ENT

Traumatology &
Emergency
Abdul Qadar Punagi
ENT Dept. Medical Faculty
Hasanuddin University
What do you want to know
Airway
Breathing
Circulation
Disability
Environment
 Otologic Disorders
Anatomy
Auricle
Ear canal
Tympanic
membrane
Middle ear
and mastoid
disorders
Inner Ear
 Traumatic Disorders of the Auricle
Hematoma
- cartilaginous necrosis
- drain, antibiotics, bulky
ear dressing close follow
up
Lacerations - single
layer closure, pick up
perichondrium, bulky
ear dressing
Use posterior auricular
block for anesthesia
Aspiration of Auricular
Hematoma
Auricular Hematoma
Auricle
Chondritis - Cellulitis ?
- infectious, difficult to treat
because poor blood
supply, cover S. Aureus
and pseudomonas
- extra care in diabetics
- inflammatory causes
related to seronegative
arthritis at times
indistinguishable from
infection usually the ear
lobe is spared
Auricular Hematoma
Blunt trauma
(wrestler)
Drain with temp
drain/ packing with
in 48hrs
Antibiotics
Complications:
Infection
Cauliflower ear
 External Otitis
Infection and
inflammation caused by
bacteria (pseudomonas,
staph), and fungi
- treat with antibiotic-
steroid drops
- use wick for tight canals
- diabetics can get
malignant otitis externa
(defined by the presence
of granulation tissue)
 Foreign Body Ear
Emergency when
associated with
vertigo, profound
hearing loss and/ or
facial parallysis
Do not irrigate
organic material or
with a perforation
Otologic ear gtts /
ENT eval
 Foreign Bodies in Ear Canal
Usually put in by
patient, some bugs fly
in
kill bugs with mineral
oil, or lidocaine
remove with forceps,
suction or tissue
adhesive
 Middle Ear
Serous Otitis Media -
Eustachian tube dysfunction -
treat with decongestants,
decompressive maneuvers
Otitis Media - infection of
middle ear effusion - viral and
bacteria
Mastoiditis - Venous
connection with brain, need
aggressive treatment (can lead
to brain abcess or meningitis)
Acute Mastoiditis
Tympanic Membrane Perforation
Etiology
 Infection, penetrating
trauma, temporal bone
fracture
Check for conductive
hearing loss with tuning
fork
Tx: Floroquinolone gtts,
no H2O
More serious injury with:
profound SNHL,vertigo,
or otorhea
TM Perforation cont.
Tympanic Membrane Perforation
Hard to see – Hx of drainage
Usually from middle ear pressure
secondary to fluid or barotrauma
Sometimes from external trauma
most heal uneventfully but all
need otology follow-up
perfs with vertigo and facial nerve
involvement need immediate
referral
treat with antibiotics
drops controversial but indicated
for purulent discharge (avoid
gentamycin drops)
 Sudden Hearing Loss /Deafness
History Exam
Timing Conversation
Severity Otoscopic
Location Tuning fork/ PTA
Inciting factors CT
Medications Lab
Associated symptoms  VDRL
 Sed rate

