UPPER AIRWAY MANAGEMENT: DR. MARION COUCH DEPT. OF OHNS UNC 2005

OBJECTIVES: LEARN HOW TO PERFORM A SURGICAL AIRWAY BE ABLE TO DIAGNOSE A DANGEROUS AIRWAY LEARN AN ALGORITHM FOR MANAGEMENT OF THE AIRWAY RESPECT THE AIRWAY.

INDICATIONS FOR TRACHEOSTOMY: UPPER AIRWAY OBSTRUCTION NEED FOR PULMONARY TOILET PROLONGED INTUBATION NEUROLOGIC DISORDERS NEED TO PROTECT THE AIRWAY REDUCE THE ‘DEAD SPACE’ REDUCE ASPIRATION TRAUMA

INDICATIONS: HEAD AND NECK SURGERIES IATROGENIC INFLAMMATION INFECTION

CONTRAINDICATIONS: IF YOU BE ASSURED THAT ORAL OR NASOTRACHEAL INTUBATION IS POSSIBLE FOR A SHORT DURATION OF TIME BETTER SAFE THAN SORRY.

PRE-OPERATIVE: SPEECH CONSULTATION NURSING CONSULTATION SOCIAL WORK CONSULTATION TELEPHONE, BG&E, MEDIC ALERT MEETING WITH OTHER PATIENTS OR A SUPPORT GROUP SUCTION MACHINE, SUPPLIES.

PERCUTANEOUS TRACH: MINIMALLY INVASIVE NO SHARPS COST EFFECTIVE TIMELY INTERVENTION EDUCATIONAL OPPORTUNITY SAFE WITH BRONCHOSCOPE.

TOTAL LARYNGECTOMY: WHAT’S THE DIFFERENCE BETWEEN THIS AND A TRACHEOSTOMY???

TECHNIQUES: SKELETONIZE LARYNX: TRANSECT STRAP MM LOW IN NECK EXPOSE THYROID GLAND REMOVE ONE LOBE IF NEEDED LEAVE PARATHYROID GLANDS

TECHNIQUE: IDENTIFY POSTERIOR BORDER OF THYROID CARTILAGE ON BOTH SIDES ROTATE LARYNX TO EXPOSE ATTACHMENT OF INFERIOR CONSTRICTOR MM. INCISE MM ALONG POSTERIOR BORDER OF THYROID ALA

TECHNIQUE: THE THYROHYOID MEMBRANE IS EXPOSED SUPERIOR HORN OF THYROID CARTILAGE IS ISOLATED AND MUCOSA IS DISSECTED FROM THE THYROID CARTILAGE LIGATE SUPERIOR LARYNGEAL NEUROVASCULAR BUNDLE

TECHNIQUE: GRASP HYOID BONE WITH ALLIS CLAMP AND CAUTERIZE ON HYOID BONE SUPERIOR AND LATERAL SURFACE AVOID HYPOGLOSSAL NERVE MOBILIZE LARYNX FROM SURROUNDING TISSUE

TECHNIQUE: TRANSECT TRACHEA (USUALLY ABOUT 4TH RING) DISSECT ALONG THE PARTY WALL AND SEPARATE TRACHEA FROM ESOPHAGUS SECURE ANTERIOR TRACHEAL WALL TO SKIN WITH HEAVY SUTURE INTUBATE TRACHEA WITH TUBE

TECHNIQUE: ENTER PHARYNX ON SIDE OPPOSITE TUMOR MAY ENTER IN VALLECULA IF LARYNGEAL TUMOR MAY ENTER IN PYRIFORM SINUS IF B.O.T. TUMOR GRASP EPIGLOTTIS WITH ALLIS USE METZENBAUM SCISSORS TO ENLARGE CUTS

TECHNIQUE: ALWAYS LOOK TO PRESERVE AS MUCH MUCOSA AS POSSIBLE ON THE TUMOR-FREE SIDE OF LARYNX!!!! CUT MUCOSA WITH CARE WATCH WHERE TUMOR IS LOCATED AT ALL TIMES

TECHNIQUE: JOIN SUPERIOR DISSECTION WITH INFERIOR DISSECTION REMOVE LARYNX MAY PASS NASOGASTRIC TUBE CLOSE WITH 3-0 VICRYL SUTURES CONNELL STITCH TO INVERT MUCOSA IN THE BAR, OUT THE DOOR……

TECHNIQUE: SECOND LAYER CLOSURE USING CONSTRICTOR MUSCLES IRRIGATE WOUND TRY A BLUE HAWAIIAN: METHYLENE BLUE AND WATER INTO PHARYNX – CHECK FOR LEAKS NOW FOR STOMA: HALF MATTRESS SUTURES

STOMA: SOME SURGEONS USE ENTIRE TRACHEAL RING AND SUTURE TO SKIN MAY ALSO BEVEL TRACHEA TO CREATE WIDE STOMA BIRD GRATE IS GOAL!!

