ENT: Acute Airway Problems

Classification

Congenital
Choanal Atresia, Laryngomalacia, Vocal Cord Paralysis, Laryngeal Webs.

Acquired
Acute Laryngitis, Supraglotittis, Croup, Foreign Bodies, Laryngotracheal Trauma.


Choanal Atresia
Congenital condition due to the persistence of the Buconasal membrane.
Unilateral or Bilateral
Emergency treatment is to provide an oral airway.
Definitive treatment by correcting the atresia.





Laryngomalacia
Most common cause of stridor
In infants and congenital abnormalities
Stridor is due to prolapse of supraglottic structures
Prolapse into laryngeal inlet during inspiration
Mechanism unknown




Clinical features:
Symptoms mild at beginning and then gradually peak
Inspiratory stridor is croaking in character
Symptoms exacerbated during sleep, crying, and in various positions (supine vs prone)

Signs:
Tachypnea, intercostal/subcostal recessions
Severe cases – cyanosis, apneic episodes, failure to thrive, pulmonary HTN

Evaluation:
Flexible Endoscope- Omega shaped epiglottis.


Treatment:
Self limiting
Severe cases:
Surgical (10%)- supraglottoplasty


Vocal Cord Paralysis
Congenital/Acquired, Unilateral/Bilateral, Adductor/Abductor

Pathology:
Malignant diseases (30%), Iatrogenic (25%), External trauma (15%), Idiopathic (15%),
Other (15%)

Vocal Cord Positions:
A- median B- paramedian C- cadaveric D- fully abducted (heavy inspiration)

Clinical Features:
Hoarseness of voice
Weak cough
Aphonia
Inhalation of food leading to respiratory tract infections
Dyspnea
Stridor

Evaluation:
Confirm stability of airway
Bronchoscopy
MRI

Treatment:
Unilateral
Compensatory position of normal cord
Speech therapy
Surgical procedures
Bilateral
Tracheostomy
To clear secretions and prevent inhalation of food (adductor paralysis).
To relieve respiratory obstruction (abductor paralysis).


Laryngeal Webs
Due to incomplete recanalization of larynx
Most common– anterior glottis

Symptoms: weak cry, aphonia, stridor, hoarseness.

Diagnosis: direct laryngoscopy



Treatment:
Thin webs are excised with micro scissors or CO2 laser. Thick webs require excision via laryngofissure and placement of a silicon keel.


Acute Laryngitis
Infectious- S. pneumoniae, H. influenza, S. aureus
Non-Infectious- vocal abuse, allergy, thermal/chemical burns, laryngeal trauma (endotracheal intubation).

Clinical Features:
Hoarseness of voice, pain in throat after talking, dry irritating cough worse at night, and general fever symptoms.

Treatment:
Vocal rest, Avoidance of smoking and alcohol, Steam inhalations, Cough sedative, Antibiotics, Analgesics, Steriods


Supraglotittis (Acute Epiglottitis)
Inflammatory condition confined to supraglottic structures, i.e. epiglottis, aryepiglottic folds and arytenoids.
Children – age 2-7
Due to H. influenzae type B
High mortality if not diagnosed and treated

Symptoms/Signs:
Rapidly progressing diseases
Presentation within a few hours
Fever, dyspnea, odynophagia, drooling
Irritable child, muffled voice
Inspiratory stridor – late feature (airway completely obstructed)



Evaluation:
Minimal investigations
X-ray: Swollen epiglottis shown as ‘thumb sign’

Treatment:
Hospitalization
Antibiotic therapy
Steriods
Hydration & Humidification
Tracheostomy


Laryngotracheobronchitis
Commonly known as croup
Most common infectious cause of airway obstruction in children
Viral – parainfluenzae virus

Symptoms/Signs:
Gradual onset; after URTI
Barking cough + hoarseness + stridor
Inspiratory stridor

Evaluation:
History and examination
X-rays

Treatment:
Hospitalization
Antibiotics
Humidification
Parenteral fluids
Severe cases – steroids + racemic epinephrine via a respiratory bronchidilator
If no response – endotracheal tube


Acute Airway Problems Assessment:
Examinations
Medical Treatment
Resuscitation and appropriate airway management.
02 ventilation
Antibiotics
Steroids
Surgical Treatment
Surgical correction
Tracheostomy
Cricoid split
Laryngeal reconstruction