 Lyme

 Blood glucose
 Sudden Hearing Loss. Cont.
Treatment
Cause dependent
Early intervention
may make a difference
May need to treat
associated symptoms
as well
 Inner Ear
peripheral vertigo (vestibulopathy)
BPPV, labyrhinthitis
- acute onset, no central signs, usually young,
horizontal nystagmus
Meniere’s - vertigo, sensorineural hearing loss,
tinnitus
Treatment
- valium, fluids, rest, manipulation for BPPV
NASAL EMERGENCIES
NASAL TRAUMA
SEPTAL HAEMATOMA
SEPTAL ABSCESS
EPISTAXIS
SINUSITIS
FOREIGN BODIES
NASAL ANATOMY
Nasal Foreign Bodies
Usually kids
Lollies, beads, small toys, food
Symptoms: persistent unilateral purulent discharge,
unilateral nasal obstruction & foetor
‘Rhinoliths’ or nasal concretions usually have a
foreign body nucleus eg. toy
Rhinolith composed largely of calcium and
magnesium salts
 Nasal Foreign Body
Symptoms:
Usually brought in by
mother
Unilateral rhinitis /
epistaxis
Diagnosis:
Nasal speculum
Rhinoscopy
X-ray
Treatment
Fly’s maggots in
nasal cavity
( nasal myasis)
Chrysomya bezziana
FOREIGN BODIES
INSPECT NOSE WITH HEADLIGHT
REMOVE IF POSSIBLE
ONE CHANCE ONLY
HARD ROUND OBJECTS
SOFT OBJECTS
SUCTION/FORCEPS
BLUNT HOOK
Nasal foreign body
Rhinolith
 Tips for Removing
Need to decongest nose prior to removal (co-
phenylcaine also anaesthetises nose)
Need to be quick or child will resist
Get parents to hold down
Nasal packing forceps best, not alligators
Bleeding uncommon
GA rarely needed
Technique
 NASAL TRAUMA
EXCLUDE SEPTAL HAEMATOMA
TREAT EPISTAXIS
REVIEW ONE WEEK CLINIC
MANIPULATE THREE WEEKS
USUALLY CLOSED FRACTURES
CHECK FOR CSF LEAK
 SEPTAL HAEMATOMA

DUE TO TRAUMA
SEPTUM GROSSLY WIDENED
BLOCKED NASAL AIRWAY
COLLAPSED EXTERNAL NOSE
NEEDS SURGICAL DRAINAGE
NECROSIS
SEPTAL ABSCESS
 Septal Hematoma
Swelling of nasal
septum that doesn’t
respond to
decongestant spray
Need drained < 48 hrs
Complications:
 Infection
 Saddle nose
Drain & pack,
antibiotics
Septal Hematoma
Septal haematoma
Septal Hematoma
Septal Hematoma
 Management - soft tissue

If septal haematoma is missed or

not treated adequately, septal
abscess may follow and result in
cartilage necrosis and “saddle”
deformity
Saddle deformity
 SINUSITIS
INFLAMATION PARANASAL
SINUSES
INTRACRAINIAL ABSCESS
MENINGITIS
ORBITAL CELLULITIS
 EPISTAXIS
TRAUMA
CONGENITAL(meningioma)
NASAL SURGERY
INFECTION
VASCULAR(hypertension, littles area, Woodruff plx, posterior
degeneration)
NEOPLASMS(juvenile angiofibroma)
DRUGS(warfarin, aspirin, cocaine)
 EPISTAXIS
GENETIC(von willebrand)
BLEEDING DISORDERS(LEUKAEMIA)
GRANULOMATOSIS(WEGENERS)
IDIOPATHIC
 Anatomy
ICA (branches of ophthalmic)
 Anterior ethmoid – supplies lateral wall of nose, nasal septum,
nasal tip
 Posterior ethmoid – posterior lateral wall of nose, superior
turbinate and sup septum
ECA (branches of internal maxillary)
 sphenopalatine – supplies the posterior septum, posterior middle
and superior turbinates
 Descending palatine – lower midseptum
 Superior labial (facial artery) anterior septum
Nasal Septal Blood Supply
 POSITION
ANTERIOR  littles
area/ Kiesselbach’s
POSTERIOR 
Woodruff’s
Vascular
anatomy of
the medial
and lateral
nasal walls
What is wrong with this picture?

The anterior and posterior ethmoidal come through the ethmoid sinuses, not from
the skull base.
LITTLE'S ( KIESSELBACH'S)
AREA
1/2 inch from the caudal border of the septum
antero-inferiorly.
Vessels anastomosing are; Anterior ethmoid,
greater palatine, and sphenopalatine, and
septal branch of superior labial.
Bleeding may be arterial or venous.

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
 Little’s area
Confluence of :
Anterior Ethmoidal a.
Greater Palatine a.
Sphenopalatine a.
Sup. Labial a.

