Impending Airway Obstruction Research Articles

Necrotizing Laryngitis in Patients with Hematologic Disease: The First Case-Report Due to PDR Acinetobacter baumannii and Literature Review.

Immunocompromised patients with hematologic diseases may experience life-threatening infections with rather uncommon manifestations. Laryngitis has been described as a potential infection in such vulnerable patients and may result in major complications, ranging from impending airway obstruction to total laryngeal necrosis. Immediate laryngoscopy is of paramount importance, as it provides quantification of laryngeal edema and evidence of necrosis. Documentation of the causative pathogen is usually feasible through tissue culture. In the literature, 14 cases of necrotizing laryngitis have already been published. Here, we present the case of a 38-year-old male with a recent diagnosis of multiple myeloma, who received the first cycle of therapy a few days before admission. The patient presented with neutropenic fever, diarrhea, and multiple organ dysfunction. His course was complicated with hemophagocytic lymphohistiocytosis and stridor. A diagnosis of necrotizing laryngitis attributed to Acinetobacter baumannii invasion of the larynx was established. This manuscript highlights that the management of patients with hematologic disease and necrotizing laryngitis should be coordinated in highly specialized centers and clinicians should have a high level of clinical suspicion and act promptly.

Migrated oesophageal foreign body retrieval with trans cervical approach in a district general hospital of Sri Lanka

A 53-year-old previously healthy patient presentated with an impending airway obstruction due to a retropharyngeal and a para-oesophageal abscess caused by a delayed impacted foreign body,failed retrieval with rigid oesophagosopy. The patient was successfully managed by exploration of the neck with trance cervical approach in a district general hospital setting. Awareness and early referral from primary care setting could have prevented a potentially life threatening complication.

Airway management in a morbidly obese patient with impending airway obstruction

Peritonsillar abscess is not an uncommon referral to the otorhinolaryngology team. Treatment entails incision and drainage, followed by antibiotics. Emergent treatment is required to avoid complications such as extension into deep neck spaces, like retropharyngeal and danger space, which may result in spread into the mediastinum and airway obstruction. Herein, we describe peritonsillar abscess management in a morbidly obese woman who presented with peritonsillar abscess with impending airway obstruction. We highlight the importance of multidisciplinary team involvement in managing the difficult airway as well as the preparedness of the difficult airway team.

Profile of tracheotomy patients at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia

Link of Video Abstract: https://youtu.be/YsAWA4NoiPw Background: The tracheotomy profile, including the degree of airway obstruction, underlying disease, following procedures, and complications, is important. The latest data regarding the profile of tracheotomy patients at ORL-HNS Dr. Soetomo General Academic Hospital has not been published yet. This research to describe the profile of tracheotomy patients at ORL-HNS Department Dr. Soetomo General Academic Hospital, Surabaya Methods: A retrospective descriptive study with total sampling covering tracheotomy patients in 2015-1019 at ORL-HNS Department Dr. Soetomo General Academic Hospital, Surabaya. Data were analyzed using SPSS version 23.0 for Windows. Result: There were 590 tracheotomy patients consisting of 452 men and 138 women, with the largest age group of 51-60 years with 167 patients (28.31%). Jackson 1 in 306 (51.86%), impending upper airway obstruction in 209 (35.42%), Jackson 2 in 38 (6.44%), Jackson 3 in 31 patients (5.25%), Jackson 4 in 3 patients (0.51%). The diagnosis includes tumors (87.29%), especially laryngeal carcinoma, then infection, neurological, trauma, and others. Procedures following tracheotomy are biopsies (11.19%), tumor surgery, and abscess incision and drainage. Complications were found in 65 patients (11.02%). Subcutaneous emphysema in 45 patients (7.63%), followed by bleeding and pneumothorax with subcutaneous emphysema (1.02%), 5 died (0.85%). Subcutaneous emphysema and bleeding in 2 patients (0.34%). Pneumothorax without subcutaneous emphysema in 1 patient (0.17%). Conclusions: There were more male tracheotomy patients than female. The age group of most patients was 51-60 years. The majority were Jackson 1, and most were diagnosed with tumors. A biopsy is the most following procedure in tracheotomy. Complications were found in 11.02% of tracheotomy patients; the most common is subcutaneous emphysema.

