You are on page 1of 9

HEAD AND NECK

Evaluation and For the purposes of this review, the upper airway refers to the
air conducting passages from the nasal and oral cavity to the

management of acute level of the carina. In addition, we will be focussing on the adult
airway. The anatomy of the head and neck is discussed else-

upper airway obstruction where in this journal.

Evaluation
Constantina P Yiannakis
Often the various elements of evaluation will occur synchro-
Omar J Hilmi
nously, either by oneself or alongside other members of the team.
However, for the purpose of this review, we have split it into the
traditional subheadings.
Abstract
It is important to remember that airway compromised patients
Upper airway obstruction can occur suddenly and result in a patient’s
can shift quickly between different priority levels. Consequently,
rapid deterioration. In this article we provide a structured approach to
evaluation should be a dynamic process and management
identifying those patients with acute airway compromise and strati-
adjusted accordingly. Revaluating the situation regularly is
fying them according to clinical urgency. This includes ways of distin-
crucial to identifying deterioration and acting upon it in a timely
guishing both the level of obstruction and its severity, based on the
manner. Assessment can frequently be challenging by the fact
clinical signs and symptoms, and the role and timing of investigations.
that the resultant hypoxia leads to confused, unco-operative
We describe the key aspects of emergency management, including
patients.
temporizing measures and airway adjuncts. Management of rare, but
important, situations are discussed such as post-thyroidectomy hae-
History
matoma, occlusion of tracheostomy and laryngectomy stomas and
The likelihood is that in the event of severe acute airway
post-obstruction pulmonary oedema (POPE) is discussed. We
obstruction, immediate airway intervention will take precedence
describe the situation when an emergency surgical airway should be
over a thorough history. A rapid handover from emergency staff
considered, along with our technique of performing one.
or bystander, while interventions are taking place, may need to
Keywords Foreign bodies; respiratory sounds; tracheostomy; upper be sufficient. The key aspect of this history is to identify factors
airway obstruction that could lead to a rapid deterioration, such as smoke inhala-
tion, trauma or evidence of severe infection. A more complete
history can be obtained later.
Introduction When possible, try to ascertain the nature of the breathing
Airway obstruction is perhaps one of the most feared emergen- difficulty. When did it start? Is it getting better or worse? Can they
cies. This may be due to the speed with which it can occur and think of anything that might have triggered it? Is there any po-
the resulting rapid deterioration. Appropriate management of the sition that makes it worse? Ask about associated symptoms such
airway forms the first step of all resuscitation protocols. Conse- as: cough, dysphonia, dysphagia, pain, neck stiffness, fever or
quently, it is vital to have a systematic approach to evaluating the recent weight loss. The history of preceding events can provide
airway as well as a robust set of management principles. The essential information, in particular any history of trauma, smoke
clinical situations in which upper airway obstruction should be inhalation (possibility of airway burns), foreign body ingestion
considered include: or infection. It is important to note that in a patient with sub-
 anaphylaxis glottic stenosis the voice is likely to be normal.
 trauma (surgical and non-surgical) Assessment of the patient’s detailed past medical history
 inhalation injuries, both caustic and burns should only be attempted once the patient has been stabilized.
 head and neck infections especially if there is associated Important aspects include previous similar episodes, airway or
shortness of breath neck surgery or known or suspected lung or thyroid pathology.
 inhaled or swallowed foreign bodies In children, a birth and perinatal history is essential. Ensure that
 laryngeal and pharyngeal malignancy. you have a record of their medications, including illicit drug use,
Here we present a structured approach to assessing acute and document their smoking status and alcohol consumption
upper airway obstructions and discuss its immediate (this has particular implications if malignancy is suspected).
management.
Examination
The first step is to do an ‘end of the bed’ assessment to establish
how unwell the patient is. If there are any concerns, call for se-
nior help. Asking the patient how they are feeling will provide a
Constantina P Yiannakis MB ChB MRCS is a Specialist Registrar in rapid assessment of their level of consciousness as well as the
Otolaryngology at Greater Glasgow and Clyde NHS Trust, Scotland, degree of airway compromise and shortness of breath.
United Kingdom. Conflicts of interest: none declared. Listen carefully for additional airway noises such as stridor,
Omar J Hilmi FRCSEd is a Consultant Otolaryngologist and Honorary stertor and wheeze. This will give clues to the level and nature of
Senior Lecturer at Greater Glasgow and Clyde NHS Trust, Scotland, the airway obstruction (Figure 1). However, the subtleties may
United Kingdom. Conflicts of interest: none declared. be difficult to distinguish in the acute setting, especially if there is

