic effects of sulfur mustard exposure. Toxicology 263:9–11PubMedCrossRefGoogle Scholar
  114. Saladi RN, Smith E, Persaud AN (2006) Mustard: a potential agent of chemical warfare and terrorism. Clin Exp Dermatol 31:1–5PubMedCrossRefGoogle Scholar
  115. Sasser LB, Cushing JA, Dacre JC (1996) Two-generation reproduction study of sulfur mustard in rats. Reprod Toxicol 10:311–319PubMedCrossRefGoogle Scholar
  116. Shimkin M, Weisburger JH, Weisburger EK (1966) Bioassay of 29 alkylating chemicals by the pulmonary-tumor response in strain A mice. J Natl Cancer Inst 36:915–935Google Scholar
  117. Shirazi SF, Balali-Mood M (1988) Comparison of early and late toxic effects of sulfur mustard poisoning in two-year periods. In: First international medical congress on chemical warfare agents in Iran, MashhadGoogle Scholar
  118. Shohrati M, Aslani J, Eshraghi M, Alaedini F, Ghanei M (2008) Therapeutics effect of N-acetyl cysteine on mustard gas exposed patients: evaluating clinical aspect in patients with impaired pulmonary function test. Respir Med 102:443–448PubMedCrossRefGoogle Scholar
  119. Shulman L (1993) The biology of alkylatingagent cellular injury. Hematol Oncol Clin North Am 72:325–335Google Scholar
  120. Sohrabpour H, Masjedi M, Bahadori M (1988) Late complications of sulfur mustard in respiratory system. Medical Journal of the Islamic Republic of Iran 2:171–173Google Scholar
  121. Somani S, Babu S (1989) Toxicodynamics of sulfur mustard. Int. J Clin Pharmacol Ther Toxicol 27:419–435Google Scholar
  122. Somani SM, Romano JA (eds) (2001) Chemical warfare agents: toxicity at low levels. CRC Press, Boca RatonGoogle Scholar
  123. Szarejko R (1974) Changes induced by mustard gas in the upper respiratory airways and on attempt at treating them in rats. Otolaryngol Pol 28:617–618PubMedGoogle Scholar
  124. Szinicz L (2005) History of chemical and biological warfare agents. Toxicology 214:167–181PubMedCrossRefGoogle Scholar
  125. Taghaddosinejad F, FayyazF A, Behnoush B (2011) Pulmonary complications of mustard gas exposure: a study on cadavers. Acta Med Iran 49:233–236PubMedGoogle Scholar
  126. Taghadosi M, Razi E, Zarea M (2002) Study of respiratory complications of chemical victims of the imposed war in Kashan. J Military Med 3:163–168Google Scholar
  127. Takeshima Y, Inai K, Bennett WP, Metcalf RA, Welsh JA, Yonehara S, Hayashi Y, Fujihara M, Yamakido M, Akiyama M et al (1994) p53 mutations in lung cancers from Japanese mustard gas workers. Carcinogenesis 15:2075–2079PubMedCrossRefGoogle Scholar
  128. Tang FR, Loke W (2012) Sulfur mustard and respiratory diseases. Crit Rev Toxicol 42:688–702PubMedCrossRefGoogle Scholar
  129. van Helden HP, Kuijpers WC, Diemel RV (2004) Asthma like symptoms following intratracheal exposure of Guinea pigs to sulfur mustard aerosol: therapeutic efficacy of exogenous lung surfactant curosurf and salbutamol. Inhal Toxicol 16:537–548PubMedCrossRefGoogle Scholar
  130. Vander A, Sherman J, Luciano D (1998) Human physiology, the mechanism of body function, 7th edn. McGraw-Hill, BostonGoogle Scholar
  131. Vijayaraghavan R (1997) Modifications of breathing pattern induced by inhaled sulphur mustard in mice. Arch Toxicol 71:157–164PubMedCrossRefGoogle Scholar
  132. Wada S, Miyanishi M, Nishimoto Y, Kambe S, Miller RW (1968) Mustard gas as a cause of respiratory neoplasia in man. Lancet 1:1161–1163PubMedCrossRefGoogle Scholar
  133. Walker I (1971) Interstrand bifunctional alkylation of DNA in mammalian cells treated with mustard gas. Can J Biochem 49:332–336PubMedCrossRefGoogle Scholar
  134. Warthin A, Weller CV (1919) The lesion of the respiratory and gastrointestinal tracts produced by mustard gas (dichloroethyl sulphide). J Lab Clin Med 4:229–264Google Scholar
  135. Watson AP, Griffin GD (1992) Toxicity of vesicant agents scheduled for destruction by the Chemical Stockpile Disposal Program. Environ Health Perspect 98:259–280PubMedPubMedCentralCrossRefGoogle Scholar
  136. Wattana M, Bey T (2009) Mustard gas or sulfur mustard: an old chemical agent as a new terrorist threat. Prehosp Disaster Med 24:19–29; discussion 30–31PubMedCrossRefGoogle Scholar
  137. Weber WM, Kracko DA, Lehman MR, Irvin CM, Blair LF, White RK, Benson JM, Grotendorst GR, Cheng YS, McDonald JD (2010) Inhalation exposure systems for the development of rodent models of sulfur mustard-induced pulmonary injury. Toxicol Mech Methods 20:14–24PubMedPubMedCentralCrossRefGoogle Scholar
  138. Wheeler GP (1962) Studies related to the mechanisms of action of cytotoxic alkylating agents: a review. Cancer Res 22:651–688PubMedGoogle Scholar
  139. WHO (2004) WHO guidance: public health response to biological and chemical weapons. World Health Organization, GenevaGoogle Scholar
  140. WHO (1970) Health aspects of chemical and biological weapons. World Health Organization, GenevaGoogle Scholar
  141. WHO (1987) United Nations official reports. S/16433 (1984); S/17911 (1986); and S/18852Google Scholar
  142. Yang JY, Yang WG, Chang LY, Chuang SS (1999) Symptomatic tracheal stenosis in burns. Burns 25:72–80PubMedCrossRefGoogle Scholar
  143. Zafarghandi MR, Soroush MR, Mahmoodi M, Naieni KH, Ardalan A, Dolatyari A, Falahati F, Mirmohammadkhani M, Mousavi B, Ghanei M (2013) Incidence of cancer in Iranian sulfur mustard exposed veterans: a long-term follow-up cohort study. Cancer Causes Control 24:99–105PubMedCrossRefGoogle Scholar
  144. Zhang Z, Riviere J, Monteiro-Riviere NA (1995) Evaluation of protective effects of sodium thiosulfate, cysteine, niacinamide and indomethacin on sulfur mustard-treated isolated perfused porcine skin. Chem Biol Interact 96:249–262PubMedCrossRefGoogle Scholar
  145. Zilker T, Felgenhauer N (2002) S-mustard gas poisoning – experience with 12 victims. Clin Toxicol (Phila) 40:251Google Scholar
  146. Zojaji R, Balali-Mood M, Mirzadeh M, Saffari A, Maleki M (2009) Delayed head and neck complications of sulphur mustard poisoning in Iranian veterans. J Laryngol Otol 123:1150–1154PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Otorhinolaryngology DepartmentMashhad Branch, Islamic Azad UniversityMashhadIran
  2. 2.Arya Teaching Medical Hospital ENT DepartmentIslamic Azad Medical UniversityMashhadIran
  3. 3.Faculty of MedicineMashhad Branch, Islamic Azad UniversityMashhadIran

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