Acquired angioedema late in the course of nivolumab treatment.

Although programmed cell death-1 inhibitors have become the mainstay of treatment for many cancers, their use can at times be accompanied by unusual side effects. We describe herein a 43-year-old patient with Lynch syndrome and colon cancer who developed facial swelling 18 months after starting nivolumab therapy. Our patient also experienced a grade 1 maculopapular rash due to this agent. Naranjo nomogram assessment showed a probable causality between nivolumab and angioedema (score of 8). Given the modest intensity of symptoms and the excellent response of metastatic colon cancer to nivolumab, this agent was continued without interruptions. She was prescribed prednisone 20 mg orally daily as needed to be taken if the swelling progressed, or if respiratory symptoms developed. The patient experienced another two similar episodes over the next months; however, they were self-limiting and did not require steroids. Subsequently, she had no further similar symptoms. Rare reports of angioedema associated with immune checkpoint inhibitor (ICI) treatment have previously been described. The exact mechanism of these phenomena is unknown, but bradykinin release leading to increased vascular permeability might be involved. Clinicians, pharmacists, and patients should be aware of this rare side effect of ICIs as it can be life-threatening when involving the respiratory tract and causing impending airway obstruction.

Corticosteroids for infectious mononucleosis

Infectious mononucleosis (IM) is a common viral infection year round, and we see patients with it in our family medicine clinic frequently. With fatigue, fever, pharyngitis, and cervical or generalized lymphadenopathy causing prolonged illness and school absences, we always look for treatments that will shorten the duration of symptoms. Does treatment with corticosteroids benefit these children? Current evidence points to small and inconsistent benefits when using corticosteroids for symptom relief in children with IM. Corticosteroids alone or in combination with antiviral medications should not be given to children for common symptoms of IM. Corticosteroids should be reserved for those with impending airway obstruction, autoimmune complications, or other severe circumstances.

Angioedema in the emergency department

Acute angioedema is mostly found in the head and neck region. Therefore, it can be life threatening by potentially endangering air way patency. Pathophysiologically angioedemas can be divided into mast cell-mediated or bradykinin-mediated forms. Differentiation is essential due to the different therapeutic strategies. In cases of doubt, initial therapy with adrenalin, antihistamines, and glucocorticoids should be initiated. This initial emergency treatment is comparable to the treatment of allergic reactions. For diagnosed or suspected hereditary angioedema, specific treatments are available. For drug-associated forms, immediate and life-long cessation of the medication is crucial. In the emergency situation, diagnosis can only be based on medical history and clinical symptoms. Recognition of impending airway obstruction and securing the airway is of highest priority; final diagnosis must be confirmed later.

Airway Obstruction from Intralaryngeal Extension of Thyroglossal Duct Cyst in an Elderly Man: A Case Report


 
 
 
 ABSTRACTObjective: To report an unusual presentation of thyroglossal duct cyst causing airway obstruction in an elderly man.
 
 
 
 
 Methods:
 Design: Case Report
 Setting: Tertiary Government Training Hospital
 Patient: One
 
 
 
 
 Results: A 71-year-old man with an anterior neck mass was brought to the Emergency Room due to progressive difficulty of breathing. A smooth, non-ulcerating right supraglottic mass obstructed the airway. Following an emergency high tracheotomy, contrast computed tomography scan of the neck revealed a hypodense mass with peripheral rim enhancement in the right supraglottis and an extralaryngeal component. Intra-operatively, a dumbbell- shaped cystic mass with a tract connected to the hyoid bone led to a Sistrunk procedure. Final histopathology findings were consistent with thyroglossal duct cyst.
 
 
 
 
 Conclusion: It is possible for an elderly patient with impending upper airway obstruction, dysphonia, and neck mass to still have a benign and congenital thyroglossal duct cyst with intralaryngeal extension.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Laryngeal Trauma, Its Types, and Management.

