AERODIGESTIVE EMERGENCIES

Background AnatomyDefinition:

The mixed airway/gastrointestinal tract that includes the oral cavity, pharynx,paranasal sinuses, sinonasal tract, larynx, pyriform sinus, pharynx, and upper oesophagus.

"aerodigestive tract." Segen's Medical Dictionary. 2011. Farlex, Inc

Aerodigestive Emergencies

Tumors

Trauma

Foreign Bodies

Infection

InfectionLudwig’s Angina: an infection of the submandibular space, mostly affecting children and young adults

Aetiology:

Dental Infections (80%) Submandibular sialadenitis, oral mucosa injuries, mandible fractures

(remaining 20%) Causative organisms include Alpha-haemolytic Streptococci, Alpha-

haemolytic Staphylococci, Bacteroides Rarely Haemophilus influenza, Escherichia coli, Pseudomonas

Risk factors:

Dental caries/recent dental treatment Immunocompromised Tongue piercing

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

Treatment:

1. Assess and protect the airway

2. Systemic antibioticsPenicillin-G (clindamycin if allergic), metronidazole

3. Surgical drainage if no improvement in 24 hoursIntraoral: if infection is localised in the sublingual spaceExtraoral: 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

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

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

Clinical Features:

Infants Children >1 yr old Adults

• Fever • Neck swelling • Poor oral intake• Rhinorrhea • Lethargy • Cough

• Sore throat • Fever • Neck stiffness • Odynophagia • Cough

• Sore throat• Fever• Dysphagia• Odynophagia• Neck pain• Dyspnea

Symptoms:

Signs:Infants Children >1 yr old Adults

• Cervical adenopathy • Retropharyngeal bulge • Stridor • Torticollis • Neck stiffness • Drooling • Agitation • Respiratory distress

• Posterior pharyngeal edema

• Nuchal rigidity• Cervical adenopathy• Drooling• Stridor• Torticollis[17]

• Trismus

Management:

Investigations:

1. Blood Investigations (FBC, blood culture, etc.)

2. Plain cervical radiograph (lateral view)• Shows widening of paravertebral space

with gas

Treatment:

1. Assess and protect the airway

2. Systemic antibiotics

3. Incision & drainage drainage Performed without anaesthesia (risk of rupture)

4. Cricothyrotomy/Tracheostomy

Trauma

Trauma

Neck trauma

Blunt

PenetratingVital

structures

Types of pathology present:• Hematoma• Oedema• Joint dislocations• Fractures of bone/cartilage

Clinical features:

• Pain /tenderness• Respiratory distress• Hoarseness of voice or aphonia• Stridor • Dysphagia and odynophagia• Haemoptysis/bleeding from the mouth• Bruises /abrasion on the overlying skin

Neck trauma

Treatment:• Observation• Voice rest• Steroids to reduce inflammation/oedema• Air humidification• Tracheostomy if pt unable to breathe

Complications:• Airway obstruction• Vocal cord paralysis• Swallowing dysfunction• Laryngeal stenosis• Infections

1. Jugular Vein

2. Carotid Artery

3. Spinal Cord

4. Cranial Nerves

Injury to Vital Structures

Neoplasm

NeoplasmProximal

Distal

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

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

Management:

Investigations:

1. CT scan to identify tumours2. Biopsy to stage3. Liver enzymes (elevated ALP in bone metastases)4. Chest x-ray (pulmonary metastases)

Treatment:

1. Radiotherapy for radiosensitive tumours2. Surgery: excision with either block resection, mandibular resection, neck

dissection, total glossectomy or laryngectomy + post-op radiation therapy depending on stage

3. Chemotherapy4. Tracheostomy/gastrostomy

Staging:

Rarely life- threatening but can cause significant morbidity

Intrinsic causes include:Primary carcinoma of the lungBreast carcinomaColon carcinomaKidney carcinomaExtracutaneous Melanoma

Extrinsic causes include:Mediastinal masses give rises to extrinsic bronchial compressionNon-Hodgkin’s lymphomaAcute lymphatic leukemiaGerm cell tumorsHodgkin’s diseaseNeuroblastoma

Distal Causes

ManagementsAvoidance of airway manipulation, muscle paralysis and general

anaesthesiaImmediate maneuvers include repositioning the patient in lateral,

prone or sitting position together with application of positive pressure support via facemask

