Upper Airway Obstruction - Stellenbosch University · resulting from an upper airway obstruction...
Transcript of Upper Airway Obstruction - Stellenbosch University · resulting from an upper airway obstruction...
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Upper Airway Obstruction
Adriaan Adriaan PentzPentz
Division of OtorhinolaryngologyDivision of OtorhinolaryngologyUniversity of Stellenbosch and Tygerberg HospitalUniversity of Stellenbosch and Tygerberg Hospital
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Stridor/Stertor
• Auditory manifestations of disordered respiratory function – ie noisy breathing resulting from an upper airway obstruction
• Merit investigation in every case
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Introduction
• Stertor– Caused by obstruction of airway above the
larynx– Vibration in tissues of nasopharynx,
oropharynx or soft palate• Stridor
– Due to airflow changes in the larynx, thrachea or bronchi
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Associated signs and symptoms
• Dyspnoea– Severity of one reflects severity of the other– Signs of respiratory embarrassment
• Nasal flaring• Accessory muscles• Cyanosis• Indrawing of soft tissues• Tracheal tug
– Beware of signs in neonate and small infant
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Associated signs and symptoms (continued)
• Cough– Harsh and barking– Subglottic inflammation/tracheal compression
• Hoarseness– Speech or crying– Vocal cord pathology
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Associated signs and symptoms (continued)
• Deglutition and respiration– Share common pathway: oropharynx– Disorders of the one may interfere with the
other– Stridor/Stertor often increase during feeding– Infants often noted to be poor or slow feeders
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General features: Stridor
• Always a symptom or a sign; never a diagnosis or a disease
• History and physical examination will indicate problem areas
• Endoscopy will confirm final diagnosis
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History and physical examination
• Character– Wheezing, snoring, croaking etc– Continuous or intermittent– Features of obstructed breathing severity (loudness)
• Age at onset: congenital could present later• Relationship to feeding, crying and exercise• Related diseases (cardiac, respiratory, neurologic)• Previous endotracheal entubation or prolonged
ventilation
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History and physical examination (continued)
• Onset– Rapid (trauma, upper respiratory tract
infection)– Slowly progressive (neoplastic cause)
• Snoring at night, daytime mouth breathing, daytime somnolence (OSAS)
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History and physical examination (continued)
• General– Alert, awake– Pattern of breathing– Congenital disorders
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History and physical examination (continued)
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History and physical examination (continued)
• Nose and oral cavity– Septal deviation– Heamatoma, abscess– Malignancy– Polyps– Rhinitis (chronic, allergic)– Choanal atresia– Post nasal drip, mucus on upper lip
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History and physical examination (continued)
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History and physical examination (continued)
• Mandible– Micrognathia– Retrognathia
• Nutritional status– Obesity– Failure to thrive
• Auscultation and palpation– Neck mass
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Special investigations
• Related organ systems– Cardiovascular (RHF)– Respiratory– Neurological
• Arterial blood gas levels• Oxygen sensor (saturation)• Radiology
– Lateral soft tissue X-ray neck– Tomography, angiography– CT/MRE
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Special investigations (continued)
• Endoscopy– Gold standard
• Evaluate nasal passages, nasopharynx, oropharynx, larynx and trachea
• General anaesthetic if required• Decide on treatment
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Special investigations (continued)
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Causes and classification
• Adult• Children• Neonatal
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Causes: Adult
• Malignancy– Nasopharynx, oropharynx, larynx
• Laryngeal trauma– post intubation
• Acute laryngitis• Supraglottitis/epiglottitis
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Causes: Children (continued)
• Laryngotracheobronchitis (Croup)• Epiglottitis• Foreign body• Trauma
– Post intubation• Retropharyngeal abscess• Laryngeal papillomata
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Causes: Children (continued)
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Causes: Children (continued)
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Causes: Neonatal
• Laryngomalacia• Congenital tumors, cysts• Webs• Subglottic stenosis• Vocal cord paralysis
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Causes: Examples
• Laryngotracheobronchitis (Croup)– Viral infection– 6 months - 3 years– Pyrexia, barking cough– Stridor: Grade I-IV
• Treatment– Hospitilisation– Oxygen and adrenaline nebulisation– Intubation in severe cases
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Causes: Examples (continued)
• Epiglottitis– Haemophilus influenza Group B– 3 years - 7 years– Pyrexia, severe sore throat– Stridor– Dribbling, breathing with raised chin, open
mouth– Cherry red epiglottitis
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Causes: Examples (continued)
• Treatment– Emergency
• IVI antibiotics
– Needs intubation• Small tube • Extubation within 48 hours
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Causes: Examples (continued)
• Laryngomalacia– Weak supraglottic framework– Self-limiting; resolves at 3 years
• Subglottic stenosis– Congenital or acquired– Beware after intubation– May need tracheostomy
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Causes: Examples (continued)
• Malignancy– Usually slow in onset– Progressive– Associated symptoms
• Hoarseness• Dysphagia/odynophagia
– Associated signs• Neck mass
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Obstructive sleep apnoea syndrome (OSAS)
• Definitions– Apnoea
• Cessation of airflow at nostrils for 10 seconds or longer
– Apnoea index• Number of apnoeas per hour of sleep
– Hypopnoea• Reduction in airflow associated with desaturation
– Sleep apnoea syndrome• 30 or more apnoeic episodes during a 7-hour sleep
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Causes of OSAS
• Nose– Polyps– Deviated nasal septum
• Pharynx– Adenoidal hypertrophy– Nasopharyngeal tumor– Large palatine/lingual tonsils– Retropharyngeal mass– Large tongue– Obesity
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Clinical features
• Frequent wakening and disturbed sleep pattern
• Snoring– Sign of partial airway obstruction
• Apnoeic episodes• Daytime somnolence
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Signs of obstructive sleep apnoea
• Poor nasal airway• Mouth breathing• Noisy respiration• Grossly hypertrophic tonsils• Short, thick neck• Obesity• Complications of OSAS:
– Pulmonary hypertension, RHF, COR pulmonale
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Special investigations
• Sleep studies/polysomnography
• Lateral X-ray neck
• CXR, ECG• Nasendoscopy• Elective
intubation
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Special investigations (continued)
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Treatment (OSAS)
• Conservative– Dietary modification– Nasopharyngeal airway– CPAP (continuous positive airway pressure)
• Surgical– Adenotonsillectomy– UPPP– Tracheostomy
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Summary
• Stridor is abnormal and should be investigated
• Laryngeal evaluation has to be performed in all patients with stridor
• Snoring for longer than 6 months in a child is abnormal