Laryngotracheal wounds are rare; however, they have a significant mortality rate. These wounds can be blunt or penetrating. Usually, the larynx is protected from blunt trauma by the sternum and jaw. A "clothesline" injury happens when the exposed neck is struck by a hard object, such as a wall wire or tree branch, or when an attack is intended to damage the larynx. Additionally, injuries may occur when the neck is stressed due to damage, such as in a rear-end accident that causes a whiplash-like injury or when the larynx is intentionally targeted for harm. Penetrating neck trauma may result in injury to the larynx. Assume a patient has suffered a penetrating or severe neck injury. It is usually evident from their medical history or a quick trauma evaluation in that case. However, it is recommended to be cautious for anterior neck injuries in general and to have a low threshold for establishing a surgical airway. The priority is securing an airway when a patient with a laryngeal injury arrives in the emergency room. The operating surgeon may request any flexible laryngoscopy, computed tomography (CT), esophagram, and chest X-ray for additional examination, depending on the nature of the damage and the patient's health. After the examination, the initial step in treating laryngeal injuries should be to locate and secure the airway. According to the evaluation and management based on the Schaefer classification system for laryngeal injury, the patient is treated based on whether the patient has impending airway obstruction or a stable airway. Medical management or observation and surgical management depend on the site and severity of the injury, patient condition, and type of injury. There are several complications related to laryngotracheal trauma, which can be minor or even fatal. Following successful treatment, postoperative and rehabilitative care, vocal rest, speech therapy, and swallowing therapy may be necessary.

DOUBLE TROUBLE: CENTRAL AIRWAY OBSTRUCTION WITH HEMOPTYSIS FROM A METASTATIC YOLK SAC TUMOR

DOUBLE TROUBLE: CENTRAL AIRWAY OBSTRUCTION WITH HEMOPTYSIS FROM A METASTATIC YOLK SAC TUMOR

Pharyngeal Lipoma-A Potentially Life Threatening Presentation.

Pharyngeal lipoma of the upper aero-digestive system is extremely rare. It is typically benign, slow growing and symptoms would depend on its size and location. Surgical intervention is often needed especially for large tumour with impending airway obstruction. Here we present a case of potentially life threatening presentation of pharyngeal lipoma.

Huge Obstructive Multinodular Goitre in a Pregnant Lady With Pre -Eclampsia: A Therapeutic Dilemma

In pregnancy there are changes in regulation of thyroid hormone that can affect hypothalamic pituitary thyroid axis. This goitrogenic stimulation can lead to enlargement of thyroid gland. We present a case of 37-year-old woman gravida 4, para 3 at 27-week gestation, who was referred for management of a huge multinodular goitre with impending upper airway obstruction. Severe pre-eclampsia made airway narrower due to oedema at pharyngeal and glottic region. In case of no life-threatening airway, surgery can be electively performed after delivery as to avoid preterm labour. However, if emergency lower segment caesarean section is needed, preferably it to be done under regional anaesthesia in severe preeclampsia cases. If this fails, general anaesthesia may be required with awake fiberoptic, jet ventilation and bronchoscopy standby in case of difficult intubation due to constricted airway. Our patient underwent emergency lower segment caesarean section under spinal anaesthesia at 31 weeks gestation due to severe pre-eclampsia. Right hemithyroidectomy was done three months postnatal. Obstructive symptoms resolved after operation.International Journal of Human and Health Sciences Vol. 05 No. 04 October’21 Page: 514-518

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.

Epiglottic abscess as a rare cause of muffled voice

A 42-year-old male presented with fever and symptoms of impending upper airway obstruction on the day of presentation. He required immediate intubation due to swollen epiglottis. The condition responded to antibiotic and steroids, and he was able to be extubated after 3 days. Two days later, however, the epiglottis started to swell up again, this time with pus discharge. Emergency exploration and drainage of the epiglottic abscess were executed, and the patient was kept intubated for a few days afterwards for the swollen epiglottis to reduce in size. Daily flexible laryngoscopy was commenced to monitor the disease status. After completing the antibiotic therapy the patient was discharged in good general condition.

