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MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
Suspicion of laryngotracheal
Airway obstruction Airway stable
Tracheotomy, local
anaesthesia
Panendoscopy
injury
History and examination
Mucosa/cartilage
disrupted
Abnormal
Fibre-optic
nasoendoscopy
Mild abnormality Normal endolarynx
CT scan
Normal
Significant mucosal/
cartilaginous injury
Thyrotomy/suturing/open reduction internal fixation
of cartilage fractures ± intraluminal stening
Figure 54.2 Management algorithm for patients presenting with laryngotracheal trauma.
Minor mucosal
laceration/haematoma
Medical management
ICU
Humidification
Voice rest
Head of bed up
Nasogastric feeding
Antireflux
? Steroids
? Antibiotics
instability, externally visible neck wounds, bleeding, bruising or an expanding haematoma.
Clinical signs suggestive of airway obstruction include stridor, tachypnoea and accessory
muscle use.
Airway Management
A thorough history and examination including breoptic nasoendoscopy can be obtained.
Fibreoptic nasoendoscopy can aid in assessing patency of the airway, vocal fold movement,
presence of lacerations, haematomas and exposed cartilage.
Options for acute management of the threatened airway include
Endotracheal intubation
•
Fibreoptic awake intubation
•
Tracheostomy under local anaesthetic
•
Cricothyroidotomy (in an emergency situation)
•
278 Head and Neck
MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
An emergency tracheostomy should be performed in a controlled environment such as the
theater setting, under local anaesthetic with the patient breathing spontaneously. In the
struggling patient inhalational anaesthesia with inspired oxygen may be administered.
Muscle relaxants should be avoided as positive pressure ventilation may aggravate an air leak
and surgical emphysema. To avoid the area of laryngotracheal injury, the tracheostomy incision is ideally placed slightly lower than usual.
In paediatric laryngeal trauma, airway control consists of inhalational anaesthesia allowing for spontaneous ventilation and securing the airway with rigid bronchoscopy and
tr acheostomy.
Once the airway is secured, further evaluation and exploration of the laryngotracheal injury
can occur by means of a laryngotracheobronchoscopy and pharyngo-oesophagoscopy.
Imaging
Imaging is used in conjunction with rather than as a replacement for operative exploration.
e gold standard imaging modalities are computed tomography (CT) with three-dimensional (3D) reconstruction and magnetic resonance imaging (MRI). Radiological ndings
may demonstrate cartilage fractures, haematoma, oedema, cricoarytenoid joint dislocation
or subluxation, subcutaneous air and airway stenosis. CT angiography is helpful in assessing
the integrity of vascular structures, especially in penetrating trauma involving zones 1 and
3 of the neck.
Management of Laryngotracheal Injuries
Non-Operative Approach
Airway stability is integral to non-operative management and assumes protection by the
patient’s own reexes or by an endotracheal tube. is generally includes patients with group
1 and 2 laryngeal injuries. ese injuries include minor mucosal lacerations without exposed
cartilage or bone, small haematomas or undisplaced single fractures of the laryngeal cartilaginous framework.
Non-operative management of these patients involves admission to a level 2/3 environment for airway monitoring for at least 24 hours and treatment with constant
humidification, head elevation, nil by mouth and voice rest. Systemic corticosteroids,
nebulised adrenaline, inhibition of gastro-oesophageal reflux and antibiotics may also
be considered.
Operative Approach
Surgery is aimed at airway preservation, prevention of secondary sequelae of healing and
restoration of function via repair of endolaryngeal and other concomitant injuries.
Endoscopic
Endoscopic evaluation of the laryngotracheal complex can be performed in the acute
and chronic setting. Imaging can be taken for documentation and therapeutic interventions can be performed. These potentially include, in the acute setting, aspiration of
vocal fold haematomas, suturing and re-approximation of vocal folds and stent insertion
to support the laryngeal framework and prevent adhesions, especially at the anterior
commissure. In the chronic setting division of webs and adhesions, cordotomy, cordectomy, arytenoidectomy or injection thyroplasty can be undertaken under endoscopic
vision. Endoscopic balloon or bougie dilatation can also be used for cricopharyngeal
stenosis, and balloon dilatation with laser can be used for the endoscopic management
of laryngotracheal stenosis.
