Case Of Upper Airway Obstruction Research Articles

Tracheoesophageal malformation: Pathogenetic evidence provided by two cases

Background The aim of this observational study is to examine cases of upper respiratory atresia, in an effort to seek pathogenetic evidence suggestive of either a primary defect in embryogenesis or of a secondary etiology. Methods Archival material of 412 fetal and perinatal autopsies with congenital malformations was reviewed in an effort to identify infants with complete upper airway obstruction without tracheoesophageal (TE) communication. Histological sections of the upper and lower respiratory tract were examined, seeking evidence of previous amniotic fluid or meconium aspiration, indicated by the presence of amniotic squamous epithelial cells, lanugo hair, or bile-stained meconium in the airways. Immunohistochemical stain for epithelial membrane antigen (EMA) and high-molecular-weight cytokeratin (CK1) were used to identify amniotic fluid and keratinizing squamous epithelial cells. Results Eight infants with upper airway obstruction were identified, three of them without a TE communication. Two of the latter, one infant with multiple atresia born at 34 weeks gestation and another with tracheal atresia born at 32 weeks, presented evidence of amniotic fluid aspiration in their lungs. Conclusions Evidence of amniotic fluid aspiration in the above two cases indicates that there had been a previous patency of the upper respiratory pathway, since the absence of a TE fistula excludes any communication with the oronasal cavity. This implicates a secondary pathogenesis for at least some cases of upper airway obstruction. Teratology 63:11–14, 2001. © 2001 Wiley-Liss, Inc.

Case report: an unusal cause of stridor in a post-liver transplant 6-year old

Polymorphic lymphoproliferative disorder is a recognised cause of upper airway obstruction in children [N. Sculerati, M. Arriga, Ann. Otol. Rhinol. Laryngol 99 (1990) 445–450]. It is associated with long-term immunosuppression therapy and frequently with Epstein–Barr virus (EBV) infection [D.W. Hanto, Annu. Rev. Med. 46 (1995) 381–394; B.D. Fletcher, H.E. Heslop, H.C. Kaste, S. Bodner, Upper airway obstruction and pulmonary abnormalities due to lymphoproliferative disease following bone marrow transplantation in children, Pediatr. Radiol. 28 (1998) 492–496]. The prevalence in reported series ranges from 4 to 13% among post-transplant children [M. Ho, R. Jaffe, G. Miller, Transplantation 45 (1988) 719–727; G.B. Hammer, S. Cao, M.G. Boltz, A. Messner, Anesthesiology 89 (1998) 263–265; B.V. Lattyak, P. Rosenthal, Post-transplant lymphoproliferative disorder presenting in the head and neck, Laryngoscope 108 (1998) 1195–1198]. This condition may present in the transplanted allograft, the gastrointestinal tract, the head and neck, and in particular in the upper airway. Previously reported cases of upper airway obstruction have been in the supraglottis, Waldeyer's ring, the glottis, and one case of an intra tracheal mass [M. Ho, R. Jaffe, G. Miller, Transplantation 45 (1988) 719–727; G.B. Hammer, S. Cao, M.G. Boltz, A. Messner, Anesthesiology 89 (1998) 263–265]. We report a case of post-transplant lymphoproliferative disorder in the sub-glottis causing acute upper airway obstruction with negative (EBV) serology.

後咽頭間隙血腫による遅発性上気道閉塞

Mechanical upper airway obstruction following a retropharyngeal hematoma is a life-threatening. We present a rare case of upper airway obstruction from a retropharyngeal hematoma in a patient with minor head and neck injuries. An 82-year-old man who had fallen from the roof of his house was transferred to the emergency department of our facility. He had a minor head injury, but retained consciousness. A computed tomographic (CT) scan and radiographs of his head and neck revealed no fracture. Six hours later, the patient complained of dyspnea and was again transferred to the emergency department. Extensive cervical swelling was noted. Emergency orotracheal intubation was performed for his severe stridor, cyanosis and dyspnea. CT scan and MRI revealed that a massive hematoma had developed in the retropharyngeal space. A few days later, the endotracheal tube was extubated; however, he again complained of difficulty in breathing, and swelling of his retropharynx made reintubation difficult. The patient underwent tracheostomy after reintubation using bronchoscopy. The retropharyngeal hematoma spontaneously resolved in about 4 weeks, after which the patient was discharged in good condition. In trauma patients with upper airway obstruction, we should include examination for retropharyngeal hematoma. The importance of airway assessment in a patient with even minor head and neck injuries should be seriously considered.

