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History andExamination ofNon- traumatic Emergency ofENT, Head, Neck andSkull Base

18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase

The emergency condition of ENT and head and neck is divided into non-traumatic emergency and traumatic emergency of ENT and head and neck.

Non-traumatic Emergency of ENT and Head and Neck

• Respiratory difculty/respiratory distress/

airway obstruction/stridor/wheeze/stertor

• Epistaxis and bleeding of ENT, head and neck

• FB in ENT, Head and Neck

• Acute infection of ENT and head and neck

infection

• Acute facial palsy

• Acute vertigo

• Acute CSF rhinorrhea

• Complication of sinusitis

• Complication of otitis media and externa

• Sudden SNHL

• Shock

• Poisoning

• Heart attack

Non-traumatic Emergency of the Aerodigestive Tract Overview of breathing

• Breathing—Breathing (or ventilation) is the process of moving air out and into the lungs to facilitate gas exchange with the internal environment and to ush out carbon dioxide and bring in oxygen.

– Normal breathing—A person’s respira-

tory rate is the number of breaths taken per minute. The normal respiration rate for an adult at rest is 12–25 breaths/min.

– Abnormal breathing—Different types of

abnormal breathing

Kussmaul breathing—It is character-

ized by a deep, rapid breathing pattern. It is typically an indication that the body or organs have become too acidic, and, in an attempt to expel carbon dioxide (an acidic compound in the blood) the body starts to breathe faster and deeper. It is caused by diabetic ketoacidosis, kidney failure, liver failure, sepsis and ingestion of toxins (salicylate, methanol, ethanol).

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025 S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck Surgery, https://doi.org/10.1007/978-981-96-1765-4_18

473

474

18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base

Biot’s respiration—It is characterized by an abnormal pattern of breathing characterized by groups of regular deep inspirations followed by regular or irregular periods of apnoea. It is caused by cerebral lesions, intracranial, opioid use and tentorial herniation. Cheyne–stokes respiration—It is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnoea. The pattern repeats, with each cycle usually taking 30 s to 2min. It is caused by brain tumour, traumatic brain injury, high altitude sickness, increased intracranial tension (ICT), chronic pulmonary oedema, kidney failure, toxic encephalopathy and hyponatraemia. Ataxic breathing—It is an abnormal pattern of breathing characterized by complete irregularity of breathing, with irregular pauses and increasing periods of apnoea. As the breathing pattern deteriorates, it merges with agonal respirations. Laboured breathing—It is termed as increased efforts required to breathe. If a patient cannot breathe easily, they may even struggle to breathe at rest. Laboured breathing can be alarming and a medical emergency condition. Other names for laboured breathing are difculty breathing, trouble breathing and uncomfortable breathing. Dyspnoea/shortness of breath— Inability to breathe normally or a feeling of suffocation. Dyspnoea is an uncomfortable abnormal awareness of breathing.

18.1.1 Diculty inRespiration (Breathing)/Respiratory Distress/Dyspnoea

Dyspnoea or respiratory distress or difculty in breathing—Dyspnoea is a term used to

characterize a subjective experience perceived and reported by an affected patient as a sensation of difcult or uncomfortable breathing that is comprised of qualitatively distinct sensations that vary in intensity. A patient with dyspnoea may say: ‘I feel short of breath’, ‘I’m having difculty in breathing’, ‘I can’t catch my breath’, ‘I feel like I’m suffocating’. Because it is a subjective phenomenon, the perception of dyspnoea and its interpretation vary from patient to patient. The experience derives from interactions among multiple physiological, psychological, social and environmental factors and may induce secondary physiological and behavioural responses. The differential diagnosis is composed of four general categories: cardiac, pulmonary, mixed cardiac or pulmonary and non-cardiac or non-pulmonary. These non-cardiac and non-

pulmonary causes include upper airway obstruction. The cause of most cases of dys-

pnoea is readily identied with a careful history and physical examination. A person can feel short of breath after intense exercise when travelling to a high altitude or going through major temperature changes. Dyspnoea should not be confused with rapid breathing (tachypnoea), excessive breathing (hyperpnea) or hyperventilation.