Rigid bronchoscopy SurgeryChemotherapyRadiotherapy

Foreign Body Aspiration/ Ingestion

FOREIGN BODY ASPIRATIONA 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 aspiratedRisk factors include:• Unconsciousness• Neurological impairment of laryngeal control• Maxillofacial injuries• Alcoholic intoxification• Loose teeth or denture

Nature of foreign bodiesNon- 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 stages1) Initial period of choking, coughing, wheezing, vomiting Last for short time Foreign body may be coughed out/ lodge in larynx/ further down

tracheobronchial tree2) Asymptomatic period• Foreign body becomes lodged and reflexes fatigue

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

A: Partial obstruction; air can pass in and out causing only wheezeB: One way obstruction; air can go in (inspiration) but not out

causing emphysema of lungsC: Total obstruction; air can neither go in nor out causing

obstructive atelectasisD:One way obstruction; air can only go out causing atelectasis

A) Aspirated bean at the level of carinaB) A piece of apple in right main bronchus

Physical Examination Larynx/ cervical trachea- Inspiratory stridor Intrathoracic trachea- Prolonged expiratory wheeze Bronchi- Unequal breath sound- DIAGNOSTIC TRIADUnilateral wheezeCoughIpsilaterally diminished breath sounds

Fiberoptic laryngoscopy

ComplicationsRecurrent pneumoniaObstructive emphysemaBronchial stenosisBronchiectasisIrreversible damage to obstructed lobePneumothoraxPneumomediastinumRecurrent haemoptysisChronic lung diseasePleural effusionBronchopleural and bronchocutaneous fistulaOsteomyelitis of the ribEmpyema cavity

Radiography• PA & lateral views of chest and neck• Inspiration and expiration• Lateral decubitus viewsPossible chest X-ray findings include:Radio-opaque FBLobar/ segmental atelectasisUnilateral hyperinflation of lobe/ segment/ entire lung, mediastinal

shiftPneumomediastinum/ pneumothoraxPneumonitis/ bronchiectasis25% may have normal appearance

X-ray neck lateral view—radiopaque foreign body at C6-C7 level.

Tablet foil with surrounding granulation tissue.

Managements• Partial obstructionCoughingGaggingThroat clearing• Complete obstruction< 1yr : back blows> 1yr: gentle abdominal thrusts while supineOlder children/ adults: Heimlich maneuverStand behind the personSudden thrust directed upwards and bacwards, below the

epigastrium, squeezes the air from the lungs, sufficient to dislodge a foreign body

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)

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

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; childrenLoss of protective mechanism; use upper denture prevents

tactile sensation, loss of consciousness, seizures, deep sleep, alcohol

CarelessnessNarrowed oesophageal lumenPsychotics

Symptoms Signs

History of initial choking or gaggingDiscomfort or pain located just above clavicle on right or left tracheaDysphagiaDrooling of saliva; in total obstructionRespiratory distress; compression on posterior wall of tracheaSubsternal or epigastric pain; oesophageal spasm

Tenderness in lower part of neckPooling of secretions in pyriform fossa on indirect laryngoscopy. Do not diasapper on swallowing

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

Management1) 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 removal3) Cervical oesophaotomy4) Transthoracic oesophagotomy

TRACHEOSTOMYProcedure of making an opening in the anterior wall of trachea and converting it into a stoma on the skin surface

Common procedure performed in critically ill patients requiring prolonged mechanical ventilation for acute respiratory failure and for airway issues.

Functions include:Alternative pathway for breathingImproves alveolar ventilation by decrease dead space and

outflow resistanceProtects the airways against aspiration of pharyngeal

secretions in comatose patientsPermits removal of tracheobronchial secretionsIntermittent positive pressure respiration required beyond 72

hoursTo administer anaesthesia

IndicationsRespiratory obstruction

Retained secretions

Respiratory insufficiency

1) Infections Acute LTB,

Diphteria Ludwig’s angina Retropharyngeal

or paropharingeal abscess

2) Trauma• Fractures of

mandible/ maxillofacial injuries

3) Neoplasm 4) Foreign body5) Laryngeal edema

due to steam, irritant fumes/gases, allergy

6) Congenital anomalies

• Tracheo-oesophageal fistula

1) Inability to cough• Coma/ paralysis of

respiratory muscles2) Painful cough• Chest injuries, rib

fractures3) Aspiration of

pharyngeal secretions

1) Chronic lung conditions

• Emphysema• Chronic bronchitis• Bronchiectasis• Atelectasis

Contraindications include:Difficult anatomyMorbid obesity with short neckLimited neck movementCervical spine injury, suspected or otherwiseAberrant blood vesselsThyroid or tracheal pathology

