9. Clinical Features:
Symptoms:
Fever
Toothache
Neck swelling
Odynophagia/dysphagia
Dysphonia/hoarseness
Trismus (spasm of the pterygoid muscles)
Signs:
Neck is tender and ‘woody-hard’ on palpation
Tongue is pushed upwards and backwards
Bilateral submandibular swelling with erythema
Purulent oral discharge
Lymphadenopathy
Stridor
10. Treatment:
1. Assess and protect the airway
2. Systemic antibiotics
Penicillin-G (clindamycin if allergic), metronidazole
3. Surgical drainage if no improvement in 24 hours
Intraoral: if infection is localised in the sublingual space
Extraoral: if it involves the submaxillary space
4. Tracheostomy
Management:
Investigations:
1. Blood Investigations (FBC, blood culture, etc.)
2. Plain cervical radiograph (lateral view)
3. CT/MRI
11. Retropharyngeal Abscess:
An abscess in the retropharyngeal
space
Retropharyngeal space:
• Lies behind the pharynx
• Between the
buccopharyngeal fascia
and prevertebral fascia
• Spans the base of the skull
to the bifurcation of the
trachea
12. Commonly seen in children < 3 years
Due to suppuration of the retropharyngeal lymph nodes secondary to upper
airway infections (ex: tonsillitis, peritonsillitis, pharyngitis, and otitis media)
In adults, it is more commonly due to penetrating injury of the posterior
pharyngeal wall/oesophagus. Pus from acute mastoiditis may also form a
retropharyngeal abscess
20. Base of Tongue Carcinoma
• Affects the posterior 1/3rd of the tongue
• Often remains asymptomatic, until cervical lymph nodes are enlarged
Risk factors:
Alcohol, tobacco, older age,
geographic location, family
history Environmental exposure
to polycyclic aromatic
hydrocarbons, asbestos, and
welding fumes may increase the
risk of pharyngeal cancer
Proximal Causes
21.
22. Spread:
• Local: spreads through the tongue musculature, epiglottis and pre-epiglottic
space, tonsils, and hypopharynx
• Lymphatic: cervical lymph nodes
• Distant metastases: bones, liver and lungs
Clinical Features:
• Sore throat
• Feeling of a lump in the throat
• Discomfort during swallowing
• Referred ear pain
• Dysphagia
• Bleeding from the mouth
• Hot potato voice
Late features
On examination:
Palpable mass at the base of the tongue
23. Management:
Investigations:
1. CT scan to identify tumours
2. Biopsy to stage
3. Liver enzymes (elevated ALP in bone metastases)
4. Chest x-ray (pulmonary metastases)
Treatment:
1. Radiotherapy for radiosensitive tumours
2. Surgery: excision with either block resection, mandibular resection, neck
dissection, total glossectomy or laryngectomy + post-op radiation therapy
depending on stage
3. Chemotherapy
4. Tracheostomy/gastrostomy
25. Rarely life- threatening but can cause significant morbidity
Intrinsic causes include:
Primary carcinoma of the lung
Breast carcinoma
Colon carcinoma
Kidney carcinoma
Extracutaneous Melanoma
Extrinsic causes include:
Mediastinal masses give rises to extrinsic bronchial compression
Non-Hodgkin’s lymphoma
Acute lymphatic leukemia
Germ cell tumors
Hodgkin’s disease
Neuroblastoma
Distal Causes
26. Managements
Avoidance of airway manipulation, muscle paralysis and general
anaesthesia
Immediate maneuvers include repositioning the patient in lateral,
prone or sitting position together with application of positive pressure
support via facemask
Rigid bronchoscopy
Surgery
Chemotherapy
Radiotherapy
29. FOREIGN BODYASPIRATION
A foreign body aspirated into air passage can lodge In larynx, trachea or
bronchi
A large foreign body which unable to pass the glottis will lodge in supraglottic
area while the smaller one will pass down the larynx into the trachea or
bronchi
Foreign bodies with sharp points (pins, needes, fish bones etc can stick
anywhere in larynx or tracheobronchial tree)
Etiology:
Children are more commonly affected (between ages of 6 months to 3 years
old)
Rare in adult
Patient will give history of choking and the type of foreign body aspirated
Risk factors include:
• Unconsciousness
