5.1 Laryngeal and Esophageal Emergencies
5.1.1 Stridor
Key Features
Stridor is an indication of airway compromise and should be considered an emergency.
The priorities are to identify the site of obstruction, restore adequate ventilation, and address the underlying cause.
Stridor is an exam finding defined broadly as noisy breathing due to partial upper airway obstruction, and it is usually high-pitched and harsh. This is to be distinguished from wheezing, which is noise due to reversible collapse of bronchioles of the lower pulmonary airway, and from stertor, a sonorous noise that is due to collapse or obstruction at the upper pharynx, such as snoring.
Clinical
The stridulous patient must be evaluated without delay, as loss of airway may progress rapidly.
Signs and Symptoms
In the adult, development of stridor may be acute or chronic. Symptoms are often nonspecific and variable. Associated symptoms will vary depending on etiology and may include dyspnea, pharyngodynia, dysphagia, odynophagia, and anxiety. Signs include audible noise with breathing and may include fever, cough, hemoptysis, and retractions. Depending on severity and acuity, the patient may be in distress, may be hypoxic, and may also display dysphonia.
Differential Diagnosis
The causes of stridor are numerous. It is useful to categorize based on the anatomic level of obstruction. As a generalization, inspiratory stridor correlates with supraglottic obstruction, expiratory stridor correlates with intrathoracic obstruction (trachea), and biphasic stridor suggests glottic or subglottic obstruction ( Table 5.1 ). Differential diagnosis includes an obstructing neoplasm, infection with edema (e.g., supraglottitis), allergy/angioedema, foreign body, traumatic injury to the airway (e.g., thyroid cartilage fracture, large hematoma), and bilateral vocal fold immobility (e.g., postoperative iatrogenic injury). Other causes include subglottic stenosis, tracheal stenosis, and tracheomalacia.
Evaluation
One must consider an acutely stridulous patient as a potential airway emergency; prompt evaluation is warranted.
Physical Exam
In critical care algorithms, the ABCs are followed: airway, breathing, circulation. Stridor is a reflection of airway narrowing and is therefore a priority. If the stridulous patient is not ventilating adequately (hypoxic or retaining CO2), rapid intervention is critical. Establishment of the airway is discussed subsequently under Treatment Options.
History is important in guiding the exam: the timing of onset; known diagnoses, such as history of angioedema or head and neck cancers; previous head and neck surgeries (thyroid surgery, previous tracheotomy); trauma; possible foreign body aspiration; current upper respiratory infection; history of intubations; and any other relevant facts.
On exam, vital signs; pulse oximetry; possibly arterial blood gases; phonation; an oral and pharyngeal exam; and a neck exam for masses, edema, crepitus, or tenderness are important. Unless the adult patient is unstable or not adequately ventilating, a flexible fiberoptic nasopharyngolaryngoscopy is usually safe and extremely helpful. This exam will reveal an estimation of glottic airway diameter, vocal fold mobility, any sites of edema or mass, or the presence of an obstructing laryngeal foreign body. Pediatric patients may selectively undergo flexible fiberoptic examination. Caution must be used, as the examination can precipitate further airway compromise.
Imaging
Plain films of the neck—posteroanterior (PA) and lateral views—may be informative but are being replaced by computed tomography (CT) or magnetic resonance imaging (MRI). In general, one should not send a patient with airway compromise for CT or MRI unless the airway has been secured; loss of the airway during imaging can be disastrous.
Labs
An arterial blood gas (ABG) test may be helpful in determining adequacy of ventilation. Less acutely, a complete blood count (CBC) with differential may be useful in a patient with infection, such as supraglottitis.
Treatment Options
The goals of treatment are (1) to determine the site(s) and degree of obstruction; (2) to stabilize the airway by forced ventilation, intubation, or surgical bypass of the site of obstruction; and (3) to treat the underlying cause.
In an unstable, poorly ventilating patient, the airway must be secured. If possible, the operating room is the safest place to do this. One should approach the airway problem algorithmically, thinking ahead about possible problems (with a plan B and plan C). The algorithm will differ depending on the etiology and the patient. There are useful generalizations, however. (1) It is absolutely critical that the otolaryngologist clearly and authoritatively take control of the airway management. (2) An upright, awake, spontaneously breathing patient is usually the safest situation. (3) One must be prepared for the possibility that sedating and paralyzing a stridulous patient for intubation may result in an inability to mask ventilate, precipitating an emergency. (4) With angioedema, tongue swelling usually precludes the ability to perform direct laryngoscopy.
If intubation is deemed to be impractical (e.g., fiberoptic laryngoscopy indicates that an endotracheal tube will not pass through a narrowed airway), awake tracheotomy is performed. In an emergency where the surgical airway must be most rapidly established, cricothyroidotomy is indicated.
Unless the fiberoptic laryngoscopy suggests otherwise, an awake fiberoptic nasotracheal intubation is often the procedure of choice (if the patient requires intubation). As a backup plan, one should have a Holinger laryngoscope, velvet-eye laryngeal suction, and Eschmann stylet assembled and ready to use. Often, the otolaryngologist can easily intubate a patient with these instruments. A ventilating rigid bronchoscope is also very helpful, if available. In these cases, the patient should be maintained with spontaneous ventilation; if the patient has airway masses or stenosis, then ventilating bronchoscopy can be diagnostic and therapeutic. In addition, a tracheotomy tray should be open and ready to use. Injecting the soft tissue over the cricothyroid membrane with 1% lidocaine and 1:100,000 epinephrine ahead of time will result in vasoconstriction and a much drier operative field if emergency cricothyroidotomy or tracheotomy becomes necessary.
Other strategies for difficult intubation include retrograde intubation by placing a needle and guidewire (from a central line kit) into the cricothyroid membrane or trachea and passing the guidewire up and out of the mouth. An orotracheal tube may then be blindly passed over the guidewire and into the trachea. There are other techniques, such as fiberoptic intubation through a laryngeal mask airway, video direct laryngoscopy, intubating endoscopes (e.g., Shikani optical stylet), or the use of a lighted stylet to be blindly introduced into the trachea.
Medically, there are helpful strategies to “buy time” or assess response to medical therapy if a patient can maintain ventilation. The patient is maintained in an intensive care unit with continuous pulse oximetry monitoring. Humidified oxygen (e.g., via face tent) will help minimize secretions. Heliox (typically 79% helium/21% oxygen mixture) has been advocated as a short-term intervention to help maximize ventilation while definitive intervention is planned. The gas functions by reducing the viscosity of the inspired air, thus reducing the mechanical work of breathing in the narrowed airway. It can be used while medical intervention is taking effect; this is an excellent means of avoiding intubation. Intravenous (IV) steroids (i.e., dexamethasone 8 mg IV every 8 hours) may reduce airway edema. In some situations, appropriate medical treatment of the underlying problem, such as infection or angioedema, can obviate the need for intubation or surgical airway.
Outcome and Follow-Up
After securing the airway, appropriate management directed at the underlying problem is undertaken. This may include biopsy, treatment of infection, and laboratory or radiographic work-up.
5.1.2 Laryngeal Fractures
Key Features
Airway obstruction can develop rapidly.
Evaluate for concurrent injuries such as pneumothorax or esophageal or vascular injury.
The treatment goals are to ensure an adequate airway, to maintain voice quality, and prevent aspiration.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