A rare case of upper airway obstruction in an infant caused by basal encephalocele complicating facial midline deformity

A four-month-old male infant with basal encephalocele of the transsphenoidal type presented with upper airway obstruction and facial midline deformity, including cleft lip, cleft palate, hypertelorism and exophthalmos. Basal encephalocele is a rare disease, and usually not detectable from the outside. In this case, initially the cause of an upper airway obstruction was considered to be posterior rhinostenosis, and posterior rhinoplasty with inferior nasal conchectomy was scheduled. However, in preoperative examination, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a bony defect in the sphenoidal bone and a cystic mass in communication with cerebrospinal fluid, herniating into the nasal cavity through the bony defect. The mass was diagnosed as a transsphenoidal encephalocele, the scheduled operation cancelled, and tracheostomy performed for airway management. The possibility of basal encephalocele should be considered in the case of upper airway obstruction with facial midline deformity.

A rare case of upper airway obstruction in an infant caused by basal encephalocele complicating facial midline deformity

A rare case of upper airway obstruction in an infant caused by basal encephalocele complicating facial midline deformity

Upper airway obstruction after transesophageal echocardiography

Although transesophageal echocardiography is considered a generally safe procedure, occasional complications have been reported. Serious esophageal trauma and Mallory Weiss tear have been described, as well as post-transesophageal echocardiography dysphagia. However, to our knowledge, upper airway and esophageal obstruction have not been previously cited. A case of upper airway obstruction resulting from a transesophageal echocardiography procedure is herein detailed.

Acute upper airway obstruction in infancy and childhood — A study of 80 cases

Eighty cases of upper airway obstruction were studied as regards to aetiopathology and their management. Their age ranged from 0– 5 years. Higher incidence was observed among male children below 3 years, and during winter months. Tracheostomy rather than endotracheal intubation was found to be the most useful procedure along with steroid therapy in managing severe obstruction. Direct laryngoscopy with clinical correlation was sufficient in most of the cases in predicting the cause of respiratory distress so as to decide the appropriate therapy. Children with respiratory failure at the time of admission had poorest prognosis, but the overall mortality rate is very minimal.

Myasthenia Gravis and Upper Airway Obstruction

Respiratory impairment in myasthenia gravis is usually attributed to weakness of the diaphragm and thoracic chest wall muscles, and is rarely attributed to upper airway obstruction. Myasthenia gravis is characterized by weakness of the striated muscles and usually affects those innervated by the bulbar cranial nerves. Weakness of these bulbar and upper airway muscles can lead to upper airway obstruction. To our knowledge, there are only five case reports in the literature associating upper airway obstruction with myasthenia gravis. Therefore, we attempted to further define its occurrence in myasthenia gravis patients by reviewing their flow volume loops. We present a case of upper airway obstruction causing respiratory symptoms in a myasthenia gravis patient. We then surveyed a total of 61 patients with myasthenia gravis who were tested in our pulmonary function laboratory between February 1990 and August 1993. Of these 61 patients, 12 had flow volume loops and 7 of these 12 disclosed a pattern of extrathoracic upper airway obstruction. The FVC was 80% or more in five of seven patients. Our data suggest that upper airway obstruction is much more common in patients with myasthenia gravis than previously recognized. In conclusion, we recommend the performance of flow volume loops in patients with myasthenia gravis to evaluate their respiratory impairment.

Massive lingual swelling following palatoplasty

We report a case of upper airway obstruction as a result of delayed massive lingual swelling following routine cleft palate repair in an otherwise healthy 12-month-old girl. We believe that ischaemia and venous congestion were the causes of macroglossia, after prolonged use of the Digman Dott tongue retractor. In any difficult and lengthy repair, we recommend the prophylactic insertion of a nasopharyngeal airway under direct vision by the surgeons after surgery to prevent potential upper airway obstruction.

Bilateral Laryngoceles

The authors present an unusual case of upper airway obstruction due to the presence of bilateral communicating laryngoceles. The use of aspiration techniques on the larger of the laryngoceles resulted in a significant improvement in upper airway function. This improvement avoided the need for a tracheostomy or intubation under potentially hazardous circumstances and allowed the eventual surgery to take place in more controlled conditions.

Lingual artery hematoma resulting in upper airway obstruction

A case of upper airway obstruction from a lingual artery hematoma after suturing of a puncture wound to the tongue is reported. The anatomy of the tongue and upper airway is reviewed to better understand the mechanism of obstruction. The emergency physician should be aware of this rare and potentially lethal complication to what might initially seem to be a trivial injury.