SURGERY 36:10 560 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

background noise. It is important to remember that the absence
of additional airway noises, such as stridor, does not exclude
airway pathology, for example, subglottic stenosis. Examples of
the different pathologies that can cause airway noises are sum-
marized in Table 1.
Stertor is the abnormal airway noise created by turbulent flow
through the naso and oropharynx and, occasionally, the supra-
glottis. It is commonly described as a low-pitched, snoring noise.
It is best to ask the patient to breathe through an open mouth to
exclude pathology in the nasal cavity or nasopharynx that may
be responsible for the noise.
Stridor refers to the abnormal airway noise that is created by
turbulent air flow through a partly narrowed airway, typically
from the supraglottis to the subglottic area. It is usually
described as being high pitched; however, the precise tonal
characteristics depend on the location of the obstruction and the
underlying pathology. It can be either inspiratory, expiratory or
biphasic.
Ensure that a full set of basic observations is obtained,
including heart rate, respiratory rate, temperature, blood pres-
sure and oxygen saturations. Interpret oxygen saturations with
caution. Patients with airway obstruction are at risk of devel-
oping worsening respiratory acidosis and consequent CO2 nar-
cosis. If these patients are on supplemental oxygen, the oxygen
saturation may remain in the high 90s right up until they desa-
turate rapidly. It is important to bear in mind that the combina-
tion of tachycardia and a rapid respiratory rate are signs of
hypercapnia and therefore indicate significant airway
compromise.
Figure 1 Anatomical correlation of the different abnormal upper res-
Look for evidence of accessory muscles of respiration being
piratory tract noises
used as well as subcostal recession and tracheal tug. Palpate the
neck and examine for range of movement. If possible, examine

Examples of pathologies associated with additional airway noises
Type of airway noise Level of obstruction Acute onset Acute on chronic

Stertor Tongue base/oropharynx Foreign body Adenotonsillar hypertrophy
Peritonsillar abscess Tongue base malignancy
Parapharyngeal and retropharyngeal abscess
Anaphylaxis
Airway Burns
Inspiratory stridor Supraglottic Anaphylaxis Laryngomalacia
Epiglottitis/supraglottis Malignancy
Parapharyngeal abscess Papilloma
Retropharyngeal abscess
Laryngotracheobronchitis
Airway Burns
Biphasic stridor Glottis/immediate subglottis Trauma Thyroiditis/haemorrhage into cyst
Vocal cord pathology Malignancy
- Inflammatory Papilloma
- Post-surgery
- Prolonged intubation
Expiratory stridor Trachea Tracheitis Tracheomalacia
Trauma Malignancy
Airway Burns

