Babak Saedi MD OTOLARYNGOLOGIST TEHRAN UNIVERSITY OF MEDICAL SCIENSES.
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Transcript of Babak Saedi MD OTOLARYNGOLOGIST TEHRAN UNIVERSITY OF MEDICAL SCIENSES.
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