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42 Dicult Airway Management forENT Surgery forNon-anesthesiologists
507
subsequent barotrauma and hemodynamic deterioration, especially in case of a completely
obstructed airway. As such, Ventrain has been
acknowledged as the lifesaver for CICV situations [53].
Ventrain can ventilate through small lumen
such as Tritube, trans-tracheal catheter, intubating catheter, hollow bougie, or airway exchange
catheter, via different airway access, either
trans- tracheal by puncture or incision, through
a tracheostomy, via oral or nasal route. It is
used electively in upper airway surgery, improving surgical eld, and maintaining adequate
ventilation. It also has a side port allowing side
stream capnography or measuring airway pressure [53].
42.6.2 Alternative Oxygenation
Techniques (THRIVE/HFNO)
42.6.2.1 Introduction
High-ow nasal cannula (HFNC) or transnasal
humidied rapid insufation ventilatory
exchange (THRIVE) is a new emerging device
for the delivery of oxygen in acute adult medical
practice. In this system, humidied oxygen is
delivered at a ow rate that reaches up to 80 L/
min and an inspired concentration of oxygen up
to 100%, making it a good option in hypoxic or
oxygen-dependant patients. The system is also
able to provide benets that are more inclusive
than other devices, which includes humidica-
tion and warming of inspired gases, patient comfort, increased compliance, effective
nasopharyngeal dead space washout, and delivery of low-level PEEP during use (Fig.42.12)
[54]. These features allow for the support of various types of patient breathing difculties, especially those at risk of respiratory deterioration
[55].
Initially, this therapy has been used successfully for the management of respiratory failure in
neonatal populations. However, it is now being
utilized more frequently in adult populations
where it has been used to treat patients with
hypoxemic respiratory failure, post-extubation in
critical care units, and following major surgery to
prevent pulmonary complications [56].
It has also been used as an aid for preoxygenation of patients; by improving dead space
washout and prolonging the “apneic ventilation” period through enhancing oxygen reserve
following induction of anesthesia. This concept
may be useful in patients in whom hypoxia is
present prior to induction of anesthesia or
highly likely following induction, such as critically ill and obese patients, or in those with
anticipated difcult airway whom a prolonged
apneic window may result due to difculties in
intubation.
Currently, HFNC therapy has a role in critical care units by improving oxygenation and
reducing the incidence of desaturation in
patients with mild to moderate hypoxia during
the period of intubation. A case series of 25
Fig. 42.12 The setup
and application of
HFNC
508
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N. A. Shallik et al.
patients in which preoxygenation was done for
10 min prior to the induction of anesthesia,
showed that the apnea period was signicantly
prolonged in patients undergoing complex airway and tracheal surgery [56]. However, there is
currently no evidence available pertaining to the
use of HFNC as a supportive tool in moderate
risk elective intubations, such as those that may
be encountered in a major head and neck surgical procedures.
These populations often have difcult airways
due to previous surgery, radiotherapy or obstructing tumors and have a higher chance of failed
intubation and difculty in securing the airway
than other patients. As such, any intervention that
may prolong the apneic time and reduce the risk
of signicant desaturation would be helpful for
this patient group [57].
42.6.2.2 Final Outcome After HFNC
Application [55]
• It increases FiO2 and maintains constant FiO2.
• It improves CO2 clearance.
• It decreases the work of breathing.
• It creates positive airway pressure.
• It helps in the washout of anatomical dead
space.
• It improves pulmonary mechanics.
• It decreases upper airway resistance.
• It helps the mucus clearance.
42.6.2.3 General Indications ofHFNC
• Preoxygenation: in all patient especially, dif-
cult airway.
• During endotracheal intubation in ICU,
Bariatric, Obstetrics, Pediatrics, etc.
• During awake intubation.
• Minor upper airway surgery using the
STRIV- Hi technique.
• Post-extubation in difcult extubation cases or
compromised respiratory patients.
• Post-extubation in long-term ICU ventilation.
• In difcult airway guidelines and algorithms.
• ARDS and Acute Hypoxemic Respiratory
Failure.
• Hypoxemia induced by severe heart failure.
• Airway instrumentation during rapid sequence
induction.
Hypoxemic and hypercapnic respiratory
•
failure.
• Postoperative in OSA patients.
• Claustrophobia from NIPPV.
• Stridor or end-of-life care.
