Babak Saedi MDOTOLARYNGOLOGIST

TEHRAN UNIVERSITY OF MEDICAL SCIENSES

Voice change

Dyspnea

Local pain

Cough

StridorHoarsenessRetraction (intercostal- suprasternal-supraclavicular)Drooling - bleeding - emphysema

HistoryPhysical examinationFiber optic laryngoscopyRadiographyArterial blood gasC.T.Scan (if general status of patient is stable)

Simplest adequate form of control should be selected

Lower level

Other medical problems

TraumaInflammatory diseasesBenign neoplasms (intrinsic – extrinsic)Malignant neoplasms (intrinsic – extrinsic)others

External laryngeal injury - blunt neck trauma - penetrating woundInternal laryngeal injury - prolonged endotracheal intubation - post tracheotomy - post surgical procedures - post irradiation - endotracheal burn (thermal – chemical)

CROUP

AND

EPIGLOTTITIS

Barking CoughHoarse VoiceInspiratory StridorVarying Degrees of

Respiratory Distress

Ages infancy [1-3] (peak 2 years)

Para influenza viruses – most frequentInfluenza A and B – most severe (esp. A)Adenovirus MeaslesRespiratory syncytial virus

Clinical Course:Recent URI several days beforeMild cough, progressing to stridor, worsening

cough, retractions.Fever usually only slightly elevated Symptoms worse at night, better in dayMost gradually recover over several days

Chest X-ray often shows classic “steeple sign”

Management:Close observation until stableWarm or cool mistSteroids – oral or nebulizedRacemic epinephrineHospitalize hypoxic, worsening children

A dramatic, potentially life-threatening form of upper airway obstruction characterized by:

High feverSore throatDyspneaRapidly progressive respiratory obstruction

Etiology:Haemophilus

influenza organism

Clinical Course:Quick onset of fever, dyspneaOften sits leaning forward, drooling Inspiratory stridorRefuses to eatWithin hours may progress to respiratory

obstruction

Can occur at any age

Physical Findings:Left picture: nearly completely blocked

airwayRight picture: airway opened after intubation

Lateral soft tissue neck x-ray:

“thumbprint” sign

TREATMENT:MAINTAIN THE AIRWAY!!Empiric antibiotics (Ceftriaxone, cefuroxime,

ampicillin plus chloramphenicol) to cover most likely organisms (P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis)

+ or - Steroids

CharacteristicCharacteristic EpiglottitisEpiglottitis CroupCroup

AgeAge Any ageAny age 6months-6months-12yrs12yrs

OnsetOnset SuddenSudden GradualGradual

LocationLocation SupraglotticSupraglottic SubglotticSubglottic

TemperatureTemperature High feverHigh fever Low-grade feverLow-grade fever

DysphagiaDysphagia SevereSevere Mild or absentMild or absent

DyspneaDyspnea PresentPresent PresentPresent

DroolingDrooling PresentPresent PresentPresent

CoughCough UncommonUncommon Characteristic Characteristic coughcough

PositionPosition Leaning forward, Leaning forward, mouth openmouth open comfortablecomfortable

X-RayX-Ray Thumb signThumb sign Steeple signSteeple sign

Prolonged intubationVentilation supportManage bronchopulmonary secretionUpper airway obstruction Obstructive sleep apneaBilateral vocal cord paralysisInability to intubateMajor head & neck surgery or trauma

Advantageslower risk of laryngotracheal injuryimproved comfort/mobilityimprove airway stabilizationallows for oral nutrition improved secretion clearance

Sternal notchThyroid cartilageCricoid cartilage

- cricothyroid membrane - innominate artery - thyroid gland (isthmus) - recurrent laryngeal nerve

Venous supplySuperior and middle

thyroid v. drain into the IJ

Inferior thyroid v. drains into the brachiocephalic trunk

Anatomy variant: thyroid ima artery, in 1.5% to 12%, in front of the trachea.

Emergent (slash trach)

Urgent (awake)

Elective

Optimally under general anesthesiaIncision between sternal notch and cricoidDissection in a vertical planeThyroid isthmus (third and fourth ring)Entrance into tracheaTracheotomy tube insertion

HemorrhageFalse routeElectrocautery fireInjury to adjacent structures

Hemorrhage [most common ]InfectionSubcutaneous emphysemaPneumomediastinumPneumothorax [most common in infant ]Obstruction of tacheotomy tubeDisplacement of tube

HemorrhageTracheoesophageal fistulaTracheal stenosisTracheocutaneous fistula