Acute Upper Airway Obstruction Research Articles

Pediatric thermal epiglottitis: insights from a tertiary center experience.

Thermal epiglottitis, a non-infectious cause of epiglottitis, is a rare entity that shares some clinical features with infectious epiglottitis. This study presents 16 years of experience in diagnosing and managing thermal epiglottitis. A retrospective descriptive study in a tertiary center in southern Israel included confirmed cases of thermal epiglottitis in children (0-18 years) between 2004 and 2020 by endoscopy. Of approximately 600,000 pediatric ER admissions between 2004 and 2020, seven children were diagnosed by endoscopy with thermal epiglottitis (mean age 24 months, 71% males). Clinical presentation included stridor, respiratory distress, and drooling. Four children had fever and elevated inflammatory markers at presentation and were treated with systemic antibiotics. All were treated with systemic steroids. The median length of stay in the PICU was five days, and four patients required intubations. All fully recovered without experiencing any sequelae. Conclusion: Thermal epiglottitis stands as a potential contributor to acute upper airway obstruction. Although it's rarity, it should be discussed in any child with acute upper airway obstruction. It is essential to inquire directly about the accidental intake of hot beverages, particularly in cases lacking fever or elevated inflammatory markers. What is Known: • Thermal epiglottitis is a rare, non-infectious condition sharing clinical features with infectious epiglottitis. • Common presentations include stridor, respiratory distress, and drooling. What is New: • Thermal epiglottitis is a potential contributor to acute upper airway obstruction, urging consideration even in the absence of fever or elevated markers. • Direct inquiry about hot beverage intake for diagnosis is essential for diagnosis.

Emergency Tracheostomy: Complications, Anesthetic Techniques, and Outcomes.

Objectives: Acute upper airway obstruction is a critical medical condition that presents considerable challenges to anesthesiologists. This study aims to provide a formal report on the incidence and outcomes of perioperative complications, as well as the factors that influence unstable intraoperative hemodynamics. Methods: This retrospective study reviewed patients aged 18 years and older who underwent emergency tracheostomy between January 2013 and October 2021. Data on perioperative complications and outcomes within the first 24 hours and 7 days after surgery were subjected to analysis. Descriptive and multivariate analyses were used to examine the results. Results: A total of 253 patients were included in the study. The mean age was 61.5 ± 12.9 years. Malignancy was detected in 78.3% of the patients. General anesthesia was administered to 43.9% of the patients. The incidence of intraoperative complications was 51.8%, with hypotension and hypertension occurring in 30.4% and 22.5% of the cases, respectively. Desaturation and cardiac arrest were observed in 4.7% and 0.8% of the patients, respectively. The mortality rate at 7 days after surgery was 1.6%. Multivariate analysis revealed that monitored anesthesia care [adjusted odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.08-3.00] and hypertensive patients (adjusted OR = 1.70, 95% CI: 1.01-2.86) were associated with unstable intraoperative hemodynamics. Conclusions: Cardiovascular instability represented the majority of the complications observed. Monitoring anesthesia care and hypertension were significant prognostic factors for unstable intraoperative hemodynamics. We recommend extensive communication between ear, nose, and throat surgeons and anesthesiologists to determine the appropriate choice of anesthesia.

Discovering the Clinical Relevance of Heart-Lung Interactions.

In 1978, Dr. Pinsky's scientific career became firmly directed toward understanding the deeper meaning of heart-lung interactions. This would define his focus for the next 45 yr. At the time, he and colleagues studied the effects of changes in intrathoracic pressure on left ventricular performance in humans, documenting that the primary effect of large negative swings in intrathoracic pressure was to increase left ventricular transmural ejection pressure, and thus left ventricular afterload, selectively. They concluded that large intrathoracic pressure changes directly influence cardiac performance. This fundamental observation was followed by many additional observations in both highly invasive animal studies supported by less invasive clinical studies, which showed that intrathoracic pressure-induced changes in the gradients for venous return to the heart and left ventricular ejection from the heart disproportionately affected both right ventricular and left ventricular function. The direct clinical implications of these results form the rationale for use of continuous positive airway pressure as a primary treatment of acute cardiogenic pulmonary edema and immediate endotracheal intubation for acute upper airway obstruction. These findings subsequently led to the practical use of dynamic changes in left ventricular stroke volume and the associated arterial pulse pressure during positive-pressure ventilation to identify volume responsiveness and, thus, to personalize resuscitation efforts in the treatment of acute cardiovascular insufficiency.

