Acute upper airway obstruction:

Obstruction from nose/mouth to main carina

It is a medical emergency

Clinical features:

o Chocking, coughing

o Stridor

o Respiratory distress

o Cyanosis

o Collapse (in complete obstruction)

Stridor:

High-pitched, monophonic sound heard with respiration

Can be inspiratory, expiratory or biphasic

Implies narrowing of the larynx or trachea (<5mm in diameter)

Snoring: is the vibration of the uvula and soft palate and the resulting sound, due to obstructed air movement during breathing while sleeping.

Causes of upper airway obstruction:

Congenital Laryngeal Anomalies

o Laryngomalacia (most common congenital cause)

o Vocal Cord Paralysis (2nd most common congenital cause)

o Subglottic stenosis (3rd most common congenital cause)

o Tracheomalacia

o Vascular Rings and Slings

Infectious

o “Croup” (Laryngotracheitis)

o Epiglottitis

o Tracheitis

o Measles

o Diphtheria

Tumor

Trauma

Foreign body aspiration

Others:

o Retropharyngeal abscess

o Subglottic Hemangioma

o Recurrent Respiratory Papillomatosis

o Post Intubation Glottic and Subglottic Lesions

o Extra-Esophageal (Gastroesophageal) Reflux Disease/Eosinophilic Esophagitis

Croup:

Laryngotracheobronchitis

Mucosal inflammation Narrowing

6 months – 6 years

95% viral most common viruses are parainfluenza viruses

Clinical manifestations:

o Fever

o Coryza

o Stridor

o Barking cough

o Hoarseness

Worse at night

Self-limiting

Steeple sign on x-ray

Acute epiglottitis:

Life-threatening

Caused by Hemophilus influenzae B

1-6 years old

Clinical manifestations:

o High fever in ill-looking patient

o Painful throat

o Difficulty breathing and swallowing

o Child sitting upright, immobile with open mouth (tripod or sniffing position)

Thumb print sign on x-ray

Bacterial tracheitis (Pseudomembranous croup):

Rare but dangerous

Similar to severe viral croup but with high fever and thick secretions

Caused by Staphylococcus aureus

Laryngomalacia:

Soft, immature cartilage of larynx collapses inward during inspiration

Folding over of epiglottis, causing omega-shaped epiglottis

Retropharyngeal abscess:

Abscess in the retropharyngeal space

Cause: complicated bacterial pharyngitis or extension of osteomyelitis

Organisms: Group A strep, anaerobes, staph. aureus

Clinical features:

o High fever

o Dysphagia

o Hyperextension of head

o Sore throat

o Drooling

o Noisy respiration.

On exam:

o Bulging of soft palate or posterior pharyngeal wall

Soft tissue neck film:

o Retropharyngeal soft tissue > ½ the width of the adjacent vertebral body

o Air in the retropharynx

Subglottic stenosis:

Narrowing of subglottic lumen

Two types:

o Congenital: birth defect

o Acquired: after intubation

Vascular rings:

Congenital anomalies that occur early in the development of the aortic arch and great vessels

They encircle the trachea/ esophagus causing stridor, and difficulty swallowing

Most common types:o Double aortic archo Right aortic arch with

aberrant left subclavian and a left ligamentum arteriosum

Assessment of severity of upper airway obstruction:

Chest retraction: None, Only on crying, At rest

Degree of stridor: None, Only on crying, At rest, Biphasic

Heart rate, Respiratory rate and O2 saturation

Management of acute upper airway obstruction:

If epiglottitis is suspected, DON’T EXAMINE THE THROAT! Because of increased risk of complete obstruction.

Investigations should be delayed

The selection of the appropriate intervention will depend on:

o The cause of upper airway obstruction

o The urgency to obtain a secure airway

Medical interventions:

o Heimlich maneuver

o Oropharyngeal airway

o Endotracheal intubation

o Helium- oxygen mixture

o Racemic epinephrine

o Corticosteroids

Beneficial in croup and post extubationNo benefit/ contraindicated in epiglottitis

Surgical or bronchoscopic interventions:

o Cricothyroidotomy

o Fiberoptic intubation

o Tracheostomy

o Laser/electrocautery/balloon dilation

o Airway stenting

Cricothyroidotomy:

1 cm vertical incision through the skin by scalpel

Horizontal incision through the cricothyroid membrane.

The resulting hole is opened by either inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp.

A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured.

A bag-valve device with the highest available concentration of oxygen is used to provide ventilation.

Bilateral auscultation and observation of the rise and fall of the chest.

Management in stable patient:

Flexible Fiberoptic Laryngoscopy (FFL)

o No sedation

o Immidiate feedback

o Can’t evaluate subglottic lesions

Airway endoscopy

o Needs special team

o Needs sedation

Spirometry

X ray

CT scan

Phoniatrics:

Phoniatrics: is a branch of medicine that deals with the organs of phonation, speech and language.

Phonation: is the voice production by the larynx i.e. vibration of the adducted tense vocal cords by the expired air.Speech: is the articulation of voice (phonation) into words by the movements of tongue, palate and lips.Language: Is the method of human communication, it has 4 modalities: comprehension, speaking, reading and writing.

How do we speak?

1. A sound voice is produced at the level of larynx. 2. This primary laryngeal sound is then is modified into speech at supralaryngeal level, i.e. mouth,

pharynx, tongue, 3. Then, it is resonated in the same areas and nose and paranasal sinuses

How voice is originally evoked in the larynx?

1. A deep breath will supply a continuous air flow at level of vocal folds.2. The vocal folds become tense and vibrate with the air flow.3. Smooth edges of vocal folds and properly functioning muscles are essential for proper voice production.