Variants of dyspnoea (Table 18.1)

(a) History/chief complaints/presentation of

the patient with dyspnoea or respiratory difculty/respirator distress

• Presentation/complaints/history of dyspnoea—Dyspnoea is also known as short-

ness of breath. It is often described as an intense tightening in the chest, air hunger, difculty breathing, breathlessness or a feeling of suffocation, shortness of breath, inability to take a deep breath or chest tightness, the sensation of difcult or uncomfortable breathing. A patient with dyspnoea may say: ‘I feel short of breath’, ‘I’m having difculty in breathing’, ‘I can’t catch my breath’, ‘I feel like I’m suffocating’. Dyspnoea may be caused by very strenuous exercise, extreme temperatures, obesity and higher altitude in a healthy person.

18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase

Table 18.1 Variants of dyspnoea with their presentation and causes

Types of dyspnoea Denition Causes Dyspnoea with

stridor Dyspnoea on

exertion Orthopnoea Breathlessness in recumbent position and relieved

Paroxysmal nocturnal dyspnoea

Trepopnoea It is dyspnoea that occurs in one lateral decubitus

Platypnoea It refers to breathlessness that occurs in the

Bradypnoea This is a condition when the patient breaths more

Tachypnoea When a patient breathes faster than normal or

Hyperpnoea When a patient breathes in more air but not

Hyperventilation When a patient breathes faster. The rate of

Apnoea Absence of breathing Complete airway obstruction Hypoventilation Hypoventilation is breathing that is too shallow or

Bendopnoea Shortness of breath on leaning forward Heart failure

Difculty in breathing with stridor due to obstructed airway

Not being able to breathe fast or deeply during physical activity

in standing or sitting position

The sensation of shortness of breath awakens the patient, often after 1 or 2 h of sleep and is relieved in the upright position

position

upright position and is relieved with recumbency

slowly than normal or decreased respiratory rate

increases respiratory rate. It can be a sign of an illness that limits how much air your lungs can take in

necessarily breathing faster. Rate of breathing is normal

breathing is more than normal

too slow to meet the needs of the body

Upper airway obstruction

Cardiac and pulmonary cause.

Heart failure, acidosis, pulmonary oedema, severe pneumonia, pleural effusion, diaphragm paralysis

Heart failure, chronic obstructive pulmonary disease (COPD), asthma, pneumonia, acid reux, anxiety

Pleural effusion is a disease involving one lung

Hepatopulmonary syndrome, patent foramen ovale, right to left shunt

Sleep apnoea, carbon monoxide poisoning or a drug overdose

COPD or pneumonia

Exercise, heart failure, sepsis

Exercise, anxiety and asthma

Brain stem stroke, hypocapnia, drugs (opioids)

475

• Duration of symptoms of respiratory distress/dyspnoea/difculty in breathing—It can be classied as acute

or chronic.

– Acute dyspnoea—If dyspnoea persists

for a short duration (less than 3 months).

– Presentation of acute dyspnoea

(Table 18.2) – Chronic dyspnoea – Presentation of chronic dyspnoea/

shortness of breath—When shortness

of breath persists for a longer time

(more than 3 months). It may produce a

cardiopulmonary compromise that

may eventually also lead to morbidity

or death (Table18.3).

• Severity of dyspnoea or difculty in res- piration—The use of accessory muscles, mental status and ability to speak deter-

mine the severity of dyspnoea. It can be classied into mild, moderate and severe on the basis of severity.

• Mode of onset of dyspnoea/respiratory

distress

– Sudden onset respiratory difculty/

dyspnoea (Table 18.4)

– Gradual onset respiratory difculty/

dyspnoea (Table 18.5)

• Progression of dyspnoea/respiratory distress

– Progressive dyspnoea (Table 18.6) – Non-progressive dyspnoea (Table

18.7)

• Types of difculty in breathing/respiratory distress

– Dyspnoea/respiratory distress in the

inspiratory phase—The respiratory distress in the inspiratory phase of respiration is known as inspiratory dys-