Tracheotomy results in upper airway management

Objectives: The study aimed to discuss the demographic characteristics and tracheotomy indications and complications of the patients who underwent tracheotomy in our clinic in the light of the literature. Patients and Methods: In this study, the records of 323 patients (216 males, 107 females; mean age: 64.9±16.4 years; range, 19 to 108 years) who underwent tracheotomy between January 2017 and December 2022 were reviewed retrospectively. Patients under the age of 18 years, patients who underwent percutaneous tracheotomy, revision tracheotomy, and tracheotomy for the second time were excluded. Demographic characteristics of the patients, comorbidities, and indications and complications of tracheotomy were reviewed from the patient charts. Results: Elective tracheotomy was performed in 170 (52.6%) patients, and emergency tracheotomy was performed in 153 (47.4%) patients. Tracheotomy-related complications were observed in 13% of the patients. When all complications were evaluated, the most common complications were bleeding, subcutaneous emphysema, and granulation tissue. Conclusion: Acute upper airway obstruction is a life-threatening condition, and tracheotomy is of vital importance in this condition. The most common complication is bleeding, and it can be minimized with the appropriate method and hemostasis. Mortality rates due to tracheotomy are very low, and it is a life-saving procedure.

An extremely rare phenomenon: Angina bullosa hemorrhagica

Introduction:Angina bullosa hemorrhagica is a disease without a concomitant hematological or vesiculobullous disorder characterized by painless hemorrhagic bullae in the oral mucosa; it is rarely seen and has a good course.Case presentation:A 45‐year‐old female patient was admitted to the emergency department with a painless hemorrhagic bulla that suddenly appeared on the soft palate. A blister, 2 cm in diameter and dark red in color, was seen extending from the hard palate's posterior to the soft palate. Nasolaryngoscopic evaluation was performed, and no additional hemorrhagic bulla was detected. She was discharged with the recommendation of oral mouthwash.Discussion:Solitary hemorrhagic bulla, suddenly occurring on the soft palate, is diagnostic for angina bullosa hemorrhagica. Some authors have reported that blisters in the posterior pharynx may progress to acute upper airway obstruction.Conclusion:Early nasolaryngoscopic evaluation in angina bullosa hemorrhagica is an excellent option to be considered by the emergency physician to prevent life‐threatening situations.

A rare primary thyroid mixed germ cell tumour: a case report

Germ cell tumours mostly occur in the gonads. Extragonadal site is rare and mainly located in the mediastinum, retroperitoneum and pineal gland. Germ cell tumour that occurs in the thyroid gland is extremely rare. We present our first description of a patient with a mixed germ cell tumour located primarily in the thyroid gland. A 35 years old gentleman presented with two months history of thyroid swelling associated with compressive symptoms. His neck ultrasound showed multinodular goiter with suspicious nodule (TR4) and FNAC revealed highly suggestive of a malignant lesion. Subsequently, the thyroid mass progressively enlarged in size causing acute upper airway obstruction that made him collapsed at Emergency Department. Core biopsy of TR4 thyroid nodule suggestive of malignant lesion which could be mixed germ cell tumour or poorly differentiated carcinoma. Abnormal laboratory tests showed a high concentration of LDH, Alpha fetoprotein and beta-HCG. He underwent emergency total thyroidectomy, debulking and tracheostomy. Histopathology reported the mass composed of mixed non-seminomatous germ cell tumour with area of necrosis (30%), primarily immature elements (80%), yolk sac tumour (15%) and embryonal carcinoma (5%). He was scheduled for chemotherapy post operatively however he succumbed to the illness due to advanced tumour and sepsis.

Negative Pressure Pulmonary Oedema – Lessons learnt

A 56 year old female patient belonging to American Society of Anaesthesiologists Physical Status (ASA-PS) 1 underwent emergency laparoscopic appendectomy. Surgery was uneventful. After reversal of the neuromuscular blockade and extubation, patient sustained acute upper airway obstruction due to laryngospasm and developed negative pressure pulmonary oedema, which resolved after a period of about 15 hours of mechanical ventilation.

