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JC WCS > ENT JC086: Upper Airway Obstruction And Tracheostomy > Flashcards

ENT JC086: Upper Airway Obstruction And Tracheostomy Flashcards

1
Q

Upper airway obstruction in Neonate / Infant

A

Causes:
Congenital
1. **Laryngomalacia
2. **Vocal cord palsy
3. **Subglottic stenosis
4. Congenital tumour, cyst
5. **Subglottic haemangioma
6. Vascular + Lymphatic malformation
7. Tracheal anomaly
8. **Craniofacial abnormalities (syndromal causes)
9. **Choanal atresia

Clinical presentation:
1. **Stridor
2. Stertor (i.e. Snoring)
3. **Choking
4. Frequent aspiration
5. Voice change: Hoarseness, **Weak cry, No cry
6. Respiratory distress: ↑ RR, **Insucking (suprasternal, intercostal, subcostal region), Accessory muscles, ↓ Air entry

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2
Q

Stridor

A
  • Important sign for ***upper airway obstruction
  • High-pitched, harsh sound
  • ∵ Turbulent airflow through partially obstructed airway —> noisy breathing
  • Inspiratory: Supraglottic, Vocal cord
  • Expiratory: Trachea, Bronchi
  • Biphasic (Inspiratory + Expiratory): Subglottis, Trachea
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3
Q

History taking of paediatric airway obstruction

A

Unstable patients: Immediate resuscitation + Intubation
Stable: History taking

History taking:
1. Perinatal history
2. Birth history
3. **Age of onset
4. Aggravating factors (e.g. worse during feeding)
5. Voice, Cry
6. **Choking on feeding
7. History of intubation (post-intubation traumatic subglottic stenosis)

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4
Q

P/E of paediatric airway obstruction

A
  1. Quality of stridor
  2. RR
  3. Signs of respiratory distress
    - **Intercostal, Suprasternal, Subcostal insucking
    - **    Nasal flaring
  4. Agitation
  5. Fatigue
  6. ↓ Consciousness (late sign)
  7. Fever
  8. ***Cyanosis (or cyanotic spell)
  9. Position of child (e.g. acute epiglottitis, retropharyngeal abscess)
  10. ***Craniofacial anomaly
  11. Neck swelling
  12. Cutaneous haemangioma
  13. Auscultation
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5
Q

Investigations of paediatric airway obstruction

A
  1. ***AP + Lateral neck X-ray
  2. CXR
  3. Endoscopy
    - **Flexible laryngoscopy (NA/LA)
    - **    Rigid laryngoscopy (GA)
    - Ventilating bronchoscopy (GA)
    - Microlaryngoscopy + CO2 laser
  4. CT virtual bronchoscopy
  5. MRI / MR angiography (look at great vessels in mediastinum)
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6
Q

Flexible laryngoscopy vs Rigid laryngoscopy vs Ventilating bronchoscopy

A

Flexible laryngoscopy:
- ***Dynamic assessment of larynx
—> Vocal cord mobility, Coordination of larynx, Laryngomalacia (cause prolapse of supraglottis)
- done awake / under LA

Rigid laryngoscopy / Laryngotracheobronchoscopy (LTB):
- More detailed examination of larynx, vocal cord, ***trachea
- done under GA
- for more severe stridor
—> severe stridor
—> biphasic stridor
—> desaturation / cyanotic spell
—> failed extraction for 3 times
—> frequent aspiration / choking
—> failure to thrive
—> XR suggestive of subglottic / tracheal obstruction
—> clinical suspicion e.g. previous intubation, cutaneous haemangioma

Ventilating bronchoscopy:
- for severe distress patient requiring anaesthetic agent during airway examination
- **bypass obstruction for difficult intubation
- **removal of foreign body in trachea

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7
Q
  1. Laryngomalacia
A
  • 軟喉症
  • Inward prolapse of arytenoids —> obstruction of larynx
  • 70-80% Stridor in infant
  • M:F = 2:1
  • presents within first ***2 weeks of life

