ENT Flashcards
Symptoms of upper airway obstruction?
Two types?
Most common symptom: STRIDOR.
Others: barking cough, hoarse voice.
What are the different types of breathing sound in upper airway obstruction?
STERTOR: partial obstruction of airway, low-pitched snoring noise produced by vibrations above level of larynx. (i.e. at level of nose / pharynx).
STRIDOR: audible change in airflow at level of larynx, trachea or bronchi
- Inspiratory stridor: turbulent airflow above vocal cords.
- Expiratory stridor: turbulent airflow in trachea or bronchi (comparable with wheeze).
- Biphasic stridor: inspiratory & expiratory component and related to pathology located at the level of the vocal cords or subglottis (just beneath vocal cords).
Acute and chronic causes of stertor?
Acute: tonsillitis, peritonsillar abscess, infectious mononucleosis, nasal foreign body, diptheria, retropharyngeal abscess
Chronic: enlarged adenoids / tonsils (chronic stertor may indicate OSA - surgical referral to consider tonsillectomy), nasal foreign body
Acute and chronic causes of stridor?
Acute: Croup (most common), Epiglottitis (or supraglottitis)
Bacterial tracheitis, Anaphylaxis, Foreign bodies
Chronic: Laryngomalacia (most common), subglottic stenosis, subglottic haemangioma, tracheomalacia, vocal cord palsy, laryngeal papillomata cysts & webs, vascular ring, chronic obstruction with foreign body
What is croup? (aetiology, symptoms)
Acute laryngotracheobronchitis
Most common cause: parainfluenza virus. Typically 1-2 years (rare <5), onset 1-2 days following URTI
- Barking cough (worse at night)
- Temp <38.5 (beware if very high fever – have they got tracheitis, epiglottitis)
- Hoarseness
- Coryzal symptoms (initial viral prodrome, several days)
Management of croup?
Keep child as calm as possible + do not attempt to examine their throat (if upset: gets worse) + can cause laryngospasm.
• Stridor when resting + relaxed: criteria to keep in.
Treatment dependent on croup score.
• Oxygen and hydration
• Oral dexamethasone (preferred to prednisolone as longer acting) - CKS: single dose 0.15mg/kg for ALL children regardless of severity
• Nebulised budesonide
• Nebulised adrenaline (may need intensive care if adrenaline starting to wear off)
• Intubation (not very common)
(High flow oxygen and nebulised adrenaline are emergency treatments).
CKS suggest admitting any child with moderate or severe croup.
How is croup classified?
Mild: Occasional barking cough, No audible stridor at rest
No or mild suprasternal / intercostal recession, Happy + prepared to eat, drink, play
Moderate: Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation, can be placated + interested in surroundings
Severe: Frequent barking cough, Prominent inspiratory (and occasionally expiratory) stridor at rest, Marked sternal wall retractions, Significant distress + agitation, or lethargy or restlessness (sign of hypoxaemia). Tachycardia occurs with more severe obstructive symptoms & hypoxaemia
When to admit for croup?
NICE CKS - anyone with mod / severe croup
Other features prompting admission:
• <6 months age
• Known upper airway abnormalities (e.g. laryngomalacia, Down’s syndrome)
• Diagnostic uncertainty (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess + foreign body inhalation)
Management of nasal foreign body?
Potential migration further into airway, therefore early removal needed, under anaesthetic if required. Usually with simple forceps or by the ‘kissing technique’: seal over the lips, occluding the unaffected nostril and blowing in the mouth (often done by mother). Unilateral, offensive nasal discharge may be presentation of chronic nasal foreign body.
Airway foreign body - presentation / diagnosis
Distal: Hx of coughing or choking on feeding – careful evaluation for airway foreign body.
Symptoms dependent on location (audible stridor + respiratory distress / asymptomatic)
Bronchus worrying site for lodging of inhaled foreign body, in older children more commonly occurs in right main bronchus
CXR (both inspiratory and expiratory): assessment of body + also associated airway collapse or air-trapping associated obstruction
• Chronic obstruction may cause secondary infection
• Bronchoscopic airway evaluation
Choking in children? management?
Usually witnessed in preschool children with sudden attack of stridor and respiratory distress, secondary to food or foreign body obstruction
- Conscious child: with effective cough (audible cry / speech, loud cough) should be regularly observed and encouraged to cough.
- Ineffective cough: (inaudible cry /speech, unable to breathe, cyanotic): assistance needed: 5 back blows, 5 abdominal thrusts if >1 year or 5 chest thrusts if <1 year old. Reassess after each intervention and repeat process as necessary.
- Unconscious child: in very severe obstruction – attempt to remove anything seen in mouth with one finger sweep then follow BLS (rescue breaths).
What is bacterial tracheitis? management?
Also known as pseudomembranous croup – caused by Staphylococcus Aureus infection and presents with similar clinical features to acute epiglottitis.
Bacterial invasion of trachea > pseudomembranous formation with purulent secretions unresponsive to conventional management.
Patients require broad spectrum antibiotics and may require prolonged intubation, with endoscopic removal of secretions.
What is acute epiglottitis?
Severe swelling of epiglottis and aryepiglottic folds secondary to bacterial infection: Haemophilus influenzae type b (Hib). Now very rare (widespread vaccination), mainly affects children 3-5 years, can rapidly progress over several hours.
Features:
• Usually rapid in onset with severe symptoms
• High fever
• Drooling / dysphagia
• Significant distress
• May be stridor, laboured breathing + muffled, quiet voice
Management of acute epiglottitis?
Never upset child as may precipitate full airway obstruction (includes ENT exam, taking blood or cannulation without anaesthetist present). Protecting airway is first priority – may require intubation or even surgical airway if there is significant swelling.
Broad-spectrum antibiotics (e.g. 3rd generation cephalosporin) should be started promptly + steroids or adrenaline nebulisers may be needed.
Main differences between croup and epiglottitis?
Croup Hoarse voice Coryzal <38.5 Barking cough Well Drooling unlikely
Mgmt: Mild - no specific treatment, Mod: oral steroids, Severe: oxygen, adrenaline / intubation / surgical airway
Epiglottitis Quiet / muffled voice >38.5 Slight cough Appears toxic Drooling & painful to swallow
Mgmt: Steroids, adrenaline nebulisers, IV antibiotic (usually ceftriaxone). Urgent: senior anaesthetist & ENT surgeons. Early intubation under GA. Occasionally urgent tracheostomy .