Defects in phonation:

Dysphonia: audible change in the patient habitual voice. It is more descriptive than ‘hoarseness’. Caused by:

1. Organic dysphonia: a. Congenital: webs, cyst b. Traumatic: mechanical, chemical, F.B. c. Inflammatory: acute or chronic laryngitisd. Neoplastic: benign or malignante. Miscellaneous: cord paralysisf. Endocrine disordersg. Drugs: virilizing anabolic hormones.

2. Functional dysphonia:a. Childhood hyperfunctional dysphoniab. Psychogenic aphonia

3. Minimal associated pathological lesions (MAPLs):a. Vocal noduleb. Reinke’s edemac. Cordal polypd. Cysts of the vocal folde. Granulomas

Diagnosis: by history, examination, laryngoscopy, electromyography (EMG)

Management: a- Medical treatment b- Phonosurgery c-Voice therapy

• Aphonia: total loss of voice.

• Phonasthenia: voice fatigue and inability to continue speaking.

• Dysodia: failure of some aspects of singing but speech normal.

Defects of resonance:

1. Hyponasality (Rhinolalia clausa):o Decreased nasal tone of voiceo Inability to produce letters (N,M and Ng) i.e. obstruction of voice flow through nose.o Produced by bilateral nasal obstruction.

2. Hypernasality (Rhinolalia aperta):o Increased nasal tone of voiceo Inability to produce letters (k) i.e. escape of voice flow through nose.o Produced by velopharyngeal incompetence (as cleft palate)

Defects of speech:

• Dysarthria: failure of articulation due to motor (muscle) disorder. (UMNL, LMNL, cerebellar lesions, extrapyramidal lesions or mixed).

• Dyslalia: Improper articulation of speech (R is pronounced as Y and S as th).

• Stuttering: stopping of speech fluency syllables. It may due to organic, neurotic, learning problem.

Defects of language:

Delayed language development: due to:

1. Motor defect: as brain damage2. Sensory defect: deafness3. Psychiatric illness.4. Environmental: learning defect.5. Idiopathic

Dysphasia or Aphasia: deterioration of language after full development, due to:

1. CVA2. Encephalitis 3. Trauma4. Tumors

Laryngopharyngeal reflux (LPR):

The reflux of gastric content into the larynx and pharynx  60% of patients with GERD have LPR Damage is caused by the acidic gastric juice, pepsin,

bile salts, bacteria and pancreatic proteolytic enzymes Laryngeal symptoms: cough, sore throat, hoarseness,

dysphonia and globus Risk factors : GERD, smoking and alcohol Diagnosis:

o Laryngoscopy: erythema and edemao Ambulatory pH monitoringo Immunologic pepsin assay

Treatment : o Behavioral changes: weight loss and dietary

changeso Medical: high dose PPIo Surgical: Nissen fundoplication

Goldenhar syndrome

Oculo-Auriculo-Vertebral (OAV) syndrome

Rare congenital defect characterized by incomplete development of the ear, nose, soft palate, lip, and mandible.

It is associated with anomalous development of the first and second branchial arches

Usually unilateral

1:3500 – 1:25000

Hearing problems:

o They may have congenital aural atresia and auditory canal stenosis. Thus, conductive hearing loss. Because of abnormal earwax drainage, the patients have recurrent severe infections, which cause sensorineural hearing loss.

o They may have a malformation in the ossicles (which originate from the first and second branchial arches) leading to conductive hearing loss.

Eagle syndrome:

It is a rare condition where an elongated temporal styloid process (more than 30mm) is in conflict with the adjacent anatomical structures.

Two forms: The classic form and the vascular one. Presentation:  unilateral sore throat, dysphagia, tinnitus, unilateral

facial and neck pain, and otalgia. In the vascular form, there is compression or dissection of the

internal carotid artery. Treatment: partial styloidectomy

Trotter’s triad: (for diagnosis of nasopharyngeal carcinoma)

1. Unilateral conductive hearing loss (secretory otitis media).

2. Ipsilateral earache and facial pain (trigeminal neuralgia).

3. Ipsilateral paralysis of the soft palate.

Gradenigo's syndrome triad (petrous apicitis): (a complication of otitis media and mastoiditis, involving the apex of the petrous part of temporal bone)

1. Diplopia (abducent nerve palsy)2. Unilateral facial pain (trigeminal nerve involvement)3. Otorrhea

The most common cause of decreased hearing:

- In children: otitis media- In adults: wax impaction

There is no lymph drainage for the vocal cords

Narrowest area of larynx:

- In children: subglottic area, at the level of the cricoid cartilage.- In adults: glottic area (vocal cords).

Otomycosis causes “wet newspaper” discharge.

Furuncle MastoiditisNo history of otitis media History of otitis mediaTenderness when moving the auricle Tenderness over the mastoidNo decreased hearing Decreased hearingPost- auricular sulcus is maintained Obliterated sulcus

The first test in Meniere disease is glycerol dehydration test, which involves ingesting glycerol or mannitol (dehydrating agents) and observing for a change in symptoms and a measurable change (improvement) in hearing

Caloric stimulation test is used in checking for brain death.

The first symptom of vestibular schwannoma (acoustic neuroma) is post auricular numbness.

Plummer-Vinson syndrome (Patterson- Brown Kelly syndrome) triad:

1. Iron deficiency anemia2. Post- cricoid dysphagia3. Upper esophageal webs

Errors:

Page 37: BPPV is the most common cause of acute vertigo and vestibular neuritis is the second most common.

Page 47: Antioxidants: vitamin E instead of vitamin A

Page 50: Kisselbach plexus: 4 arteries. Posterior ethmoidal artery does not form part of the plexus.

Page 121: rhinoplasty instead of cranioplasty