Laryngeal diphtheria: still a problem

<p class="abstract"><strong>Background:</strong> Globally diphtheria has been showing a declining trend due to effective childhood vaccination programmes. However, inadequate healthcare delivery systems and other social factors have led to diphtheria re-emerging and remaining endemic in many regions of the world. Securing airway by emergency tracheostomy plays a pivotal role in the management of laryngeal diphtheria in addition to antitoxin.</p><p class="abstract"><strong>Methods:</strong> This was a retrospective study conducted in Department of ENT, Maulana Azad Medical College from January 2015 to December 2018. The study included cases of diphtheria with stridor or impending airway obstruction. The information collected included age, gender, socioeconomic status and immunization status. The month of presentation was noted to establish the seasonal trend of the infection. </p><p class="abstract"><strong>Results:</strong> Maximum number of cases was in the age group of 3 to 9 years (62.3% of total cases). Male children predominated over female children with overall sex ratio of 3:1. Most of the cases presenting to us were partially immunized (51.8%) or unimmunized (44.6%). The maximum number of cases was reported in the month of August to November (96 out of 122 cases). Emergency tracheostomy was done in 86.9% (106 out of 122 cases).</p><p class="abstract"><strong>Conclusions:</strong> Diphtheria still continues to be a major public health issue in India. Early recognition and treatment are necessary to prevent morbidities and mortalities. Tracheostomy is a speedy and efficient lifesaving procedure in the management of laryngeal diphtheria.</p><p class="abstract"> </p>

Medical Management of Epiglottitis.

Epiglottitis is most commonly caused by bacterial infection resulting in inflammation and edema of the epiglottis and neighboring supraglottic structures. Acute infection was once found predominantly in children ages 2 to 6 years old, but with the introduction of the Haemophilus influenzae B (HiB) vaccine the incidence of cases in adults is increasing. Typical clinical presentation of epiglottitis includes fever and sore throat. Evidence of impending airway obstruction may be demonstrated by muffled voice, drooling, tripod position, and stridor. Radiographs can be helpful in diagnosing epiglottitis; however, they should not supersede or postpone securing the airway. An airway specialist such as an otolaryngologist, anesthesiologist, or intensivist should ideally evaluate the patient immediately to give ample time for preparing to secure the airway if necessary. All patients with epiglottitis should be admitted to the intensive care unit for close monitoring.

Complete Surgical Resection Following Neoadjuvant Dabrafenib Plus Trametinib in BRAFV600E-Mutated Anaplastic Thyroid Carcinoma.

Background: When achieved, complete surgical resection improves outcomes in anaplastic thyroid carcinoma (ATC). However, most ATC patients present with advanced inoperable disease, often with impending airway obstruction, increased hemorrhage risk, and significant dysphagia. Novel treatment strategies are critically needed to improve disease control and decrease locoregional morbidity. The objective of this study was to determine the feasibility and effectiveness of a neoadjuvant regimen by using dabrafenib with trametinib followed by surgical resection in patients with initially unresectable BRAFV600E-mutated ATC.Methods: Case series of six consecutive patients with BRAFV600E-mutated ATC diagnosed between January 2017 and February 2018. Pathologic confirmation of ATC was obtained before treatment. BRAFV600E status was ascertained via immunohistochemistry or sequencing of circulating tumor DNA. All patients received dabrafenib and trametinib (DT) followed by surgical resection and adjuvant chemoradiation. Three patients also received pembrolizumab.Results: Complete surgical resection was achieved in all patients. Histopathologic analyses of resected specimens showed high pathologic response rates with significantly decreased ATC viability and residual papillary thyroid carcinoma components. Overall survival at six months and one year was 100% and 83%, respectively. Locoregional control rate was 100%. Two patients died of distant metastases without evidence of locoregional disease at 8 and 14 months from diagnosis. The remaining four patients had no evidence of disease at the last follow-up.Conclusions: We report the first series in the literature of BRAFV600E-mutated ATC patients with locoregionally advanced disease treated with DT followed by surgical resection. We demonstrated feasibility of complete resection, decreased need for tracheostomy, high pathologic response rates, and durable locoregional control with symptom amelioration.