Acute Upper Airway Obstruction as Atypical Manifestation of Uncommon Aetiologies- A Case Series

Acute upper airway obstruction, an emergent situation, can sometimes put the clinician in a dilemma with no positive history or clinical findings to aid in the diagnosis. A myriad of conditions causes upper airway obstruction. Priority is to secure the airway and then seek out the underlying cause. Computed tomography scan is an important imaging modality for reaching a definitive diagnosis and might at times, reveal unexpected findings. In this case series, authors report three cases of acute upper airway obstruction which were atypical manifestation of diseases. Case 1 is about Lemierre’s syndrome with compromised airway in the absence of abscess formation. Case 2 depicts an atypical presentation of Boerhaave syndrome as retropharyngeal accumulation of air and pneumomediastinum. Case 3 is about retropharyngeal haematoma in a patient with anticoagulant therapy without any definite history of trauma. Treatment with reversal of anticoagulation was successful in the case 3. It is important for the clinician to be aware of the unusual reasons for airway compromise, as early suspicion can translate into better patient survival. Airway should be secured by either intubation or tracheostomy. Many a time, radiological and blood investigations help to arrive at a definite diagnosis.

Acute upper airway obstruction by a hairy polyp in an infant

Acute upper airway obstruction by a hairy polyp in an infant

Bacterial laryngotracheobronchitis as one cause of airway obstruction in older children

Laryngitis, tracheitis and bronchitis is a common, usually self-limiting viral infection. Bacterial laryngitis, tracheitis and bronchitis is caused by secondary bacterial infection of a viral laryngeal infection leading to a mucopurulent exudate that can cause acute upper airway obstruction and eventually lead to a life-threatening condition. Bacterial tracheitis should be considered in the differential diagnosis of any child with acute upper airway obstruction. This diagnosis should also be considered in any child with viral croup that does not respond to conventional treatment. The correct way to definitively diagnose bacterial tracheitis is by direct visualisation of the trachea by bronchoscopy, but this may not be necessary in all cases. Management includes close observation and monitoring, early initiation of broad-spectrum antibiotics, pain management, and clearing the airways of lingering secretions. The decision to secure an airway by intubation or tracheotomy should be made on an individual basis depending on the severity of symptoms and the patient’s condition. If diagnosed early and treated properly, complete recovery can be expected. We present two patients diagnosed with laryngotracheobronchitis, in whom a correct diagnosis allowed successful recovery.

DESCENDING NECROTIZING MEDIASTINITIS (DNM) DISGUISING AS A MEDIASTINAL MASS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: DNM is an uncommon infection arising in the head or neck which tracks between the cervical fascial planes into the mediastinum. We report a case of DNM with a challenging presentation. CASE PRESENTATION: A 56-year-old male on chronic hemodialysis recovering from COVID pneumonia, presented to the emergency department with 2 days of shortness of breath. He was hypertensive, tachycardic and hypoxic, in respiratory distress, requiring immediate initiation of noninvasive ventilation. Shortly after arrival, he went into cardiac arrest. Resuscitation efforts were successful. Intensive management included mechanical ventilation, broad spectrum antibiotics, vasopressors and continuous renal replacement therapy for suspected septic shock. Chest x-ray showed mediastinal widening, confirmed by CT, to be due to a 7.5 cm lobulated, soft tissue density in the mediastinum impinging on the trachea. Bronchoscopy via endotracheal tube showed no obstruction except for some dynamic airway collapse. Trans-bronchial needle aspiration of the mediastinal mass was non-diagnostic. In 2 days, he improved, was extubated but then emergently re-intubated due to acute upper airway obstruction. Repeat imaging revealed a large retropharyngeal abscess extending from C1 level to the thyroid gland. It wrapped around anteriorly and communicated with a large collection in the superior mediastinum surrounding the trachea. Also noted was an enlarging pleural effusion. Urgent surgical drainage of the retropharyngeal space, superior mediastinum and pleural fluid was performed. Cultures grew Staphylococcus aureus. Mediastinal exploration and tracheostomy followed. He steadily improved and was discharged. DISCUSSION: DNM is a life-threatening infection that originates in the neck;retropharyngeal abscess in this case. It spreads caudally through cervical fascial planes facilitated by gravity and negative intrathoracic pressures (1). Oral flora are the usual pathogens (2). Diagnosis needs a high index of suspicion to obtain necessary imaging. Favorable outcomes are seen with early diagnosis, airway protection, antibiotics and timely surgical drainage (3).Our patient had narrowing of the proximal trachea due to compression from the fluid collection requiring emergent re-intubation. His initial chest CT reported a soft tissue density concerning for malignancy. It was the second CT that suggested an abscess. Looking back, prior chest x-rays showed progressive mediastinal widening over 10 days, making malignancy less likely. Review of old imaging remains invaluable. CONCLUSIONS: Deep neck infection leading to mediastinitis requires early diagnosis, antibiotic administration as well as operative management for source control. REFERENCE #1: Benedetto C, et al. Catastrophic descending necrotizing mediastinitis of the anterior and posterior compartments: A case report. Radiol Case Rep. 2020;15(10):1832-1836 REFERENCE #2: Brook I, Frazier EH. Microbiology of mediastinitis. Arch Intern Med. 1996 Feb 12;156(3):333-6. Erratum in: Arch Intern Med 1996 May 27;156(10):1112. PMID: 8572845. REFERENCE #3: Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg. 2010 Mar;251(3):528-34. doi: 10.1097/SLA.0b013e3181c1b0d1. PMID: 19858699. DISCLOSURES: No relevant relationships by Rana Hejal, source=Web Response No relevant relationships by Willie McClure, source=Web Response No relevant relationships by Tanmay Panchabhai, source=Web Response No relevant relationships by Layla Sankari, source=Web Response No relevant relationships by Apoorwa Thati, source=Web Response

