Section 12

65-year-old presents to A+E with an acute episode of stridor.

What is stridor?

  • Sound caused by a disrupted airflow, resulting from a partial obstruction of the respiratory tract at the level or below the larynx.
  • Three types of stridor, depending on the location of the airway obstruction.
    • Inspiratory: suggests a laryngeal obstruction.
    • Biphasic: obstruction at the level of subglottis.
    • Expiratory: tracheal stridor is also called a wheeze.

List four differential diagnoses for acute onset stridor.

  • Foreign body aspiration
  • Laryngeal tumour
  • Supraglottitis/epiglottitis
  • Deep neck space infection/abscess
  • Anaphylaxis 

What initial management would you give to manage the stridor?

  • Sit patient upright
  • High flow humidified oxygen
  • Heliox (mixture 21%oxygen, 79% helium – enables less airway resistance than air reducing the work of breathing)
  • Nebulised adrenaline 
  • Dexamethasone
  • If infective cause – antibiotics

Describe two early and two late complications of tracheostomy.

  • Early– aspiration, asphyxia, haemorrhage, obstruction, emphysema, pneumothorax, cricoid injury
  • Late– cellulitis, subglottic stenosis, tracheo-cutanous/oesophageal fistula, vocal cord palsy, tube displacement, atelectasis, tracheomalacia, dysphagia, tracheal stenosis, difficult decannulation. 

Supporting Information

Adult causes

Paediatric causes

Extraluminal

Neurological

Mediastinal tumour

Iatrogenic – after thyroidectomy

Anomalous blood vessels

Trauma

Mural

Angioneurotic oedema

Granuloma

Vagal/laryngeal nerve palsy

Malignancy

Laryngeal web

Laryngomalacia

Subglottic stenosis

Luminal

Laryngotracheobronchitis

TB

Laryngeal papillomatosis

Foreign body

 

Laryngitis

 

Epiglottitis

DEFINITION –  a sound caused by a disrupted airflow, resulting from a partial obstruction of the respiratory tract at or below the larynx.
There are three types of stridor, depending on the location of the airway obstruction.

Inspiratory: suggests a laryngeal obstruction.
Biphasic: obstruction at the level of subglottis.
Expiratory: tracheal stridor is also called a wheeze.

Immediate measures

  1. Intensive monitoring e.g. emergency department Resus. If you are on a ward, alert the emergency team. Get the crash trolley or emergency equipment. Monitor oxygen saturations and respiratory rate closely.
  2. Keep everyone calm. This is very distressing for the patient so do not add to their burden.
  3. High flow oxygen. If immediately available consider:
    • Humidification
    •  Heliox
  1. Nebulised adrenaline (1mg = 1ml of 1:1000 adrenaline; you can try between 1mg and 5mg driven on oxygen), assess response and repeat if necessary.
  2. Call for specialist help: experienced anaesthetist, experienced ENT surgeon.
  3. Secure good IV access and send blood including group and save. If possible, take a blood gas and blood cultures.
  4. High dose steroid e.g. dexamethasone 8mg IV initially.
  5. Avoid putting instruments in the mouth until senior help arrives (unless the patient arrests).
  6. Take a history and examine the patient. Treat the cause.
  7. Endotracheal intubation should be first-line for acute airway compromise but sometimes it is not possible and a surgical airway is needed.

IMPENDING AIRWAY DISASTER TRIAD

  • Rapid onset aphagia or severe dysphagia, frequently associated with a severe sore throat
  • Rapid onset laryngeal voice change: hoarse, croaky, husky or no voice
  • Systemically very unwell: pyrexia, tachycardia, tachypnoea

There may be associated trismus or torticollis. Beware of any patient who develops these signs after admission: situations deteriorate rapidly. In the presence of neck trauma, any of the above should be taken very seriously. Stridor is a late sign of airway compromise.