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
 Posterior Epistaxis
Unable to visualize
bleeding site
Can lose large
volume quickly
Treatment options:
 posterior/ anterior
pack
Nasal endoscopy with
cauterization
Artery ligation
 Patient History
Previous bleeding episodes
Nasal trauma
Family history of bleeding
Hypertension - current medications and how
tightly controlled
Hepatic diseases
Use of anticoagulants
Other medical conditions - DM, CAD, etc.
 Physical Exam
Measure blood pressure and vital signs
Apply direct pressure to external nose to
decrease bleeding
Use vasoconstricting spray mixed with
tetracaine in a 1:1 ratio for topical anesthesia
IDENTIFY THE BLEEDING SOURCE
Physical Exam - Equipment
Protective equipment - gloves, safety goggles
Headlight if available
Nasal Speculum
Suction with Frazier tip
Bayonet forceps
Tongue depressor
Vasoconstricting agent (such as
oxymetazoline)
Topical anesthetic
 Local Causes of Epistaxis
 Nasal trauma (nose picking,
foreign bodies, forceful nose
blowing)
 Allergic, chronic or infectious
rhinitis
 Chemical irritants
 Medications (topical)
 Drying of the nasal mucosa
from low humidity
 Deviation of nasal septum or
septal perforation
Bleeding polyp of the septum
or lateral nasal wall (inverted
papilloma)
Neoplasms of the nose or
sinuses
Tumors of the nasopharynx
especially Nasopharyngeal
Angiofibroma
Vascular malformation
 Systemic Causes of Epistaxis
Systemic arterial Anticoagulants (ASA,
hypertension NSAIDS)
Endocrine Causes: Hepatic disease
pregnancy,
pheochromocytoma Blood diseases and
Hereditary coagulopathies such as
hemorrhagic Thrombocytopenia,
telangectasias ITP, Leukemia,
Osler Rendu Weber Hemophilia
Syndrome Platelet dysfunction
 Drugs!
Thrombocytopenia: chemotherapy, quinidine,
sulfa preparations, H2 blockers, oral antidiabetic
agents, gold salts, rifampin, heparin, alcohol
Affecting coagulation pathway: Warfarin, Heparin
Affecting platelet function: Aspirin, clopidogrel,
nsaids
Herbs that may cause bleeding: Dong quai,
Danshen, Feverfew, Garlic, Ginger, Gingko,
Ginseng
LOCAL CAUSES

[4] Neoplasms:
Carcinom of the Nasopharynx
Of the
 nose,
 nasopharynx and
sinuses.

Angiofibroma

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
 Local Causes
[4] Miscellaneous:

Septal spur,
foreign bodies

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
 Most Common Causes of
Epistaxis
Disruption of the nasal mucosa - local trauma,
dry environment, forceful blowing, etc.
Facial trauma
Scars and damage from previous nosebleeds that
reopen and bleed
Intranasal medications or recreational drugs
Hypertension and/or arteriosclerosis
Anticoagulant medications
 Types of Nosebleeds
ANTERIOR
Most common in younger population
Usually due to nasal mucosal dryness
May be alarming because can see the
blood readily, but generally less severe
Usually controlled with conservative
measures
 Types of Nosebleeds
POSTERIOR
Usually occurs in older population
May also have deviation of nasal
septum
Significant bleeding in posterior
pharynx
More challenging to control
Therapeutic Equipment to be Available
Variety of nasal packing materials
Silver nitrate cautery sticks
10cc syringe with 18G and 27G 1.5inch
needles
Local anesthetic
Gelfoam, Collagen absorbable hemostat,
Surgicel or other hemostatic materials.
General Epistaxis Supplies
Packing Tray
 MANAGEMENT
EPISTAXIS
NASAL CAUTERY : Chemicals or Electrical
NASAL PACKS
TYPES
SURGERY
EMBOLIZATION
 Packing materials
Vaseline Gauze
Merocel - polyvinylchloride
Surgicel – oxidized cellulose
Gelfoam – purified pork skin
gelatin
 Treatment of Anterior Epistaxis
Localized digital pressure for minimum of 5-10
minutes, perhaps up to 20 minutes
Silver nitrate cautery - avoid cautery of bilateral
nasal septum as this may lead to necrosis and
perforation of the septum
Collagen Absorbable Hemostat or other topical
coagulant
Anterior nasal packing for refractory epistaxis -
may use expandable sponge packing or gauze
packing
 Anterior Epistaxis – Tips
Spray mucosa with co-phenylcaine spray
Insert co-phenylcaine on cotton wool
Wait 10 minutes
Apply silver nitrate to source of bleeding
May need to repeat above sequence
Packing occasionally needed for support
Suction very useful
Send home with ointment
 Traditional Anterior Pack

Usually, 1/2 inch Iodiform or NuGauze is used.

