Core Curriculum Syllabus: Emergencies in Otolaryngology-Head and Neck Surgery
Airway Obstruction

Airway obstruction will be covered separately in the adult, child, newborn or infant. Although the etiologies and treatment of airway obstruction may vary between different age groups, some common principles of evaluation and treatment are worth emphasizing. First, try to anticipate airway problems before the patient's airway becomes completely obstructed and mobilize support quickly. After assessing the patient's potential for airway compromise, look for a cause. The patient will often require multiple endoscopy (laryngoscopy, bronchoscopy and esophagoscopy), which in addition to helping identify an etiology may also help establish an airway. Then the airway may be secured by either intubation or tracheotomy.

Adult with Airway Obstruction

History

  • Precipitating event
    • Aspiration
    • Trauma
    • Allergic reaction
    • Systemic illness
  • Time course
  • Previous intubation or neck trauma

Physical Examination

  • Total obstruction - without any air movement, aphonic, no choking or coughing
  • Stridor
    • Inspiratory - glottic or supraglottic
    • Expiratory - subglottic or intrathoracic
    • Biphasic - subglottic or tracheal; severe higher or lower obstruction may also be biaphasic
  • Suprasternal or intercostal retractions
  • Fatigue with decrease in stridor may herald impending decompensation
  • Cyanosis
  • Mirror or fiberoptic exam of hypopharynx

Ancillary Studies

  • Soft tissue lateral of neck
  • Chest x-ray
  • Tomograms, xeroradiograms
  • CT scan

Endoscopy

  • Direct laryngoscopy, rigid bronchoscopy and esophagoscopy
  • May simultaneously establish airway

Etiology

  • Traumatic
    • Laryngeal or tracheal fracture
    • Oropharyngeal laceration
    • Edema from injury to head and neck
    • Subglottic stenosis or granulation tissue secondary to intubation
  • Infectious
    • Epiglottitis (more supraglottitis in adult)
    • Peritonsillar abscess
      • Signs & Symptoms: sore throat, fever, "hot potato" voice, drooling, bulging tonsil
      • Treatment: aspiration vs I&D vs tonsillectomy (noninvolved side tends to bleed more than usual)
    • Deep neck abscess
    • Parapharyngeal space
    • Prevertebral space
    • Submental space - Ludwig's angina
  • Mechanical
    • Foreign body
    • Blood
    • Vomitus
  • Neoplastic
    • Tumors occluding airway
    • Tumors eroding into major vessels with massive blood loss into airway
  • Allergic

Treatment

  • Oropharyngeal obstruction
    • Heimlich maneuver for total obstruction (aphonic, no choking or coughing)
    • Remove blood, vomitus, etc.
    • Extend head (if you are sure there is no cervical spine injury) and apply anterior traction to mandible, and/or tongue as needed
    • Oro or nasopharyngeal airway
    • If unsuccessful, proceed to intubation or tracheotomy
  • Laryngotracheal obstruction
    • Conservative: close observation, steroids, racemic epinephrine, oxygen, humidification
    • Intubation: Often difficult in severe airway or facial trauma due to distortion and bleeding. Contraindicated in laryngeal or tracheal fracture.
    • Standard tracheotomy - Indicated in any patient with upper airway obstruction who cannot be safely or successfully intubated.
      • Technique
        1. Horizontal skin incision
        2. Separate strap muscles in midline
        3. If necessary, mobilize or divide thyroid
        4. Visualize tracheal rings, identify level
        5. Incise trachea under direct visualization. Do not incise first tracheal or cricoid ring
        6. Create inferiorly based tracheal flap
        7. Put traction suture through tip of flap
        8. Insert tube under direct visualization
        9. Confirm proper placement of tube by inspection and auscultation
        10. Prevent early dislodgement because reinsertion even with traction suture can be difficult
        11. May change after 2 to 3 days when tract formed

      Sideview of larynx and trachea with head in extention
    • Cricothyroidotomy - Indicated in emergency situation when standard tracheotomy not feasible or advisable
      1. Incision through skin and cricothyroid membrane
      2. Insert tube or stent incision open
      3. Requires PRECISE surface identification of anatomy. If landmarks ambiguous, proceed with standard tracheotomy or needles.
      4. Contraindicated in laryngeal or tracheal trauma or infection and in young children.
      5. Conversion to standard tracheotomy if prolonged airway support is needed
    • Large bore needles inserted percutaneously into trachea. Not procedure of choice, but can be life saving as a temporizing measure.

