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UPPER AIRWAY OBSTRUCTION AND TRACHEOSTOMY
in the United Kingdom for front of neck airway (FONA) as the safest and quickest way to
secure the airway. Extend the patient’s neck, palpate the cricothyroid membrane in the midline and incise the skin vertically and the underlying membrane horizontally using a size
10 scalpel. Insert an airway bougie and railroad a size 6 endotracheal tube over the bougie
into the airway.
Tracheostomy
Indications of tracheostomy:
Upper airway obstruction
•
Prolonged ventilation
•
Removal of secretions
•
Part of another procedure (major head and neck surgery/laryngectomy/
•
pharyngolaryngectomy)
Eects of tracheostomy:
Laryngeal bypass – loss of cough and phonation
•
Reduction in respiratory dead space
•
Loss of nasal mucosa ltration and humidication
•
Increased risk of infection
•
Tube acts as foreign body leading to local inammation
•
Complications:
Immediate (haemorrhage, air embolism, local damage)
•
Intermediate (extubation, obstruction, subcutaneous emphysema, infection, stulae)
•
Late (tracheocutaneous stula, tracheal stenosis)
•
e procedure should be carried out in an operating theatre under sterile conditions, under
general or local anaesthesia. e patient should be supine, with the neck extended. A horizontal incision is sited halfway between the sternal notch and the lower border of the cricoid
cartilage. Incise the skin and dissect through the subcutaneous tissues to the strap muscles,
which are retracted laterally, following blunt dissection in the midline to separate them.
e thyroid isthmus should be clamped, divided and transxed. e anterior tracheal wall
is identied and the tracheotomy should be made between the second and fourth tracheal
rings. Before entering the trachea, select an appropriately sized tracheostomy tube and check
that the cu and all connecting equipment works properly. Having informed the anaesthetist that the trachea is about to be opened, the tracheotomy can be performed (vertical slit,
horizontal slit or tracheal window). e anaesthetist should withdraw the endotracheal tube
and, when the tip is immediately above the tracheotomy, withdrawal can stop and the tracheostomy tube should be inserted. e cu should be inated and the tube connected to
the ventilator. e incision should be closed loosely and the tracheostomy tube secured in
position with tapes and sutures.
KEY POINTS
• Assessment of the airway should be part of an overall systematic approach to
managing the critically ill patient.
• The assessment should determine the level(s) of airway obstruction.
• Action should be decisive.
• The least invasive intervention that will bypass the level of the lowest obstruction
should be used.
• Any intervention should be carried out by someone who is experienced in the use of
that technique.
288 Head and Neck
VOICE DISORDERS AND LARYNGITIS
Further Reading
1. e National Tracheostomy Safety Project. http://www.tracheostomy.org.uk
2. Frerk C, Mitchell VS, McNarry AF, et al. Dicult Airway Society 2015 guidelines for
management of unanticipated dicult intubation in adults. Br J Anaesth 2015; 115(6):
827–848.
3. Pracy JP, Brennan L, Cook TM, et al. Surgical intervention during a can’t intubate can’t
oxygenate (CICO) event: emergency front of neck airway (FONA). Clin Otolaryngol 2016;
41(6): 624–626.
57. VOICE DISORDERS AND LARYNGITIS
e assessment and evaluation of a patient with a voice disorder should be done in a multidisciplinary clinic by a laryngologist and a speech therapist. Persistent or progressive
dysphonia may suggest an organic lesion in the larynx, while intermittent dysphonia may
suggest a functional disorder.
History
History should dierentiate:
Dysphonia/hoarseness: any impairment of voice or diculty speaking
•
Dysarthria: diculty in articulating words
•
Dysarthrophonia: dysphonia in conjunction with dysarthria (e.g. cerebrovascular
•
accident)
Dysphasia: impairment of the comprehension of spoken or written language
•
Odynophonia: pain when talking
•
It is important to know the patient’s occupation and professional and recreational voice
usage. It is valuable to use self-administered questionnaires and the perceptual rating of
voice questionnaire to assess the voice (Figur e 57.1). ese tools help with understanding the
severity of the voice problem and help in measuring outcomes aer treatment.