Coat the gauze with a topical antibiotic ointment prior to placement.
Other Anterior Nasal Packs
Formed expandable
sponges are very
effective
Available in many
shapes, sizes and
some are
impregnated with
antibacterial
properties
Correct direction for placement of nasal
packing
CAUTERIZATION

1) Chemicals;
Silver Nitrate stick, chromic acid bead.
2) Electrical
 Apply ointment and advise against
blowing and nose picking.

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
Treatment of Posterior Epistaxis
IV pain medication and antiemetics may be
helpful
Use topical anesthetic and vasoconstrictive spray
for improved visualization and patient comfort
Balloon-type episaxis devices often easiest
Foley catheter or other traditional posterior packs
may be necessary
Traditional Posterior Pack
(Bellocq’s tampon)
 Raza M. Jafri, FRCS
docraza@khi.comsats.net.pk
 Raza M. Jafri, FRCS
docraza@khi.comsats.net.pk
 Posterior Balloon Packing
Always test before placing
in patient
Fill “balloons” with water,
not air
Orient in direction shown
Fill posterior balloon first,
then anterior
Document volumes used
to fill balloons
Posterior pack
 Duration of Packing Placement
Actual duration will vary according to the patient’s
particular needs.
Typically, anterior pack at least 24-48 hours,
sometimes longer.
Posterior pack may need to remain for 48-72 hours. If
a balloon pack is used, advised tapered deflation of
balloons - most successful when volume is
documented.
Complications of packing
Toxic shock
Ulcerations
Nasopulmonary reflex
 Other Treatments for Refractory Epistaxis
Greater palatine foramen block
Septoplasty
Endoscopic cauterization
Selective embolization by interventional radiologist
Internal maxillary artery ligation
Transantral sphenopalatine artery ligation
Intraoral ligation of the maxillary artery
Anterior and posterior ethmoid artery ligation
External carotid artery ligation
 Greater Palatine Foramen Block
Mechanism of action is
volume compression of
vascular structures
Lidocaine 1% or 2% with
epinephrine 1:200,000
used or Lidocaine with
sterile water.
Do not insert needle more
than 25mm
 Surgical/invasive management
Selective arterial embolization
Posterior endoscopic cautery
Internal maxillary artery ligation
Ethmoid artery ligation
OTHER TREATMENTS
Ligation of vessels
Maxillary artery
Ethmoid arteries
External Carotid artery

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
OTHER TREATMENTS
Embolization
Catheters with iced water lavage
2% lignocaine and adrenaline
injection in greater palatine
foramen

Raza M. Jafri, FRCS

docraza@khi.comsats.net.pk
Preventive Measures
Keep allergic rhinitis under control. Use saline nasal
spray frequently to cleanse and moisturize the nose.
Avoid forceful nose blowing
Avoid digital manipulation of the nose with fingers
or other objects
Use saline-based gel intranasally for mucosal dryness
Consider using a humidifier in the bedroom
Keep vasoconstricting spray at home to use only prn
epistaxis
Tripod Fracture
Maxillofacial Trauma-Specific Fractures
(blow-out)
Orbital Fractures
Usually through floor
or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff
deformity
Subcutaneous
emphysema
LeFort Fractures
 Body 30-40 %
Angle 25-30 %
Condyle 15-17 %
Symphysis 7-15 %
Ramus 3-9 %
Alveolar 2-4 %
Coronoid Process 1-2 %
Maxillary Fractures
LeFort I
Definition:
Horizontal fracture of
the maxilla at the
level of the nasal
fossa.
Allows motion of the
maxilla while the
nasal bridge remains
stable.
 Maxillary Fractures
LeFort I
Clinical findings:
Facial edema
Malocclusion of the
teeth
Motion of the maxilla
while the nasal bridge
remains stable
 Maxillary Fractures
LeFort I
Radiographic
findings:
Fracture line which
involves
 Nasal aperture
 Inferior maxilla
 Lateral wall of maxilla