Table 1

SURGERY 36:10 561 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

the oral cavity making a particular note of any trismus. This, in
conjunction with neck stiffness, will have a direct impact on
airway intervention options, such as intubation. Evidence of
broken or missing dental plates should be looked for at this stage,
especially in confused patients. Occasionally impacted dentures
may be a cause of upper airway obstruction.
Several assessment tools have been developed to help identify
potential difficult airways. In our practice, examples of these
include the Mallampati and Lemon system as utilized in the
ATLS.1,2
Oral continence gives a useful measure of how unwell the
patient is, as the inability to swallow saliva indicates significant
dysphagia and odynophagia.
Ideally, a complete ENT examination should be performed,
including direct visualization of the airway using a fibre-optic
nasolaryngoscope. However, this should only be done by mem-
bers of the team with the appropriate training and skills, most
often an ENT surgeon. If the patient is not in extremis, this
should take place in a controlled environment, such as theatre or
resuscitation room but airway intervention should not be delayed
in a critically unwell patient. Instrumenting the airway carries the
risk of tipping a patient from partial into complete airway
obstruction.
Figure 2 Coronal view of retrosternal goitre causing displacement and
Investigations compression of the trachea
The nature and timing of any investigations will largely depend
of the severity of the airway obstruction. Performing these
should not delay securing the airway. Bedside investigations
such as blood sampling for baseline urea and creatinine, full
blood count, C-reactive protein, liver function and clotting
should be performed. If there is evidence of infections, blood
and sputum should be sent for microscopy, culture and sensi-
tivity. Arterial blood gas sampling may also provide useful in-
formation about CO2 retention and respiratory acidosis. Any
rise in CO2 above 6 kPa in the absence of a pre-existing lung
condition is a warning sign of the potential need for urgent
intervention.
Any form of imaging should be used with extreme caution as
it takes the patient out of an area where intervention and
resuscitation are possible. It is therefore reserved for stable pa-
tients or those with a secured airway.
Plain radiographs have no role in the assessment of acute
airway compromise. However, in less critical situations, they can
be used to help establish the location of radio-opaque foreign
bodies.
Figure 3 Axial view of a retrosternal goitre causing displacement and
Computed tomography (CT) can provide useful diagnostic compression of the trachea
information and aid in planning treatment. Examples include
abscesses in the neck and thorax, pathology in the distal
Management
tracheobronchial tree, and malignancy. In particular, they allow
one to assess the extent of the pathology, and facilitates surgical The aim of management is to secure the airway. This is achieved
planning, for example the ability to secure an airway distal to an by either resolving the underlying pathology or bypassing it. In
obstruction (Figures 2 and 3). MRI should be avoided in cases of an emergency situation the gold standard is to secure the airway
acute airway obstruction as the duration of the procedure and the with a cuffed endotracheal tube, but this may not always be
restricted access to the patient is unacceptable in a patient that possible. The management strategy therefore depends on the
may rapidly deteriorate. severity of the airway obstruction as well as the probability of
Direct visualization of the airway through laryngoscopy and rapid deterioration. A critically impaired airway needs emer-
bronchoscopy is performed in theatre and may complete the gency management as this takes priority over everything else. An
airway assessment. This also carries the advantage that endo- airway that is likely to deteriorate in the near future similarly
scopic interventions can be performed at the same time. needs urgent intervention to prevent it become critical, for

