Life-threatening Airway Compromise Research Articles

Pyolaryngocele Presenting with Acute-onset Stridor.

This case describes the classic imaging findings of pyolaryngocele and highlights the importance of prompt imaging for diagnosis of clinically occult airway lesions. The case also highlights how pyolaryngoceles can become large and present with acute-onset clinical symptoms, including stridor and dyspnea. Pyolaryngoceles represent an uncommon but life-threatening complication of laryngoceles. Laryngoceles are frequently seen as an incidental, abnormal, air-filled dilation of the laryngeal saccule related to various local pathologies of the larynx. They are often asymptomatic. Occasionally they can become secondarily infected, in which case they are called pyolaryngocele, and they can cause rapid-onset, life-threatening airway compromise.

Pyolaryngocele Presenting with Acute-onset Stridor

Case presentation: This case describes the classic imaging findings of pyolaryngocele and highlights the importance of prompt imaging for diagnosis of clinically occult airway lesions. The case also highlights how pyolaryngoceles can become large and present with acute-onset clinical symptoms, including stridor and dyspnea.Discussion: Pyolaryngoceles represent an uncommon but life-threatening complication of laryngoceles. Laryngoceles are frequently seen as an incidental, abnormal, air-filled dilation of the laryngeal saccule related to various local pathologies of the larynx. They are often asymptomatic. Occasionally they can become secondarily infected, in which case they are called pyolaryngocele, and they can cause rapid-onset, life-threatening airway compromise.

System-Based Multidisciplinary Initiatives for Improvement in Tracheostomy Care and Safety: Experience of an Academic Health Institution Hospital Network

Tracheostomized patients represent a unique patient population at risk of life-threatening airway compromise. There can be a presumption that these patients have a “safe” or low-risk airway. Clinicians and other care providers may be unfamiliar with both tracheostomy tubes and best practices for tracheostomy maintenance, assessment, and emergency triage or resuscitation. A review of the highest- acuity emergency airway calls at our university hospital revealed that well over 20% of the emergencies that triggered these activations were in patients with existing tracheostomy tubes. Further analysis of the tracheostomy-related airway emergencies at that time was very informative. Under the auspices of our multidisciplinary airway safety committee, we developed a core tracheostomy-focused team and implemented numerous quality and safety initiatives. Here we present a focused review and discussion of tracheostomy-related clinical issues at the University of Pennsylvania Health System (UPHS) and a summary of quality and safety improvement efforts related to the care of tracheostomized patients based on responses to locally identified safety opportunities. Our experience with tracheostomy-related quality improvement (QI) efforts led us to reach out to the Patient Safety Authority. The Pennsylvania Patient Safety Reporting System (PA-PSRS) data presented by Gardner et al. highlights the categories of airway-related events documented across a range of facilities in the Commonwealth of Pennsylvania. We frame our efforts in the context of both the PA-PSRS data and international perspectives from the U.K. and highlight barriers to implementation and learnings from our iterative and interdisciplinary approach to tracheostomy-related challenges.

711 Atypical Presentation of a Ruptured Thyroid Cyst

Abstract Introduction Thyroid cysts are a common finding with the bulk of cases being benign and approximately only 5% being malignant. The majority of these cysts are managed conservatively in the absence of malignancy or compressive symptoms. Case presentation A middle-aged female patient presented with sudden onset anterior neck bruising but minimal specific symptomatology. On examination, the patient had bruising around the anterior neck and chest wall. CT and MRI scanning of the neck revealed the bruising was attributed to a ruptured thyroid cyst. On follow up, an ultrasound guided fine-needle aspirate revealed the histology to be inflammatory follicular thyroid tissue. D iscussion The case demonstrated a rare presentation, given the lack of trauma in her history nor the presence of more sinister conditions as demonstrated by the fine-needle aspirate. Normally hemorrhage of thyroid cysts are due to trauma or abnormal thyroid vasculature. There are a few previous case reports of similar presentations where ruptured thyroid cysts led to life-threatening airway compromise requiring intubation. Early recognition of these thyroid cyst complications is crucial. Conclusion Neck and anterior chest wall hematoma can be a sign of thyroid cyst rupture/hemorrhage. It is important to recognize this sign to prevent life-threatening airway compromise.

Post-transplant Lymphoproliferative Disease (PTLD) of The Larynx in an Adult With Kidney Transplant; A Case Report

Post-transplant lymphoproliferative disease (PTLD) is a clinicopathologic entity characterized by an abnormal lymphocytic proliferation that occurs in immunosuppressed patients following organ transplantation. Several sites in the head and neck may be affected by PTLD with rare involvement of the larynx. Affected patients often present with symptoms and signs suggestive of a malignant lesion. Early diagnosis using histopathologic examination is paramount to prevent life-threatening airway compromise. The authors of this manuscript report a 52-year-old women, diagnosed case of renal failure for which she had undergone kidney transplant, who presented with symptoms of laryngeal PTLD. The clinical work-up and management of these cases is reviewed.