CT of the face and

head
coronal cuts
3-D reconstruction
 Maxillary Fractures
LeFort II
Definition:
Pyramidal fracture
 Maxilla
 Nasal bones

 Medial aspect of the

orbits
 Maxillary Fractures
LeFort II
Clinical findings:
Marked facial edema
Nasal flattening
Traumatic telecanthus
Epistaxis or CSF
rhinorrhea
Movement of the
upper jaw and the
nose.
 Maxillary Fractures
LeFort II
Radiographic
imaging:
Fracture involves:
 Nasal bones
 Medial orbit

 Maxillary sinus

 Frontal process of the

maxilla
CT of the face and
head
 Maxillary Fractures
LeFort III
Definition:
Fractures through:
 Maxilla
 Zygoma
 Nasal bones
 Ethmoid bones
 Base of the skull
 Maxillary Fractures
LeFort III
Clinical findings:
Dish faced deformity
Epistaxis and CSF
rhinorrhea
Motion of the maxilla,
nasal bones and
zygoma
Severe airway
obstruction
 Maxillary Fractures
LeFort III
Radiographic
imaging:
Fractures through:
 Zygomaticfrontal suture
 Zygoma

 Medial orbital wall

 Nasal bone

CT Face and the

Head
Peritonsillar Abscess
Sudden increase in
pain
Difficulty swallowing
Displacement of
uvula
Unilateral swelling of
anterior tonsil pillar
Peritonsillar Abscess
 Epiglottitis
Clinical Picture
Older children and adults
decrease incidence in children
secondary to HIB vaccine
Onset rapid, patients look
toxic
prefer to sit, muffled voice,
dysphagia, drooling,
restlessness
 Epiglottitis
Avoid agitation
Direct visualization if patient allows
soft tissue of neck
- thumb print, valecula sign
Prepare for emergent airway, best achieved in a
controlled setting
Unasyn, +/- steroids
Epiglottitis
UPPER AIRWAY OBSTRUCTION
(UAO)
AETIOLOGY
LARYNGEAL EDEMA
is a life-threatening condition characterized by acute or
gradual onset with swelling of the laryngeal mucosa
acquired angioedema
(allergic/immunpathomechanism)
hereditary angioedema
increased capillary pressure due to superior vena cava
syndrome, internal jugular vein ligation
lowered plasma osmotic failure induced by renal failure
impaired lymphatic flow and increased capillary
permeability to proteins
PATIENT’S COMPLAINTS,
SIGNS
 Principles of airway management techniques
Try simple manoeuvres to open airway
Jaw thrust is used when other methods have failed.
Oropharyngeal airway or nasopharyngeal airway may be useful in
the unconscious patient.
If the patient is not immediately intubated the coma position
(semiprone, slightly head down) should be used.
Laryngeal Trauma
Anatomy and Physiology of
Larynx
Airway, tracheobronchial protection,voice
Hyoid, thyroid, cricoid
Innervation - RLN, SLN
Supraglottis - soft tissue
Glottis - ca joint,cartilage, neuromuscular
coordination
Subglottis - cricoid, narrowest in infants
Anatomy and Physiology of
Larynx
Mechanism of Injury
Blunt -mva, strangulation, clothesline,
cspine
Penetrating
GSW (gun shoot wound): damage related to velocity
Knife: easy to underestimate damage
 History
Hoarseness or change in voice
Dysphagia
Odynophagia
Difficulty breathing - more severe
injury
Anterior neck pain
 Physical exam
Stridor -inspiratory, expiratory or both
Subcutaneous emphysema
Hemoptysis
Laryngeal tenderness,ecchymosis, edema
Loss of thyroid cartilage prominence
Associated injuries - vascular, cspine, esophageal
 Schaefer’s classification system
Group I - minor hematoma or lacs, no fx or airway
compromise, flexible scope +/- CT, medical
management
Group II -mod. edema, lacs, no exposed cart.
nondisplaced fx. varying airway,trach +/- CT
Group III - Massive edema, disrupted mucosa,
displaced fx, cord immobility, varying airway, trach and
endoscopy
Group IV multiple unstable fx, a.c. trauma, required a
stent
 Complications
Granulation tissue - most common, prevention key,
can lead to fibrosis and stenosis of larynx or trachea,
tx is site specific and includes laser excision,
laryngofissure and cricoid split
Immobile vocal fold - cricoarytenoid joint or RLN
injury. If arytenoid mobile, may observe for return of
nerve function
Management of Laryngeal Trauma
 Stridor: Introduction