NEED FOR RECONSTRUCTION: 3 CM

COMPLICATIONS: PHARYNGOCUTANEOUS FISTULA STOMAL STENOSIS PHARYNGEAL STENOSIS HYPOTHYROIDISM HYPOPARATHYROIDISM STOMAL RECURRENCE HEMATOMA

COMPLICATIONS: DYSPHAGIA DUE TO CRICOPHARYNGEAL MUSCLE HYPERTROPHY AIRWAY OBSTRUCTION CAROTID ARTERY EXPOSURE FISTULA WOUND BREAKDOWN

MANAGEMENT OF FISTULA: CREATE MEDIAL CONTROLLED FISTULA AND USE PACKING OTHER INSTITUTIONS LEAVE DRAINS IN PLACE, OFF SUCTION CAROTID PROTECTION

NEED FOR EMERGENT TOTAL LARYNGECTOMY? DATA NOT COMPELLING ENOUGH TO PROCEED WITHOUT PROPER PRE-OPERATIVE PLANNING. ESTABLISH AIRWAY ETT, TRACH, SHAVE TUMOR GET TISSUE DIAGNOSIS SCAN, STAGE PATIENT DISCUSS WITH PATIENT

PEARLS: ENTER PHARYNX ON SIDE OPPOSITE OF TUMOR. SAVE AS MUCH MUCOSA AS POSSIBLE WITHOUT COMPROMISING TUMOR MARGINS. IF TUMOR IS IN PYRIFORM SINUS – THINK FLAP RECONSTRUCTION

PEARLS: A DEAVER RETRACTOR INSERTED THROUGH MOUTH INTO VALLECULA CAN HELP FIND PHARYNGEAL MUCOSA FOR ENTRY INTO PHARYNX. TRACHEOESOPHAGEAL PUNCTURE MAY BE PERFORMED AFTER REMOVAL OF LARYNX USUALLY 1.5 CM FROM SUPERIOR EDGE

PEARLS: FEEDING CAN BE DONE THROUGH A TUBE THAT EXTENDS FROM TEP OR VIA A NG TUBE. COMFORT OF PATIENT

PEARLS: IF DOING T.L. FOR B.O.T. TUMOR, RESECT LARYNX AND PROCEED CEPHALD. EXPOSE TONGUE TUMOR AND RESECT WITH 2 CM. MARGINS. USE FROZEN –SECTIONS TO CONFIRM NEGATIVE MARGINS.

PEARLS: ALWAYS CONSIDER BIOPSYING A PERSISTENT FISTULA TO RULE OUT TUMOR NO DATA FOR GIVING PATIENT ANTIBIOTICS WHILE DRAINS ARE IN PLACE

FOR ALL OF ONCOLOGY: NATIONAL COMPREHENSIVE CANCER NETWORK WWW.NCCN.ORG STAGING ALGORITHMS EVIDENCE-BASED TREATMENT

FOREIGN BODIES: USUALLY DOWN RIGHT MAIN STEM BRONCHUS. MUST REMOVE QUICKLY. CHEST X-RAYS. AVOID THORACOTOMY. DON’T LET CHILDREN EAT PEANUTS UNTIL THEY CAN SPELL THEM.

PERITONSILLAR ABSCESS: SEE TRISMUS, FEVER, OTALGIA, ODYNOPHAGIA. “HOT POTATO” VOICE, DROOLING. MANAGEMENT CONTROVERSIAL: NEEDLE ASPIRATION INCISION & DRAINAGE QUINSY TONSILLECTOMY

MANAGEMENT: AUGMENTIN OR CLINDAMYCIN CLOSE FOLLOW-UP MOST ARE TREATED AS OUTPATIENTS BUT MONITOR AIRWAY CLOSELY

EPIGLOTTITIS: MEDICAL EMERGENCY DROOLING, HIGH FEVER, STRIDOR, ODYNOPHAGIA. DO NOT MANIPULATE PATIENT OR AIRWAY!!!! AFTER INTUBATION, SWAB EPIGLOTTIS, DRAW BLOOD CULTURES

Haemophilus influenzae type B infection: RARE!

TREATMENT OF EPIGLOTTITIS: AMPICILLIN CHLORAMPHENICOL OR CEPHALOSPORINS PROTECT AIRWAY

ADULT EPIGLOTTITIS OR SUPRAGLOTTITIS: LESS CONCERN ABOUT LARYNGOSPASM SO EXAMINE AIRWAY SMOKING CRACK OR IMMUNOCOMPROMISED FACULTATIVE ANAEROBES OR PAE. ANTIBIOTICS, PROTECT AIRWAY, CONSIDER STEROIDS.

LUDWIG’S ANGINA SUBMANDIBULAR SPACE SUBLINGUAL SPACE SUBMAXILLARY SPACE (INFERIOR) INFECTION SPREADS FROM DIGASTRIC MUSCLE FROM THE SUBMENTAL AREA TO THE SUBMAXILLARY COMPARTMENT

LUDWIG’S ANGINA DENTAL ABSCESS WOODY OR BRAWNY EDEMA CAN NOT OPEN MOUTH NASOTRACHEAL INTUBATION OR TRACHEOTOMY I & D OR ANTIBIOTICS STREP, FACULTATIVE ANAEROBES, STAPH

AIRWAY MANAGEMENT: JAW THRUST ORAL AIRWAY, NASAL TRUMPETS MASK AIRWAY ORAL OR FIBEROPTIC INTUBATION JET VENTILATION SURGICAL AIRWAY – CRICOTHYROIDOTOMY OR TRACH