Large Cervical Osteophytes Mimicking a Hypopharyngeal Neoplasm

Hypertrophic anterior osteophytes of the vertebrae affecting the anterior longitudinal ligament of the spine are typical of diffuse idiopathic skeletal hyperostosis (DISH), a spinal disorder of the elderly also known as Forestier Disease, from the name of the first author who reported it in 1950. Usually, patients are asymptomatic or have mild dysphagia, due to compression of the digestive tract but less commonly can have acute dyspnea requiring to secure the airway has been rarely reported. Diagnosis is usually obtained with radiologic exams that reveal a bony mass. In some cases, fibrosis and inflammation due to the constant movement of the cricoid lamina over a projecting osteophyte are also seen with the CT Scan. In this paper, we describe a distinct entity of a giant lesion of the cervical spine that appeared as a pseudotumor of cervical soft tissue and caused acute upper airway obstruction requiring emergency tracheostomy. Details of his clinical examination, radiologic imaging, and surgical management are provided and discussed.

The Contentious Management of Anaplastic Thyroid Carcinoma with Acute Airway Obstruction during COVID-19 Pandemic

There are many important concerns and issues raised in managing acute airway obstruction cases with regards to the current COVID-19 pandemic. As a further matter, a patient with a huge thyroid mass in anaplastic thyroid carcinoma (ATC) presenting with impending airway obstruction poses treatment challenges, as immediate active intervention is necessary despite the risk of spreading of COVID-19 viruses. The unknown status of COVID-19 of the patient will add additional concerns during active assessment and treatment as patients with this undifferentiated thyroid carcinoma commonly deteriorate fast. This carcinoma may also invade the trachea and result in upper airway obstruction leading to a fatal outcome. Therefore, an appropriate treatment strategy is essential. This report highlights a case of an ATC patient who presented with diffuse cemented-hard anterior neck, whereby the whole management of ATC with acute airway obstruction during this COVID-19 pandemic is purely contentious and challenging. The issue of providing artificial ventilation either via intubation or tracheostomy is made more complicated as the patient presents with an acute upper airway obstruction whilst the COVID-19 status is unknown. While endotracheal intubation approach was not easy, the trachea was also difficult to be identified externally due to the huge ‘cemented-hard’ mass plastered over the compressed trachea. Due to the advanced disease, surgical intervention was not an option.

A Case Report: Probably Concurrent Nasogastric Tube Syndrome and Cerebrovascular Disease in a Postoperative Patient

Nasogastric tube syndrome (NTS) is characterized by acute upper airway obstruction due to bilateral vocal cord paralysis. Although NTS is a rare cause of vocal cord paralysis, it has the potential of causing serious morbidities even mortality. We here with present a case of concurrent NTS and cerebrovascular disease patient. 73 year-old male was admitted to our university hospital emergency department with acute respiratory distress and stridor days after his cholecystectomy operation and laryngoscopy showed bilateral vocal cord paralysis. The patient was admitted to the intensive care unit (ICU) and urgent tracheotomy was performed. On the day after his discharge from the hospital, his vocal cord movements fully recovered state. Nasogastric tube syndrome can be considered in patient who complains because of acute upper airway obstruction with nasogastric tube inserted. Thinking NTS early may be reducing the complication rate.