Clinical features:
- Inspiratory stridor
- **Normal cry
- **No cyanosis
- Worsen on supine position, improves in prone, sitting, hyperextension of neck
- Feeding difficulties (e.g. choking)

Natural course:
- **Self-limiting
- **Resolution by 12-18 months

Complications:
- OSA
- ***Failure to thrive
- Cor pulmonale
- Chest deformity

Treatment:
- ***CO2 Supraglottoplasty / Laser aryepiglottoplasty

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8
Q
  1. Vallecula and Laryngeal cyst
A
  • Stridor in neonate
  • Presented with respiratory distress
  • GA for excision
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9
Q
  1. Subglottic stenosis
A

Definition:
- Full term infant: Subglottic diameter <4 mm
- Preterm: Subglottic diameter <3.5 mm

Stenosis:
- Membranous vs Cartilaginous
- **Congenital (abnormal cricoid ring) vs **Acquired (post-intubation)

Grading of Subglottic stenosis: **Laryngotracheobronchoscopy (i.e. Rigid bronchoscopy)
- Size the airway with ET tube (largest tube with air leak at 25 cmH2O)
- **Cotton-Myers classification:
—> Grade 1: <50% obstruction
—> Grade 2: 50-70%
—> Grade 3: 71-99%
—> Grade 4: 100%

Treatment:
1. **CO2 laser
2. Balloon dilatation
3. **Laryngotracheal reconstruction (LTR) (definitive: for abnormal cricoid ring)

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10
Q
  1. Bilateral vocal cord palsy
A

Congenital
- Stridor shortly **after birth
- **Weak cry / no cry
- Choking
- Idiopathic
- Need to rule out ***CNS pathology e.g. Arnold-Chiari malformation (abnormal herniation of cerebellum)

Acquired
- Post-cardiac, lung, thyroid surgery (Recurrent laryngeal nerve damage)

Treatment:
1. Treat underlying cause
2. Conservative
3. **Bilateral: 50% tracheostomy
4. **Congenital palsy majority recover at 2-5 yo
5. Definitive surgery after adolescence: Lateralisation / Arytenoidectomy

Unilateral vocal cord palsy
- Post-cardiac, Post-thyroid surgery
- Majority have good compensation by other cord
- **Speech therapy
- **Medialisation of vocal cord
- Injection laryngoplasty

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11
Q
  1. Subglottic haemangioma
A
  • Mass (Haemangioma) below vocal cord
  • Symptomatic by ***3 months
  • Inspiratory (Supraglottic, Vocal cord) to Biphasic stridor (Subglottis, Trachea)
  • ***Recurrent croup
  • 50% cutaneous haemangioma

Treatment:
1. **Systemic steroid (to shrink haemangioma)
2. CO2 laser (for obstruction)
3. **Propranolol (to shrink haemangioma)
4. Tracheostomy (for circumferential haemangioma)
5. α2 interferon

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12
Q
  1. Laryngeal cleft
A

Congenital midline defect of posterior larynx, trachea, anterior wall of esophagus due to ***Incomplete formation of tracheoesophageal septum

  • **Benjamin-Inglis classification:
  • Type 1-4

Treatment:
- Endoscopic repair of laryngeal cleft

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13
Q
  1. Congenital disorder of trachea
A
  1. Tracheomalacia
  2. Vascular compression of trachea (by great vessels)
  3. Tracheal stenosis (e.g. post-intubation): Balloon dilatation vs Tracheoplasty
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14
Q
  1. Congenital head and neck tumours
A

E.g. Teratoma

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15
Q
  1. Lymphatic malformation
A
  • ***Cystic hygroma
  • 60% at birth
  • 75% in head and neck region (others e.g. axilla)

Treatment:
- Surgical excision
- Injection ***OK432 (attenuated strain of Streptococcus pyogenes) —> shrink cystic hygroma