SURGERY 36:10 562 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

example in patients with suspected airway burns. The clinical types of airway adjuncts alongside their roles and contraindica-
features of compromised airway compromise and their man- tions are summarized in Table 3.
agement are summarized in Table 2. While securing the airway is taking place, normal emergency
interventions should run in parallel. This would include: estab-
Severe compromise lishing intravenous access, blood sampling, including arterial
If there is any indication that there is significant airway blood gasses, and intravenous antibiotics if indicated. Imaging is
compromise, your priority should shift from making the diag- almost always deferred until the airway is secure.
nosis to securing the airway. Call for senior help. This should If no significant improvement is seen, definitive control of the
include anaesthetics, ENT, and, if in A&E, senior A&E doctors. airway is required. It is essential to have an open discussion with
Ensure that the patient is moved quickly and safely to an area for anaesthetic colleagues and agree a workable plan. Often this will
appropriate monitoring and intervention. If you are in A&E this involve an attempt by anaesthetics at intubation while ENT
would be the resuscitation department. If on the ward it may surgeons are ready to gain front of neck access.
require moving the patient to HDU or ITU. Inform theatres that If the airway is lost completely in a ‘can’t intubate, can’t
there is a patient with a critical airway that may require ventilate emergency’, an emergency surgical airway will be
controlled intubation with the back-up of surgical intervention required (Box 1).
having a full tracheostomy tray opened and ready should the
need arise. Moderate compromise
Temporizing measures include: Although the principles of management are the same as above,
 Nebulized adrenaline: there is almost always an inflam- these patients often respond to temporizing measures. This
matory component to any acute airway obstruction. This is means that there is time for more specialized input in estab-
usually at a dose of 1 ml of 1:1000 adrenaline with 4 ml of lishing the exact nature and level of the airway obstruction. This
0.9% saline. Doses can be given concurrently while steps is aided by the use of fibre-optic laryngoscopy which can be done
towards definitive management are made. Tachycardia in either in A&E or theatres.
this situation should be assumed to be related to wors- These patients should remain in a critical care environment
ening airway obstruction, not the use of adrenaline. until significant improvement is seen as the potential to tip into
 Intravenous steroids: the principle that most cases of acute severe airway compromise remains. If there are signs of deteri-
airway compromise will contain some element of inflam- oration it is important to act on these immediately to secure the
mation also applies to the use of steroids. However, this airway.
will take 6 hours to work so should not be relied upon in
an acute situation. The most commonly used in airway Mild compromise
obstruction is dexamethasone at a dose of 6.6 mg, how- These patients are unlikely to require airway intervention.
ever, up to 8 mg can be given per dose at a maximum of However, certain pathologies have the potential to rapidly
three times daily. change resulting in a critical airway, for example, anaphylaxis
 Heliox: consists of 79% helium and 21% oxygen and has a and airway burns. Often there is time for imaging to be
density that is nearly six times lower than that of atmo- considered. Frequently, this is in the form of a CT scan of the
spheric air. This results in significantly lower turbulence neck and chest. It is important to include the chest as, given the
and subsequently a greater proportion of laminar flow. fascial planes in the neck, there is potential for infection to track
This reduces the airway resistance and can increase the down into the mediastinum. CT is preferable to MRI for several
flow rates by up to 50% buying time in an acute reasons, including the fact that it is more readily available, can
situation.3 be done quickly and there is the option of radiologically guided
 Transnasal humidified rapid-insufflation ventilator ex- interventions, such as abscess drainage. Ultrasound has limited
change (THRIVE): it has been recognized that apnoeic use in the management of upper airway compromise. Neck
oxygenation on its own prolongs the time to desaturations abscesses are rarely amenable to drainage under ultrasound
and can increase the success of first pass intubation. control.
THRIVE takes this a step further by adding continuous
positive airway pressure via nasal cannula to the tradi- Discussion
tional apnoeic oxygenation. This may improve oxygena- While the key step in managing airway obstruction is its early
tion through flow-dependent dead-space flushing.4,5 recognition, certain conditions deserve special consideration.
These are temporizing measures and can be used in combi-
nation with appropriate airway adjuncts. Anaphylaxis
The use of airway adjuncts in the management of acute This may be either a known reaction to a specific allergen, or the
airway obstruction is of limited value and, with the exception of first presentation. Patients will typically present with rapid onset
endotracheal intubation and tracheostomy, they should be of breathing difficulties after exposure, which may be obvious
considered as temporising measures only. The use of Guedel with swelling involving the tongue and lips or may need to be
airways may cause trauma or increase irritation causing cough- specifically looked for if it is involving the uvula or larynx.
ing and further deterioration of the clinical situation. Using a bag- Angioedema commonly involves the tongue and lips and can
mask to either ventilate or assist in ventilating the patient with a occur without exposure to allergens. It is frequently caused by
degree of CPAP, is almost universally acknowledged as an ACE inhibitor use and these should be withheld if suspected.
effective airway intervention with limited risk. The different Allergies and angioedema normally respond to the use of

SURGERY 36:10 563 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

Figure 4 Management of unanticipated difficult intubation in adults. (Reproduced from the Difficult Airway Society 2015 Guidelines, with kind
permission.)

Summary of the clinical features and management of different degrees of airway compromise
Clinical features Management

Severe Reduced level of consciousness, agitation or confusion Call for senior help
Tachycardia >120 Consider immediate airway intervention either intubation or
Tachypnoea >20, or, in the event of impending failure, reduced surgical airway
or absent Adrenaline nebulizers
Hypoxia and cyanosis IV dexamethasone
Additional airway noises Heliox
Drooling IV antibiotics if infective origin
Pyrexia
Arterial blood gases (ABGs): respiratory acidosis and rise in CO2
Moderate Tripod position with use of accessory muscles As the patient is clinically stable, consider rapid investigations
Additional airway noises to establish cause and guide further management:
Dysphonia C CT neck and thorax
Tachycardia >100 C Routine blood tests
Tachypnoea C Indirect and direct visualization
ABG mild respiratory acidosis and rise in CO2
Hypoxia (if not on oxygen)
Confusion
Mild Dysphonia Focus is on defining the underlying cause to target treatment.
Additional airway noises Patient will still require admission for treatment and
investigation, but some test may be deferred.

