ENT Airway Problems and EMergencies; teaching to Foundation Year (FY) Doctors

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Mr Sanjay VermaMr Sanjay Verma
PhD FRCS(ORL-HNS) MAPhD FRCS(ORL-HNS) MA
Consultant ENT and skull baseConsultant ENT and skull base
surgeonsurgeon
FY1 Teaching:FY1 Teaching:
Common ENT Airway problemsCommon ENT Airway problems
and Emergenciesand Emergencies

2.  IntroductionIntroduction

Anatomy and PhysiologyAnatomy and Physiology

ExaminationExamination

PathologyPathology
• HoarsenessHoarseness
• DysphagiaDysphagia
• StridorStridor

3. Anatomy of the ThroatAnatomy of the Throat

4. PharynxPharynx

5. PharynxPharynx
 3 parts3 parts

NasopharynxNasopharynx

OropharynxOropharynx

HypopharynxHypopharynx

6.  Waldeyer’s RingWaldeyer’s Ring
PharynxPharynx

7.  View from behindView from behind
HypopharynxHypopharynx

10. LarynxLarynx

11. LarynxLarynx
 FunctionsFunctions
•
Main function: Sphincter to protect lowerMain function: Sphincter to protect lower
airwaysairways
•
Cough productionCough production
•
SpeechSpeech

13. Level of Vocal CordsLevel of Vocal Cords

14. Section through LarynxSection through Larynx

15. Innervation of LarynxInnervation of Larynx
 Recurrent Laryngeal Nerve has longRecurrent Laryngeal Nerve has long
course so susceptible to traumacourse so susceptible to trauma

16.  Vocal cords have poor lymphatic drainageVocal cords have poor lymphatic drainage
 Early glottic cancers have good prognosisEarly glottic cancers have good prognosis
 Sub and Supraglottic tumours have poorerSub and Supraglottic tumours have poorer
prognosisprognosis
Lymphatic Drainage of VocalLymphatic Drainage of Vocal
CordsCords

17. Lymphatic Drainage of VocalLymphatic Drainage of Vocal
CordsCords

18. Anatomy of the NoseAnatomy of the Nose

24. ExaminationExamination

25. Examination of the ThroatExamination of the Throat

26. Oral CavityOral Cavity

30. Examination of the NoseExamination of the Nose

34. Pathology of the ThroatPathology of the Throat

35. HoarsenessHoarseness

36. HoarsenessHoarseness
 InflammatoryInflammatory

AcuteAcute

Chronic (Specific / Non-specific)Chronic (Specific / Non-specific)
 NeoplasticNeoplastic

Benign - PapillomatosisBenign - Papillomatosis

Malignant - Squamous Cell CarcinomaMalignant - Squamous Cell Carcinoma
 Neurological - Central / PeripheralNeurological - Central / Peripheral
 Mechanical - e.g. nodules or cystsMechanical - e.g. nodules or cysts
 Non-OrganicNon-Organic

42.  T1a - limited to one vocal cordT1a - limited to one vocal cord
 T1b - limited to both vocal cordsT1b - limited to both vocal cords
 T2 - extends to supra or subglottis orT2 - extends to supra or subglottis or
impaired cord mobilityimpaired cord mobility
 T3 - vocal cord fixationT3 - vocal cord fixation
 T4 - extension outside larynxT4 - extension outside larynx
Glottic T stagingGlottic T staging

45. DysphagiaDysphagia

47. Acute Tonsillitis
 Gram positive bacterial infection
 Often multiple bacteria in crypts-
anaerobes
 If Strep pyogenes- risk of RF, antibiotics
 Infectious mononucleosis- JDLN, resistant
to antibiotics
 Quinsy- peritonsillar abscess

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Quinsy
 Complication of supurative tonsillitis
 Inferior - medial displacement of tonsil and
uvula
 Dysphagia, ear pain, muffled voice, fever,
trismus
 Treatment
- Antibiotics, I&D, +/-steroids

50. Indications for Tonsillectomy
 Recurrent Tonsillitis – 7 attacks in 1 year
OR 5 attacks for 2 consecutive years OR
3 attacks in 3 years (SIGN)
 Chronic tonsillitis
 Obstructive sleep apnoea
 Asymmetric tonsils IF suspicious
(removed as biopsy)

51. TONSILLAR
DISSECTION

52. Haemostasis with
bipolar
Haemostsasis
with ties

53. Complications of Tonsillectomy
 Primary Haemorrhage
 Reactionary Haemorrhage
 Pain
 Secondary Haemorrhage (5-7 days post
op)