42.6.3 Tubeless Anesthesia or Tube
Free ofUpper Airway Surgery
The SponTaneous Respiration using IntraVEnous
and High-ow nasal oxygen (STRIVE Hi)
approach to minor upper airway surgery, which is
an open airway technique, and has recently been
developed to facilitate micro-laryngoscopy and
endoscopic airway surgery in adults without
endotracheal tube.
The use of high-ow nasal oxygen (HFNO)
is gaining popularity in anesthesia, especially in
critical care, as it improves oxygenation and
ventilation in both apneic or spontaneously
breathing patients [58]. In apneic patients, the
Transnasal Humidied Rapid Insufation
Ventilatory Exchange (THRIVE) technique has
been associated with a prolonged apnea time
and a reduced rate of rising of end tidal carbon
dioxide (ETCO2). In spontaneously breathing
patients, multiple physiological benets of
HFNO have been described, which include (1)
an increased FiO2, (2) generation of positive airway pressure, (3) improved respiratory mechanics, and (4) reduced upper airway resistance. To
date, these clinical benets during spontaneous
ventilation have been limited to awake patients
(respiratory supportive care, preoperative preoxygenation, postoperative support), sedated
patients [procedural bronchoscopy, or awake
ber-optic intubation (AFOI) or asleep patients
with obstructive sleep apnea (OSA). The use of
HFNO in spontaneously breathing patients
undergoing general anesthesia has not been previously described.
Spontaneous respiration using intravenous
anesthesia is the primary technique used at our
institution for tubeless airway surgery. We did
more than 150 patients using this technique
without any complications. Although we have
found spontaneous ventilation to be associated
AL GRAWANY
42 Dicult Airway Management forENT Surgery forNon-anesthesiologists
509
with numerous benefits, general anesthesia
can have detrimental effects on respiratory
mechanics, which may limit the application of
the technique in certain patient subgroups,
particularly those with severe respiratory
comorbidity.
Propofol associated with reduced tidal and
minute ventilation, decreases respiratory frequency and an upper airway prone to collapse.
We hypothesized that the clinical benets of
HFNO to oxygenation, ventilation and upper airway patency described in awake and sedated
patients would be ideally suited to spontaneously
breathing patients undergoing general anesthesia.
We report our initial experience combining
HFNO with our previously described spontaneous respiration technique using intravenous anesthesia in patients undergoing micro-laryngoscopic
surgery [59].
Take Home Messages
• Airway management is challenging,
being able to recognize and anticipate
the difculty makes the whole process
efcient and safe. Difcult airway can
be due to difculty with mask ventilation, use of supraglottic device, tracheal
intubation or extubation.
• The familiarity with airway equipment
is of paramount important, including the
different types of supraglottic devices,
direct and indirect laryngoscopes.
Providers who deal with airway should
be familiar with the recent equipment
and recent techniques including the use
of apneic oxygenation techniques.
• It is worth mentioning that difcult airway management is a vast chapter with
much extensive topics requiring a separate textbook for full discussion. Due to
editing limitations in this chapter, we
summarize the basic ideas and managements relevant to the ENT surgeon’s
day-to-day practice focusing on the
common problems and providing a very
basic guidance for a practical and safe
management of difcult scenarios.
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Part V
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Laryngology and Esophagology
AL GRAWANY
Physiology oftheVoice
andClinical Voice Assessment
MayedRadiAlkhafaji andDinaEmam
43
43.1 Introduction
S & is the way of communication used by people. Speech is an expression of
ideas and thoughts by means of articulate vocal
sounds. Speech requires movement of sound
waves through the air. Speech itself is air that is
moved from the lungs through a series of anatomic structures that mold sound waves into
intelligible speech. This capacity can be accomplished in any volume from a soft whisper to a
loud shout by varying the force and volume of air
expelled from the lungs.
43.2 Voice Physiology
• Voice=Voiced Sound+Resonance+Articul
ation
Voiced sound: The basic sound produced by
vocal fold vibration is called “voiced sound.”
This is frequently described as a “buzzy” sound.
Resonance: Voiced sound is amplied and
modied by the vocal tract resonators (the throat,
mouth cavity, and nasal passages). The resonators produce a person’s recognizable voice.
M. R. Alkhafaji (*) · D. Emam
ENT Department, Hamad Medical Corporation,
Doha, Qatar
e-mail: mradi@hamad.qa; DEmam@hamad.qa
Articulation: The vocal tract articulators (the
tongue, soft palate, and lips) modify the voiced
sound. The articulators produce recognizable
words.