Table 2

SURGERY 36:10 564 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

Summary of airway adjuncts alongside their roles and contraindications
Type Role Contraindication

Oropharyngeal airway Creates conduit through the mouth to the Trismus
posterior pharynx Paediatrics esp. epiglottitis
Poorly tolerated if intact gag reflex
Facial trauma
Supraglottic, glottic or subglottic obstruction
Nasopharyngeal airway Creates conduit through the nose to the Nasal/facial trauma
posterior pharynx Epistaxis
Supraglottic, glottic or subglottic obstruction
Supraglottic airway Maintain supraglottic patency during general Absolute:
C Laryngeal mask airway anaesthetic or in unconscious patient C Glottic or subglottic obstruction
C i-gel Can be inserted relatively easily and C incomplete mouth opening/trismus
C AirQ atraumatically C Complete upper airway obstruction
Provide some degree of airway protection Relative:
against gastric contents C Increased risk of aspiration
Allow for limited intermittent positive pressure C Suspected or known upper airway abnormality
ventilation C Need for high airway pressures
Intubation (trans oral) Establishes secure airway suitable for Relative:
ventilation C Facial fractures
C Upper airway trauma
Complete obstruction of supraglottis and glottis
Intubation awake fibre optic Pt with severe trismus Any laryngeal/subglottic pathology
Needle cricothyroidotomy Temporising method only elevated CO2 as does not alleviate narcosis, laryngeal or airway
trauma
Tracheostomy See below Obstructing goitre/front of neck pathology

Table 3

intravenous steroids, antihistamines and, if necessary, adrena- patient then needs to be transferred to theatre for formal re-
line. However, airway support may be required in extreme cases. exploration and haemostasis.

Trauma Inhalation injuries
Non-surgical trauma: laryngeal or airway trauma is rare. Caustic airway injuries and burns can deteriorate rapidly.
Disruption of the laryngeal skeleton or tracheal integrity can Asymptomatic patients can progress to complete obstruction
cause progressive airway obstruction and, if suspected, urgent within hours. Consequently, it is recommended that these pa-
ENT assessment is recommended. While most cases can be tients are assessed early by ENT surgeons and the airway team.
managed without the need for airway intervention some will Intubation by an experienced anaesthetist to secure an airway is
require a definitive tracheostomy as a primary procedure. This is recommended before clinical signs of obstruction become
because intubation can further traumatize the area and, in some apparent if an airway burn is suspected.
cases, create false tracks out with the airway.
Head and neck infections
Surgical trauma e post-thyroidectomy haematoma: the thy- These can cause airway compromise either as a result of direct
roid is a highly vascularized gland and, consequently, there is the (cellulitic) swelling of the airway as in supraglotitis (see Head
potential for significant bleeding. The incidence of postoperative and neck infections) or as a result of airway compression by an
bleeding is low (0.3e1%). If a rapidly expanding haematoma expanding abscess (Figures 5 and 6) or surrounding inflamma-
goes unrecognized, it can lead to airway compromise and tory process. The cellulitic processes can progress rapidly.
asphyxiation.6 Patients typically present with neck pain and Treatment is primarily medical with antibiotics, based on local
swelling. This may be associated with signs and symptoms of empirical guidelines, and steroids. However, patients may
airway compromise, including, hypoxia, stridor and dyspnoea. If require airway support in severe cases (Figure 7). Abscesses
suspected, remove all dressings and carefully examine the neck have a more protracted presentation but generally require some
and assess the airway. If there is any sign of airway compromise, form of drainage in addition to medical management.
immediately open the incision and if the strap muscles have been
closed separate them to decompress the deep space. This is Foreign bodies
usually done with a pair of scissors inserted at the edge of the These can occur anywhere from the nasal cavity to the distal
wound. Evacuate the haematoma using a Yankauer sucker. The bronchi and are most common in children. Not surprisingly,

SURGERY 36:10 565 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

Emergency front of neck access

An emergency cricothyroidotomy or tracheostomy is an immediate
airway procedure that is done as a last resort in a patient with
impending or absolute airway obstruction. This situation classically
occurs in an anaesthetized patient where intubation has been un-
successful and ventilation is impossible. It can also occur in patients
that have become significantly obtunded by carbon dioxide related
narcosis, secondary to progressive airway obstruction. The single aim
of the procedure is to establish an airway with a cuffed tube and
return ventilation. Several different approaches exist and it is
important that each surgeon is familiar and practised with one
technique. Here we outline our technique. Bear in mind that given the
nature of procedure and the situation, only minimal equipment will
be available.