• Neurological impairment of laryngeal control
• Maxillofacial injuries
• Alcoholic intoxification
• Loose teeth or denture
30. Nature of foreign bodies
Non- irritating: plastic, glass or metallic foreign bodies (may remain
symptomless for long time)
Irritation type: Vegetables, peanuts, beans, seeds can cause
congestion and edema of tracheobronchiol mucosa
Clinical features; can be divided into 3 stages
1) Initial period of choking, coughing, wheezing, vomiting
Last for short time
Foreign body may be coughed out/ lodge in larynx/ further down
tracheobronchial tree
2) Asymptomatic period
• Foreign body becomes lodged and reflexes fatigue
31. 3) Later symptoms- depending on the site
• Laryngeal FB- pain in the throat, hoarseness of voice, croupy cough,
aphonia, dyspnoea, wheezing, haemoptysis
• Tracheal FB
- Sharp: cough, haemoptysis, odynophagia
- Loose (seed): move up and down the trachea between the carina and
the undersurface of vocal cords causing audible slap and palpatory
thud. Asthmatoid wheeze may be present
• Bronchial FB
- Enter the right bronchus because it is wider and more vertical
32. A: Partial obstruction; air can pass in and out causing only
wheeze
B: One way obstruction; air can go in (inspiration) but not out
causing emphysema of lungs
C: Total obstruction; air can neither go in nor out causing
obstructive atelectasis
D:One way obstruction; air can only go out causing atelectasis
33. A) Aspirated bean at the level of carina
B) A piece of apple in right main bronchus
39. Managements
• Partial obstruction
Coughing
Gagging
Throat clearing
• Complete obstruction
< 1yr : back blows
> 1yr: gentle abdominal thrusts while supine
Older children/ adults: Heimlich maneuver
Stand behind the person
Sudden thrust directed upwards and bacwards, below the
epigastrium, squeezes the air from the lungs, sufficient to
dislodge a foreign body
40.
41. Emergency tracheostomy should be done if Heimlichs’s
manoeuvre fails
Once acute respiratory emergency is over, FB can be removed
by direct laryngoscopy
Tracheal and bronchal FB can be removed by bronchoscopy
and under general ansthesia.
Not indicated unless there is airway obstruction/ they are of
vegetable nature that likely to swell up (seeds)
42.
43. FOREIGN BODY INGESTION
• Ingested foreign body may lodge in tonsil, base of tongue,
pyriform fossa, oesophagus
• Commonest site is at or just below the cricopharyngeal
sphincter
44. Flat objects like coins are held up at the sphincter while others
are held in upper oesophagus beneath the sphincter due to
poor peristalsis
Foreign bodies that can pass the sphincter either lodge at
bronchoaortic constriction or at cardiac end
Causes include:
Age; children
Loss of protective mechanism; use upper denture prevents
tactile sensation, loss of consciousness, seizures, deep sleep,
alcohol
Carelessness
Narrowed oesophageal lumen
Psychotics
45. Symptoms Signs
History of initial choking or
gagging
Discomfort or pain located just
above clavicle on right or left
trachea
Dysphagia
Drooling of saliva; in total
obstruction
Respiratory distress;
compression on posterior wall
of trachea
Substernal or epigastric pain;
oesophageal spasm
Tenderness in lower part of
neck
Pooling of secretions in
pyriform fossa on indirect
laryngoscopy. Do not diasapper
on swallowing
46. Investigation
Plain X-rays; radio-opaque foreign body
- Lateral view of neck
- Posteroanterior and lateral view of chest
Fluoroscopy
- To look for radio- lucent foreign body
47.
48. Management
1) Food bolus can be impacted in normal oesophagus – either
above cricopharyngeus, arch of aorta or gastro-oesophageal
sphincter
Can be managed medically- muscle relaxant, prokinetic agent
and anti- inflammatory drugs
Frequently the bolus may move on over 2 hours
2) Oesophagic removal
3) Cervical oesophaotomy
4) Transthoracic oesophagotomy
51. Common procedure performed in critically ill patients requiring
prolonged mechanical ventilation for acute respiratory failure
and for airway issues.