Child with Airway Obstruction

History

  • Stridor - inspiratory, expiratory, biaphasic
  • Fever
  • Difficulty swallowing
  • Foreign body
  • Trauma, including prior intubation

Physical Examination

  • Supraclavicular/intercostal retractions, cyanosis
  • Positional changes
    • Epiglottitis - breathing is better sitting up

Ancillary Studies

  • Soft tissue lateral of neck
  • Chest x-ray
  • Airway management overrides importance of x-rays

Endoscopy

  • Direct laryngoscopy, rigid bronchoscopy and esophagoscopy
    • Bronchoscope sizes: 6 months to 3 years - 4 mm; 3 to 12 years - 5 mm; over 12 years - 6 mm
  • May be needed to establish airway

Etiology

  • Congenital
    • May have both a congenital and an acquired problem
  • Infectious
    • Epiglottitis
      • Febrile, toxic appearing child who prefers sitting up and cannot swallow his own saliva
      • Inspiratory stridor
      • Tonsils okay
      • Blood cultures - H. influenza
      • To OR to make diagnosis, intubate
    • Acute tonsillitis
      • R/O mono, possibility even in children
    • Peritonsillar abscess
      • May have to take child to OR to drain or perform tonsillectomy, but intubation can be treacherous so have a good anesthesiologist and a trach set available
    • Laryngotracheal bronchitis (croup)
      • concentric narrowing of airway
      • monitor closely; may need to intubate
    • Papillomata
      • More common in young children, but all ages affected
      • DNA virus - Human papilloma virus subtypes HPV 6 & 11
      • Palliation - CO2 laser
      • Many spontaneously regress, but in a small percentage of patients papillomas recur for many years
    • Viral Respiratory Infection
      • In a child with some airway obstruction, any additional airway compromise such as the edema resulting from a URI may lead to frank airway distress
  • Mechanical
    • Foreign body
      • ALWAYS SUSPECT IN CHILD WITH RAPID ONSET OF AIRWAY PROBLEMS
      • Do not turn child upside down
      • Rigid bronchoscopy with removal of foreign body is the treatment of choice
      • Rarely may need to perform tracheostomy or thoracotomy to remove
  • Traumatic
    • Prior intubation - subglottic stenosis
    • Laryngeal or tracheal fracture
  • Neoplastic
    • Submucosal mass effect
      • Rhabdomyosarcoma
        • Tonsillar masses
      • Neurofibroma
        • Macroglossia
        • Supraglottic mass
  • Allergic

Treatment

  • Conservative: close observation, steroids, racemic epinephrine, oxygen, humidification
  • Intubation: tube about the size of the patient's little finger, prevent movement of the tube after intubation
  • Tracheotomy: 1 to 1.5 years - size 1; 1.5 to 4 years - size 1 or 2; 4 to 7 years - size 2 or 3; 7 to 12 years - size 3 or 4; over 12 years - size 5 to 8

Newborn with Airway Obstruction

History

  • Stridor
    • Inspiratory - glottic or supraglottic
    • Expiratory and biaphasic - subglottic
    • Present from birth - laryngomalacia, unilateral vocal cord paralysis, webs, cysts and vascular rings
    • Later - bilateral vocal cord paralysis and others
  • Atypical cry
    • Muffled - supraglottic obstruction
    • High-pitched, weak - webs and vocal cord paralysis
    • Croupy - subglottic stenosis
  • Feeding difficulty
    • Laryngotracheoesophageal clefts, neurogenic dysfunction and laryngeal webs
    • Can lead to aspiration induced pneumonia
    • Choanal atresia - infants are obligate nasal breathers
  • Failure to thrive