476

Table 18.2 Differential diagnosis of acute dyspnoea with presentation

Symptoms along with acute difculty in respiration/dyspnoea Differential diagnosis Dyspnoea with H/O aspiration of foreign body (FB), sudden onset cough,

choking Dyspnoea with pain, fever, barking cough, inspiratory stridor, hoarse voice Infection (ALTB), acute epiglottitis Dyspnoea with H/O trauma, bleeding disorder Haemorrhage Dyspnoea with H/O food, drug intake, exposure to allergen, abdominal

cramp, swollen eye and mouth, chemosis Dyspnoea with H/O surgery like total thyroidectomy Iatrogenic (e.g. post-surgical,

Dyspnoea with H/O trauma present, difculty in speaking, stridor, bruising on neck, neck swelling

Dyspnoea with exposure to poisonous gas, fumes, coughing and phlegm, scratchy throat, stinging eye, runny nose

Dyspnoea with H/O poisoning present, dysphagia, vomiting, dizziness, disorientation, headache

H/O trigger—Chemical, fumes, smoke, Pollen, tobacco, smoking, episodic dyspnoea, family H/O asthma, seasonal and diurnal variation +, wheezing, productive cough

Hyperventilation, sweating, nervousness, trembling Anxiety H/O chest pain, hay fever, productive cough Acute pneumonia H/O blood loss Anaemia Dyspnoea with fatigue and weakness, swelling of legs and ankle, reduced

ability to exercise Dyspnoea with rapid shallow breathing, pallor, dizziness with light

headedness, fatigue Dyspnoea with chest pain, cough, excessive sweating, fever, cyanosis, pain

in calf muscle Dyspnoea with chest and muscle pain, confusion, dizziness, headache Carbon monoxide poisoning Dyspnoea with chest pain, cough, tachycardia, fatigue, cyanosis Collapsed lung Dyspnoea with heartburn, regurgitation, dysphagia, haematemesis and

melena

18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base

Foreign body in tracheobronchial tree

Angioedema(allergic reaction)

instrumental) Blunt trauma to the larynx or trachea

Inhalation injury

Poisoning

Asthma

Heart failure

Hypotension

Pulmonary embolism

Hiatus hernia

Table 18.3 Differential diagnosis of chronic dyspnoea with presentations

Symptoms along with chronic dyspnoea D/D Fever, pain Chronic Infections H/O long intubation, throat pain, difculty in speaking Post intubation Hoarseness, cough, globus, haemoptysis, stridor or dyspnoea Amyloidosis larynx Hoarseness, cough, dysphagia and dyspnoea secondary to upper airway

obstruction Change of voice, dysphagia, H/O smoking Carcinoma: larynx, laryngopharynx,

Progressive dyspnoea, dysphagia Benign tumours of larynx, trachea Dyspnoea with change of voice, cough Mediastinal mass/tumours/nodes Change of voice, H/O surgery B/L vocal cord paralysis Common in children Subglottic haemangioma Children, stridor worse on infection, supine position but relieved in the

prone position Dyspnoea in all positions Tracheomalacia Change of voice in children, progressive dyspnoea Respiratory papillomatosis H/O productive cough, H/O exacerbation in winter season, smoking,

gradual onset dyspnoea Dry hacking cough, discomfort in chest, unexplained weight loss,

tiredness and weakness

Sarcoidosis larynx

oesophagus, endotracheal, thyroid

Laryngomalacia

COPD

Interstitial lung brosis

18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase

Table 18.4 Differential diagnosis of sudden onset respiratory difculty with the presentation

Symptoms along with sudden onset dyspnoea Differential diagnosis Sudden onset dyspnoea with H/O FB ingestion, choking, cough Foreign body aspiration Sudden onset dyspnoea with no breathing, agitation Food bolus Sudden onset dyspnoea with H/O, drug intake Angioedema Sudden onset dyspnoea with H/O, trauma to neck or chest Laryngotracheal injury Sudden onset dyspnoea with H/O poisoning, cough while taking meal Aspiration Sudden onset dyspnoea with fever, cough, neck pain, odynophagia Infections like ALTB, crups, acute epiglottitis Sudden onset dyspnoea with inspiratory stridor may progress to

complete obstruction Sudden onset dyspnoea, H/O trauma Trauma to the larynx and trachea Sudden onset dyspnoea while having meal Café coronary H/O chest pain, haemoptysis, H/O deep vein thrombosis Pulmonary thromboembolism Unilateral chest pain Pneumothorax

