Airway Obstruction

Laryngomalacia (congenital laryngeal stridor)

75% of all causes of stridor in infants. Most common congenital abnormality of the larynx. Weakness of the supraglottic larynx leads to prolapse of the supraglottis during inspiration, producing stridor and sometimes cyanosis. The condition manifests at birth or soon after, and usually disappears by 2 years of age. Stridor is increased on crying and feeding but subsides on placing the child in prone position.

Classification of laryngomalacia:

Type I: inward collapse of the aryepiglottic folds Type II: a long, tubular epiglottis which curls on itself, often occurs in association with type I laryngomalacia Type III: anterior, medial collapse of the cuneiform and corniculate cartilages to occlude the laryngeal inlet during inspiration Type IV: posterior inspiratory displacement of the epiglottis against the posterior pharyngeal wall or inferior collapse to the vocal folds Type V: short aryepiglottic folds

Alternative classification of laryngomalacia ( Olney et. al, 1999)

Type I: prolapse of mucosa overlying the arytenoid cartilages Type II: foreshortened aryepiglottic folds Type III: posterior displacement of the epiglottis

Direct laryngoscopy showed elongated epiglottis, curled upon itself (omega-shaped ), floppy aryepiglottic folds and prominent arytenoids. Flexible laryngoscope is very useful to make the diagnosis. Mostly, treatment is conservative. An endoscopic aryepiglottoplasty may be required to release the epiglottis and reduce the aryepiglottic fold. Tracheostomy may be required for some cases of severe respiratory obstruction

Omega-shaped epiglottis in laryngomalacia

Subglottic stenosis:

Congenital / Acquired

Congenital It is due to abnormal thickening of cricoid cartilage or fibrous tissue seen below the vocal cords. Child may remain asymptomatic till upper respiratory infection causes dyspnoea and stridor. Cry is normal.
Diagnosis is made when subglottic diameter is less than 4 mm in full-term neonate (normal 4.5-5 .5 mm) or 3 mm in premature neonate (normal 3.5 mm). Many cases of congenital stenosis improve as the larynx grows but some may require surgery.

Acquired

Subglottic stenosis is seen most commonly in premature babies who required prolonged ventilation by endotracheal tube, but may occur at any age from intubation or trauma. Clinical features include stridor on exertion, or with respiratory infection.
Tracheostomy may be necessary to secure airway. Treatment is highly specialized and laryngotracheoplasty may required. Subglottic stenosis cannot always be avoided.

Endoscopic view showing moderate subglottic stenosis

Bilateral vocal cord palsy:

The commonest cause used to be thyroid surgery, but now most causes are idiopathic. Voice is preserved, with stridor most evident on exertion. Flexible laryngoscopy reveals limitation of abduction of the cords on inspiration. Management includes observation only, a choice of intralaryngeal procedures to increase the airway at the glottic level, or tracheostomy.

Malignancy :

Malignant lesions of the larynx and hypopharynx can present with stridor due to tumour obstruction of the airway or by causing vocal cord palsy and oedema. Stridor can also occur after radiation for laryngeal cancers.

It is not always possible to secure the airway before tracheostomy. Debulking the tumour to improve the airway while awaiting definitive management is an option. Tumours presenting with stridor are usually well advanced locally and may need total laryngectomy for clearance

Foreign body sudden onset of stridor in formerly normal child regard as d/t FB until proved otherwise. H/O choking and coughing (esp while eating) likelihood of aspiration Peanuts = dangerous and never give to youngsters. Examination and CXR may be entirely normal Only way TRO FB in bronchus bronchoscopy.

Larger FB - lodge in the larynx and cause severe respiratory distress. It may be possible to remove it by the Heimlich manoeuvre if fails, endoscopy or tracheostomy will be necessary.

Management outline of airway obstruction:

The management of airway insufficiency always depends on the severity of the obstruction, and severe obstruction necessitates immediate airway support by oxygen, endotracheal intubation or even tracheostomy.
If time and the childs condition allow, every child with stridor should have a PA chest X-ray and a lateral soft-tissue film of the neck, which will show the larynx and upper trachea clearly. If a vascular ring or tracheooesophageal fistula is suspected, a barium swallow is a necessary investigation

Neonates may be intubated without the need for general anaesthesia but great care must be taken not to damage the larynx and cause further obstruction from haematoma or oedema. Older children, unless so anoxic as to be unconscious, will require general anaesthesia for intubation, and at the same time the larynx, trachea and bronchi should be inspected. The diagnosis is then usually apparent and further management can be directed appropriately.