Beware of thermal epiglottis! A case report describing \u2018teapot syndrome\u2019

BackgroundThe type of scalding injury known as ‘teapot syndrome’, where hot liquid is grabbed by the child with the aim of ingestion and falls over a child causing burns on the face, upper thorax and arms, is known to cause peri-oral and facial oedema. Thermal epiglottitis following scalds to face, neck and thorax is rare and can occur even in absence of ingestion of a damaging agent or intraoral burns, Awareness of the possibility of thermal epiglottitis, also in scald burns, is imperative to ensure prompt airway protection.Case presentationWe report the case of a child with thermal epiglottitis after a scalding burn from boiling milk resulting in mixed deep burns of the face, neck and chest, but no history of ingestion. Upon presentation there was a progressive stridor and signs of respiratory distress requiring intubation. Laryngoscopy revealed epiglottis oedema, confirming the diagnosis of thermal epiglottitis. Final extubation took place 5 days after initial burn.ConclusionsThermal epiglottitis following scalds to face, neck and thorax is rare and can occur even in absence of ingestion and intra-oral damage. Burns to the peri-oral area should raise suspicion of additional damage to oral cavity and supraglottic structures, even in absence of intra-oral injury or initial respiratory distress. Awareness of the occurrence of thermal epiglottitis in absence of intra-oral injury is important to diagnose impending upper airway obstruction requiring intubation.

Lingual Abscess: Predisposing Factors, Pathophysiology, Clinical Manifestations, Diagnosis, and Management.

Lingual abscess is a rare disorder, and current knowledge regarding clinical manifestations and treatment modalities has not been well established. This study presented 6 cases of lingual abscess patients between January 2012 and December 2017. There were three men and three women. Median age was 54 years. Odynophagia and local pain were the common presenting symptoms. Local trauma was the main predisposing factor of anterior abscess, while lingual tonsillitis or infected thyroglossal cyst was the predisposing factor of posterior abscess. An impending airway obstruction was identified in two patients, requiring tracheostomy. All patients achieved an excellent outcome with a combination of surgical drainage and proper antibiotics as well as using proper investigation for detecting unusual areas of lingual abscess. According to the data from the study's results and review of the relevant literature, an abscess located at the anterior two-thirds of the tongue is easy to diagnose while the posterior one-third of the tongue abscess is relative difficulty. Using contrast-enhanced computed tomography increases diagnostic accuracy, especially on the tongue base and deep space infection. The management strategies include (1) protecting the airway, (2) draining the abscess by needle aspiration or surgery, and (3) administering antibiotics early. Our series showed a superiority of surgical drainage when the patients present with marked tissue edema, deep loculated infection, and airway obstruction.

SKULL-BASE MENINGOENCEPHALOCELE PRESENTING AS A LABIOGNATOPALATOSCHIZIS AND BILATERAL MACROSTOMIA ON IMPENDING PARTIAL AIRWAY OBSTRUCTION IN A NEONATE

A unique skull-base meningoencephalocele presenting as a labiognatopalatoschizis and bilateral macrostomia in a neonate is reported, with impending partial airway obstruction. Surgical management requires neurosurgical intervention and plastic reconstruction. This case report presented a term neonate was noted to have a soft, fxed, 5-cm mass fulled of his mouth with the impending partial airway obstruction. The patient had several episodes of apnea related to partial airway obstruction by the mass. Computed tomography (CT) scan showed a large complex cystic and solid mass on lamina cribrosa of ethmoidal bone. Focal calcifcation was seen within the mass. The mass extended resulting in the complete cleft of lip and palate, and bilaterally macrostomia. The brain on CT scan was normal with no dysmorphic structures. A transcranial approach by the neurosurgeon was performed to excise the cephalocele and close the dura mater. The bone defect on lamina cribrosa of ethmoidal bone was closed using periosteum tissue. The procedure was followed by total excision of the prolapsed brain tissue and osteotomy on the left palate and then nasal airway reconstruction continued with gradual reconstruction with external compression for close loopholes of the palate. Three months after the initial surgery, a defect of the palate was narrowing and without cranial nerve defcits. Skull-base transethmoidal meningoencephalocele with labiognatopalatoschizis and bilateral macrostomia is a rare congenital abnormality. Neurosurgical procedures through transcranial approach are safe and provide excellent results. Moreover, gradual reconstruction will improve a patient’s quality of life and activity of daily living