Table 18.5 Differential diagnosis of gradual onset dyspnoea with presentation

Symptoms along with gradual onset dyspnoea Differential diagnosis Progressive dyspnoea, change of voice, dysphagia Laryngeal tumours (benign and malignant) Dysphagia, gradual onset dyspnoea, change of voice Hypopharyngeal carcinoma Dysphagia, gradual onset dyspnoea Oesophageal carcinoma Fever, cough, throat pain, Infections Gradual onset dyspnoea, change of voice, fever Mediastinal tumours/lymph node/mass Progressive dyspnoea Tracheal tumours

Bilateral abductors paralysis

477

Table 18.6 Differential diagnosis of progressive dyspnoea with a presentation

Symptoms along with progressive dyspnoea Differential diagnosis Gradual onset progressive dyspnoea over months, hoarseness of

voice, H/O smoking, dysphagia Dysphagia with gradual onset dyspnoea Carcinoma oesophagus Sudden onset progressive dyspnoea over a short period of hours,

H/O drug or food intake Sudden onset progressive dyspnoea over days, H/O FB

aspiration, H/O choking, gag Gradual onset dyspnoea over days, pain in throat, odynophagia Acute infection—Epiglottitis, ALTB, cruop Non-productive cough, occupational or environmental history Pulmonary brosis

Table 18.7 Differential diagnosis of non-progressive dyspnoea with presentation

Symptoms along with non- progressive dyspnoea Differential diagnosis Non-progressive dyspnoea with H/O FB aspiration, choking, gag, Non-vegetative FB Dyspnoea on activity, wheezing, persistent cough, difculty in

coughing mucus out, frequent cold

pnoea. This is caused by obstruction above the vocal cords and presented with inspiratory stridor.

– Dyspnoea/respiratory distress in the

expiratory phase—The dyspnoea in the expiratory phase is caused by lower

Carcinoma larynx

Angioneurotic oedema,

Vegetative foreign body

Subglottic and tracheal stenosis

airway obstruction and presented with wheeze.

– Biphasic dyspnoea/respiratory dis-

tress—Biphasic dyspnoea is caused by an obstruction in the trachea and is presented with biphasic stridor.

478

18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base

• Continuity of dyspnoea – Episodic/single episode—Infective

causes, anaphylaxis, CO poisoning, sudden blood loss, FB in bronchus and trachea

– Continuous—Asthma, chronic obstruc-

tive pulmonary disease (COPD), heart dysfunction, interstitial lung disease, obesity, pulmonary hypertension, carcinoma larynx, carcinoma subglottis, tracheal stenosis, subglottic stenosis

• Occurrence of dyspnoea – Rest – Exertional—Neuromuscular dyspnoea – Position

Dyspnoea on lying at—Orthopnoea Dyspnoea in the lateral position Dyspnoea when upright—Platypnoea

• Diurnal and seasonal variation—Asthma

• Relieving factors—Rest, medication

• Precipitating factors—Cigarette smoking,

occupational and environmental.

• Associated symptoms/illness—

Pulmonary, cardiac and neuromuscular.

• Family history—Asthma is a hereditary

disease that can run in the family.

18.1.2 Airway Obstruction/Diculty inBreathing/Laboured Breathing

It is termed as increased efforts required to breathe. If a patient cannot breathe easily, they may even struggle to breathe at rest. A laboured

breathing can be alarming and a medical emergency condition. Other names for laboured breathing are difculty breathing, trouble breathing and uncomfortable breathing.

1. History/chief complaint (a) Presentation of respiratory obstruction

• General symptoms/complaints of respiratory obstruction/laboured breathing—The airway obstruction can be presented with various symptoms or complaints. These symptoms vary in children and adults (Table18.8).

• Site-specic symptoms of respira-

tory obstruction

– Upper airway obstruction—It

refers to an anatomic narrowing or occlusion of the upper airway extending from the nose to the glottic region, resulting in a decreased ability to move air in(ventilate). It may be acute or chronic, partial or complete. It is characterized by low-pitched noisy breathing (stertor) and highpitched sound on inspiration (inspiratory stridor).