Coagulopathy, clotting disorderProthrombin time or APTT > 1.5 time reference rangeThrombocytopenia

Evidence of infection in the soft tissues of neck at the insertion site

Need for proximal or distal extension tracheostomy tube placement

TypesEmergency 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

HighAbove level of isthmus (isthmus lies against II, III, IV tracheal

rings)At the 1st tracheal ringsCan cause perichondritis of cricoid cartilage and subglottic

stenosisIndicated in laryngeal carcinomaMidDone through II or III tracheal ringsLowBelow level of isthmusTrachea is deep at this level and close to several large vesselsDifficulties with tracheostomy tube which impinges on

suprasternal notch

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

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

Techniques

PositionPatient lies supine with a pillow under the shoulders so

that neck extended- brings the trachea forward

AnaesthesiaNo anaesthesia required in unconscious patients/ in

emergency procedureIn conscious patients, 1-2% lignocaine with epinephrine is

infiltrated in the line of incision and the area of dissectionSometimes, general anaethesia with intubation can be

used

Steps of Operation1) A vertical incision is made in the midline of neck extending

from cricoid cartilage to just above sternal notch2) After incision, tissues are dissected in the midline. Dilated

veins are either displaced or ligated3) Straps muscles are separated in the midline and retracted

laterally4) Thyroid isthmus is displaced upwards or divided between

the clamps, and suture- ligated5) A few drops of 4% lignocaine are injected into the trachea

to supress the cough when trachea is incised6) 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

7) Tracheostomy tube is inserted and secured by tapes8) 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

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.

Percutaneous Dilational TracheostomyIndicationsProlonged mechanical ventilationAirway protection against pulmonary aspirationProlonged need for intratracheal suctionUpper airway obstruction Trauma or infection in oral cavity, pharynx or larynxMinimisation of sedation

Contraindications Unstable fractures of cervical spine Severe local infection of the anterior neck Uncontrollable coagulopathy

Relative contraindicationsAge under 15 years oldGross distortion of the neck from haematoma, tumor,

thyromegaly, scarring from previous neck surgerySuspected tracheomalaciaEvidence of infection in soft tissues of neckObese and/ short neck which obscures landmarkInability to extend neck because of cervical fusion

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

Post- operative Care1) 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 it3) 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

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

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

ComplicationsImmediate(at time of operation)

Intermediate(1st few hours/

days)

Late(with prolonged use of tube for

weeks or months)1. Haemorrhage2. Apnoea3. Pneumothorax due to

injury to apical pleura4. Injury to recurrent

laryngeal nerve5. Aspiration of blood6. Injury to oesophagus

1. Bleeding2. Tube displacement3. Blocking of tube4. Subcutaneous

emphysema5. 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

Referencesi. PL Dhingra, Diseases of Ear, Nose and Throatii. Peter Dixon, Toronto Notes 2014iii. Harold Ludman and Patrick J Bradley, ABC of Ear, Nose and Throativ. Irfan Mohamad, Hazama Mohamad, Hashimah Ismail, 2011, Bilateral Pulmonary Aspiration of Teeth and

the Migration of a Foreign Body from One Main Bronchus to Anotherv. 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 Reviewvii. http://www.lifeguardacademy.co.uk/blogs/2012/sequence-treatment-adult-or-child-chokingviii. Nora H Cheung, MD, Lena M Napolitano, MD, Tracheostomy: Epidemiology, Indications, Timing, Technique,

and Outcomesix. Ludwig's Angina in Children, http://www.aafp.org/afp/1999/0701/p109.htmlx. Retropharyngeal Abscess, http://emedicine.medscape.com/article/764421-clinical#b4xi. Evidence-Based Diagnosis and Management of ENT Emergencies, xii. http://www.medscape.com/viewarticle/551650_4xiii. Airway Emergencies in Cancer, http://www.bioline.org.br/pdf?cm07007xiv. Neck Trauma Follow-Up, http://emedicine.medscape.com/article/827223-followup#e6 xv. http://www.uptodate.com/contents/overview-of-tracheostomy#H9xvi. 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