Head and Neck 279
MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
Open
An open approach to traumatic laryngotracheal injury is recommended for patients with
group 3 and 4 injuries or laryngeal fractures that are deemed unsuitable for endoscopic
repair. Laryngeal fractures are repaired by raising the perichondrial layer and stabilising
the fracture with wires, adaption alloy miniplates or alternatively non-metallic biodegradable plates which will absorb over 1.5 to 3 years. Group 5 injuries (complete cricotracheal
separation) require emergency tracheostomy and immediate repair.
An open approach is used less oen in the chronic setting, and it usual ly addresses functional
decits relating to airway, voice and swallow. Cricotracheal resection may be performed for
chronic subglottic stenosis, type I Isshiki open thyroplasty to medialise a paralyzed vocal
fold, and cricopharyngeal myotomy for cricopharyngeal stenosis. Reconstruction where
there is cartilage loss may involve local muscle aps, such as strap muscle or sternocleidomastoid, or the use of free gras, such as rib cartilage. Longer term stents may be used where
there has been signicant damage to the laryngotracheal complex.
Future Directions
Laryngeal Tissue Engineering
Growth factors, such as basic broblast growth factor (bFGF), transforming growth factor
(TGF)-β3 and granulocyte-macrophage colony-stimulating factor (GM-CSF), have been
used experimentally and have shown some promising results in vocal fold regeneration and
reduction of scar formation. e potential use of stem cells in a suitable scaold as a therapy
for future reconstruction is also promising based on in vivo and in vitro animal studies.
However this area of research is currently limited to the laboratory stage.
Laryngotracheal Transplantation
e concept of laryngotracheal transplantation has been present for decades but still remains
in its infancy. It is only suitable for a subset of patients who have endured severe trauma,
requiring laryngectomy, and carries with it the challenges of a prolonged recovery and lifelong immunosuppression. ere have been isolated reports of successful laryngeal transplant with long-term survivorship despite issues with chronic rejection.
Conclusion
e aetiology of trauma to the larynx and trachea is wide-ranging, resulting in com-
•
plex and potentially life-threatening injuries.
A multidisciplinary approach will enable airway protection and assessment of the
•
extent of injury to determine the best management and timing of any potential operative intervention.
Depending on the degree of injury, patient comorbidities and treatment-specic fac-
•
tors, treatment may involve operative or non-operative techniques.
Chronic upper aerodigestive tract dysfunction is a likely sequela and requires pro-
•
longed rehabilitation.
Further Reading
Bell RM, Krantz BE, Weigelt JA. ATLS: a foundation for trauma training. Ann Emergency
Med 1999; 34: 233–237.
Lee WT, Eliashar R, Eliachar I. Acute external laryngotracheal trauma: diagnosis and man-
agement. Ear Nose roat J 2006; 85: 179–18 4.
Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial inju-
ries: a 28-year experience. Ann oracic Surg 1998; 65: 182–186.
280 Head and Neck
PHARYNGITIS
55. PHARYNGITIS
Introduction
Pharyngitis is dened as inammation of the pharynx. It can be generalised or localised to
a specic area (tonsillitis). e presenting symptom is usually a sore throat, and this is the
most common presentation for primary care consultation. Most cases of pharyngitis are due
to infection: viral in 40–60% and bacterial in 5–30% of cases. Non-infectious causes include
dry air, allergy/post-nasal drip, chemical injury, gastro-oesophageal reux disease (GERD),
smoking, neoplasia and endotracheal intubation.
Gabhs Bacterial Pharyngitis
Group A beta-haemolytic streptococci (GABHS) are the most common cause of bacterial
pharyngitis and are spread via respiratory secretions through close contact. e incubation
period is 1–5 days and individuals are most infectious in the early stages of the disease.
e classical history is a sore throat, fever, chills, malaise, headaches, anorexia and abdominal pain. Although indistinguishable from viral aetiologies, several features are suggestive
of GABHS, such as pharyngeal erythaema, enlarged tonsils, tonsillar exudate, fever, cervical
lymphadenopathy, so palate petechiae and a scarlet fever rash.
Scottish Intercollegiate Guidelines Network (SIGN) guidelines recommend that the Centor
clinical prediction score should be used to dierentiate between GABHS and viral pharyngitis, therefore, assisting the decision on antibiotic prescription.
e Centor score gives 1 point each for
Tonsillar exudate
•
Tender anterior cervical lymph nodes
•
History of fever
•
Absence of cough
•
e likelihood of GABHS infection increases with increasing score and is 25–86% with a
score of 4 and 2–23% with a score of 1.