Examination
Examination should include:
Neck for stigmata of previous surgery or masses
•
Nasal cavity
•
Findings implying cranial nerve or neurological disease
•
Laryngoscopy can be supplemented with stroboscopy, laryngography, or digital acoustic voice
analysis. Videolaryngostroboscopy is the standard of care for a voice clinic.
Management
ere are four broad categories of voice disorders:
Inammatory
•
Structural or neoplastic
•
Neuromuscular
•
Muscle tension
•
Similarly, treatment for voice pathology can be split into the ve modalities shown in
Fi g u re 57. 2 .
Head and Neck 289
VOICE DISORDERS AND LARYNGITIS
GRBAS:
‘Grade’
‘Roughness’
‘Breathiness’
‘Asthenia’
‘Strain’
Scored 0–3, to each of
these five dimensions
Voice Handicap Index 10
(VHI-10):
10 questions, scored from
0-4
0 = never
1 = almost never
2 = sometimes
3 = almost always
4 = always
Max score = 40
Figure 57.1 Commonly used objective assessment measures.
Voice Symptom Scale
Scored 0-4 for each item
on frequency response
1 = occasional
2 = some of the time
3 = most of the time
Max VoiSS score = 120
Reflux Symptom Index
Scored 0-5 for 9 questions
(0 = no problem up to
5 = severe problem)
If score is >10 then should
consider evaluation for
laryngopharyngeal reflux
Treatment overview:
• Vocal hygiene, lifestyle and dietary advice (VH)
• Voice (speech) therapy (VT)
• Specialist therapy e.g. singing therapy or osteopathy (ST)
• Medical treatment (MT)
• Phonosurgery (PS)
(VoiSS):
0 = never
4 = always
(RSI):
Figure 57.2 Treatment overview.
Specic Voice Disorders and Their Management
Laryngitis
Laryngitis is a descriptive term indicating a degree of erythema, oedema, epithelial change
that may include ulceration, leukoplakia, and/or stiness of the mucosa of the vocal fold.
Oen there is an increased amount of thick mucus present. Most acute laryngitis is associated with upper respiratory tract infections. Chronic laryngitis has close links with smoking,
alcohol, reux, occupational exposures, social activities, allergies, and vocal/throat hygiene.
e voice is usually hoarse (rough, strained, breathy, or whispery), which may be due to vocal
fold stiness from the inammatory process and/or secondary to muscle tension imbalance.
e majority of acute infections are self-limiting. Treatment of chronic laryngitis consists of
voice hygiene (VH) with reduced use/abuse and rest.
Arytenoid Granuloma
Ary tenoid granulomas are benign inammatory lesions that arise from the perichondrium
of the vocal processes (F igure 57.3). ey result from trauma-related injury, predominately
secondary to intubation or repeated impact from throat clearing/coughing. Reux is
accepted as an important aetiological factor, and it also slows down the healing process.
290 Head and Neck
VOICE DISORDERS AND LARYNGITIS
Figure 57.3 Arytenoid granuloma.
Symptoms:
Dysphonia and/or vocal fatigue
•
Tickling sensation
•
Discomfort
•
Management:
Reducing laryngeal irritants, i.e. stopping smoking, improving VH, treating any reux.
•
voice therapy (VT), which includes raising awareness of, and reducing, hyperfunctional vocally abusive behaviour.
Phonosurgery (PS) does not usually cure arytenoid granulomas when used in isolation as
there is a high rate of recurrence.
Botulinum toxin injections into the thyroarytenoid muscle can be helpful in dicult
•
cases to stop impact, allowing healing.
Vocal Fold Polyps
Vocal fold polyps are benign swellings of greater than 3 mm that arise from lamina propria
of the vocal folds (Fi g u re 57.4).
Most common cause of structural dysphonia.
