Upper Airway Disorders Flashcards
Purposes of sinuses
Absorb shock Lighten skull Voice resonance Filter, humidify and warm air Immune response (IgA and IgG)
Type of cells in mucous membrane in sinuses
Pseudostratified columnar ciliated epithelium (with goblet cells)
Inflammation or infection of the nose and sinuses; usually involves runny nose, facial pain and nasal obstruction
Rhinosinusitis
Common symptoms of rhinosinusitis
runny nose (purulent rhinorrhea) facial pain nasal obstruction
Acute vs. Chronic Rhinosinusitis
Acute: up to 4 weeks, then total resolution
Chronic: 12 weeks or more of signs/symptoms
Most common cause of ACUTE rhinosinusitis
Viral (Rhinovirus, influenze, coronavirus)
In rarer cases, what bacteria can cause acute rhinosinusitis
Streptococcus pneumoniae, H. Influenza, and Moraxella catarrhalis
Treatment of Acute Rhinosinusitis
Most self-limiting, so usually treat symptoms
Severe symptoms: antibiotics
Intranasal steroid (inflammation)
Saline irrigations
What can complicate acute sinusitis?
Loss of anatomic border or hematologic spread (cellulitis or abscesses)
Since symptom-based diagnosis of chronic rhinosinusitis is usually unreliable, how do you diagnosis it?
Computed tomography and nasal endoscopy (gold standard)
Chronic Rhino-sinusitis is __________
multifactorial
Most common predisposing factor for chronic rhinosinusitis
Allergies (IgE mediated)
genetic predisposition to chronic sinusitis and bronchiectasis; autosomal recessive; disorganized microtubules in cilia
Primary ciliary dyskinesia
kartegener’s syndrome: CRS, situs inversus, and bronchiectasis
genetic predisposition to chronic sinusitis; autosomal recessive; defective chloride transport gene; frequent aeruginosa infections
Cystic fibrosis
Treatment strategies for chronic sinusitis
- Mechanical (irrigation, mucolytics)
- Anti-inflammatory (antihistamine and steroids)
- Anti-Microbial
Systemic condition of sinuses; idiopathic and autoimmune process; necrotizing granulomas affecting upper and lower airways and kidneys
Granulomatosis with polyangitis (wegener’s)
Systemic condition of sinuses; chronic granulomatous disease; primarily pulmonary, although almost any organ system can be involved
Sarcoidosis
Indications for sinus surgery
Medical management failed
Anatomic obstruction
Need to restore proper function
Surgery is a definitive treatment for chronic rhinosinusitis (True or False)
False; does not cure it
Symptoms that make you worry about a sinonasal tumor
Frequent, unexplained nosebleeds
Sinonasal discharge
Sinus pain
Unusual symptoms (visual changes, excessive tearing, neck nodes)
inflammation of the pharynx; “sore throat”; 3rd most common chief complaint presented to physician; viral most common, but streptococcus pyogenes possible
Pharyngitis
Most common bacteria involved in pharyngitis
Group A beta hemolytic Streptococcus pyogenes
Physical exam findings for pharyngitis
Erythema Edema Swollen tonsils White tonsillar exudates (symmetrical) Possible petechiae Foul breath
Treatment for pharyngitis
Prompt antibiotic treatment reduces duration and symptoms
Why is it important to promptly treat pharyngitis with antibiotics?
Complications of pharyngitis involve glomerulonephritis and acute rheumatic fever
Common cold viruses involved in pharyngitis
Rhinovirus
Coronavirus
Parainfluenzae
Influenzae virus A, B, C
double stranded DNA virus; part of the Herpes virus family; 90% of world’s population infected; remains latent in B lymphocytes; can result in airway obstruction, meningitis and splenic rupture
EBV (Mono)
*also associated with Burkitt’s lymphoma, oral hairy leukoplakia (HIV), and nasopharyngeal carcinoma.
Treatment for Mono
- Supportive, rest, antipyretics
- Avoid contact sports (splenomegaly)
- Steroids for airway obstruction
- NO penicillins (can cause rash)
Abscess involved with trismus, hot potato/muffle voice and drooling; pain with swallowing, dehydration and fever
Peritonsillar abscess (PTA)
Treatment for peritonsillar abscess
Incision and drainage
Antibiotics
Tonsillectomy rarely needed
Symptoms of a retropharyngeal abscess
Painful swallowing (odynophagia)
Neck stiffness
Sore throat
Fever
Treatment for retropharyngeal abscesses
Incision and drain (I & D)
Antibiotics
odynophagia
painful swallowing
reduced ability to open mouth; “lock-jaw”
trismus
Most infections of deep neck spaces (retropharyngeal) are…
polymicrobial (aerobic, anaerobic, gram negative)
Complications of PTA and RPA
Mediastinitis Airway obstruction IJV thrombosis (Lemierre's) Necrotizing Fasciitis Sepsis
inflammation and cellulitis of submandibular space, spreading to the sublingual space via fascial planes; tongue is forced upward and backward (airway obstruction); source is typically dental in origin.
Ludwig’s Angina
- Treatment includes I & D, IV abx, and airway control
Functions of the larynx
Voice production
Protect airway from aspiration/cough
Airway/breathing
Inc. intra-abdominal pressure for valsalva and defecation
When does hoarseness indicate a referral to an otolaryngologist
dysphonia persists longer than 2 weeks or accompanied by other symptoms such as otalgia, dysphagia or difficulty breathing
Common causes of hoarseness
Neurologic injury (recurrent laryngeal nerve injury)
Alteration of vocal fold lining (GERD, lesions, etc.)