A full blood count may show leukocytosis, which is highly suggestive of bacterial infection.
Rapid antigen detection tests (RADTs) or throat swabs for culture are not currently advocated in the United Kingdom.
Streptococcal pharyngitis usually has a 5–7-day self-limiting course. Non-steroidal
anti-inammatory drugs (NSAIDs) and paracetamol are eective for symptom relief.
Chlorhexidine gluconate and benzydamine hydrochloride mouthwashes can alleviate the
intensity of pharyngeal discomfort and a single dose of oral or intramuscular corticosteroids
(in conjunction with antibiotic therapy) can reduce pain and hasten symptom resolution.
e use of antibiotics is discretionary, and most guidelines recommend that antibiotics
should not be prescribed for symptomatic management, especially with less severe presentations (e.g. 0–2 Centor criteria). Penicillin is the antimicrobial agent of choice for GABHS.
For adults, oral penicillin V 500 mg, four times daily for 10 days is prescribed. Alternatives
include narrow-spectrum cephalosporins (cephalexin) or macrolides (azithromycin, clarithromycin). Avoid ampicillin-based antibiotics, including co-amoxiclav, due to the risk of
rash in infectious mononucleosis (IM).
Complications of Gabhs Pharyngitis
Complications can be regarded as suppurative (peritonsillar, parapharyngeal and retropharyngeal abscesses) and non-suppurative (rheumatic fever, post-streptococcal reactive
arthritis/glomerulonephritis, scarlet fever and paediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections [PANDAS]).
Head and Neck 281
PHARYNGITIS
Peritonsillar Abscess
A peritonsillar abscess (PTA) is a collection of pus between the brous capsule of the tonsil
and the superior constrictor muscles, usually at the upper pole. ere has been an increase
in the incidence of PTA, with GABHS and anaerobes such as Fusobacterium necrophorum
and Streptococcus milleri clearly identied as causative organisms. e history is progressive,
unilateral sore throat over 3–4 days with odynophagia, trismus, ipsilateral otalgia, headache,
fever and lymphadenopathy. e patient oen develops a ‘hot potato’ voice and, on examination, trismus is virtually pathognomonic. e tonsil is displaced medially by the hyperaemic,
bulging mucosa over the peritonsillar space and the jugulodigastric nodes are tender and
enlarged.
Drainage of pus is often curative and bacteriological specimens do not need to be sent
to the laboratory routinely. This can be performed by either needle aspiration or an
incision and drainage (with scalpel and forceps). Although drainage is the primary
treatment, antibiotics are recommended for resolution of infection. A combination of
benzylpenicillin and metronidazole is the preferred choice. In patients with penicillin allergy, erythromycin/clarithromycin should be used. The use of a single dose of
intravenous steroid in addition to antibiotic therapy significantly reduces throat pain,
time in hospital, fever and trismus. Interval elective tonsillectomy after recurrent PTA
is recommended.
Non-Gabhs Bacterial Pharyngitis
Pathogens in non-GABHS include Haemophilus inuenza, Moraxella catarrhalis,
Corynebacterium haemolyticum, Mycoplasma pneumonia and Borrelia species. Sexually
transmitted bacterial infections such as Neisseria gonorrhoeae, Chlamydia trachomatis and
Treponema pallidum can also lead to tonsillopharyngeal infections. Anaerobic bacteria can
also be co-pathogens in GABHS infections, with a synergistic eect leading to suppurative
complications.
Although diphtheria (Corynebacterium diphtheria) has almost been eradicated due to vaccination, this condition can rapidly lead to signicant airway obstruction or delayed exotoxin-induced myocarditis and neuritis, therefore, a high diagnostic suspicion needs to be
maintained.
Viral Pharyngitis
Viral pharyngitis is common. Rhinovirus, parainuenza and corona are the most common
etiological agents, but adenovirus, coxsackie, herpes simplex, Epstein-Barr virus (EBV),
cytomegalovirus (CMV) and human immunodeciency virus (HIV) may also be causal.
Symptoms are similar to those of GABHS pharyngitis, although milder and features coryza,
exanthema and cough and treatment is usually symptomatic.