Harsh, high-pitched, musical sound produced by

turbulent airflow through partially obstructed
upper airway
Poiseuille’s Law: Resistance inversely proportional
to radius to 4th power
Bernoulli’s Law: Pressure decreases as velocity
increases, causing tendency to collapse
 Stridor: Introduction
Supraglottic obstruction: Inspiratory stridor (high-
pitched)
Extrathoracic trachea obstruction – includes
glottis & subglottis: Biphasic stridor (intermediate
pitch)
Intrathoracic trachea obstruction: Expiratory
stridor (wheeze)
Stertor = Low-pitched inspiratory sound from
nose/nasopharynx (snoring)
 Stridor
..
Croup = most common cause of acute stridor
Laryngomalacia = most common cause of congenital
chronic stridor
First step: Determine degree of distress
Decreased intensity may indicate resolution or
exhaustion
 Stridor
Positional stridor: Laryngomalacia, micrognathia,
macroglossia, vascular compression
Optimal position: Prone with neck extended
Weak Cry: Disorder of TVC’s or poor pulmonary
function
Hoarseness: Laryngeal lesion (Normal voice does
NOT rule out laryngeal lesion)
 Stridor
Passage of nasal catheter to determine patency:
Oral airway will bypass choanal atresia
Pierre-Robin sequence: Nasopharyngeal airway to
temporize
ALWAYS maintain high index of suspicion for
foreign body (airway or esophagus)
 Stridor
Transnasal flexible endoscopy in stable
patients while awake; can also evaluate
swallow
 Radiographic Imaging
C-spine
CT if airway stable and mild abnormality on flexible
exam.
Good for intermediate cases with scope limited by
edema
Angiography and contrast esophagrams considered
 Stridor: Imaging
Lateral and A/P neck films: Inspiration distends
hypopharynx, places epiglottis in vertical position,
and stretches A-E folds diagonal
Barium swallow: Aspiration, posterior laryngeal
cleft, TEF, vascular ring, non-radioopaque
esophageal foreign body (Difficult to distinguish
cleft vs. aspiration)
Stridor: Imaging
Stridor: Imaging
MRI: superior to angiography in diagnosis of
vascular rings because images airway and vessels
simultaneously
Used as second line if Echo/plain films/barium
swallow nondiagnostic because of sedation
requirement
T1 fast spin echo w/ cardiac gating: weighting of
choice
Pickhardt: completely normal A/P & Lateral CXR
rule out vascular ring
 Stridor: Imaging
Airway flouroscopy: dynamic study, evaluates
multiple sites
Average exposure 1-2 minutes, 10 mR
Technique: evaluate diaphragm movement, focal
air trapping, airway from NP to mainstem bronchi
in A/P, oblique, and lateral projections
Good for subglottic stenosis,
tracheobronchomalacia, bronchial foreign body,
oropharyngeal collapse
 Stridor: Epiglottitis
Rhode Island study (18 years)
1974: Children 6/100,000/yr, Adults 0.8/100,000/yr
1992: Children 0.3/100,000/yr, Adults 3/100,000/yr
Smoking increases risk >2X
Stridor in 80% of children, 27% of adults
Epiglottitis due to thermal injury from illicit drug use
(4 cases)
Children w/ mild to moderate sx: Immediate
introduction of artifical airway has significantly
decreased number of deaths
 Aspiration: Introduction
Penetration of secretions/other material below
TVCs
Aspiration during sleep in all normal, healthy
individuals
Children: Swallow dysfunction impairs respiratory
function
Complications: Tracheitis, bronchitis,
bronchospasm, pneumonia, pulmonary abscess, ?
SIDS
Aspiration: Introduction