– Upper airway obstruction in neo-

nates—It is a common and potentially devastating problem in neonates. Children born with congenital craniofacial, pharyngeal or laryngeal abnormalities are at an increased risk for severe upper airway obstruction (UAO) (Table18.9).

Table 18.8 Symptoms of airway obstruction in adults and children

Adult with obstructed airway Child with an obstructed airway Agitation, shortness of breath

Dyspnoea/respiratory difculty Cyanosis (bluish-coloured skin) Confusion Difculty breathing Gasping for air Panic High-pitched breathing noises such as wheezing Unconsciousness No breathing

Choking or gagging Respiratory difculty/dyspnoea Sudden violent coughing Vomiting Noisy breathing or wheezing Struggling to breathe Cyanosis No breathing H/O FB aspiration

18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase

Table 18.9 D/D of acute upper airway obstruction in neonates with presentation

Symptoms Signs Diagnosis Severe airway obstruction, cyclical cyanosis, cry

alleviate the symptoms, difcult feeding Apnoeic spell, noisy breathing, poor ability to sleep Small mandible, malocclusion Micrognathia Feeding difculty, snoring Noisy high-pitch breathing Macroglossia Harsh noisy breathing (inspiration stridor), get louder

over the rst several months of life

Frequent shortness of breath and stridor Wheezing Laryngeal web Difculty in breathing in both phases, multiple

episodes of croup, poor weight gain Persistent cough, stridor Stridor Subglottic haemangioma

Table 18.10 D/D of acute upper airway obstruction in children with presentation

Symptoms Signs Diagnosis Drooling, dysphagia, dysphonia, dyspnoea,

fever, throat pain Sore throat, dysphagia, dyspnoea, drooling Massive tonsillar enlargement,

Sudden onset of coughing, choking when eating or playing, sudden onset respiratory distress, positive H/O FB aspiration

Sudden onset respiratory distress following food, drugs, venom

Respiratory distress following thermal injury, positive history of exposure to smoke in a conned place

Respiratory distress with a positive history of trauma

Odynophagia, fever, noisy breathing, Hot potato voice

Fever, anorexia, sore throat White or greyish membrane over

Noisy breathing, barking cough, hoarseness of voice

Loud barking cough, aggravated by crying and coughing, fever, hoarse voice

Pain in oor of mouth, H/O dental extraction, toothache

Dyspnoea, H/O thyroid surgery, H/O stroke Inspiratory stridor, voice normal B/L vocal cord paralysis

Cyanotic spell B/L choanal atresia

Distress in the supine position and infection, get relief in the prone position

Biphasic high-pitch stridor Subglottic stenosis

Stridor, high-grade fever, lethargy Acute epiglottitis

mucosal oedema Inspiratory or biphasic stridor

decrease air entry into the lung

Facial swelling, ushing, stridor Anaphylaxis

Carbon deposit around the mouth, carbonaceous sputum, oedema

Oedema, bleeding Trauma

Stridor, tenderness, trismus, Toxic appearance

tonsil, toxaemia, enlarged cervical lymph node

Oedema and membrane over larynx

Noisy breathing Acute laryngotracheitis

Swelling in neck Ludwig’s angina

Laryngomalacia

Infectious mononucleosis

FB aspiration

Inhalational injury

Retropharyngeal abscess

Oropharyngeal diphtheria

Laryngeal diphtheria

ALTB

479

Upper airway obstruction in

children

Acute airway obstruction in children—Acute airway

obstruction may occur at any age and should be considered an emergency. Airway obstruction may occur at different anatomical levels, may be partial or

complete and may occur abruptly (Table18.10).

