Upper Airway Disorders Flashcards by Geun Young Park

Purposes of sinuses

Absorb shock
Lighten skull
Voice resonance
Filter, humidify and warm air
Immune response (IgA and IgG)

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Type of cells in mucous membrane in sinuses

Pseudostratified columnar ciliated epithelium (with goblet cells)

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Inflammation or infection of the nose and sinuses; usually involves runny nose, facial pain and nasal obstruction

Rhinosinusitis

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Common symptoms of rhinosinusitis

runny nose (purulent rhinorrhea)
facial pain
nasal obstruction

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Acute vs. Chronic Rhinosinusitis

Acute: up to 4 weeks, then total resolution
Chronic: 12 weeks or more of signs/symptoms

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Most common cause of ACUTE rhinosinusitis

Viral (Rhinovirus, influenze, coronavirus)

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In rarer cases, what bacteria can cause acute rhinosinusitis

Streptococcus pneumoniae, H. Influenza, and Moraxella catarrhalis

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Treatment of Acute Rhinosinusitis

Most self-limiting, so usually treat symptoms
Severe symptoms: antibiotics
Intranasal steroid (inflammation)
Saline irrigations

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What can complicate acute sinusitis?

Loss of anatomic border or hematologic spread (cellulitis or abscesses)

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Since symptom-based diagnosis of chronic rhinosinusitis is usually unreliable, how do you diagnosis it?

Computed tomography and nasal endoscopy (gold standard)

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Chronic Rhino-sinusitis is __________

multifactorial

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Most common predisposing factor for chronic rhinosinusitis

Allergies (IgE mediated)

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genetic predisposition to chronic sinusitis and bronchiectasis; autosomal recessive; disorganized microtubules in cilia

Primary ciliary dyskinesia

kartegener’s syndrome: CRS, situs inversus, and bronchiectasis

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genetic predisposition to chronic sinusitis; autosomal recessive; defective chloride transport gene; frequent aeruginosa infections

Cystic fibrosis

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Treatment strategies for chronic sinusitis

Mechanical (irrigation, mucolytics)
Anti-inflammatory (antihistamine and steroids)
Anti-Microbial

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Systemic condition of sinuses; idiopathic and autoimmune process; necrotizing granulomas affecting upper and lower airways and kidneys

Granulomatosis with polyangitis (wegener’s)

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Systemic condition of sinuses; chronic granulomatous disease; primarily pulmonary, although almost any organ system can be involved

Sarcoidosis

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Indications for sinus surgery

Medical management failed
Anatomic obstruction
Need to restore proper function

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Surgery is a definitive treatment for chronic rhinosinusitis (True or False)

False; does not cure it

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Symptoms that make you worry about a sinonasal tumor

Frequent, unexplained nosebleeds
Sinonasal discharge
Sinus pain
Unusual symptoms (visual changes, excessive tearing, neck nodes)

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inflammation of the pharynx; “sore throat”; 3rd most common chief complaint presented to physician; viral most common, but streptococcus pyogenes possible

Pharyngitis

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Most common bacteria involved in pharyngitis

Group A beta hemolytic Streptococcus pyogenes

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Physical exam findings for pharyngitis

Erythema
Edema
Swollen tonsils
White tonsillar exudates (symmetrical)
Possible petechiae
Foul breath

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Treatment for pharyngitis

Prompt antibiotic treatment reduces duration and symptoms

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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?

1. Superior Labial Artery 2. Anterior and Posterior Ethmoidal Arteries 3. Grater Palatine Artery 4. 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