•
Oen solitary, but occasionally bilateral.
•
Figure 57.4 Right-side haemorrhagic vocal fold polyp.
Head and Neck 291
VOICE DISORDERS AND LARYNGITIS
More common in men than in women.
•
Smoking association.
•
Predominately presents at age 30–50 years.
•
Occasionally, a sulcus, mucosal bridge, or intracordal cyst is found immediately oppo-
•
site on the contralateral vocal fold. ese are thought to cause polyp formation; therefore, contralateral examination is crucial.
Symptoms:
Dysphonia: voice is lowered in pitch and cuts out in speech.
•
Lost vocal dynamic range partially.
•
Straining to speak.
•
Very seldom, large polyps can cause dyspnoea and episodes of choking.
•
Management:
VT, but unlikely to result in polyp resolution.
•
Treatment of concomitant inammatory conditions.
•
Most polyps need surgery
•
PS options include laser or cold steel.
•
e goal of surgery is to restore the smooth edge of the vocal cord to allow full
•
closure and normal vibration.
Vocal Fold Nodules
Vocal fold nodules are small bilateral swellings (less than 3 mm in diameter) that develop on
the free edge of the vocal fold at the maximal contact area (Fig ure 57. 5).
Associated with certain occupations (e.g. teaching, singing).
•
In children, found more oen in boys than in girls.
•
In adults, strikingly more frequent in women, predominately less than 30 years old.
•
Aetiology of vocal nodules is thought to be voice abuse rather than overuse.
Symptoms:
Voice oen husky and breathy.
•
Worsening symptoms with voice use.
•
Oen associated with discomfort on phonation.
•
Phonation may become a little deeper in pitch and associated with breaks.
•
Figure 57.5 Vocal fold nodules. Bilateral, symmetric phonatory lesions along the anterior one
third of the membranous vocal folds (a). After VT, the nodules remained, and the lesions were
resected with CO2 laser PS (b).
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VOICE DISORDERS AND LARYNGITIS
Management:
If nodules are not causing signicant problems, they should be le alone.
•
Aggravating factors, such as inadequate lubrication, infections, and reux, should be
•
treated to reduce their irritant eects.
Mainstay for persistent vocal nodules is VT with VH. Not infrequently, the voice and
•
function improve, but the nodules persist.
Surgery should be reserved for those who fail voice therapy and remain symptomatic.
•
Surgical aim is precise excision of the nodule alone, with no exposure of the underlying ligament.
Pseudocysts
Pseudocysts are so named because the lesion has no cyst wall but is lled with serous uid,
having an appearance similar to that of a blister.
Likely due to phonotrauma.
•
Initial management is VH.
•
PS might be necessary if symptoms are recalcitrant to therapy.
•
Reinke’s Oedema
Reinke’s oedema is a result of oedema of the subepithelial space (Reinke’s space), as shown
in Fig ure 57. 6.
Almost exclusively found in smokers.
•
Hypothyroidism may be found as a concomitant feature.
•
Reinke’s space contains lakes of oedema.
•
e sex distribution is equal, but the pitch-lowering eects on the voice are more con-
•
spicuous in women.
Age at presentation is 40–60 years.
•
Symptoms:
Deepening of the pitch of the voice in women
•
Gruness
•
Inability to raise the pitch of the voice
•
Choking episodes
•
Reux symptoms
•
Management:
Conservative measures like VH and smoking cessation manage symptoms well in most cases.
Treat underlying hy pothyroidism, infections, or reux. VT may help in a well-motivated patient.
Figure 57.6 Reinke’s oedema.
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VOICE DISORDERS AND LARYNGITIS
Surgical treatment should be considered if:
Leukoplakia is present and a histological diagnosis is necessary.
•
Gross oedema causes choking episodes or airway embarrassment.
•
e inability to accomplish pitch elevation of the voice is problematic.
•
ere is signicant potential for worsening the patient’s condition by causing scarring aer PS.