Infectious Mononucleosis (Glandular Fever)
Glandular fever is a common, acute, systemic viral infection caused by EBV. IM is primarily a disease of young adults and the incubation period is 5–7 weeks. e most common
symptom is tender cervical adenopathy, accompanied by sore throat. Pharyngeal signs range
from acute follicular tonsillitis, profuse exudate, petechiae on the so palate and sometimes
a PTA. Airway obstruction can be seen, as well as periorbital oedema (Hoagland sign) and
cranial nerve neuropathies.
e diagnosis is made from the clinical picture, together with mononucleosis on the peripheral blood lm. CMV infection and toxoplasmosis can give a similar clinical picture.
Traditionally, the Hoagland criteria was used to conrm the diagnosis of IM: >50% lymphocytes and >10% atypical lymphocytes with fever, pharyngitis, adenopathy and a positive
serological test. e serological Paul Bunnell and monospot tests are similar in terms of
sensitivity (63–95%) and specicity (84–100%). e gold standard is serological evidence of
EBV-specic immunoglobulin M (IgM) antibody.
282 Head and Neck
PHARYNGITIS
e systemic manifestations of EBV infection include generalised lymphadenopathy, hepatosplenomegaly, rubelliform skin rash and, rarely, gastrointestinal, cardiovascular, respiratory,
neurological and haematological manifestations. e oncological risks following EBV-related
IM include Hodgkin’s disease, Burkitt’s lymphoma, lymphoproliferative disorders in immunocompromised patients and the development of nasopharyngeal carcinoma. A history of IM
signicantly increases the risk of future multiple sclerosis.
Treatment is symptomatic for mild to moderate cases. Antivirals are generally not recommended, apart from severe manifestations when used as an adjunct to corticosteroids.
Steroids are indicated for acute upper airway oedema rather than symptom control. Contact
sports should be avoided for 4–6 weeks even in the absence of splenic enlargement because
of the risks of splenic rupture.
Non-EBV Viral Pharyngitis
CMV infection in the immunocompetent host rarely results in clinically apparent disease.
Infrequently, a mononucleosis-like syndrome with mild pharyngitis can be seen, particularly in older adults. Symptoms are similar to IM, but lymphadenopathy is less common.
Type 1 herpes simplex infection primarily involves the oral cavity/oropharynx, aecting
younger children, causing severe vesicular and ulcerative stomatitis of the lips, tongue,
gums, buccal mucosa and oropharynx. e treatment is supportive with analgesics and uids. Acyclovir is active against herpes virus but is eective only if started at the onset of
infection.
Herpes zoster pharyngitis arises from reactivation of the virus aer previous chickenpox
(i.e. shingles/cold sores). e pharyngeal features include odynophagia, vesicles and shallow
ulcers in the distribution of cranial nerves V, IX and X. Treatment with antivirals should
be started within 72 hours of onset of the lesions. Acyclovir has previously been the drug of
choice, but valacyclovir/famciclovir are equally eective and have more convenient dosing
regimens with decreased incidence of post-herpetic neuralgia.
Hand, foot and mouth is caused by coxsackieviruses and is characterised by a vesicular eruption in the oral cavity/oropharynx causing dysphagia and dehydration, with vesicles on the
hands and feet. It is normally accompanied by pyrexia, malaise and vomiting. e illness is
short-lived and mainly aects young children. Currently, it is not susceptible to antiviral agents
or vaccination, therefore, prevention requires public health interventions and surveillance.
Non-Specic Chronic Pharyngitis
Non-specic chronic pharyngitis is common and relies on a history of long-standing variable throat discomfort without any specic aetiological factors, with oen little to nd on
clinical examination. Aetiological factors include heavy smoking, industrial/occupational
irritants, chronic sinusitis with post-nasal drip, acid reux, poor dental hygiene, psychological stress or Chlamydia pneumoniae infection. Exclusion of malignancy is imperative and
treatment is supportive by removing causative factors.
Specic Chronic Pharyngitis
Syphilis is a spirochaete infection (T. pallidum) acquired through sexual intercourse. e most
frequent extragenital sites for the primary lesion (chancre) are the lips, tongue, buccal mucosa
and tonsil. Secondary syphilis occurs 4–6 weeks aer the primary lesion and features fever,
headache, malaise, generalised lymphadenopathy, mucocutaneous rash and sore throat. e
pharynx displays hyperaemia and inammation and there may be mucus patches or ‘snail track’
ulcers. Serological tests for syphilis include Venereal Disease Research Laboratory (VDRL), rapid
plasma reagin (RPR) and tests to detect specic treponemal antibodies. Penicillin is t he treatment
of choice, with 2.4 mega units intramuscularly in a single dose.
