Babak Saedi MD OTOLARYNGOLOGIST TEHRAN UNIVERSITY OF MEDICAL SCIENSES

Voice change Dyspnea Local pain Cough

Stridor Hoarseness Retraction (intercostal- suprasternal-supraclavicular) Drooling - bleeding - emphysema

History Physical examination Fiber optic laryngoscopy Radiography Arterial blood gas C.T.Scan (if general status of patient is stable)

Simplest adequate form of control should be selected Lower level Other medical problems

Trauma Inflammatory diseases Benign neoplasms (intrinsic – extrinsic) Malignant neoplasms (intrinsic – extrinsic) others

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

CROUP AND EPIGLOTTITIS

Barking Cough Hoarse Voice Inspiratory Stridor Varying Degrees of Respiratory Distress Ages infancy [1-3] (peak 2 years)

Para influenza viruses – most frequent Influenza A and B – most severe (esp. A) Adenovirus Measles Respiratory syncytial virus

Clinical Course:  Recent URI several days before  Mild cough, progressing to stridor, worsening cough, retractions.  Fever usually only slightly elevated  Symptoms worse at night, better in day  Most gradually recover over several days

Chest X-ray often shows classic “steeple sign”

Management:  Close observation until stable  Warm or cool mist  Steroids – oral or nebulized  Racemic epinephrine  Hospitalize hypoxic, worsening children

A dramatic, potentially life-threatening form of upper airway obstruction characterized by:  High fever  Sore throat  Dyspnea  Rapidly progressive respiratory obstruction

Etiology: Haemophilus influenza organism

Clinical Course:  Quick onset of fever, dyspnea  Often sits leaning forward, drooling  Inspiratory stridor  Refuses to eat  Within hours may progress to respiratory obstruction Can occur at any age

Physical Findings: Left picture: nearly completely blocked airway Right 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

CharacteristicEpiglottitisCroupAge Any age 6months-12yrs OnsetSuddenGradual LocationSupraglotticSubglottic Temperature High fever Low-grade fever DysphagiaSevere Mild or absent DyspneaPresentPresent DroolingPresentPresent CoughUncommon Characteristic cough Position Leaning forward, mouth open comfortable X-Ray Thumb sign Steeple sign

Prolonged intubation Ventilation support Manage bronchopulmonary secretion Upper airway obstruction Obstructive sleep apnea Bilateral vocal cord paralysis Inability to intubate Major head & neck surgery or trauma

Advantages lower risk of laryngotracheal injury improved comfort/mobility improve airway stabilization allows for oral nutrition improved secretion clearance

Sternal notch Thyroid cartilage Cricoid cartilage - cricothyroid membrane - innominate artery - thyroid gland (isthmus) - recurrent laryngeal nerve

Venous supply Superior 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 anesthesia Incision between sternal notch and cricoid Dissection in a vertical plane Thyroid isthmus (third and fourth ring) Entrance into trachea Tracheotomy tube insertion

Hemorrhage False route Electrocautery fire Injury to adjacent structures

Hemorrhage [most common ] Infection Subcutaneous emphysema Pneumomediastinum Pneumothorax [most common in infant ] Obstruction of tacheotomy tube Displacement of tube

Hemorrhage Tracheoesophageal fistula Tracheal stenosis Tracheocutaneous fistula