N and airway Flashcards
What is stridor?
A high pitched inspiratory noise
Due to laryngeal obstruction
What does stridor lead to?
Can lead to respiratory distress Tracheal tug (increased effort) Costal recession (using ribs to breathe)
Ways of dealing with someone with Stridor
Keep patient and parent of child calm
Oxygen via a mask
Adrenalin nebuliser - every 20minutes as needed - decongestant - blood vessels constrict and linings smaller
Steroids - dexamethasone IV or prednisolone Oral or budesonide nebuliser
If medical management of stridor fails what do you do?
Establish airway through the skin - emergency tracheostomy - but usually not needed
Congenital causes of stridor x3
Congenital subglottic stenosis
Larygnomalacia
Bilateral vocal cord palsy
What is congenital subglottic stenosis?
Narrow/small cricoid cartilage
With infection will swell and therefore further narrowing leads to croup in children
What is laryngomalacia?
“floppy larynx”
Like a tulip bulb that hasn’t completely opened yet
Normally better by 2 years of age
Management of laryngomalacia?
Anti-reflux because effort to breathe in can suck acid up oesophagus and cause reflux
Rarely still persistent - but if it is and too much effort to breathe with poor weight gain - can open it up surgically
Management of bilateral vocal cord palsy
Children need tracheostomy 50% of the time
Acquired causes of stridor
- Trauma (blunt or endotracheal tube prolonged intubation in premature baby) leads to scarring therefore acquired subglottic stenosis
- Burn
- FB
- Infection
- Neoplastic
Tumour cause of stridor in children and adults
In children mostly benign papillomas
In adults mostly neoplastic malignant eg. squamous carcinoma
What is stertor?
Low pitch inspiratory sound due to pharyngeal obstruction
What is stertor when you have complete blockages
Apnoea
Commonest cause of stertor/obstructive sleep apnoea in children and adults
Child - adenoid and tonsil hypertrophy
Adult - raised BMI
Treatment of child stertor
Remove tonsils and adenoids
Treatment of adult stertor/sleep apnoea
Lose weight
Mandibular advancement splint
Mask with pressure from a machine at night to hold airway open - CPAP
What is nose lined with?
Pseudostratified ciliated columnar epithelium
Associated features of nasal obstruction
Itching, sneezing, rhinorrhoea, epiphora (watery eye)
Purulence, facial pain, anosmia, postnasal drip
Blood discharge and pain
Significant history for nasal obstruction
Asthma
Previous surgery or trauma
Smoking
Pregnancy
Cancer red flags with nasal obstruction
Persistent unilateral obstruction Bloody discharge Persistent pain Weight loss Cervical LN >50 years Woodworker - resins within hard woods are particularly irritant to nose and have been shown to be carcinogenic Previous polyps Teenage boy with epistaxis
What is rhinomanometry
Tests of nasal airflow - nasal inspiratory peak flow
4 congenital causes of nasal obstruction
Choanal atresia
Dermoid cyst
Meningoencephalocoele
Structural deformity
What is choanal atresia and how treated
Opening from back of nose into nasopharynx hasn’t developed yet
Treated by putting a hole in the atresic plate
What is a dermoid cyst and how treated
Cyst under the skin
Treated surgically
What is meningoencephalocoele
Defect in skull base and brain comes down and causes obstruction
Acquired causes of nasal obstruction
Trauma
Infective is rare but can get septal abscess
What is a septal haematoma
Cherry red swelling bilaterally in the nose - pericondrium is stripped off the septal cartilage and if its not addressed in first 24hours - will lose septal cartilage
Inflammatory causes of nasal obstruction
Allergic rhinitis
Rhinosinusitis
Adenoiditis
Vasculitis
What is allergic rhinitis and how do you treat it?
Inflammation caused by airborne pathogen
Identify allergen and avoid it
Can also use topical steroids and/or antihistamines
Oral antihistamines if severe
What is rhinosinusitis?
Sinusitis is an infection of paranasal sinuses
Usually bacterial
Most commonly associated with URTI but can occur with asthma
Symptoms of rhinosinusitis?
Frontal headache
Purulent rhinorrhoea
Facial pain with tenderness
Fever
Treatment of rhinosinusitis
Nasal douching
Topical nasal steroids
Lose dose antibiotics
If polyps - oral steroids and polypectomy
What is adenoiditis
Inflammation of adenoid tissue at the back of the nose - often a pus-like discharge from the nose
Upper midline neck lump
Thyroglossal cyst
Dermoid cyst
Lymph nodes
Lower midline neck lump
Thryoid gland mass
Lymph nodes
Upper lateral neck lump
Salivary gland
Neurogenic and vascular neoplasms
Lymph nodes
Lower lateral neck lump
Lymph nodes
Under 20 with a neck lump
Congenital
inflammatory
lymphomas
20-40 years old neck lump
Branchial cyst
Salivary gland
Thyroid neoplasm
over 40 neck lump
Malignant neoplasm
ANY Lateral neck lump in adult >40 is malignant until proven otherwise
What is a branchial cyst
2nd arch abnormality Usually after URTI Patients 15-20 Usually painless Treatment is surgical
How can you tell it is thryoglossal duct cyst
Will move with swallowing
What is warthins tumour?
A benign tumour of the parotid gland
Medication which can cause epistaxis?
Warfarin Heparin Aspirin Clopidogrel Dabigatran, rivaroxaban, apixaban Garlic
Initial management of epistaxis?
ABC IV access and bloods Pressure and ice pack Control HTN Correct coagulopathies (FFP, whole blood, platelets, reverse anticoagulant) Topical decongestants/vasoconstrictors Cautery Nasal packing
Surgical treatment of epistaxis?
Artery ligation
Embolization - if still bleeding after ligation or bleeding site difficult to reach - or comorbities which prohibit GA - only effective when bleeding
What is Samters triad
Triad of asthma, aspirin sensitivity and nasal polyps
Management of Nasal polyps
Topical corticosteroids
When do nasal polyps require further ENT investigation
Unilateral or epistaxis
Management of allergic rhinosinusitis
Loratadine
Systemic decongestants - pseudoephedrine
Sodium chromoglicate nasal spray
Beclometasone steroid nasal spray
Presentation of retropharyngeal abscess
Ill child with stiff, extended neck/torticollis who fails to eat or drink
Manage with incision and drainage