Chronic airway obstruction in children (Table 18.11) Upper airway obstruction in

adult

Acute upper airway obstruction (Table 18.12)

480

Table 18.11 Differential diagnosis of chronic upper airway obstruction in children with the presentation

Symptoms Sign Diagnosis Dyspnoea with wheeze, cough with bloody

phlegm, fever, pus-like crust from nose, joint pain

Dyspnoea with rib pain, dysphagia, ear pain Saddle nose, rashes, swollen joint Relapsing polychondritis Cough, haemoptysis, recurrent airway

infection H/O prolong intubation, TB, radiation

therapy, H/O frequent pneumonia Noisy cough, exercise intolerance, prolonged

respiratory infection, choking during feeding H/O prolonged intubation, hoarseness of

voice and acute respiratory distress (anteromedial dislocation of arytenoid)

Dyspnoea, stridor, hoarseness of voice, persisting cough, increased mucous production, H/O trauma, prolonged intubation

Hoarseness of voice, dysphagia, H/O smoking Growth present in I/L Laryngeal tumour Progressive dyspnoea, chest pain, cough with

haemoptysis, night sweat Dyspnoea, normal voice Stridor, both cords in the midline B/L abductor palsy Dyspnoea relived by a prone position Noisy breathing Laryngomalacia

18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base

Stridor Granulomatosis polyangitis

Wheeze (low pitch), stridor Tracheobronchopathia

osteochondroplastica

Stridor (biphasic) Tracheal stenosis

Rattling or noisy stridor, blue spell, halt in breathing while crying

Granulation over vocal cords, stridor

Cyanosis, poor weight gain, repeated croup in children

Weight loss, anaemia, lymphadenopathy

Tracheomalacia

Long-term intubation

Subglottic stenosis

Mediastinal mass, bilateral

Table 18.12 Differential diagnosis of acute airway obstruction inadults with presentation

Symptoms Sign Diagnosis Hoarseness of voice, dysphagia, H/O

smoking, stridor Odynophagia, dyspnoea, hoarseness, fever Tachycardia, fever, stridor, Acute epiglottitis Allergic reaction, H/O drugs or food

ingestion, H/O insect bite, H/O trigger like stress, strenuous exercise

Dyspnoea, normal voice On I/L both cords in midline B/L abductor palsy Dyspnoea with a history of trauma Haematoma or laceration over

H/O FB inhalation, choking, gasping Stridor, tracheal thud, decreased

Table 18.13 Differential diagnosis of chronic airway obstruction in adults with presentation

Symptoms Signs Diagnosis Dyspnoea, hoarseness of voice, dysphagia On I/L mass present Supraglottic tumour Hoarseness of voice On I/L mass present in glottis Glottic tumour

Chronic upper airway obstruction in adults (Table

18.13)

– Mid/central airway obstruc-

tion—Central airway obstruction

(CAO) refers to a variety of obstructive processes that impede airow

Growth on I/L Carcinoma larynx

Oedema of larynx on I/L Angioneurotic oedema

Trauma to larynx

neck

FB in larynx and trachea

air entry

within the central airways (trachea and mainstem bronchi). CAO may be due to malignant or benign disease and represents a signicant source of mortality and morbidity with a signicant impact on quality of life.

18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase

481

Symptoms/chief complaints of

mid-airway obstruction

Shortness of breath—This is

probably the most common complaint. It is constant, occurring at rest or on exertion, occasionally positional with laboured breathing in the recumbent position and not responsive to bronchodilators. The degree of shortness of breath does not necessarily correlate with the degree of obstruction. The diameter of the tracheal lumen must be <8mm for dyspnoea on exertion to develop and <5mm for dyspnoea at rest. Cough—Cough is chronic, persistent and dry, but may present acutely in FB aspiration or be productive of purulent sputum in post-obstructive pneumonia, squamous cell carcinoma, primary airway tumours (carcinoid tumours and adenoid cystic carcinoma), endobronchial metastases, infections (e.g. tuberculosis), inammatory diseases (e.g. granulomatosis with polyangiitis [formerly known as Wegener’s granulomatosis]) and benign airway tumours (e.g. hamartomas) frequently cause haemoptysis. Chronic bronchitis frequently presents with bloodstreaked purulent secretions, which may be misleading in the diagnosis of CAO. Haemoptysis—This is a common symptom, especially in tracheal lesions, and may be massive, although most studies report mild to moderate haemoptysis. Wheeze—It may be inspiratory or expiratory. The location of the wheeze does not always con-

form to the site of the airow obstruction, and it may be heard over the trachea or lung elds. Unilateral wheeze suggests obstruction distal to the carina. Wheeze may also be positional and unresponsive to bronchodilators. Stridor—Stridor develops when the airway diameter is <5 mm and represents severe subglottic or tracheal stenosis. Inspiratory stridor suggests extra-thoracic airway obstruction at or above the vocal cords and is best heard over the neck, while expiratory stridor may be due to an intrathoracic obstruction. Biphasic stridor is present in subglottic or tracheal stenosis. Manoeuvres that increase airow such as hyperventilation may accentuate the stridor, and neck exion may change its intensity.