Pharyngeal tuberculosis (TB) is uncommon, but occasionally, can be seen in patients with
widespread miliary TB. Lupus vulgaris is a low-grade cutaneous form of TB and has been
described in the nasal cavities and pharynx. e diagnosis is usually made by association
Head and Neck 283
PHARYNGITIS
with pulmonary disease, and systemic treatment with triple therapy (isoniazid, rifampicin
and pyrazinamide) is rst line.
Toxoplasmosis is caused by the protozoan Toxoplasma gondii. Infection is usually asymptomatic, but some patients may have a sore throat with malaise, fever and cervical adenopathy. Serological diagnosis is oen restricted due to cost. e disease is usually self-limiting
and therefore treatment is unnecessary.
Scleroma is a chronic infective condition caused by Klebsiella rhinoscleromatis. e disease
begins in the nose and only secondarily spreads to the pharynx where it produces granulomatous lesions and scarring.
Candidiasis
Oropharyngeal candidiasis (OPC), or thrush, is a common infection typically caused by
the yeast Candida albicans. For symptomatic infection to occur, there must be local mucosal disease, a history of radiotherapy or immunocompromise (diabetes/immunosuppressive drugs). When symptomatic, it presents with pain and dysphagia and examination
reveals small white/creamy-white plaque-like lesions on the tongue, palate, buccal mucosa
or oropharynx (pseudomembranous lesions). Mild disease responds well to local therapy
such as nystatin drops or lozenges and for moderate to severe disease, oral uconazole is
recommended.
HIV and AIDS
Pharyngeal presentation of HIV disease includes acute seroconversion illness (pyrexia,
pharyngitis, malaise, mucous membrane ulceration, cervical lymphadenopathy), opportunistic infections (Candida, TB, syphilis, CMV, Cryptococcus), oral hairy leukoplakia (OHL),
oral aphthous ulceration, lymphoid tissue hyperplasia and neoplastic lesions (non-Hodgkin’s
lymphoma [NHL], Kaposi’s sarcoma [KS], squamous cell carcinoma [SCC] of the head and
neck, Hodgkin’s disease, myeloma and leiomyosarcoma in children).
Role of Tonsillectomy
e referral criteria for tonsillectomy in the presence of recurrent sore throats that are used
currently in the United Kingdom are based on the following SIGN guidelines:
Sore throats are due to acute tonsillitis.
•
e episodes of sore throat are disabling and prevent normal functioning.
•
Seven or more well-documented, clinically signicant, adequately treated sore throats
•
in the preceding year
or
ve or more such episodes in each of the preceding years
•
or
three or more such episodes in each of the preceding 3 years.
•
Further Reading
Scottish Intercollegiate Guidelines Network (SIGN). e management of sore throat and indi-
cations for tonsillectomy. National Clinical Guideline. Edinburgh: SIGN; April 2010.
Centor R, Witherspoon J, Dalton H, et al. e diagnosis of strep throat in adults in the emer-
gency room. Med Decis Making 1981; 1(3): 239–2 46.
National Institute for Health and Clinical Excellence (NICE). Respiratory tract infections:
antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract
infections in adults and children in primary care. NICE Clinical Guidelines, CG69.
Issued: July 2008.
284 Head and Neck
UPPER AIRWAY OBSTRUCTION AND TRACHEOSTOMY
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56. UPPER AIRWAY OBSTRUCTION AND TRACHEOSTOMY
Introduction
e upper aerodigestive tract, larynx, trachea and bronchi form the conduit between the
external environment and the lungs to facilitate gas exchange. e larynx acts to protect the
airway from aspiration during swallowing and is the primary organ for phonation. e narrowest site of the adult airway is the glottis and abnormal narrowing of the laryngotracheal
complex causes breathlessness, particularly on exertion.
Pathophysiology of the Airway
In laminar airow, airway resistance is dictated by the diametre of the airway and by the
density of inspired gas (Poiseuille’s law):
=
R
4
where R = resistance, n = v iscosity, l = length and r = radius.
