JC86 (ENT) - Upper airway obstruction Flashcards
Ddx causes of upper airway obstruction in neonates and infant
Laryngomalacia
Vocal cord palsy
Subglottic stenosis
Congenital tumor or cysts
Subglottic hemagioma
Vascular and lymphatic malformation
Tracheal anomaly
Craniofacial abnormalities
Choanal atresia
Ddx causes of upper airway obstruction in older children
Croup
Epiglottitis
Retropharyngeal abscess
Recurrent respiratory papillomatosis
Obstructive sleep apnea
Foreign body obstruction
Causes of upper Airway obstruction in adults
Tumor: nasal cavity, larynx, thyroid
Infection: Parapharyngeal abscess, peritonsillar abscess, Ludwig’s angina, Submandibular abscess
Trauma
OSA
Foreign body
anaphylaxis
Clinical presentation of upper airway obstruction in infants and children
Stridor*
Stretor
Choking
Frequent aspiration
Voice changes: Hoarseness, weak cry, unable to cry
Respiratory distress: Tachypnea, Insucking of intercostal muscles, use of accessory muscles, air entry
Stridor
Describe the sound
Pathophysiology of the sound
Differentiate the areas of obstruction between inspiratory, biphasic and expiratory stridor
High-pitched, harsh sound
Cause: Turbulent airway through partially obstructed airway
Inspiratory: Supraglottis, vocal cord
Biphasic: Subglottis, trachea
Expiratory: trachea, bronchi
Stretor
Describe sound
Cause of sound
Areas of obstruction
Low-pitched inspiratory sound, like snoring
Cause: Turbulent airflow above larynx
Obstruction: Nasal cavity, nasopharynx and soft palate
Outline history taking questions for neonate presenting with upper airway obstruction (if not in distress)
Perinatal history Birth history Age of onset Aggravating factors Voice production, Ability to cry Any choking or aspiration during feeding History of intubation and upper airway damage
Outline P/E for neonate with upper airway obstruction
Respiratory exam:
- Respiratory rate
- Insucking of intercostal, Suprasternal or subcostal muscles
- Signs of respiratory distress
- Quality of stridor
- Auscultate lung fields
General inspection:
- Cyanosis
- Agitation or fatigue
- Decrease consciousness
- Neck swelling and craniofacial anomaly
- Cutaneous hemangioma
- Nasal flaring
First-line investigation for neonate presenting with upper airway obstruction
X-ray: AP and lateral neck
CXR
Endoscopy: flexible (LA) or rigid laryngoscopy (GA), Ventilating bronchoscopy (GA)
CT virtual bronchoscopy
MRI/ MRA
Indications for flexible vs rigid laryngoscopy/ Laryngotracheobronchoscopy
Flexible:
- Dynamic assessment of larynx and vocal cord mobility
- Laryngomalacia (congenital softening of the tissues of the larynx)
Rigid:
- Severe stridor with desaturation/ cyanotic spells
- Frequent aspiration and choking
- Failed extubation for 3 times
- Failure to thrive
- X-ray shows subglottic or tracheal obstruction
Most common cause of stridor in infant?
Laryngomalacia
Laryngomalacia
- Demographic
- Age of onset
- Presentation
- Time course
- Demographic: 70-80% stridor in infant, M:F = 2:1
- Age of onset: 2 weeks of life
- Presentation:
» Inspiratory stridor, normal cry, no cyanosis or desaturation
» Stridor worse on supine position, improves in sitting or prone position or hyperextension of neck
» Feeding aspiration - Time course: Self-limiting, resolution by 1.5 years old
Laryngomalacia
complications
tx
- Complications: OSA Failure to thrive Cor pulmonale Chest deformity
Tx:
CO2 supraglottoplasty
Laser aryepiglottoplasty
Vallecula and laryngeal cyst
Define vallecula anatomical position
Pathogenesis of vallecula cyst
Presentation in neonates
Vallecula is depression in the oropharynx that located anterior to the epiglottis and posterior to the tongue base
Vallecular cysts are benign retention cysts of the minor salivary glands.
» commonest site is the lingual surface of epiglottis
» distort the epiglottis when they increase in size and eventually fill the vallecula, blocking laryngeal inlet
Presentation:
- Stridor at birth, respiratory distress
Subglottic stenosis
Define the size of subglottic in pre-term and full-term infants
Types
Classification system for stenosis severity
Tx
Subglottic diameter:
- <4mm in full-term
- <3.5mm in pre-term
Types:
Membranous, Cartilaginous
Congenital or acquired
Cotton-Myers Classification: Sizing airway with ET tube I: <50% obstruction II: 50-70% III: 71-99% IV: 100%
Tx:
Opening subglottic stenosis with CO2 laser
Laryngotracheal reconstruction
Vocal cord palsy
Congenital and acquired causes
Presentation in neonates
Congenital:
- Idiopathic
- Arnold-chiari malformation
Acquired:
- Most Iatrogenic damage: cardiac, lung, thyroid surgery
Presentation:
- Stridor after birth
- Weak cry or no cry
- Choking
Vocal cord palsy
Treatment options
Congenital cause:
- Watchful waiting and conservative Tx: Most congenital palsy resolves at 2-5 years old
- Definitive surgery after adolescence: Lateralization or arytenoidectomy
Bilateral palsy: Tracheostomy
Unilateral palsy:
- Medialization or vocal cord
- Injection laryngoplasty
- Speech therapy
Subglottic hemangioma
Age of onset
Presentation
Tx
Age: 3 months
Presentation:
- Inspiratory to biphasic stridor
- Recurrent croup
Tx:
- Systemic steroid
- CO2 laser
- a2- interferon
- Tracheostomy
- Propranolol** 2mg/kg/day
Mainstay treatment for subglottic haemagioma in neonates
S/E
Propranolol +/- CO2 laser ablation
2mg/kg/day
S/E:
Hypoglycaemia, hypotension, bradycardia
Laryngeal cleft
- Describe the defect
- Classification system for severity
- Congenital midline defect of posterior larynx, trachea and anterior wall of esophagus
- Due to incomplete formation of tracheoesophageal septum
Classification:
- Benjamin-Inglis classification
Complications of tracheotomy