61. StridorStridor

62. Stridor
Harsh, high-pitched sound indicative of airway
obstruction.
 Inspiratory Supraglottic Glottic
 Biphasic Subglottic Extrathoracic Trachea
 Expiratory Intrathoracic Trachea

63. Stridor - Assessment
 What level ?? History – What sort of stridor
 How severe ?? Accessory muscles
Tracheal tug / Recession
Pulse
pCO2 Retention
 Does the airway need securing ??
Severe or patient getting tired

64. Stridor -management
 SIT PATIENT UP
 OXYGEN
 RE-HYDRATION (i.v.)
 STEROIDS (Nebulised, i.v. or oral)
 ADRENALINE NEBULISER
 HELIOX – Helium / oxygen mixture
 ANTIBIOTICS
 AIRWAY INTERVENTION
Intubation Bronchoscopy
Tracheostomy

65. Paediatric Laryngeal Abnormalities
 CONGENITAL
Laryngomalacia
Glottic web
Subglottic haemangioma
 ACQUIRED
Trauma Subglottic Stenosis
Infection Croup Epiglottitis
Neoplasia Laryngeal Papillomatosis

66. Laryngomalacia
 The larynx develops with redundant
tissue around the laryngeal inlet
 INSPIRATORY stridor
 NOT at birth. Comes on in initial weeks of life
 Worse with feeding
 Resolves in 3rd
year of life
 If failing to thrive – redundant mucosa trimmed
(via endoscope)

67. Laryngeal Infection

68. LARYNGO-TRACHEO-BRONCHITIS
“CROUP”. Parainfluenza types I and II.

69. EPIGLOTTITIS (haemophilus influenzae B)

70. “Croup” vs Epiglottitis
Croup Epiglottitis
 Age 1-3 years 3-6 years
 Duration URTI (days) Short (hours)
 Clinical “Viral” Unwell*
 Stridor Loud Quiet
* Decreased conscious level, circumoral pallor, rapid
deterioration.

71. Airway Foreign Bodies
 RIGHT main bronchus (more vertical)
 May get air trapping, distal to FB.
 Monophonic wheeze (asthma
POLYphonic)
 URGENT bronchoscopy if suspicious

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Paediatric ENT problemsPaediatric ENT problems

75. Nasal Cavity/ Nasopharynx

76. Adenoid Hypertrophy
Symptoms of hypertrophy and chronic
infection:-
A) Noisy eating
B) Rhinorrhoea
C) Snoring
D) Nocturnal obstruction – APNOEA
E) Otitis Media with Effusion

77. ADENOIDS NARROWING THE AIRWAY

78. ADENOID PAD
BEING
“ENGAGAED” BY
CURETTE

79. Complications of
Adenoidectomy
 Primary Haemorrhage
 Reactionary Haemorrhage
 Regrowth of adenoidal tissue

80. Ears

82. Acute Otitis Media
 Common in children
 Painful, fever
 TM inflamed with pus in middle ear
 Role of antibiotics
 Bacterial resistance
 Complications

84. Mastoiditis
 Bacterial infection of mastoid bony
process
 Protrusion of auricle
 Strep pneumoniae- resistance
 Can spread to brain- disability / death
 Less common with advent of antibiotics
 Mastoidectomy

86. • Child pulls at ears
• Hearing loss
• Otalgia
• Slow speech or mental
development
• Tympanic membrane
shows:
• Dull or yellowish discolouration
• Air bubbles/ fluid level
• Bulging/ retraction
Serous otitis media (Glue ear)

87. Glue ear
 Definition
− Fluid present in the middle ear as a result of inflammation
 Demographics
− Commonest cause of acquired hearing loss
− 18 month – 6 years 21% affected
 Risk Factors
− As for ASOM

88. Glue ear: aetiology
 Eustachian tube dysfunction
 Negative middle ear pressure
 Serous fluid build up in middle ear-
conductive loss
 Retraction pockets/ Erosion of ear canal

89. Glue ear: management
 Often resolves therefore treat expectantly
 No medical treatment of proven benefit
 If no resolution after 12 weeks then
grommets inserted or hearing aid fitted
 Consider adenoidectomy if symptomatic or
recurrent OME

90. Chronic Otitis Media (COM)
 Otorrhoea > 3 months
 Recurrent infections
 Hearing loss
 Safe tubo-tympanic (central perforation)
 Unsafe attico-antral (attic disease)

93. Cholesteatoma
 Eustachian tube dysfunction
 Longstanding retraction pocket
 Accumulation of keratin
 Skin cyst slowly erodes bone
 Can cause hearing loss, facial paralysis,
dizziness, intracranial sepsis
 Treatment- surgery/ conservative

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95. MiscellaneousMiscellaneous