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MBBS IV - Junior Clerkship WCS > JC86 (ENT) - Upper airway obstruction > Flashcards

JC86 (ENT) - Upper airway obstruction Flashcards

1
Q

Ddx causes of upper airway obstruction in neonates and infant

A

Laryngomalacia
Vocal cord palsy
Subglottic stenosis
Congenital tumor or cysts

Subglottic hemagioma
Vascular and lymphatic malformation

Tracheal anomaly
Craniofacial abnormalities
Choanal atresia

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2
Q

Ddx causes of upper airway obstruction in older children

A

Croup

Epiglottitis

Retropharyngeal abscess

Recurrent respiratory papillomatosis

Obstructive sleep apnea

Foreign body obstruction

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3
Q

Causes of upper Airway obstruction in adults

A

Tumor: nasal cavity, larynx, thyroid

Infection: Parapharyngeal abscess, peritonsillar abscess, Ludwig’s angina, Submandibular abscess

Trauma
OSA
Foreign body
anaphylaxis

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4
Q

Clinical presentation of upper airway obstruction in infants and children

A

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

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5
Q

Stridor
Describe the sound
Pathophysiology of the sound
Differentiate the areas of obstruction between inspiratory, biphasic and expiratory stridor

A

High-pitched, harsh sound

Cause: Turbulent airway through partially obstructed airway

Inspiratory: Supraglottis, vocal cord
Biphasic: Subglottis, trachea
Expiratory: trachea, bronchi

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6
Q

Stretor

Describe sound
Cause of sound
Areas of obstruction

A

Low-pitched inspiratory sound, like snoring

Cause: Turbulent airflow above larynx

Obstruction: Nasal cavity, nasopharynx and soft palate

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7
Q

Outline history taking questions for neonate presenting with upper airway obstruction (if not in distress)

A 
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
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8
Q

Outline P/E for neonate with upper airway obstruction

A

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
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9
Q

First-line investigation for neonate presenting with upper airway obstruction

A

X-ray: AP and lateral neck

CXR

Endoscopy: flexible (LA) or rigid laryngoscopy (GA), Ventilating bronchoscopy (GA)

CT virtual bronchoscopy

MRI/ MRA

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10
Q

Indications for flexible vs rigid laryngoscopy/ Laryngotracheobronchoscopy

A

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
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11
Q

Most common cause of stridor in infant?

A

Laryngomalacia

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12
Q

Laryngomalacia

  • Demographic
  • Age of onset
  • Presentation
  • Time course
A
  • 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
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13
Q

Laryngomalacia

complications
tx

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

Tx:
CO2 supraglottoplasty
Laser aryepiglottoplasty

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14
Q

Vallecula and laryngeal cyst

Define vallecula anatomical position
Pathogenesis of vallecula cyst
Presentation in neonates

A

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

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15
Q

Subglottic stenosis

Define the size of subglottic in pre-term and full-term infants
Types
Classification system for stenosis severity
Tx

A

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

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16
Q

Vocal cord palsy

Congenital and acquired causes
Presentation in neonates

A

Congenital:

  • Idiopathic
  • Arnold-chiari malformation

Acquired:
- Most Iatrogenic damage: cardiac, lung, thyroid surgery

Presentation:

  • Stridor after birth
  • Weak cry or no cry
  • Choking
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17
Q

Vocal cord palsy

Treatment options

A

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
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18
Q

Subglottic hemangioma

Age of onset
Presentation
Tx

A

Age: 3 months

Presentation:

  • Inspiratory to biphasic stridor
  • Recurrent croup

Tx:

  • Systemic steroid
  • CO2 laser
  • a2- interferon
  • Tracheostomy
  • Propranolol** 2mg/kg/day
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19
Q

Mainstay treatment for subglottic haemagioma in neonates

S/E

A

Propranolol +/- CO2 laser ablation
2mg/kg/day

S/E:
Hypoglycaemia, hypotension, bradycardia

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20
Q

Laryngeal cleft

  • Describe the defect
  • Classification system for severity
A
  • Congenital midline defect of posterior larynx, trachea and anterior wall of esophagus
  • Due to incomplete formation of tracheoesophageal septum

Classification:
- Benjamin-Inglis classification

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21
Q

3 congenital disorders of the trachea

A

Tracheomalacia

Vascular compression: extrinsic compression on trachea

  • lymphatic malformation (Cystic hygroma)
  • vascular anomalies: vascular ring/ double aortic arch; aberrant subclavian or pulmonary artery

Tracheal stenosis

22
Q

Tracheomalacia

Describe the defect
Causes
Presentation

A

the cartilage that keeps the airway (trachea) open is soft such that the trachea partly collapses especially during increased airflow