1 The patients’ neck is extended to demonstrate the airway struc-
tures. Gripping the larynx and palpating the midline can help
define the position.
2 A vertical midline incision is made. The exact position of this Figure 5 Coronal view of a right sided parapharyngeal abscess
depends on whether the intention is to enter the airway through
the trachea or cricothyroid membrane.
3 The incision is deepened to enter the airway in the midline either
through the cricothyroid membrane or trachea and the blade can
be rotated to open the fenestration.
4 At this point, a Bougie can be inserted and an ET tube ‘railroaded’
over this (Figure 4) or a tube simply inserted into the airway. The
cuff is inflated and the airway suctioned.

Once the airway is secured and the patient stabilized, the can be
transferred to theatre for the formation of a formal tracheostomy and
haemostasis in a controlled fashion by an experienced surgeon.
Immediate complications include haemorrhage, surgical emphysema
and pneumothorax, with subglottic stenosis occurring at a later date.
However, all of these complications are preferable to the likely fatal
consequences of non intervention.

Box 1

organic matter, e.g. food bolus is the most common. Larger ob-
jects tend to become lodged in the larynx or proximal trachea. Figure 6 Axial view of a right sided parapharyngeal abscess
However, the right main bronchus remains the most common
site in adults and children.
Presentation tends to have three phases, with the first being The decision to progress to endoscopic evaluation of the
the initial choking stage. The patient or their family will describe airway is frequently based on history alone. This is particularly
an episode of coughing, gasping and, occasionally, stridor. There relevant in children where there may be nothing to be found on
is often a history of playing with small objects or eating. This can examination, simply a history of intermittent cough and choking.
then resolve completely as the normal reflexes relax. This second Plain radiographs of the neck and chest may be able to demon-
phase can last from hours to weeks. The final stage is when the strate radio-opaque foreign bodies or evidence of consolidation
patient presents with the complications of the foreign body, associated with a bronchial foreign body. However, as with most
namely, airway obstruction, infection and erosion of surrounding acute airway pathologies, this should not delay definitive inter-
structures. vention. Endoscopic evaluation may include direct laryngoscopy
Symptoms and signs depend on the location of the foreign as well as flexible bronchoscopy as both procedures allow for
body. Those in the larynx will present with dysphonia or aphonia interventions at the same time.
with associated airway compromise and dysphagia. Those in the
trachea may still present with airway compromise, with no change Malignancy
to the voice. However, stridor or wheeze may still be present. Patients with a history malignancy may present with airway
Foreign bodies in the bronchial tree classically present with the obstruction. Typically, this is of gradual onset on a background
triad of cough, unilateral wheeze and reduced breath sounds. of symptoms such as hoarseness or dysphagia in the case of

SURGERY 36:10 566 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

in the creation of a false tract into the surrounding tissue, the
consequence of which may be complete loss of the airway. The
more recent the tracheostomy, the sooner closure will occur. If
possible, extend the patients neck. Re-insert the introducer into
the tracheostomy tube. A pair of tracheal dilators can be helpful
in opening up the stoma. Insert the tracheostomy at 90 degrees to
its normal position and carefully rotate it 90 degrees while
advancing. Remove the introducer and check that the tube is in
the trachea, rather than a false passage. This can be done by
feeling the movement of air from the stoma onto your hand or, if
the patient is ventilated, by the return of CO2. Insert the inner
cannula and secure the tube. If there is any doubt about the
position of the tube, do not ventilate the patient through the tube
as this will cause surgical emphysema and further complicate the
picture and severity of the situation. As mentioned earlier, the
patient can be ventilated via a face-mask or trans oral endotra-
cheal tube instead. It is essential to have good lighting and suc-
tion available during this process.

Laryngectomy stoma occlusion
As with tracheostomies, occlusion of laryngectomy stomas is rare
if patients receive appropriate care. The emergency management
is similar to an occluded tracheostomy, with the exception that
there may not be a tube or stoma button in place. The patient
should still receive concurrent nebulizers and flexible suctioning
to remove the plug or secretions. The laryngostome is the only
Figure 7 Sagittal view of a tracheostomy tube placed through the
crico-thyroid membrane in an emergency. The arrow shows the airway for the patient so attempts at oral bag and mask must not
complete supraglottic airway obstruction secondary to supraglottitis be attempted.