In humans, there are four main body systems
involved in the production of speech.
1. The respiratory system
2. Laryngeal system
3. Articulation
4. The nervous system
The rst three systems are responsible for the
physical manifestations of speech, and the nervous system is responsible for regulates these
systems on both the conscious level.
The rhythmicity center of the medulla: The
respiratory center is gray matter in the pons and
the upper Medulla, controls automatic breathing
consists of interacting neurons that re either
during inspiration (I neurons) or expiration (E
neurons)
• I neurons—stimulate neurons that innervate
respiratory muscles (to bring about
inspiration)
• E neurons—inhibit I neurons (to “shut down”
the I neurons and bring about expiration)
• Apneustic center (located in the pons)—stim-
ulate I neurons (to promote inspiration)
• Pneumotaxic center (also located in the
pons)—inhibits apneustic center and inhibits
inspiration
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_43
515
516
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M. R. Alkhafaji and D. Emam
43.2.1 The Respiratory System
andAirow
The respiratory system is also called the power
system and it’s rule is the development and maintenance of a column of air under pressure, which
is presented to the glottis and subglottis, whereas
the diaphragm is the important muscle for inspiration and expiration—and in particular controlled expiration—is necessary for vocalization.
The relaxing diaphragm interact with the muscles of expiration along with the natural elastic
recoil of the act of expiration, also the abdominal
muscles play an important rule especially the
inner most layers especially in sustaining a long
or powerful sound.
• Contraction of external intercostal mus-
cles>elevation of ribs and sternum>increased
front- to-back dimension of thoracic cav-
ity>lowers air pressure in lungs>air moves
into lungs.
• Contraction of diaphragm>diaphragm moves
downward> increases vertical dimension of
thoracic cavity > lowers air pressure in
lungs>air moves into lungs.
This increase of volume lowers the air pressure in the alveoli to below atmospheric pressure.
Because air always ows from a region of high
pressure to a region of lower pressure, it rushes in
through the respiratory tract and into the alveoli.
This is called negative pressure.
Breathing changing the pressure inside the
lungs relative to the pressure of the outside atmosphere. In contrast to inspiration, during expiration the diaphragm and intercostal muscles relax.
This returns the thoracic cavity to its original volume, increasing the air pressure in the lungs, and
forcing the air out.
• Any pulmonary pathology starting from acute
upper respiratory tract infection up to the
obstructing and restrictive pulmonary diseases
can affect the power of the voice as well as
weakness in the abdominal wall muscles, also
pathology of the thoracic cage as pectus exca-
vatum and kyphosis along with calcications
of the cartilaginous part of the ribs with age
can affect the power of the voice.
43.2.2 Vocal Folds (Also Called Vocal
Cords)
The vocal cord length is varied between adults
and children and between males and females.
The length in adult female is approximately
15–18mm while in males it is about 20–22mm.
The vocal cords can vibrate together and create
sound if they are present in the midline with the
presence of subglottic pressure; the pitch is predominantly determined by the stretch of the vocal
cord intrinsic muscles while the power of the
voice depends on the subglottic pressure.
During the adduction position which is the
position of the vocal cords during vocalization
there will be a small opened gap. Naturally, the
thing which will make the two cords completely
adducted for more clear voice is explained by the
Bernolli rule which says if a stream of air passes
between two surfaces that will create a negative
pressure and tends to pull them together.
• So as a general rule is any factor will affect the
elasticity of the vocal cords, musculature, reg-
ularity of the surface, the completeness of the
closure or the mucus that lubricate the vocal
cords will have an impact on the voice
quality.
One vibratory cycle of the vocal cords is as
follows:
• Column of air pressure opens bottom of vocal
folds
• Column of air continues to move upward, now
toward the top of vocal folds, and opens the top
• The low pressure created behind the fast-
moving air column produces a “Bernoulli
effect” which causes the bottom to close, fol-
lowed by the top
• Closure of the vocal folds cuts off the air col-
umn and releases a pulse of air
• New cycle repeats
43.2.2.1 Vocal Tract—Resonators
andArticulators
The nose, pharynx, and mouth amplify and modify sound, allowing it to take on the distinctive
qualities of voice the way that voice is produced
is analogous to the way that sound is produced by
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43 Physiology oftheVoice andClinical Voice Assessment
517
a trombone. The trombone player produces sound
at the mouthpiece of the instrument with his lips
vibrating from air that passes from the mouth.