Airway management in children with cleft palate and/or micrognathia

Abstract Cleft lip and/or palate is the commonest congenital craniofacial abnormality affecting approximately 1 in 700 newborns each year. It comprises of a heterogenous group of disorders affecting facial growth and cosmesis, that are associated with increased risk of airway obstruction, sleep disordered breathing (SDB), glue ear and chronic ear disease, feeding difficulties, and failure to thrive (FTT). Cleft palate (CP) can be accompanied by an abnormally undersized jaw, known as micrognathia; although micrognathia can also be found in isolation. The craniofacial abnormalities found in these children can lead to a reduction in airway size due to the tongue falling backwards. The risk of airway obstruction ranges from intermittent airway collapse during sleep (obstructive sleep apnoea, OSA) to potentially life-threatening airway compromise necessitating intubation or a tracheostomy. This paper sets out to describe the pathophysiology of airway compromise in these children, recognising clinical symptoms and appropriate referral strategy, as well as a broad range of management options.

1371 Iatrogenic Lingual Hematoma Resulted in Impending Airway Compromise

INTRODUCTION: Rapidly expanding lingual hematoma can result in life-threatening airway compromise. We describe a rare case of iatrogenic large tongue hematoma in a patient on Rivaroxaban after securing the endotracheal tube tightly with a thread for an ERCP. CASE DESCRIPTION/METHODS: An 82-year-old male with history of atrial fibrillation on rivaroxaban, and newly-diagnosed adenocarcinoma of the pancreatic head. He had recently undergone endoscopic placement of an uncovered self-expanding metal metal stent (SEMS), and after deployment, a very tight waist was noted. He presented to the emergency department 5 days after ERCP with vomiting and fever. Laboratory data were significant for AST 3075 IU/L, ALT 1311 IU/L, ALP 1432 IU/L, and total bilirubin of 10.4 mg/dL. CT abdomen and pelvis showed evidence of possible biliary stent occlusion versus incomplete expansion. An ERCP was performed during which a plastic stent was inserted through the SEMS. The day after the procedure, the patient developed tongue swelling and speech difficulty. IV diphenhydramine was administered with no improvement. An emergent flexible nasolaryngoscopy was performed demonstrating tongue edema with dark red/black discoloration extending to the floor of the mouth and swelling of the aryepiglottic folds (Figure 1a). He was treated with IV dexamethasone, famotidine, and diphenhydramine, and was transferred to the ICU for closer observation. The hematoma was thought to have resulted from tightly securing the endotracheal tube with a thread during the ERCP (Figure 2b). The patient was observed for 24 hours in the ICU after which he improved clinically and tongue swelling subsided without need for further intervention. DISCUSSION: This case illustrates a rare and a serious iatrogenic injury to the tongue as a result of securing the endotracheal tube too tightly with a thread. Lingual hematoma should be identified early to avoid impending airway compromise. Recognition of this potential complication by anesthesiologists and interventional endoscopists is necessary to prevent it.

Effect of an electronic treatment plan on acute management of hereditary angioedema

Hereditary angioedema (HAE) is a rare congenital disorder arising from decreased or dysfunctional complement C1 inhibitor (C1-INH),1 which manifests as painful, unpredictable, episodic swelling for which patients often present to the emergency department (ED). Edema of the face and oropharynx may be associated with life-threatening airway compromise, and abdominal swelling may be painful and debilitating. The latter may be associated with unnecessary surgeries or procedures,2-4 whereas airway and facial swelling is often mistaken for allergic or anaphylactic angioedema.

Massive Retropharyngeal Hematoma with Airway Obstruction after Minor Injury

AbstractRetropharyngeal hematoma can cause life-threatening airway compromise. We present a case of massive retropharyngeal hematoma following minor injury. The patient required immediate tracheostomy followed by evacuation of hematoma and cervical stabilization.

Massive facial teratoma managed with the ex utero intrapartum treatment (EXIT) procedure and use of a 3-dimensional printed model for planning of staged debulking

Abstract Teratomas are the most frequent solid tumor found in neonates. However, only 1.5% of neonatal teratomas originate from facial structures. Neonatal facial teratomas are associated with polyhydramnios, preterm birth, pulmonary hypoplasia, cleft palate, cleft lip, and life-threatening airway compromise. The overall survival reported with these lesions has been between 17 and 87.5%; however survival in the setting of antenatally diagnosed facial teratomas has only been described anecdotally. We present a case of an antenatally diagnosed massive facial teratoma originating from the pterygomaxillary fossa, which was associated with polyhydramnios and pre-term birth. We managed this complex tumor with an ex utero intrapartum treatment (EXIT) procedure, multidisciplinary medical and surgical team, and staged excision and reconstruction aided by use of a 3-dimensional printed model. Here we review the surgical management of this rare and complex tumor.

Presentation and Management of Giant Fibrovascular Polyps of the Hypopharynx and Esophagus.