Causes of airway obstruction

The causes of obstruction of any luminal structure can be divided into:

  1. Outside the wall (extramural)
  2. In the wall (intramural)
  3. Inside the lumen (intraluminal)

Extramural – tumour, abscess or haematoma in the neck
Intramural – tumour of the larynx, paralysis of the vocal cords, epiglottitis, subglottic stenosis
Intraluminal – foreign body, blood or secretions inside the airway

Tracheostomy procedure

  1. G/A or local
  2. Extend neck
  3. Transverse incision 2cm below cricoid (midline vertical in emergency) also halfway between cricoid and suprasternal notch. Lateral extension is medial SCM.
  4. Separate straps
  5. Divide or retract isthmus
  6. Cut disc in 2nd/3rd disc
  7. Tube
  8. Close skin and apply padding etc.

Complications

  • Early– aspiration, asphyxia, haemorrhage, obstruction, emphysema, pneumothorax, cricoid injury
  • Late– cellulitis, subglottic stenosis, tracheo-cutanous/oesophageal fistula, vocal cord palsy, tube displacement, atelectasis, tracheomalacia, dysphagia, tracheal stenosis, difficult decannulation.

Tracheostomy for airway obstruction due to cancer–>risk  of stomal recurrence–> question emergency laryngectomy.

Foreign body in pharynx/larynx/oesophagus

  • Common objects; fish bone, meat, food bolus, coin, nuts, seeds, small toy parts and batteries
  • Clinical features; flinching due to sharp pain on swallowing, drooling, airway compromise, cough, voice change, perforation–>neck mediastinitis/surgical emphysema.
  • Diagnosis/localisation
    • Pain above cricoid should be visible on FNE if FB there
    • Look for surgical emphysema
    • Lateral soft tissue x-ray if radiopaque, increased pre-vertebral shadow or air in the oesophagus may indicate perf.
    • FNE
    • Barium swallow
    • Failure to locate–>still go to theatre.

Treatment by location

  • Oropharyngeal– L/A, magill’s forcep removal (may need laryngoscope)
  • Hypopharyngeal– as above, if not possible–> G/A and direct laryngoscopy
  • Oesophageal
    • Soft–>hyoscine to relax muscle–> if fails–>oesophagoscopy
    • Sharp FB– immediate oesophagoscopy
    • Normally settle in narrowing:
      • cricopharyngeus
      • External impingement aortic arch
      • Left main bronchus.
    • Laryngeal/tracheal- rigid/flexi bronchoscope if not –> cardiothoracic
    • Repeated foreign body–>barium swallow.

After scoping– assess for perforation before commencing oral intake. Tachycardia/pyrexia may be signs of perforation indicating need for repair.

Deep neck space infections

  • Retropharyngeal space– contains fat, lymph nodes, small vessels
    • Anterior margin: pretracheal layer of the deep cervical fascia
    • Posterior margin: alar fascia, which separates the retropharyngeal space from the danger space
    • Lateral margins: prevertebral layer of the deep cervical fascia
    • Superior margin: the skull base / clivus
    • Inferior margin: the point at which the alar fascia fuses with the middle layer of the deep cervical fascia, typically around the T4 vertebral body – inferior pharynx
  • Parapharyngeal space– contains fat, trigeminal nerve, maxillary artery, ascending pharyngeal artery, small part of pterygoid plexus of veins:

Presentation– pyrexia, poor feeding, irritable, drooling, stridor, neck pain.

Investigation:

  • Lateral neck x-ray- widening of prevertebral soft tissue which is normally 7mm C2-C4 and 17mm C4-T1

Treatment– ABCDE- AIRWAY! IandD after airway secured, likely intraorally, may need to go through the neck.

Complications– septicaemia, endocarditis, great vessel thrombosis, pyopnuemonitis, purulent pericarditis, bronchial erosion, aspiration pneumonia and Grisel syndrome (1 rare cause of torticollis that involves subluxation of atlanto-axial joint from inflammatory ligamentous laxity following an infectious process in the head and neck, usually a retropharyngeal abscess.)

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