Functions include:
Alternative pathway for breathing
Improves alveolar ventilation by decrease dead space and
outflow resistance
Protects the airways against aspiration of pharyngeal
secretions in comatose patients
Permits removal of tracheobronchial secretions
Intermittent positive pressure respiration required beyond 72
hours
To administer anaesthesia
53. Contraindications include:
Difficult anatomy
Morbid obesity with short neck
Limited neck movement
Cervical spine injury, suspected or otherwise
Aberrant blood vessels
Thyroid or tracheal pathology
Coagulopathy, clotting disorder
Prothrombin time or APTT > 1.5 time reference range
Thrombocytopenia
Evidence of infection in the soft tissues of neck at the insertion site
Need for proximal or distal extension tracheostomy tube placement
54. Types
Emergency Elective Permanent
•Airway obstruction is
complete and there is
urgent need to
establish the airway
•Planned, unhurried
procedure
•Therapeutic; to
relieve respiratory
obstruction
•Prophylaxis; to guard
against anticipated
respiratory obstruction
or aspiration of blood
or pharyngeal
secretions in extensive
surgery
•Bilateral adductor
paralysis
•Laryngea l stenosis
55. High
Above level of isthmus (isthmus lies against II, III, IV tracheal
rings)
At the 1st tracheal rings
Can cause perichondritis of cricoid cartilage and subglottic
stenosis
Indicated in laryngeal carcinoma
Mid
Done through II or III tracheal rings
Low
Below level of isthmus
Trachea is deep at this level and close to several large vessels
Difficulties with tracheostomy tube which impinges on
suprasternal notch
56. Tracheostomy tubes
Patients who need ventilation (assisted
breathing with a respirator or breathing
machine) require tracheostomy tubes that
are blocked and sealed by what is called
a cuff (also called a balloon) located on
the lower outer cannula. The cuff blocks
any air from flowing around the tube and
assures that the patient is well
oxygenated. All the air must therefore
flow in and out through the tube itself. A
pilot tube attached to the cuff stays
outside the body and is used to inflate or
deflate the cuff.
CUFFED TUBE
57. Cuffless tubes are primarily used in non-
ventilated patients that have no difficulty
swallowing and have no danger of
aspiration. Since there is no cuff, it allows
air to pass into the upper trachea and
larynx so the patient can cough and speak
normally. Cuffless tubes are usually worn
over a long period of time so require a very
accurate fit in order to prevent pressure
sores in the trachea or at the tracheal
stoma.
CUFFLESS TUBE
58. Techniques
Position
Patient lies supine with a pillow under the shoulders so
that neck extended- brings the trachea forward
Anaesthesia
No anaesthesia required in unconscious patients/ in
emergency procedure
In conscious patients, 1-2% lignocaine with epinephrine is
infiltrated in the line of incision and the area of dissection
Sometimes, general anaethesia with intubation can be
used
59. Steps of Operation
1) A vertical incision is made in the midline of neck
extending from cricoid cartilage to just above sternal
notch
2) After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated
3) Straps muscles are separated in the midline and
retracted laterally
4) Thyroid isthmus is displaced upwards or divided
between the clamps, and suture- ligated
5) A few drops of 4% lignocaine are injected into the
trachea to supress the cough when trachea is incised
6) Trachea is fixed with a hook and opened with a vertical
incision in the region 2nd and 3rd rings. The it is
converted into circular opening
60. 7) Tracheostomy tube is inserted and secured by tapes
8) Skin incision should not be sutured or packed tightly as
it may lead to development of subcutaneous
emphysema
9) Gauze dressing is placed between the skin and flange
of the tube around the stoma
61.
62.
63. This requires a 3-cm vertical skin incision initiated below the
inferior cricoid cartilage. The strap muscles are retracted
laterally. The thyroid isthmus is retracted either superiorly or
inferiorly or divided. An incision is created in the anterior
trachea at the first or second tracheal rings. A sideways “H”
incision at the level of the second tracheal ring is ideal and
provides an open-book exposure without resection.
64. Percutaneous Dilational Tracheostomy
Indications
Prolonged mechanical ventilation
Airway protection against pulmonary aspiration
Prolonged need for intratracheal suction
Upper airway obstruction
Trauma or infection in oral cavity, pharynx or larynx
Minimisation of sedation
Contraindications
Unstable fractures of cervical spine
Severe local infection of the anterior neck
Uncontrollable coagulopathy
65. Relative contraindications
Age under 15 years old
Gross distortion of the neck from haematoma, tumor,
thyromegaly, scarring from previous neck surgery
Suspected tracheomalacia
Evidence of infection in soft tissues of neck
Obese and/ short neck which obscures landmark
Inability to extend neck because of cervical fusion
66. PDT vs Surgical Tracheostomy
Bedside PDT is simple and has fewer complications compared
to surgical tracheostomy
Bedside PDT is less expensive