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16
Q
  1. Vascular anomaly
A
  1. Vascular ring (e.g. Double aortic arch)
  2. Aberrant subclavian artery
  3. Aberrant pulmonary artery
  4. Extrinsic compression of trachea
17
Q
  1. Craniofacial abnormalities
A
  1. Pierre Robin syndrome
  2. Treacher Collin syndrome
  3. ***Apert syndrome
  4. Crouzon syndrome

Manifestations:
1. **Hypoplastic mandible —> Mandibular distraction
2. **Hypoplastic maxilla
3. **Retrognathia (small receding chin)
4. **Choanal atresia
- 1:8000 live birth
- F:M = 2:1
- **Failure of breakdown of buccopharyngeal membrane —> obstruction at back of nasopharynx
- Unilateral:Bilateral = 3:2
- Bilateral: ENT emergency —> ∵ Neonates are **obligate nasal breather
- Treatment: Transnasal opening of atresia

18
Q

Causes of Upper airway obstruction in Toddlers / OIder Children

A

Infective
1. **Croup
2. **Epiglottitis
3. Retropharyngeal abscess

Others:
1. Recurrent respiratory papillomatosis (benign tumors (papilloma) form along the aerodigestive tract)
2. Obstructive sleep apnea
3. ***Foreign body ingestion

19
Q
  1. Croup
A

aka Laryngotracheobronchitis
- **Subglottic
- 6 months - 3 yo (peak at 2 yo)
- Recurrent croup need to rule out underlying **subglottic stenosis

Causative agents:
1. **Parainfluenza virus
2. **Influenza virus type A
3. ***RSV
4. Mycoplasma pneumoniae

Clinical features:
- Preceded by URTI
- Hoarseness
- ***Barking cough
- Biphasic stridor

Investigations:
- X-ray (***Steeple sign)

Treatment:
1. Close observation
2. 5-10% will need admission
3. **Systemic steroid
4. **Nebulised adrenaline
5. Intubation

20
Q
  1. Acute epiglottitis
A

**ENT + Paediatric emergency
- **Supraglottic
- 2-6 yo (peak at 3-4 yo)

Causative agents:
1. ***Hib
2. β-haemolytic Streptococcus
3. Pneumococcus
4. Staphylococcus

Clinical features:
- Rapidly worsening sore throat
- High fever
- **Inspiratory stridor
- **Drooling
- ***Unable to speak / Muffled “hot potato” voice
- Tripod sign

Investigation:
- X-ray (***Thumb sign) (ONLY do x-ray when stable)

Treatment:
1. Keep calm
2. NO attempt for throat exam, blood taking, IV access
3. Diagnosis by **history
4. Bring patient to **OT
5. Inform senior paediatrician, ENT, anaesthetist
6. Gaseous induction followed by **intubation to secure airway
7. Blood culture + Set up IV line
8. **3rd gen Cephalosporin

21
Q

Epiglottitis vs Croup

A

Acute epiglottitis (**Supraglottic):
- **Haemophilus influenzae type B
- 2-4 years
- toxic and unwell
- abrupt onset
- high fever
- minimal/absent cough
- **unable to speak
- **drooling saliva

Croup (**Subglottic):
- **VIRUS
- 3 month - 3 years
- well looking
- **viral prodrome
- moderate fever
- **barking cough
- hoarse voice
- ***able to swallow

22
Q
  1. Retropharyngeal abscess
A
  • Commonest deep neck infection in <4 yo
  • caused by Infected retropharyngeal LN (∵ retropharyngeal LN disappear in adult —> parapharyngeal abscess)

Clinical features:
- **Mimic croup
- History of URTI
- Toxic, fever
- Head hyperextended, stiff neck
- **Inspiratory stridor
- Dysphagia, drooling

Investigations
- X-ray (↑ Retropharyngeal space)

23
Q
  1. Recurrent respiratory papillomatosis (RRP)
A

Mean age of presentation: 2 yo

Causative agents:
- **HPV 6, 11
- Mother infected with **genital warts —> transmitted during delivery