In managing paediatric airway problems, the airway is secured with a direct laryngoscopy. If endotracheal intubation is difficult, a laryngeal mask airway or a rigid bronchoscope is used to maintain the airway and ventilate the patient while tracheostomy is performed. If rapid deterioration occurs and there is not sufficient time for a tracheostomy, a cricothyrotomy can provide emergency oxygenation. In adults, endotracheal intubation is usually possible

Tracheostomy
Tracheostomy is making an opening in the anterior wall of trachea and converting it into a stoma on the skin surface

Functions of Tracheostomy
1) Alternative pathway for breathing 2) Improves alveolar ventilation
In respiratory insufficiency by the dead space and resistance to airflow

3) Protects the airways

By using cuffed tube, tracheobronchial tree is protected against aspiration of pharyngeal secretions(in bulbar paralysis or coma) and blood(in haemorrhage from pharynx, larynx or maxillofacial injuries)

4) Permits removal of tracheobronchial secretions

When patient is unable to cough as in coma , head injuries, respiratory paralysis; or when cough is painful

5) Intermittent positive pressure respiration (IPPR)

If IPPR is required beyond 72 hours, tracheostomy is superior to intubation

6)To administer anaesthesia

When endotracheal incubation is difficult or impossible

Indications
1.

2.
3.

Respiratory obstruction Retained secretions Respiratory insufficiency

Respiratory obstruction

Infections
Acute laryngo-tracheo -bronchitis, acute epiglottitis, diphtheria Ludwig's angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess

Trauma
External injury of larynx and trachea Trauma due to endoscopies, especially in infants and children Fractures of mandible or maxillofacial injuries

Neoplasm

Foreign body larynx Oedema larynx due to steam, irritant fumes or gases, allergy , radiation Bilateral abductor paralysis Congenital anomalies

Laryngeal web, cysts, tracheo -oesophageal fistula Bilateral choanal atresia

Retained secretions

Inability to cough
Coma e.g. head injuries, CVA, narcotic overdose Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain- Barre syndrome, myasthenia gravis Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning

Painful cough
Chest injuries, multiple rib fractures, pneumonia

Aspiration of pharyngeal secretions

Bulbar polio, polyneuritis, bilateral laryngeal paralysis

Respiratory insufficiency Chronic lung conditions(emphysema, chronic bronchitis, bronchiectasis, atelectasis)

Indications in infants and children

Infants (mostly congenital lesions) Subglottic haemangioma Subglottic stenosis Laryngeal cyst Glottic web Bilateral vocal cord paralysis

Children (mostly inflammatory or traumatic lesions) Acute laryngo-tracheo-bronchitis Epiglottitis Diphtheria Laryngeal oedema (chemical/thermal injury) External laryngeal trauma Prolonged intubation Juvenile laryngeal papillomatosis

Complications
Immediate
Haemorrhage Apnoea

This follows opening of trachea in a patient who had prolonged respiratory obstruction. This is due to sudden washing out of CO2 which was acting as a respiratory stimulus. Treatment is to administer 5% CO2 in oxygen or assisted ventilation

Pneumothorax due to injury to apical pleura Injury to recurrent laryngeal nerves Aspiration of blood Injury to oesophagus

Intermediate(first few hours or days) Bleeding, reactionary or secondary Displacement of tube Blocking of tube Subcutaneous emphysema Tracheitis and tracheobronchitis with crusting in trachea Atelectasis and lung abscess Local wound infection and granulations

Late(with prolonged use of tube for weeks and months)

Haemorrhage, due to erosion of major vessel Laryngeal stenosis, due to perichondritis of cricoid cartilage Tracheal stenosis, due to tracheal ulceration and infection Tracheo-oesophageal fistula, due to prolonged use of cuffed tube or erosion of trachea by the tip of tracheostomy tube Problems of decannulation(commonly in infants and children) Persistent tracheocutaneous fistula Problems of tracheostomy scar Corrosion of tracheostomy tube and aspiration of its fragments into the tracheobronchial tree

References
Diseases of ear, nose & throat, Dhingra Lecture Notes on Diseases of the Ear, Nose, and Throat