Laryngotracheal Stenosis
In adults, approximately 50% of airway stenosis is seen post-intubation. Major risk factors
include duration of ventilation, sizing of ventilation tubes, excessive cu pressures and the
patient’s response to injury. Other aetiologies include bilateral vocal cord palsy, granulomatosis with polyangiitis (GPA), idiopathic subglottic stenosis (ISS), supraglottic stenosis,
previous papilloma treatment, glottic web, tracheomalacia, vascular lesion, amyloidosis and
congenital subglottic stenosis.
Diagnosis and Management
A history must establish previous prolonged ventilation, the duration of shortness of breath
and coexisting medical problems. Voice changes and chronic cough are common but exertional dyspnoea is the main symptom. Chronic airway obstruction is sometimes misdiagnosed as asthma or chronic obstructive pulmonary disease.
Examine the severity of stridor, chest recession, body morphology (body mass index) and
neck scars. Perform breoptic nasal endoscopy to assess vocal cord mobility, evidence of
laryngopharyngeal reux (LPR), pooling of secretions in the hypopharynx and the degree
of stenosis if visible. If a tracheostomy is in place, the lower airway can also be assessed if the
patient will tolerate temporary removal of the tracheostomy tube.
Investigate with a high-resolution computed tomography (CT) scan and request respiratory
function testing to determine the severity of airway compromise but also to monitor the
response to treatment. If there is any evidence of disordered swallowing, breoptic endoscopic evaluation of swallowing (FEES) or videouoroscopy are helpful. Treat LPR with a
twice daily proton pump inhibitor and an alginate suspension aer the evening meal. Always
manage patients within a multidisciplinary team including an ENT and thoracic surgeon,
respiratory physician and speech and language therapist.
Intra-Operative Assessment
e denitive airway assessment is airway endoscopy. Flexible bronchoscopy allows assessment of the dynamic airway and rigid bronchoscopy is essential in tracheal stenosis.
Suspension microlaryngoscopy, with jet ventilation, allows binocular vision with two hands
free for surgery and use of the carbon dioxide laser where required. Prior to suspension, map
the stenotic segment (by measuring the distance from the lips/teeth at the proximal and distal extremities of the stenosis) then grade the severity of the stenosis using the Myer–Cotton
grading system (Table 56.1).
Head and Neck 285
UPPER AIRWAY OBSTRUCTION AND TRACHEOSTOMY
Table 56.1 Myer-Cotton grading system
Grade I No obstruction to 50% obstruction
Grade II 51–70% obstruction
Grade III 71–99% obstruction
Grade IV No detectable lumen
Surgery for Laryngotracheal Stenosis
Traditionally, endoscopic surgery for stenosis is employed in the rst instance. Inammatory
stenoses may respond to steroid injection, radial cuts (laser or cold steel) or dilatation. Such
procedures oen need to be repeated periodically. More mature stenoses may require topical
mitomycin-C application or tracheobronchial stents. Failure of endoscopic treatment may
require open tracheal or cricotracheal resection.
Idiopathic Subglottic Stenosis
ISS is a rare, slowly progressive, bro-inammatory process of unknown aetiology, leading
to narrowing of the airway in the subglottis. e diagnosis is one of exclusion and must follow the anatomical description above with no history of intubation or tracheostomy in the
last 2 years, no neck trauma or surgery, no neck radiotherapy and be antineutrophil cyto-
histology must be sent to exclude other inammatory conditions or a low-grade neoplasm.
e majority of patients can be managed with endoscopic airway surgery once or twice a
year. Aggressive laser ablation of the stenosis is not advised as this will risk more severe stenosis recurrence. Cricotracheal resection has been used to treat this condition but there are
concerns over the post-operative voice due to the resection being in close proximity to the
vocal cords. A laryngossure and posterior cricoid split can instead be performed.
Granulomatosis with Polyangitis
GPA is an immune disorder characterised by inammation of small- and medium-sized vessels.
Most patients have other manifestations such as nasal crusting, subglottic stenosis and lungs or
kidneys involvement. e presence of a positive cytoplasmic antinuclear cytoplasmic antibody
(cANCA) test may aid diagnosis, but a denitive diagnosis will be made by tissue histology.
Approximately 25% of GPA patients have involvement of the larynx, trachea and bronchi;
however, subglottic involvement is most commonly seen. Intra-lesional corticosteroid injections, radial cuts and dilatation will treat the majority of new stenoses, but tracheostomies
and long-term stents may be required.