Clinical features:
- Papilloma can occur from **lips to **lungs

Treatment:
1. Laryngeal debrider
2. ***CO2 laser

24
Q
  1. Foreign body
A
  • common between 1-3 yo

Accurate history:
- Witness
- Choking episodes, coughing spells, aspiration

Clinical features:
- Variable S/S
- **Stridor + **Wheeze
- Auscultation: Unilateral ***decrease air entry, Wheezing

Investigations:
- CXR: **Hypoinflation of inspiration, **Hyperinflation on expiration (air-trapping) (but 25-50% normal CXR)

25
Q

Causes of Upper airway obstruction in Adults

A
  1. Tumour
    - Nasal cavity to Larynx
    - Thyroid
  2. Infection
    - Peritonsilar abscess (Quinsy)
    - Ludwig’s angina
    - Submandibular abscess
    - Parapharyngeal abscess
  3. Bilateral vocal cord palsy
    - Tumour
    - CVA
    - Post-op
  4. Trauma
  5. OSA
  6. Foreign body
  7. Anaphylaxis
26
Q

History taking of Upper airway obstruction in Adults

A

記: Nose, Pharynx, Throat

Nose:
1. Nasal symptoms
2. Dyspnea

Pharynx:
3. Dysphagia
4. Blood in saliva

Throat:
5. Sore throat
6. Hoarseness
7. Neck swelling, pain

Others:
8. Smoking, drinking
9. Fever

27
Q

P/E + Investigations of Upper airway obstruction in Adults

A

P/E:
1. Vital signs
2. Fever
3. Head and Neck exam
4. Oral cavity
5. Thyroid
6. Neck LN

Investigations:
1. X-ray neck
2. CXR
3. **Urgent CT neck with contrast (if suspect deep neck infection)
4. **Laryngoscopy (look for airways obstruction + vocal cord movement)

28
Q

Peritonsillar abscess

A
  • Quinsy
  • Collection of pus between **tonsillar capsule + **superior constrictor
  • usually unilateral

Clinical features:
- **Sore throat
- **Trismus
- Dysphagia
- Odynophagia
- Airway obstruction
- ***Peritonsillar swelling
- Deviation of uvula to other side

Management:
1. Incision + Drainage
2. Antibiotics

29
Q

Ludwig’s angina

A

Infection of Floor of mouth, Submental, Submandibular space

Clinical features:
- Septic
- **“Hot-potato” voice
- Dysphagia
- Tender swelling at Submental area
- **Superior, posterior displacement of tongue (Board-like swelling)
- ***Trismus
- Airway obstruction

30
Q

Parapharyngeal abscess

A

Deep neck infection

Clinical features:
- Neck swelling
- Airway obstruction
- Stridor

Causes:
- Tonsillitis
- ***Dental origin

Management:
1. ***Transcervical drainage
2. Tracheostomy if severe obstruction

31
Q

Acute epiglottitis in Adults

A

Clinical features:
- Sore throat
- Rapid onset
- Dysphagia

P/E:
- Painful over central neck

Management:
1. Close airway monitoring
2. IV **Augmentin / Cefotaxime (3rd gen)
3. +/- **Intubation / Tracheostomy

32
Q

Tumour

A
  1. CA layrnx
    - CA supraglottis
    - CA glottis
    - CA subglottis
  2. CA hypopharynx
  3. CA thyroid
33
Q

Laryngeal trauma

A

Blunt trauma causing fracture of thyroid cartilage + swollen larynx

Management:
1. Immediate secure of airway
2. Tracheostomy

34
Q

Bilateral vocal cord palsy

A

Clinical features:
- Inspiratory stridor

Causes:
1. Tumour
2. CVA
3. Iatrogenic (e.g. Thyroidectomy)

Management:
- Emergency tracheostomy

35
Q

Tracheostomy

A

Indications:
1. **Upper airway obstruction (e.g. failed intubation)
2. **Assisted ventilation (e.g. respiratory failure)
3. Prolonged intubation
4. ***Bronchial toilet (e.g. to clear sputum from severe pneumonia)