Physical Examination

  • Supraclavical/intercostal retractions, cyanosis
  • Positional changes
    • Laryngomalacia - worse with supine vs prone
  • Other anomalies - Assess for presence of:
    • Cranial anomalies
    • Pectus excavatum
    • Cardiopulmonary anomalies
    • Imperforate anus

Ancillary Studies

  • Cervical X-rays - lateral and AP
  • Barium swallow - cinefluoroscopic studies

Endoscopy

  • Direct laryngoscopy, rigid bronchoscopy and esophagoscopy
  • Bronchoscope sizes - less than 5 pounds - 3 mm; average newborn to 6 months - 3.5 mm

Congenital Etiologies

  • Laryngomalacia
    • Most common
    • May be associated with pectus excavatum, retrognathia or subglottic stenosis
    • Inspiratory stridor, severe in supine position, usually present from birth
    • Endoscopy - flexible or rigid
      • Long narrow epiglottis with floppy aryepiglottic folds
      • Venturi effect - airway narrows from oropharynx to trachea, as airway becomes smaller air moves more rapidly creating negative pressure which causes loose aryepiglottic folds and arytenoids to collapse first which narrows airway more causing floppy epiglottis to fold blocking the airway
    • Treatment rarely required, outgrown in 18 months
  • Vocal cord paralysis
    • Second most common
    • Unilateral more frequent than bilateral with unilateral left more common than right
      • Left associated with cardiovascular or pulmonary defect
      • Right usually solitary finding
    • Unilateral symptoms can be minimal
    • Bilateral abductor paralysis causes severe inspiratory and expiratory stridor
    • Endoscopy - flexible or rigid (place tip of laryngoscope in vallecula to avoid distortion of endolarynx)
    • Treatment unilaterally generally not required, movement may return within three to six months
    • Bilateral abductor paralysis requires a trach and in event of no return of function, additional surgery
  • Congenital subglottic stenosis
    • Third most common
    • White male infants most commonly affected
    • Associated abnormalities include cleft palate, imperforate anus and tracheoesophageal fistula
    • Greatest obstruction usually 2 to 3 mm below vocal cords, involves either abnormally shaped or small cricoid cartilage or redundant submucosal fibrous tissue
    • Biaphasic stridor, cyanosis and barking cough suggest croup or laryngotracheal bronchitis, but subglottic stenosis follows a more protracted course
    • Treatment - gentle dilation, CO2 laser with or without stenting, for mild stenosis. Cricoid split and laryngotracheoplasty with costal cartilage or hyoid bone interposition may be required in more severe stenosis.
  • Laryngeal webs and atresias
    • Incomplete epithelial breakdown during the 10th week of embryogenesis
    • Most common location between cords, but can be in supraglottic or subglottic spaces
    • Treatment - CO2 laser lysis, occasionally more extensive procedures required
    • Atresias - rare, trach at delivery is imperative
  • Laryngotracheoesophageal clefts and fistulas
    • Tracheal atresia with TE fistula is not compatible with sustained life
  • Laryngeal cysts (fluid) and laryngoceles (air)
  • Tracheomalacia
    • Rare, usually associated with other anomalies like vascular rings
    • Wide, flat arch not as strong as more circular one
  • Hemangioma
    • Worse when infant cries
    • Treatment - CO2
  • Vascular rings
  • Choanal atresia
    • A newborn is an obligate nasal breather capable of exchanging air through his nose while he feeds
    • Can be mimicked by mucosal swelling from viral respiratory infection or nasal decongestant drops
  • Laryngeal cysts/neoplasms
  • Macroglossia
    • Relative macroglossia because of underdevelopment of the mandible in patients with the Pierre Robin Syndrome

Treatment

  • Varies with etiology - Intubation, rigid bronchoscopy or tracheotomy may be indicated depending on the nature of the problem


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©2001-2006 Baylor College of Medicine
Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
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Last modified: Jan. 23, 2006