babak saedi md otolaryngologist tehran university of medical scienses
TRANSCRIPT
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Babak Saedi MDOTOLARYNGOLOGIST
TEHRAN UNIVERSITY OF MEDICAL SCIENSES
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Voice change
Dyspnea
Local pain
Cough
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StridorHoarsenessRetraction (intercostal- suprasternal-supraclavicular)Drooling - bleeding - emphysema
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HistoryPhysical examinationFiber optic laryngoscopyRadiographyArterial blood gasC.T.Scan (if general status of patient is stable)
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Simplest adequate form of control should be selected
Lower level
Other medical problems
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TraumaInflammatory diseasesBenign neoplasms (intrinsic – extrinsic)Malignant neoplasms (intrinsic – extrinsic)others
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External laryngeal injury - blunt neck trauma - penetrating woundInternal laryngeal injury - prolonged endotracheal intubation - post tracheotomy - post surgical procedures - post irradiation - endotracheal burn (thermal – chemical)
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CROUP
AND
EPIGLOTTITIS
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Barking CoughHoarse VoiceInspiratory StridorVarying Degrees of
Respiratory Distress
Ages infancy [1-3] (peak 2 years)
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Para influenza viruses – most frequentInfluenza A and B – most severe (esp. A)Adenovirus MeaslesRespiratory syncytial virus
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Clinical Course:Recent URI several days beforeMild cough, progressing to stridor, worsening
cough, retractions.Fever usually only slightly elevated Symptoms worse at night, better in dayMost gradually recover over several days
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Chest X-ray often shows classic “steeple sign”
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Management:Close observation until stableWarm or cool mistSteroids – oral or nebulizedRacemic epinephrineHospitalize hypoxic, worsening children
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A dramatic, potentially life-threatening form of upper airway obstruction characterized by:
High feverSore throatDyspneaRapidly progressive respiratory obstruction
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Etiology:Haemophilus
influenza organism
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Clinical Course:Quick onset of fever, dyspneaOften sits leaning forward, drooling Inspiratory stridorRefuses to eatWithin hours may progress to respiratory
obstruction
Can occur at any age
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Physical Findings:Left picture: nearly completely blocked
airwayRight picture: airway opened after intubation
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Lateral soft tissue neck x-ray:
“thumbprint” sign
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TREATMENT:MAINTAIN THE AIRWAY!!Empiric antibiotics (Ceftriaxone, cefuroxime,
ampicillin plus chloramphenicol) to cover most likely organisms (P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis)
+ or - Steroids
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CharacteristicCharacteristic EpiglottitisEpiglottitis CroupCroup
AgeAge Any ageAny age 6months-6months-12yrs12yrs
OnsetOnset SuddenSudden GradualGradual
LocationLocation SupraglotticSupraglottic SubglotticSubglottic
TemperatureTemperature High feverHigh fever Low-grade feverLow-grade fever
DysphagiaDysphagia SevereSevere Mild or absentMild or absent
DyspneaDyspnea PresentPresent PresentPresent
DroolingDrooling PresentPresent PresentPresent
CoughCough UncommonUncommon Characteristic Characteristic coughcough
PositionPosition Leaning forward, Leaning forward, mouth openmouth open comfortablecomfortable
X-RayX-Ray Thumb signThumb sign Steeple signSteeple sign
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Prolonged intubationVentilation supportManage bronchopulmonary secretionUpper airway obstruction Obstructive sleep apneaBilateral vocal cord paralysisInability to intubateMajor head & neck surgery or trauma
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Advantageslower risk of laryngotracheal injuryimproved comfort/mobilityimprove airway stabilizationallows for oral nutrition improved secretion clearance
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Sternal notchThyroid cartilageCricoid cartilage
- cricothyroid membrane - innominate artery - thyroid gland (isthmus) - recurrent laryngeal nerve
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Venous supplySuperior and middle
thyroid v. drain into the IJ
Inferior thyroid v. drains into the brachiocephalic trunk
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Anatomy variant: thyroid ima artery, in 1.5% to 12%, in front of the trachea.
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Emergent (slash trach)
Urgent (awake)
Elective
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Optimally under general anesthesiaIncision between sternal notch and cricoidDissection in a vertical planeThyroid isthmus (third and fourth ring)Entrance into tracheaTracheotomy tube insertion
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HemorrhageFalse routeElectrocautery fireInjury to adjacent structures
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Hemorrhage [most common ]InfectionSubcutaneous emphysemaPneumomediastinumPneumothorax [most common in infant ]Obstruction of tacheotomy tubeDisplacement of tube
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HemorrhageTracheoesophageal fistulaTracheal stenosisTracheocutaneous fistula
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