Presents with expiratory stridor

Causes: 
prolonged intubation
history of tracheotomy
chronic bronchitis 
emphysema
diffuse pulmonary fibrosis
23
Q

Cystic hygroma

  • Cause
  • Presentation
  • Associated conditions
A

macrocystic lymphatic malformation causing sponge-like collection of abnormal growth that contains clear lymphatic fluid

Presentation:

  • Neck growth
  • Swallowing or breathing difficulties

Associated conditions:
- Turner, Down, nuchal lymphangioma, fetal hydrops

Treatment:

  • Surgical excision
  • Sclerosing agents: Picibanil (OK-432), Ethanol, Bleomycin
24
Q

List 3 vascular anomalies that causes upper airway obstruction in neonates

A

Vascular ring- double aortic arch
Aberrant subclavian artery
Aberrant pulmonary artery

25
Q

List Craniofacial abnormalities and associated syndromes that cause upper airway obstruction

2 Tx options

A

Hypoplastic mandible
Hypoplastic maxilla
Retrognathia
Choanal atresia

Syndromes:

  • Pierre robin
  • Treacher Collin
  • Apert
  • Crouzon

Maxillomandibular advancement
Mandibular distraction

26
Q

Choanal atresia

  • Demographics
  • Cause
  • Ix
  • Tx
A

Demographics:
1 in 8000, Female predominant

Cause: Failure to breakdown buccopharyngeal membrane
Unilateral atresia: BIlateral atresia = 3:2

Ix: soft catheter cannot pass through airway, CT scan

Treatment:
Bilateral = stenting, neonatal oropharyngeal airway device. transnasal opening of atresia
Unilateral = obligate nasal breather for 6 months (normal infants are obligate nasal breather for 2-6 months)

27
Q

Croup/ Laryngotracheobronchitis

  • Age of onset, peak age
  • Causative pathogens
  • Presentation
A

Age: 6 months to 3 years, peak at 2 years old

Causative:

  • Parainfluenza virus
  • Influenza virus type A
  • Respiratory Syncitial Virus
  • Mycoplasma pneumoniae

Presentation:

  • URTI, Hoarsenss
  • BARKING COUGH, BIPHASIC STRIDOR
  • X-ray Steeple sign
28
Q

Croup

Tx options

A

Close observation, 10% admission

Systemic steroid
Nebulised adrenaline
Intubation

29
Q

Acute epiglottitis

  • Age of onset, Peak
  • Causative pathogens
  • Presentation
A
  • Age: 2-6 years, peak 3-4 years old
  • Pathogens: Hemophilus influenzae type B, B- hemolytic streptococcus, Pneumococcus, Staphylococcus
- Presentation: 
Rpaidly worsening sore throat 
High fever 
Inspiratory stridor 
Drooling 
Hot potato voice 
Tripod sign
X-ray neck: thumb sign
30
Q

Acute epiglottitis

Management plan

A

Diagnosis by history

Emergency OT

Gaseous induction and intubation to secure airway

Blood culture and IV line after intubation

3rd gen cephalosporin

31
Q

Most common deep neck infection in young children?

A

Retropharyngeal abscess

32
Q

Retropharyngeal abscess

  • Site of infection
  • Presentation
A

Infected retropharyngeal LN

Presentation: like croup

  • Inspiratory stridor
  • Head hyperextended and stiff
  • Dysphagia, dribbling
  • Fever
  • XR neck: increase retropharyngeal space
33
Q

Recurrent respiratory papillomatosis

Cause
Age of presentation
Sites of involvement
Tx

A

Cause:
HPV 6,11 - Vertical transmission from mother during delivery, mother infected with genital warts

Age: 2 years old

Site: lips to lungs

Tx:
Laryngeal debridement
Co2 laser ablation

34
Q

Foreign body aspiration

Peak age
Approach to diagnosis
Presentation

A

Peak: 1-3 years old

Diagnosis mainly by History, by witness

Presentation:

  • Choking and coughing
  • Stridor and wheeze
  • Auscultation: decreased air entry
  • CXR (up to 50% normal): Hypo-inflation on inspiration, hyperinflation on expiration
35
Q

Outline history taking questions for adult with upper airway obstruction

A

HPI:

  • Sore throat
  • Any dyspnea, dysphagia, hoarseness of voice
  • Any blood in saliva?
  • Any nasal symptoms?
  • Fever?
  • Neck swelling?

Ddx:

  • Triggering allergens?
  • Preceding infections?
  • Previous malignancies?
  • Thyroid signs?
  • Previous surgery or irradiation?