Obstruction des voies aériennes par hernie du ballonnet de la sonde d'intubation au cours d'inhalation de protoxyde d'azote

A typical case of upper airway obstruction due to deformation of a low pressure tracheal tube cuff is reported. It would seem that this herniation may have been due to nitrous oxide diffusing withing the air-filled cuff, thereby causing it to overdistend. This increase in pressure occurred after 3 hours of inhalation of a mixture of oxygen and nitrous oxide. The deformed cuff may either block the lumen at the end of the tube, or push the tube against the tracheal wall. The result is, in either case, a mechanical obstruction of the airway, with hypoxia, and then anoxia. In the reported case, it was the decrease of SpO 2 which alerted the anaesthetist. Pulse oximetry was helpful for an early diagnosis. To avoid such accidents, it is suggested either to inflate the cuff with the gas mixture with which the patient is ventilated, or to deflate it every 30 min.

Dystonia presenting as upper airway obstruction

Dystonic extrapyramidal reactions due to neuroleptic medications are a common entity in emergency medicine. However, it is not widely reported that dystonia can be associated with airway compromise and death. We describe a case of upper airway obstruction due to a dystonic reaction to haloperidol, present radiographic evidence of airway compromise, and explain the physiologic mechanisms involved.

Management of Upper Airway Obstruction

The tongue is the most common cause of upper airway obstruction, a situation seen most often in patients who are comatose or who have suffered cardiopulmonary arrest. Other common causes of upper airway obstruction include edema of the oropharynx and larynx, trauma, foreign body, and infection. The management of the patient with upper airway obstruction depends upon the cause of the obstruction, the training and skills of the rescuer, and the availability of adjuncts necessary to perform advanced airway techniques. In most cases, merely positioning the patient or performing one of the three maneuvers designed to elevate the tongue will open the airway of the comatose patient or the victim of cardiac arrest. In patients with suspected foreign body obstruction, abdominal or chest compression should be performed immediately, with digital extraction of the foreign body reserved for those in whom these maneuvers are unsuccessful. Most patients with obstruction secondary to edema, trauma, or infection can be managed initially with orotracheal or nasotracheal intubation. Intubation should be attempted prior to surgical management of the airway in most cases of upper airway obstruction. Occasionally, however, cricothyroidotomy or tracheostomy is necessary to establish an airway. The choice of technique depends primarily on the experience and skills of the rescuing physician or paramedic. In most cases, cricothyroidotomy is technically more simple and more easily performed than tracheotomy, especially for the physician who has not been trained in surgery or otolaryngology and for the nonphysician rescuer. No matter what the method employed in establishing an airway in a patient with upper airway obstruction, it must be performed quickly and a source of ventilation provided for the patient once the airway has been secured.

Hyperreactivity to cow milk in young children with pulmonary hemosiderosis and cor pulmonale secondary to nasopharyngeal obstruction

Six black infants and young children with high titers of milk precipitins were identified by screening the sera of 160 children with idiopathic chronic lung disease. None of the six had immunoglobulin deficiency, elevation of sweat chlorides, SS hemoglobin, or recurrent aspiration. All six children had typical manifestations of milk-induced pulmonary hemosiderosis: recurrent pulmonary infiltrates (6/6), hemosiderin-laden pulmonary macrophages (5/6), intermittent wheezing (5/6), eosinophilia (4/6), anemia (4/6), iron deficiency (4/4), failure to thrive (4/6), and elevated levels of serum IgE (4/4). Three children also had chronic rhinitis and eventually developed large adenoids, hypercapnia and acidosis during sleep, and right heart failure. Elimination of cow milk from the diet, symptomatic therapy, and adenoidectomy when indicated resulted in improvement of all six patients. Pulmonary hemosiderosis and some cases of upper airway obstruction with pulmonary hypertension appear to be two stages, early and delayed, of the same immunophysiologic process. Early dietary intervention may prevent the cardiovascular complications of this process.

AIRWAY OBSTRUCTION IN INFECTIOUS MONONUCLEOSIS.

Upper airway obstruction in children often presents interesting and unusual problems. Severe obstruction resulting from profound hyperplasia of Waldeyer's ring is unusual whereas mild obstruction is common. The case to be presented is one of profound obstruction, secondary to infectious mononucleosis, necessitating an emergency tonsillectomy and adenoidectomy. A 20-year review of the available literature uncovered a number of cases of upper airway obstruction of various etiologies.7,8Johnson1in 1944 reported the first two proven cases of infectious mononucleosis in the Negro. One of these had an anginose obstruction. The Negro child was having intermittent respiratory distress, and tracheotomy was thought necessary on several occasions. The first case of surgical intervention, a tracheotomy was reported by Jones and Jones2in 1949. Librach3in 1951 presented one case of obstruction due to infectious mononucleosis and reviewed six others, all of which were treated with tracheotomy. In 1953 a