Symptoms of unilateral vocal fold paralysis
Breathy, weak dysphonia
Poor cough
Dysphagia
The vast majority of laryngeal lesions causing hoarseness involve _____ of the vocal fold
Superficial Layers
superficial lamina propria and epithelial cover
The cause of most benign vocal fold lesions is…
phonotrauma (vocal abuse)
lesion that may involve the entire aerodigestive tract; most common benign neoplasms of the larynx in children
Recurrent respiratory papillomatosis
Recurrent respiratory papillomatosis is usually caused by what viruses
HPV types 6 and 11
HPV Vaccines
Only Gardasil-9 in the US as of 2017
Treatment for vocal fold lesions
Combination of medical treatment, speech therapy and surgery
> 90% of laryngeal carcinomas are
Squamous cell
Largest risk factor for laryngeal carcinoma is
Smoking (especially in combination with alcohol)
Laryngeal tumors are most common on
the vocal folds
Symptoms of a laryngeal tumor
Hoarseness (most common) Dysphagia Hemoptysis Pain Airway compromise Neck mass
A neck mass in an adult is considered a __________ until proven otherwise
cancer
Best imaging technique(s) for determining where a laryngeal tumor is
PET/CT*
Laryngoscopy
Treatment for early stage (I or II) laryngeal tumors vs. late stage (III or IV)
Early stage (I or II): single modality, such as surgery or radiation Late stage (III or IV): combined modality: surgery followed by radiation
complete separation of the digestive and respiratory tracts; tracheal opening made in the anterior of neck; done in advanced laryngeal cancer (whole larynx is removed)
Total laryngectomy
Why are head and neck cancer treatment difficult?
Due to the highly complex functional and aesthetic locations at which these tumors develop
Signs and symptoms of pediatric obstructive sleep apnea (OSA)
Mouth breathing Snoring/snorting Gasping Dysphagia/choking Poor sleep and attention
Treatment for pediatric obstructive sleep apnea
Surgery: Adenotonsillectomy
Non-surgery: CPAP and/or weight loss
high pitched breath sound from turbulent airflow through narrowed larynx/trachea; sign of upper airway obstruction
Stridor
low pitched breath sound, nonmusical and snoring; airway noise from nose, nasopharynx and oropharynx
Stertor
high pitched sound; indicating lower airway (lungs) disease; more commonly end expiratory
Wheezing
Inspiratory stridor implies that the narrowing is at the level of the…
Supraglottic/glottis
Expiratory stridor implies that the narrowing is at the level of the…
trachea
Biphasic stridor implies that the narrowing is at the level of the…
subglottis
Wheezing vs. Stridor
Wheezing: lower respiratory; continuous whistling sound on expiration
Stridor: upper respiratory; high pitched sound on inspiration
“thumb sign” on an X-ray is indicative of
Epiglottitis (epiglottis is swollen and bulging into pharynx)
*Airway Emergency
Epiglottitis/Supraglottitis is typically caused by what bacteria?
- Hib (H. flu) type B
- Streptococcus species
Treatment for epiglottitis/supraglottitis
- Secure airway (intubation, tracheotomy)
- IV antibiotics
- Steroids
common pediatric VIRAL respiratory illness (influenza, measles, RSV); barking cough, stridor, hoarseness; swelling from inflammation leads to airway narrowing
Croup
- Steeple Sign on X-ray (tracheal narrowing)
Treatment for croup
- Steroids
- Nebulized epinephrine (bronchodilation)
- Cool mist (decrease mucous viscosity)
Epiglottis vs. Croup
Epiglottis: Haemophilus Influenza B, rapid, tripod, muffled voice, thumbprint sign
Croup: Parainfluenza virus, slow, barking cough, lying back, hoarse, steeple sign
most common cause of stridor in infants
Laryngomalacia (congenital softening of the tissues of the larynx above the vocal cords)
congenital softening of the tissues of the larynx above the vocal cords; floppy cartilage leads to collapse and inspiratory stridor
Laryngomalacia
Why is laryngomalacia worse when supine?
floppy cartilage leads will collapse with gravity
Treatment for laryngomalacia
Most self-limiting
10% need surgery (supraglottoplasty)
narrowing of the larynx or trachea; caused by trauma, chronic inflammation, neoplasms or can be congenital/idiopathic
laryngotracheal stenosis
Long term intubation (>7-10 days) or too large of a tube can contribute to
laryngotracheal stenosis
Symptoms of laryngotracheal stenosis
Shortness of breath with exertion
High pitched inspiratory stridor
No aid with inhalers
Tightness of throat
Benefits of tracheostomy (surgically created airway) vs. laryngectomy
Still have full airway (larynx is not taken out); reversible
Indications for a tracheostomy
- Bypass upper airway obstruction
- Prolonged intubation to avoid complications
- Cure for OSA
What benign neoplasm is associated with severe, unilateral recurrent epistaxis in young male?
Juvenile Nasopharyngeal Angiofibroma (JNA)
What part of the anterior septum is responsible for 90% of anterior nosebleeds?
Kiesselbach’s Plexus
What arteries are included in kiesselbach’s plexus?
- Superior Labial Artery
- Anterior and Posterior Ethmoidal Arteries
- Grater Palatine Artery
- Sphenopalatine Artery
True or False? Posterior bleeds (10%) can be life threatening
True
These infections are dangerous as they can cross fascial layers and spaces and lead to significant morbidity and airway obstruction.
Deep Neck Infections
The tumor of apex of lung that can cause compression of subclavian artery, phrenic nerve, and also recurrent laryngeal nerve (leads to hoarseness)
Pancoast Tumor