Sarcoidosis
A diagnosis of sarcoidosis depends on the presence of typical clinical features and noncaseating granulomatous inammation on histology with the exclusion of other known
causes of granulomas (tuberculosis, leprosy, syphilis and fungal disease).
Anatomically, laryngeal sarcoid has a predilection for the supraglottic region, particularly the epiglottis, aryepiglottic folds and arytenoids. Vocal cord paralysis is also reported as a result of perineural invasion. Laryngeal disease tends to progress slowly with a relapsing and remitting course.
High-dose systemic steroids have been recommended as the rst-line treatment, but endoscopic steroid inltration and laser reduction surgery have been used.
Bilateral Vocal Cord Mobility Impairment
Bilateral vocal cord mobility impairment (BVCMI) produces a reasonable voice but with a
degree of dyspnoea as the vocal cords tend to lie in the median or paramedian position. ere
are three principal causes: bilateral laryngeal denervation (neck and chest malignancy or
thyroid surgery), bilateral cricoarytenoid joint xation (trauma or rheumatoid arthritis) and
inter-arytenoid scarring (following endotracheal intubation).
286 Head and Neck
UPPER AIRWAY OBSTRUCTION AND TRACHEOSTOMY
Surgery is directed at improving the aperture of the posterior glottis. Endoscopic partial
posterior cordectomy and partial arytenoidectomy can be performed using the CO2 laser
or where there is potential for recovery in time, a tracheostomy or vocal cord suture lateralisation procedure may be performed temporarily. Various reinnervation operations have
been described; however, these are infrequently performed. Inter-arytenoid scarring can be
treated with posterior laryngeal mucosal advancement aps or posterior cricoid split with
cartilage graing; however, aspiration is almost universal post-operatively.
Acute Upper Airway Obstruction
e causes of upper airway obstruction are varied with some being immediately apparent
whereas others are subtle. Aetiologies of rapidly progressive airway obstruction include penetrating or blunt trauma to the head and neck region, infections or oedema of the upper
airway, vocal cord paralysis and foreign body inhalation. Primary malignancy of the head
and neck may also present with acute airway obstruction.
Symptoms and Signs
In the absence of acute trauma to the upper airway, presenting symptoms include dyspnoea,
cough, voice change, dysphagia, pain on swallowing or referred otalgia. Stridor denotes turbulent airow and heralds complete airway obstruction. Inspiratory stridor is usually from
obstruction at and above the glottic larynx, whereas expiratory stridor is from the intrathoracic airway and biphasic from the subglottis and trachea.
On examination, there may be increased work of breathing and accessory muscles of respiration use. Dysphonia indicates a laryngeal injury, and the greater the degree of hoarseness, the
greater the severity. Drooling implies either pharyngeal or oesophageal obstruction or the
avoidance of swallowing due to pain and bleeding denotes mucosal trauma or exposure of a
vascular structure by an invasive lesion. Signicant pharyngeal trauma and fractures of the
laryngeal skeleton or trachea may give rise to surgical emphysema, which may independently
worsen the upper airway obstruction.
Management
In resuscitation scenarios, the principle of an ABCDE approach is adopted. Examine to
exclude or address any immediately reversible causes of airway obstruction as it should be
secured by the least invasive technique that the attending clinician is capable of without
delay. Where the airway is suciently stable but no cause for the airway compromise has
been identied, the examination should include a transnasal breoptic endoscopy.
Medical Interventions
Administer high-ow oxygen via a face mask with a reservoir bag and use of humidication
if practically possible. Heliox (80% helium:20% oxygen) results in less turbulent ow and
allows the patient to experience reduced resistance during breathing. Steroids reduce mucosal oedema. Broad-spectrum antibiotics should be given in any case where acute infection is
suspected. Adrenaline nebulisers also can help to reduce airway oedema.
Airway Interventions and Cricothyroidotomy
Simple airway adjuncts such as an oral Guedel airway or nasopharyngeal airway may assist
with situations of supraglottic airway compromise. Endotracheal intubation is the intervention of choice where there has been a loss of respiratory drive necessitating assisted ventilation, or in cases of progressive upper airway obstruction. e usual route of intubation is via
the mouth. An alternative route is transnasal intubation using endoscopic guidance.
In the emergency setting of ‘can’t intubate, can’t oxygenate’ (CICO), a surgical cricothyroidotomy using the ‘scalpel–bougie’ technique is supported by the Dicult Airway Society
Head and Neck 287
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