Reduction glottoplasties are performed using cold steel or laser. Care should be taken minimise
epithelial excision due to the risk of causing a permanent scar and hoarseness. e myxematous
material is aspirated/removed/vaporised, and then the epithelial edges are apposed, aer excision
of redundant mucosa as necessary. Oen, good results are obtained by simply treating one side.
Cysts
Cysts are found less frequently than polyps and nodules, and sulci and mucosal bridges even
less so. ere are two primary types of cyst: mucous retention cyst and epidermoid cyst. A
mucous retention cyst (Figure 57.7) is a blocked minor salivary gland.
Epidermoid cysts (Fi g u re 5 7.8) are lined by squamous epithelium and are lled with keratin
and cholesterol debris. ey are thought to arise as a result of voice abuse/misuse. For both
types of cysts, a denitive diagnosis is only possible by microlaryngoscopy and cordotomy
(Fi g u re 57.9).
Figure 57.7 Mucous retention cyst.
Figure 57.8 Epidermoid cyst.
294 Head and Neck
VOICE DISORDERS AND LARYNGITIS
Figure 57.9 Epidermoid cyst approached via cordotomy and mucosal ap.
Adult Laryngeal Papilloma
Associated with human papillomavirus (HPV) genotypes 6 and 11
•
Bimodal incidence
•
Juvenile: 2–4 years
•
Adult: 20–40 years
•
Small risk of malignant transformation in adult papilloma
•
Presentation:
Progressive dysphonia
•
Dyspnoea
•
Stridor
•
Tre atme nt:
Endoscopic excision. Options include:
•
Cold steel
•
Microdebrider
•
Laser
•
Adjuvant treatments:
•
Cidofovir—falling out of favour due to carcinogenic potential
•
Interferon-α—rarely used due to signicant risk of side eects and morbidity,
•
including neurological sequelae, leukopenia, cardiac dysfunction, and hepatorenal failure
Bevacizumab—antiangiogenic monoclonal antibody that appears to work and is
•
in the process of undergoing randomised controlled trials (RCTs)
Photodynamic therapy—starting to emerge, but more evidence is needed before
•
it becomes widely used
HPV vaccine—quadrivalent vaccine for HPV 6/11/16/18 is now oered to males and
•
females at ages 11–12 years in the United Kingdom
Tracheostomy—should be avoided if possible due to risk of seeding the stoma or distal
•
airways
Vocal Cord Palsy/Paresis
Vocal cord palsy/paresis oen presents with breathy voice and symptoms of aspiration. An
obvious laryngeal paresis will show asymmetry of movement on abduction and adduction,
where the aected side ‘lags behind’ the normal side. Asymmetry maybe subtle and may
Head and Neck 295
VOICE DISORDERS AND LARYNGITIS
only be apparent on prolonged endoscopic observation while asking the patient to phonate
and then sni repeatedly. Bilateral palsies/paresis present with upper airway symptoms, dyspnoea, stridor, and respiratory compromise.
Causes include:
Iatrogenic injury (surgery)
•
Malignant disease
•
Trauma
•
Idiopathic
•
Neurological disease
•
It is fundamental to rule out malignancy with computed tomography (CT) of the skull base
to thorax. Some centres use electromyography (EMG) to evaluate the laryngeal musculature.
Management:
VT—strategies to allow compensation and decrease aspiration.
•
Surgery
•
Injection medialisation procedure—endoscopic administration of absorbable
•
semi-permanent materials (e.g. hydroxyapatite, collagen)
Laryngeal framework surgery—which may include insertion of an implant
•
Laryngeal reinnervation
•
Bilateral palsies/paresis may need a tracheostomy acutely, but a range of other proce-
•
dures may be used to improve the airway, such as a cordectomy.
Muscle Tension Dysphonia (MTD)
Muscle tension imbalance causing MTD is one of the biggest causes or contributors to
voice disorders. Although it is oen a diagnosis of exclusion (i.e. the vocal folds look normal and move normally), it is oen present with inammatory, structural, and neurological conditions as the laryngeal muscles try to overcome a deciency in voice production.