Process:
- GA / LA if failed intubation
- Dissection down to trachea
- Incision between ***2nd / 3rd tracheal ring
- Insertion of tracheostomy tube

Complications:
Early
1. Bleeding
2. Misplaced tube, false tract
3. ***Surgical emphysema (gas within SC / neck region)
4. Pneumothorax
5. Obstructed tube
6. Dislodged tube

Late
1. **Granuloma
- skin / suprastomal (inside trachea)
2. **Stenosis
- subglottis / suprastomal / stomal / cuff / tip
3. ***Tracheo-innominate fistula
4. Tracheoesophageal fistula
5. Suprastomal (airway) collapse (∵ destroyed cartilage)
6. Chest infection

Prevention of complications:
1. CXR (to rule out pneumothorax)
2. Check tube tip position, 1-2 cm above carina for infants (∵ short trachea, check whether tip is impinging on carina)

36
Q

Care of Tracheostomy

A
  1. Immediate post-op: CXR
  2. Emergency preparation (e.g. dislodged tube) - secure tapes
  3. Frequency suction to prevent blockage
  4. Cleaning of tube with daily dressing
  5. Position of tube
  6. Change of tube (first change 5-7 days)
  7. Feeding
  8. Speech
  9. Home care
    - long-term plan
    - tubes
    - equipment
37
Q

Tracheostomy tube selection

A

Different models and sizes

  1. Appropriate size for age (paediatrics) + body build (adult size 7-8 portex)
    - Paediatric: Shiley, Tracoe, Portex
  2. Plastic vs Metal (old, seldom used)
  3. Cuffed tube (for those on ventilators, prevent air leak) vs Non-cuffed (mainly for children)
    - Short term use, need regular change of tubes every week
  4. Non-fenestrated vs Fenestrated (for speech)
    - Fenestrated: promote translaryngeal airflow, help phonation, risk of granuloma formation around fenestrated area
  5. Long-term tube
    - with outer + inner tube (only need to clean inner tube which is easily pulled out)
  6. Speaking valve
    - one-way valve allows free air flow into lungs
    - valves closed on exhalation
    - directing expired air up larynx + out through mouth and nose
38
Q

Obstructive sleep apnea syndrome (OSAS)

A

Neonates / Children:
- Adenotonsillar hypertrophy

Investigation:
- ***Nocturnal SaO2 monitoring (screening for young children, uncooperative for PSG)
—> Positive oximetry (i.e. at risk of OSA):
—> >=3 desaturation clusters (desaturation equal to ↓ in SaO2 >=4%, 1 cluster equal to >=5 desaturation episodes in 10-30 mins)
—> >=3 SaO2 <90%

Treatment:
- Tonsillectomy / Adenoidectomy

S/S:
Night time:
- Snoring
- Witnessed apnea
- Restlessness
- Unusual position: prone, sitting, extended neck
- Laboured breathing
- Excessive sweating
- Secondary nocturnal enuresis
- Parasomnias (sleep walking)

Daytime:
- Irritability, behavioural problem: social withdrawal, hyperactivity, aggressiveness
- Poor concentration / attention
- Failure to thrive
- Upper airway obstruction / Mouth breathing
- Morning headache

Adult:
- Obesity
- Snoring
- Daytime sleepiness
- Hypertension
- HT, DM, Stroke risk ↑

Investigations:
- ***Polysomnography (gold standard: AHI >5 in adults, >1 in children)
- Sleep endoscopy
- Multilevel obstruction
- Epworth sleepiness scale

Treatment:
- Weight reduction
- Optimise nasal condition
- ***CPAP (gold standard)
- UPPP (Uvulopalatopharyngoplasty), Palatal surgery
- Genioglossus advancement
- Radiofrequency palatoplasty + turbinectomy

JC WCS (134 decks)

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