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
3 congenital disorders of the trachea
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
Tracheomalacia
Describe the defect
Causes
Presentation
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
Cystic hygroma
- Cause
- Presentation
- Associated conditions
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
List 3 vascular anomalies that causes upper airway obstruction in neonates
Vascular ring- double aortic arch
Aberrant subclavian artery
Aberrant pulmonary artery
List Craniofacial abnormalities and associated syndromes that cause upper airway obstruction
2 Tx options
Hypoplastic mandible
Hypoplastic maxilla
Retrognathia
Choanal atresia
Syndromes:
- Pierre robin
- Treacher Collin
- Apert
- Crouzon
Maxillomandibular advancement
Mandibular distraction
Choanal atresia
- Demographics
- Cause
- Ix
- Tx
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)
Croup/ Laryngotracheobronchitis
- Age of onset, peak age
- Causative pathogens
- Presentation
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
Croup
Tx options
Close observation, 10% admission
Systemic steroid
Nebulised adrenaline
Intubation
Acute epiglottitis
- Age of onset, Peak
- Causative pathogens
- Presentation
- 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
Acute epiglottitis
Management plan
Diagnosis by history
Emergency OT
Gaseous induction and intubation to secure airway
Blood culture and IV line after intubation
3rd gen cephalosporin
Most common deep neck infection in young children?
Retropharyngeal abscess
Retropharyngeal abscess
- Site of infection
- Presentation
Infected retropharyngeal LN
Presentation: like croup
- Inspiratory stridor
- Head hyperextended and stiff
- Dysphagia, dribbling
- Fever
- XR neck: increase retropharyngeal space
Recurrent respiratory papillomatosis
Cause
Age of presentation
Sites of involvement
Tx
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
Foreign body aspiration
Peak age
Approach to diagnosis
Presentation
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
Outline history taking questions for adult with upper airway obstruction
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?
First line investigations for adult with upper airway obstruction
XR neck: AP and lateral
CXR
Urgent CT neck with contrast
Laryngoscopy
Peritonsillar abscess/ Quinsy
- Nidus of infection
- Presentation
- Tx
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
Parapharyngeal abscess
- Sources of infection
- Presentation
- Tx
Source:
Tonsillitis
Dental abscess/ dental root infections
Presentation:
- Neck swelling
- Airway obstruction
- Stridor
Tx:
- Transcervical drainage
- Tracheostomy
Ludwig’s angina
- Nidus of infection
- Presentation
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
Pediatric OSA
Consequences of OSA on cardiovascular, metabolic and neurocognitive function of children
Cardiovascular: BP dysregulation, LV strain, endothelial dysfunction
Metabolic: Insulin resistance if obese, dyslipidemia
Neurocognitive: Daytime sleepiness, neurocognitive deficit, Hyperactivity attention deficits, Impulsivity, Concentration difficulties
Causes of sleep-related breathing disorders in neonates
Oral cavity - Macroglossia (Beckwith-Wiedemann), Vallecula cysts, Craniofacial malformation
Nasal cavity - nasal aplasia/ stenosis/ atresia, nasopharyngeal masses
Causes of sleep related breathing disorders in children
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)
Nightime symptoms and signs of Paed OSA
Snoring Witnessed apnoea Restlessness Unusual position- prone, sitting, extended neck Laboured breathing Excessive sweating Secondary nocturnal enuresis Parasomnias - sleep walking
Daytime symptoms and signs of Paed OSA
Irritability, behavioural problem - social withdrawal, hyperactivity, aggressiveness
Poor concentration or attention
Failure to thrive
Upper airway obstruction, mouth breathing
Morning headache
Indication for polysomnography in adult and children
Apnea hypoopnea index (AHI >5 in adult
>1 in children
Screening tool for paediatric OSA
Polysomnography
Noctural SaO2 monitoring (screening)
criteria: 3+ desaturation events with SaO2 < 90%
Adult OSAS - treatment
Conservative:
- Weight reduction
- Optimise nasal condition
Ventilator:
- Continuous Positive Airway Pressure (CPAP machine)
Surgeries:
- Uvulopalatopharyngoplasty UPPP
- Palatal surgery
- Genioglossus Advancement
- Radiofrequency palatoplasty and turbinectomy
Pediatric OSAS
Treatment options
1) Tonsillectomy, adenoidectomy
2) CPAP (indicated if residual OSAS, craniofacial abnormality, high GA risk)
Tracheostomy
Indications
o Upper airway obstruction (if failed intubation)
o For assisted ventilation
o Prolonged intubation
o Bronchial toilet (clear sputum in severe pneumonia)
Tracheostomy
- Types
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
Complications of tracheotomy
Measures to maintain tracheostomy
- 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