MTD can lead to trauma and structural changes in the vocal fold mucosa. MTD therefore ecompasses a group of conditions characterised by an imbalance of the synergist and
antagonist muscles aecting vocal fold position and tensioning. Muscles are hyperfunctional or hypofunctional, giving recognizable patterns of clinical presentation and laryngeal appearance.
e degree of dysphonia is variable, ranging from an intermittent problem related to a particular voice task (e.g. teaching) to severe and constant hoarseness. Other symptoms include:
Pitch: too high or low
•
Reduced range
•
Sensation of tightness, constriction, or lump in the throat
•
Eortful voice production
•
Discomfort on speaking or singing
•
Voca l fati gue
•
Treatment consists of identifying precipitating causes and treating as appropriate, such as:
Vocal hygiene and lifestyle advice
•
Voice therapy targeted at specic muscle groups
•
Laryngeal manipulation
•
Behavioural therapy
•
Medical treatment (e.g. reux management)
•
Spasmodic Dysphonia (SD)
SD is a voice disorder arising from a focal dystonia involving certain laryngeal muscles but
reecting central motor processing issues/abnormalities. It is a task-specic dystonia: the
spasm occurs only on phonation, and it can be overridden by vegetative phenomena, such as
296 Head and Neck
DYSPHAGIA AND ASPIRATION
laughing, chanting, or singing. ere is a background of normal speech overlaid with vocal
spasms that are not under voluntary control. is leads to the typical strained and strangled
speech pattern of adductor dysphonia (more common) and the breathy pattern of abductor
dysphonia. SD is readily controlled with injections of botulinum toxin to the aected muscle
groups, combined with VT to eliminate hyperfunction.
KEY POINTS
When assessing a patient, it is important to consider the following questions:
• What are the patient’s expectations? (Always ask this in voice consultations.)
• Is there any suspicion of a malignant or premalignant condition?
• Could the potential complications of an intervention, particularly surgical treatment,
create more problems than the intervention can help?
Further Reading
Costello D, Sandhu G. Practical Laryngology, 2015.
Mohan S, Young K, Judd O. A Practical Guide to Laryngeal Framework Surgery, 2018.
58. DYSPHAGIA AND ASPIRATION
Dysphagia
Dysphagia is the term used to describe diculty with swallowing solids, liquids, or both. It
implies impairment of one or more of the phases of swallowing. Dysphagia usually arises as
a complication of another health condition (see Table 58.1). It can be divided into oropharyn-
geal (high) dysphagia and oesophageal (low) dysphagia.
Aspiration
Aspiration is the entry of food or liquid into the airway below the true vocal folds. It may be due
to incompetent or inadequate airway protection and ill-timed, uncoordinated events before,
during, or aer the swallow has triggered. Silent aspiration is dened as foreign material entering the trachea or lungs without an outward sign of coughing or attempts at expulsion.
Clinical Assessment
e history should include the onset, duration, progression, and severity of the symptoms,
as well as the types of food that give problems. Typically, malignant dysphagia presents with
a short and progressive history, including a need to change to foods with soer textures and
more liquid consistency, and associated weight loss. Conversely, in neuromyogenic dysphagia it can be more dicult to swallow uids.
A breoptic endoscopic examination of the upper aerodigestive tract should be performed in
all cases of dysphagia. e assessment of swallow (breoptic endoscopic evaluation of swallowing— FEES) is very useful in identifying aspiration, in evaluating secretion management,
and for visual feedback to the patient during compensatory procedures to aid swallowing
and reduce aspiration. e examination can be performed at the bedside, and ideally a digital
recording is made. Foodstus of dierent textures that have been dyed with food colouring
to enhance their visibility can be given. Bolus ow during swallow, laryngeal penetration
and aspiration, and post-swallow residue should be documented. Endolaryngeal sensation
can also be assessed.
Head and Neck 297
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