Aspiration: Introduction
Swallow at 16 weeks gestation
Suckle at 34 weeks gestation
Chewing at 6 months of age
3 categories of aspirate: orally ingested,
oral/airway secretions, regurgitated gastric
contents
 Aspiration: History
GER = abnormality most commonly associated w/
chronic aspiration
GER si/sx: Postprandial cough, regurgitation,
emesis, bronchospasm, laryngospasm, central
apnea, bradycardia
Risk factors: Depressed consciousness,
prematurity/swallow dysfunction, CP, epilepsy,
muscular dystrophy, intestinal motility disorder,
scoliosis
 Aspiration: Workup
NP reflux suggests swallow dysfunction
Lateral neck and plain chest films: 14% of films
normal
MBS & Barium swallow: Ba swallow 50-85%
sensitive, 70-75% specific for GER
Scintiscan: Study of choice for gastric emptying
 Aspiration: Treatment
Surgery for GER: Fundoplication if failure after 6
weeks on medication
Surgery for chronic aspiration
G/J tubes most common
Trach – Temporary or complimentary
In setting of congenital TVC paralysis, should delay
laryngeal surgery
Laryngeal diversion/separation: Lindeman, modified
Lindeman
Cincinnati: Bilateral submax glands/parotid ducts,
obviates need for trach
 Aspiration: Foreign Body
Esophageal foreign bodies – respiratory sx in 10%
Vegetable matter most common airway FB: NUTS,
carrot pieces, beans, sunflower/watermelon seeds
Conforming objects/balloons most common
airway FB causing death; at least 2 deaths from
latex gloves in MD’s office; spherical objects
second most common
Aspiration: Foreign Body
Natural history: 3 stages
Choking/coughing/gagging
Asymptomatic interval (up to ½ cases diagnosed
beyond 1 week)
Complications: cough, hemoptysis, pneumonia,
lung abscess, fever, malaise
Workup: I/E CXR, lateral decubitus
Exam, films usually normal 1st 24 hours
Aspiration: Foreign Body
Foreign Body Aspiration
Most prevalent
under age 4
Smaller objects
aspirated/ larger
swallowed
Laryngeal objects –
potential airway
emergency
 Foreign Body cont.
Remove in
controlled fashion
Laryngeal: ASAP
Bronchial: same day
of diagnosis
Esophageal: variable
Airway Management
Tracheotomy under local anesthesia is preferred
method for adults
CT
Fiberoptic intubation or DL with direct visualization
Pedi - inhalation anesthesia with spontaneous
respirations followed by rigid endoscopic
intubation
 Emergency Management
Airway Control
Control airway:
Chin lift.
Jaw thrust.
Oropharyngeal suctioning.
Manually move the tongue forward.
Maintain cervical immobilization
Acute Total Obstruction of UAT
Such as  Café coronary

Heimlich Manuv
Grading dyspnoe (Jackson’s)
Grade I : Retraction suprasternal
Grade II : Retraction Suprasternal + sub xyphoid
Grade III : Gr.II + R. supraclavicular + mild cyanosis
Grade IV : Gr III + R. Intercostal + severe cyanosis
apnoe

Indication Tracheostomy : suitable for Gr.II,

Gr IIIemergency tracheostomy / ETT
Gr IV ETT/cricothyroidotomy
Principles of airway management techniques
3. Surgical airway
• cricothyroidotomy
• percutanous tracheotomy
• emergency tracheostomy
 Conclusions
Key to recognition is high index of
suspicion
Assess airway first and base
management on flow diagram
Don’t forget about associated
vascular or esophageal injuries
 Airway Obstruction
Aphonia - complete upper airway
Stridor - incomplete upper airway
Wheezing - incomplete lower
airway
Loss of breath sounds- complete
lower airway
Thank you
for your
attention