Orthopnea—Orthopnea or orthopnoea is shortness of

breath (dyspnoea) that occurs when lying at, causing the person to have to sleep propped up in bed or sitting in a chair.

Diseases specic symptoms of central airway obstruction Symptoms of central airway

obstruction in adults (Table

18.14)

Symptoms of central airway

obstruction in children (Table 18.15)

– Lower airway obstruction—

Lower airway obstruction can occur at the level of secondary bronchi or bronchioles. It is characterized clinically by high-pitch wheeze and hyperinated chest, apart from other signs of respiratory distress.

482

Table 18.14 D/D of differential diagnosis of mid-airway obstruction in adults with clinical presentation

Symptoms and sign Diagnosis Dyspnoea, cough, haemoptysis, shortness of breath,

ushing, fever, chills, night sweat, haemoptysis Dyspnoea, stridor, cough, haemoptysis, asthma Primary airway tumour granulation Dyspnoea, stridor (noisy breathing), cough (high pitch),

rattling sound or wheeze Sudden respiratory distress

Choking, gagging, cough, fever Dyspnoea with cough, sputum production, wheezing, chest

pain and fever Dyspnoea with neck swelling, hoarseness of voice,

dysphagia, etc.

Table 18.15 D/D of mid-airway obstruction in children with clinical presentation

Symptoms and signs Diagnosis Respiratory distress in children under 2 years of age. Barking seal-like cough,

hoarse voice, start in night harsh inspiratory stridor, tachypnoea, tachycardia Respiratory distress in child, 2, 3 days history of upper respiratory tract infection

(URTI), hoarseness of voice stridor, septic look, copious secretion Dyspnoea, stridor (noisy breathing), cough (high pitch), rattling sound or wheeze

stridor, which alters on position of the patient Dyspnoea with barking cough, usually begins at night, hoarseness of voice,

6 months to 3 years old kid, anxiousness, restlessness Sudden onset respiratory distress, gagging, stridor, intractable cough, fever,

dyspnoea, U/L wheeze, decreased breath sound Tumours originate from trachea, causing difculty in breathing, stridor,

haemoptysis, cough stridor, wheeze Tumour metastasizes to the trachea, difculty in breathing, stridor, wheezing Extrinsic tumour of trachea Dyspnoea, stridor (noisy breathing), cough (high pitch), rattling sound or wheeze Tracheal stenosis Asymptomatic or H/O aspiration stridor, cyanosis Laryngo tracheo—

18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base

Mediastinal mass (teratoma, cyst, lymphoma)

Tracheal stenosis

FB in the trachea or bronchus

Endobronchial or tracheobronchial infection

Extra-thoracic and distant malignancies like thyroid, oesophageal, renal cell, colorectal carcinoma

Viral/acute laryngotracheobronchitis

Bacterial tracheitis

Tracheomalacia Tracheal stenosis

Spasmodic croup

FB in trachea or main bronchus

Intrinsic tumour of trachea

Oesophageal cleft

Table 18.16 Causes of lower airway obstruction

Breathing in a large amount of smoke from a re Asthma Chronic bronchitis Emphysema Cystic brosis COPD Mediastinal tumour Lung carcinoma Endobronchial tumour

– Causes/differential diagnosis of

lower airway obstruction (Table

18.16)

(b) Type of obstruction

• Complete airway obstruction—A complete obstruction indicates a total inability to get air in or out of the lung (Table18.17)

• Partial airway obstruction (Table

18.18)

airway obstruction is present with stridor.

(d) Duration of obstruction—It can be for

short duration (acute) or long duration (long).

(e) Time of onset

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