Smoking or drinking habit?

36
Q

First line investigations for adult with upper airway obstruction

A

XR neck: AP and lateral
CXR
Urgent CT neck with contrast
Laryngoscopy

37
Q

Peritonsillar abscess/ Quinsy

  • Nidus of infection
  • Presentation
  • Tx
A

Collection of pus between tonsillar capsule and superior constrictor

S/S:

  • Odynophagia and dysphagia
  • Peritonsillar swelling
  • Deviation of uvula away from lesion side
  • Trismus
  • Sore throat, airway obstruction

Tx:
Incision and drainage, antibiotics

38
Q

Parapharyngeal abscess

  • Sources of infection
  • Presentation
  • Tx
A

Source:
Tonsillitis
Dental abscess/ dental root infections

Presentation:

  • Neck swelling
  • Airway obstruction
  • Stridor

Tx:

  • Transcervical drainage
  • Tracheostomy
39
Q

Ludwig’s angina

  • Nidus of infection
  • Presentation
A

Infection of floor of mouth, submental and submandibular space

Presentation:

  • Hot-potato voice, dysphagia
  • Tender swelling at submental area
  • Superior and posterior displacement of tongue
  • Airway obstruction
  • Trismus
40
Q

Pediatric OSA

Consequences of OSA on cardiovascular, metabolic and neurocognitive function of children

A

Cardiovascular: BP dysregulation, LV strain, endothelial dysfunction

Metabolic: Insulin resistance if obese, dyslipidemia

Neurocognitive: Daytime sleepiness, neurocognitive deficit, Hyperactivity attention deficits, Impulsivity, Concentration difficulties

41
Q

Causes of sleep-related breathing disorders in neonates

A

Oral cavity - Macroglossia (Beckwith-Wiedemann), Vallecula cysts, Craniofacial malformation

Nasal cavity - nasal aplasia/ stenosis/ atresia, nasopharyngeal masses

42
Q

Causes of sleep related breathing disorders in children

A

Oral cavity - Macroglossia (e.g. Down), Adenotonsillar hyperplasia, Obesity (parapharyngeal fat), Vascular malformation compression

Nasal cavity
- Rhinitis, nasal polyps
- Septal deviation, Narrow nasopharynx (syndromal facies)

43
Q

Nightime symptoms and signs of Paed OSA

A 
Snoring
Witnessed apnoea
Restlessness
Unusual position- prone, sitting, extended neck
Laboured breathing
Excessive sweating
Secondary nocturnal enuresis
Parasomnias - sleep walking
44
Q

Daytime symptoms and signs of Paed OSA

A

Irritability, behavioural problem - social withdrawal, hyperactivity, aggressiveness
Poor concentration or attention
Failure to thrive
Upper airway obstruction, mouth breathing
Morning headache

45
Q

Indication for polysomnography in adult and children

A

Apnea hypoopnea index (AHI >5 in adult

>1 in children

46
Q

Screening tool for paediatric OSA

A

Polysomnography
Noctural SaO2 monitoring (screening)

criteria: 3+ desaturation events with SaO2 < 90%

47
Q

Adult OSAS - treatment

A

Conservative:
- Weight reduction
- Optimise nasal condition

Ventilator:
- Continuous Positive Airway Pressure (CPAP machine)

Surgeries:
- Uvulopalatopharyngoplasty UPPP
- Palatal surgery
- Genioglossus Advancement
- Radiofrequency palatoplasty and turbinectomy

48
Q

Pediatric OSAS

Treatment options

A

1) Tonsillectomy, adenoidectomy

2) CPAP (indicated if residual OSAS, craniofacial abnormality, high GA risk)

49
Q

Tracheostomy

Indications

A

o Upper airway obstruction (if failed intubation)
o For assisted ventilation
o Prolonged intubation
o Bronchial toilet (clear sputum in severe pneumonia)

50
Q

Tracheostomy

- Types

A

Fenestrated tubes for phonation
 Translaryngeal airflow for phonation
 risk of granuloma formation around fenestrated area

Non-fenestrated:
-Plastic Cuffed tube for long-term use
- non-cuffed tube for short-term use

51
Q

Complications of tracheotomy

A
52
Q

Measures to maintain tracheostomy

A
  • Immediate CXR post-insertion to check tube tip position and r/o pneumothorax
  • Clean tube and change dressing daily
  • Frequent suction to prevent blockage
  • Change entire tube periodically to prevent blockage
  • Secure tube with tapes always

MBBS IV - Junior Clerkship WCS (131 decks)

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