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Acute Upper Airway Obstruction Secondary to Retained Respiratory Secretions in a Patient with SARS-CoV-2 Respiratory Failure Treated with Prolonged CPAP

SARS-CoV-2 is a novel coronavirus which can cause respiratory failure requiring ventilatory support. We describe the first documented case of life-threatening upper airway obstruction due to retained secretions around a nasogastric (NG) tube in a patient suffering from this disease who was managed with prolonged continuous positive airways pressure (CPAP). This case highlights the need for awareness around the development of an upper airway mass due to tenacious secretions in SARS-CoV-2 positive patients and the need to develop preventative strategies in order to prevent avoidable mortality. Keywords: Airway obstruction; CPAP; SARS-CoV-2; Coronavirus; Nasogastric tube; Non-invasive ventilation.

Ultrasound-guided superior laryngeal nerve block - A description of the technique

Complications in airway management remain a common cause of anesthesia-associated mortality. When a patient is considered with anticipated difficult airway, the management depends on several variables, however, at present, the standard of management continues to be the patient awake approach. In scenarios of acute upper airway obstruction, the only way to guarantee adequate ventilation is to obtain a translaryngeal or transtracheal access, for which, it is necessary to use local anesthesia and grade I / II sedation, avoiding loss of spontaneous ventilation. For this purpose, we propose ultrasound-guided superior laryngeal nerve block, in order to standardize an ultrasound landmark that is reproduceable, with a high success rate, which allows limiting complications related to regional anatomic techniques and thus facilitating the securing of the airway in these patients.

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

Critical upper airway obstruction as the first symptom of acute myeloid leukemia - an anesthesiologic reminder.

Acute upper airway obstruction can be fatal. Early recognition of airway distress followed by diagnostic laryngoscopy and prompt intervention to secure airway control is crucial. We here present a 62-year old male patient who presented with cough and increasing respiratory distress for three weeks. Within the next 24 h, he developed symptoms of critical upper airway obstruction, endotracheal intubation was not possible, and an acute surgical tracheotomy was performed to retain patent airways. A computer tomography scan revealed severe laryngopharyngeal soft tissue thickening and upper airway obstruction caused by leukemic infiltration. He was diagnosed with acute leukemia and responded to induction chemotherapy. This case report points out the importance of establishing the diagnosis of critical upper airway obstruction in patients presenting with respiratory symptoms, and highlights the emergency management of airway obstruction due to malignant infiltration of leukemic blasts. laryngotracheal trauma, bleeding, tonsillar hypertrophy, paralysis of the vocal cords or folds, allergic reactions, and acute infections affecting the upper respiratory tract.1 We present a 62-year old male patient with cough and increasing respiratory distress for the last three weeks. Within 24 h in hospital, he developed symptoms of critical upper airway obstruction. Endotracheal intubation with the patient awakes and selfbreathing using a fiber optic scope was not possible, thus an acute surgical tracheotomy was performed to retain patent airways. Acute myeloid leukemia (AML) with leukemic infiltrations of the upper airways was found to be the underlying cause.

Effects of COVID-19 Pandemic on Otolaryngology Surgery in Italy: The Experience of Our University Hospital.

Otolaryngology and head and neck surgery underwent drastic changes during the COVID-19 pandemic. Since March 10, the first day of the lockdown in Italy, diagnostic and therapeutic procedures were limited to emergency and oncology cases, while outpatient procedures and clinical examinations were temporarily suspended to limit virus diffusion and to reallocate personnel into wards dedicated to COVID-19. In our otolaryngology unit, between March 10 and April 28, 2020, we performed 96 surgical procedures; they mainly consisted in diagnosis and treatment of malignant tumors of the head and neck (77%), management of acute upper airway obstruction in adults and children (14.7%), drainage of abscesses of the head and neck (6.2%), and treatment of nasal bone fractures (2.1%). When comparing these data with those of the same period in 2019 for emergency and oncology procedures, we noticed a drastic reduction of head and neck abscesses and nasal bone fractures, while oncology surgery remained stable.