laryngeal or pharyngeal malignancy or ‘hot potato’ speech if the Post-obstruction pulmonary oedema (POPE)
tongue base is involved. Occasionally, oesophageal or lung pri- POPE, or negative pressure pulmonary oedema, is a potentially
mary’s may present with airway obstruction either due to direct life-threatening form of acute respiratory distress that can occur
mass effects on the airway or bilateral vocal cord palsies. Any after the relief of severe airway obstruction.
patient with a thyroid, mass and stridor needs to be urgently The combination of negative pressure pulmonary oedema
assessed by a senior ENT surgeon and anaesthetist as front of hypoxia and the sudden correction of the obstruction, regardless
neck access may not be an option if they deteriorate. of the cause, can give rise to respiratory distress. POPE is char-
acterized by tachypnoea, tachycardia, crepitations and wheeze,
Tracheostomy occlusion and displacement
which can occur almost immediately following the relief of
With appropriate tracheostomy care, occlusion of the tube
airway obstruction or up to 24 hours after relief of the acute
should be rare. However, if not recognized, this can rapidly lead
obstruction.7 Chest x-ray demonstrates rapid, bilateral changes
to airway obstruction. Administer concurrent nebulizers with
consistent with pulmonary oedema.
0.9% saline with high-flow oxygen. This will help to loosen any
The management depends on the severity and is predomi-
mucus plugs. Next, using a wide-bore flexible suction catheter,
nantly supportive in nature by maintaining an adequate airway
attempt to suction through the tracheostomy tube. If this fails to
and oxygenation. Any patient where there has been relief of
relieve the obstruction, then remove the inner tube and suction
acute upper airway obstruction should be considered at risk of
through the remaining, outer tube. If this fails, assist ventilation
POPE post-relief. Consequently, they should be kept under close
with a tight-fitting face mask and bag ventilation (ensuring any
observation and, if suspected, early involvement of the anaes-
cuff is deflated) and seek urgent ENT assistance. The obstruction
thetic or intensive care team should be sought. In severe cases
may be distal and the patient may need to be transferred to
airway support, such as PEEP, CPAP or even mechanical venti-
theatre for emergency bronchoscopy.
lation may be required.8
If the tube becomes displaced, the priority is maintaining the
airway, not reinsertion of the displaced tube. In a tracheostom-
Conclusion
ized patient, as opposed to a patient with a laryngectomy, there is
nearly always at least a partial upper airway in continuity with Successful management of upper airway obstruction requires a
the larynx. Consequently, bag and mask ventilation and transoral flexible approach. The key aspect of success is recognizing the
intubation are acceptable forms of airway management if rein- problem early and getting appropriate personnel in place to
sertion of the tube is problematic. If feasible, the tube should be manage the condition before it deteriorates to complete
replaced as the stoma will start to close. However, repeated at- obstruction. Emergency front of neck access is rarely required
tempts to reinsert the tube may cause further trauma and result but if felt necessary should not be delayed. A

SURGERY 36:10 567 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
HEAD AND NECK

REFERENCES increasing apnoea time in patients with difficult airways. Anaes-
1 Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict thesia 2015; 70: 323e9.
difficult tracheal intubation: a prospective study. Can Anaesth Soc 5 Oliveira L, Cabrera D, Barriouevo, et al. Effectiveness of apneic
J 1985; 32: 429e34. oxygenation during intubation: a systematic review and meta-
2 Reed MJ, et al. Can an airway assessment score predict difficulty analysis. Ann Emerg Med 2017; 70: 483e94.
at intubation in the emergency department? Emerg Med J 2005 6 Pironi D, Pontone S, Vendettuoli M, et al. Prevention of complications
Feb; 22: 99e102. during reoperative thyroid surgery. Clin Ter 2014; 165: e285e90.
3 Harris PD, Barnes R. The uses of helium and xenon in current 7 McConkey PP. Postobstructive pulmonary oedemada case series
clinical practice. Anaesthesia 2008; 63: 284e93. and review. Anaesth Intensive Care 2000; 28: 72e6.
4 Patel A, Nouraei S. Transnasal Humidified Rapid-Insufflation 8 Udeshi A, Cantie SM, Pierre E. Postobstructive pulmonary edema.
Ventilatory Exchange (THRIVE): a physiological method of J Crit Care 2010; 25. 508 e1-e5.

SURGERY 36:10 568 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.