The vibration within the mouthpiece produces
sound, which is then altered or “shaped” as it
passes throughout the instrument. As the slide of
the trombone is changed, the sound of the musical instrument is similarly changed.
43.2.3 The Nervous System
• The brain typically formed of two cerebral
hemispheres connected with nerve bers called
corpus callosum. The speech centers are present
mostly in the left hemisphere and in one-third of
the people who are left-handed the speech is
controlled by the right side of the brain.
• Parts in the brain involved in speech:
– Cerebrum: The brain is formed of lobes,
the speech is controlled by the frontal lobe
and temporal lobes.
• Brocas area: an area in the frontal lobe of the
dominant hemisphere on the left side of the
brain, the function of this area is speech production and it is found to be the most active area
immediately before you speak, even if someone
has the ability to produce sound the Brocas area
is necessary to express the language Brocas area
is made up of Brodmann area 44 (pars opercularis) and 45 (pars triangularis).
– Wernicks area: Works with the angular
gyrus, insular cortex, and basal ganglion to
process word sequences to determine context and meaning
– Angular gyrus: Assembles information to
help us understand words and concepts
– Insular cortex: Buried underneath the outer
lobes of the cerebral cortex, the insular cortex is important for many functions, including motor control, emotions, and
self-awareness, but also important in the processing of language
43.3 Voice Assessment
inOutpatient Department
A successful voice assessment determines the
cause, the severity, and the prognosis of the problem and enables the planning of the most appropriate treatment program. The voice assessment
is complicated and time consuming and it cannot
be done in routine ENT clinics; it needs to be
done in a specialized voice clinic that is well
structured and involves a diagnostic and
therapeutic team. The multidisplinary team
should include an ENT doctor specialized in laryngology, speech language pathologist, physiotherapist, psychiatrist, and a voice coach and a
singing teacher who work together as a team in
order to achieve a proper diagnosis and treatment
for the different cases of voice disorders.
Voice assessment is multidimensional and it
includes history taking, observation, clinical
examination, auditory evaluation, and measurement of vocal cords function and physiology.
43.3.1 Voice Case History
A detailed voice history is required in order to do
proper assessment and diagnosis for any patient
with voice disorder and then to plan your treatment strategies for each case, the history should
be detailed regarding the voice change, onset,
course and duration, vocal cord demands and
stressors, history of reux, history of special habits as smoking and alcohol consumption.
History should include also medications history as well as the medical and surgical history
especially neck surgeries and cardiothoracic
surgeries.
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43.3.2 Observation (Posture,
Breathing, Palpation)
Observation will include general observation for
the general appearance of the patient which is a
sign of the patient well-being mode and energy,
fascial expressions, asymmetry or weakness,
tremors, involuntary movements, frequent throat
clearance, or coughing.
Position of the neck is important because of
the impact on the intrinsic and extrinsic muscles
of the larynx, poor posture contributes to many
voice disorders and correction of posture has
been part of the voice therapy for many years.
Observation should include also observation
of breathing, normal breathing will insure a good
power for voice production, so observation for
any abnormal breathing, use of accessory respiratory muscles, how frequent the patient inhales
during conversation and if the patient is running
out of air during conversation with excessive
shoulder and upper chest movements listing to
patient breathing can differentiate between pulmonary and laryngeal disorders.
Palpation for muscles tension is important
particularly in the evaluation and treatment of
muscle tension dysphonia, and palpation for ten-
sion over the temporomandibular, jaw, fascial
muscles, and larynx is also important as there is a
variety of protocols related to muscles tension
and common sites for palpation.
43.3.3 Patient Questionnaire?
Voice disorder is very common and it has its
impact on the patient lifestyle and communication especially for the professional voice users
and those who depend on their voice in their
work as teachers, lecturers, etc.
In most of the specialized voice centers, there
will be a questionnaire in order to help the diagnosis and plan the treatment and also to follow up
the patient in order to see the improvement and
also to facilitate researches.
The questionnaires can be created by each
center, but there are well-known questionnaires
known worldwide such as Vocal Performance
Questionnaire, Voice Handicap Index, and Voice
Symptoms Scale.
43.3.4 Endoscopic Evaluation
withaNasopharyngoscopy
andVideo Stroboscope
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