Surgical tracheostomy in the operating room remains the back-
up method in difficult cases
67. Post- operative Care
1) Constant supervision
Look for bleeding, displace or blocking of tube
2) Suction
Depending on amount of secretions, suction may be required
every half an hour
Suction injuries to tracheal mucosa should be avoided by
applying suction to the catheter only when withdrawing it
3) Prevention of crusting and tracheitis
Proper humidification, by using humidifier
If crusting occurs, a few drops of normal saline or Ringer’s
lactate are instilled into the trachea every 2-3 hours to loosen
crusts
A mucolytic agent such as acetylcysteine solution can be
instilled to liquify tenacious secretions or to loosen crust
68. 4) Care of tracheostomy tube
Inner cannula should be removed and cleaned for the first 3
days
Outer cannula unless blocked or displaced should not be
removed for 3-4 days to allow a track to be formed when
tube placement will become easy
If cuffed tube is used, it should periodically deflated to
prevent pressure necrosis or tracheal dilation
69. Decannulation
• Prologed use of tube lead to tracheobronchial infections,
tracheal ulceration, granulation or stenosis
• For decannulation, tracheostomy tube is plugged and the
patient closely observed. If patient can tolerate it for 24
hours, tube can be safely removed
• After tube removal, wound is taped and patient again
closely observed
• Healing of wound takes place within a few days or a week
70. Complications
Immediate
(at time of operation)
Intermediate
(1st few hours/ days)
Late
(with prolonged use of
tube for weeks or months)
1. Haemorrhage
2. Apnoea
3. Pneumothorax due to
injury to apical pleura
4. Injury to recurrent
laryngeal nerve
5. Aspiration of blood
6. Injury to oesophagus
1. Bleeding
2. Tube displacement
3. Blocking of tube
4. Subcutaneous
emphysema
5. Tracheitis and
tracheobronchitis with
crusting in trachea
6. Atelectasis and lung
abscess
7. Local wound infection
and granulations
1. Haemorrhage due to
major vessels erosion
2. Laryngeal stenosis
due to perichondritis
of cricoid cartilage
3. Tracheal stenosis
due to tracheal
ulceration
4. Tracheo-oesophageal
fistula
5. Problems of
decannulation
6. Keloid or unhealthy
scar
7. Corrosion of tube and
aspiration of
fragments into the
tracheobronchial tree
71.
72. References
i. PL Dhingra, Diseases of Ear, Nose and Throat
ii. Peter Dixon, Toronto Notes 2014
iii. Harold Ludman and Patrick J Bradley, ABC of Ear, Nose and Throat
iv. Irfan Mohamad, Hazama Mohamad, Hashimah Ismail, 2011, Bilateral Pulmonary Aspiration of Teeth and the
Migration of a Foreign Body from One Main Bronchus to Another
v. Hari Shankar Sharma, Sanjay Sharma, Management of laryngeal foreign bodies in children
vi. Ajay Philip, V. Rajan Sundaresan, Philip George, Satyabrata Dash, Regi Thomas, Anand Job, and V. K.
Anand, 2013, A Reclusive Foreign Body in the Airway: A Case Report and a Literature Review
vii. http://www.lifeguardacademy.co.uk/blogs/2012/sequence-treatment-adult-or-child-choking
viii. Nora H Cheung, MD, Lena M Napolitano, MD, Tracheostomy: Epidemiology, Indications, Timing, Technique,
and Outcomes
ix. Ludwig's Angina in Children, http://www.aafp.org/afp/1999/0701/p109.html
x. Retropharyngeal Abscess, http://emedicine.medscape.com/article/764421-clinical#b4
xi. Evidence-Based Diagnosis and Management of ENT Emergencies,
xii. http://www.medscape.com/viewarticle/551650_4
xiii. Airway Emergencies in Cancer, http://www.bioline.org.br/pdf?cm07007
xiv. Neck Trauma Follow-Up, http://emedicine.medscape.com/article/827223-followup#e6
xv. http://www.uptodate.com/contents/overview-of-tracheostomy#H9
xvi. Guidelines for Percutaneous Dilatational Tracheostomy (PDT) from the Danish Society of Intensive Care
Medicine (DSIT) and the Danish Society of Anesthesiology and Intensive Care Medicine (DASAIM)
http://www.danmedj.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname=9104900.PDF
Notes de l'éditeur
The submandibular space is composed of two spaces separated anteriorly by the mylohyoid muscle: the sublingual space, which is superior, and the submaxillary space, which is inferior. The spread of infection is halted anteriorly by the mandible and inferiorly by the mylohyoid muscle5(Figure 4). The infectious process expands superiorly and posteriorly, elevating the floor of the mouth and the tongue. The hyoid bone limits the process inferiorly, and swelling spreads to the anterior aspect of the neck, causing distortion and a “bull neck” appearance5 (Figure 5). This then evolves to an infectious compartment syndrome of the submandibular and sublingual spaces.6
A child may sit leaning forward to maximize the airway. Examination may reveal carious molar teeth, neck rigidity or drooling. The presence of stridor, dyspnea, decreased air movement or cyanosis requires prompt attention because it may indicate an impending airway crisis.
The high mortality rate of retropharyngeal abscess is owing to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery.
Hot potato voice: A term for a defect of resonance in which the speech has a muffled quality, fancifully likened to a person speaking with a hot potato in the mouth