Fibrovascular polyps of the hypopharynx and esophagus are rare, with few case reports in the literature. In this article, we present our institutional experience with a focus on airway and surgical management. Case series. Tertiary academic institution. A retrospective review was conducted of 4 patients that presented to a tertiary medical center with fibrovascular polyps between 1990 and 2012. Patient demographics, clinical presentation, diagnostic studies, and surgical approaches were reviewed. A review of the published literature was also performed. The average age at presentation was 72 years (range, 59-85 years). Among the 4 patients, 2 presented with airway compromise requiring tracheotomy. All patients had removal of the polyp shortly after presentation; 2 underwent transcervical approaches with lateral pharyngotomy/esophagotomy, and the other 2 had endoscopic removal. The polyps arose from the hypopharynx in 3 patients and upper esophagus in 1. Three patients had complete resolution of their symptoms and remained disease free. One patient had recurrence of the polyp 2 years later and is currently being observed. Fibrovascular polyps are rare tumors of the hypopharynx/esophagus that present in older adults. Although benign, they can cause life-threatening airway compromise that may necessitate tracheotomy. We present 4 cases of fibrovascular polyps and discuss our evolving surgical management, including endoscopic removal.

Primary Tuberculosis of pharynx-diagnostic difficulties, complications and treatment

Primary tuberculosis of the upper respiratory tract is extremely rare and poses a diagnostic challenge. Due to delay in diagnosis the disease may progress to life threatening airway compromise. Here we report a case of chronic granulomatous infection of the upper respiratory tract involving the oropharynx. Initial biopsy revealed acute on chronic inflammation with no epitheloid granuloma and no acid fast bacilli was found on Ziehl-Nielsen staining of the biopsy. As a result of delay in diagnosis the disease progressed to involve the soft palate, valopharyngeal isthmus, and supraglottis compromising the airway and needed emergency tracheostomy. Where there is strong clinical suspicion repeat biopsy should be performed. The life threatening complication of pharyngeal tuberculosis such as stenosis and adhesion leading to airway compromise can occur during the course of treatment and should be closely monitored . It can be managed effectively with radiofrequency uvulopalatoplasty as demonstrated in the case report.

The Thoracic Inlet Index in patients with tracheal obstruction caused by chest wall deformity: Validation in patients and age-matched controls

AimWe present a novel index for evaluating severity of airway-threatening thoracic inlet compromise in childhood. Two indices were validated in three cases and sixty asymptomatic controls. MethodsWe developed an index to determine severity of thoracic inlet narrowing. Two different measurement methods were evaluated: Thoracic Inlet Index (TII) was determined at the site of greatest airway compromise at the level of the innominate artery crossing the anterior trachea and TII (anatomic) using purely skeletal measurements, both determined from thoracic CT scan. We sought to validate both indices to determine which was more predictive of the risk of airway compromise. Three patients who presented with life threatening airway compromise were compared to sixty age matched asymptomatic controls obtained from the trauma registry. ResultsThe mean TII in controls was 3.89. The TII was consistent at various ages. In patients, mean TII was 12.16 (range of 11.31–12.95). For TII the difference between controls and symptomatic patients was highly significant (P=0.0012). The mean TII (anatomic) in controls was 3.5. The TII (anatomic) was less consistent when evaluated in different age groups. In patients mean TII (anatomic) was 6.32 (range 5.38–7.59). For TII (anatomic), the difference between controls and symptomatic patients was also significant (P=0.0474) but did not discriminate as well as the functional index. ConclusionsThe TII measured at the level of the innominate artery crossing on thoracic CT scan appears to be the most useful. A level of greater than 10 was highly predictive of airway compromise in our patient group.

An unusual case of life-threatening airway compromise complicating a neck dissection

Sir, The potential complications associated with neck dissection classically include damage to important neurovascular structures within the dissection parameters. However, there are no documented cases within the literature that describe severe delayed airway compromise as a result of unilateral or bilateral neck swelling in the perioperative period. A degree of post-operative swelling is to be expected, but delayed airway compromise requiring intubation and intensive care unit support following neck dissection is uncommon. We report an unusual case of severe unilateral neck swelling developing secondary to an elective neck dissection together with a discussion of current diagnostic and management strategies. A 64-year-old male underwent a left modified radical neck dissection (levels I–V) following previous excision of a 2.4 mm Breslow thickness melanoma on the left shoulder and subsequent cytology-confirmed metastatic lymphadenopathy in the left posterior triangle. Pre-operative intravenous augmentin was administered, and three drains were placed at the conclusion of surgery. Following an uncomplicated recovery, all drains were removed and the patient was discharged 6 days later. He subsequently presented 48 h post-discharge with rapid onset swelling of the left side of the neck. A CT scan suggested a collection in the submandibular region causing moderate airway compromise and midline airway shift (Figs. 1a, b and 2a, b). Re-exploration of the neck dissection identified marked swelling of the anterior belly of the digastric and myoglossus muscles, but no collections or haematoma. Microbiology swabs of the neck sent from theatre confirmed the presence of Staphylococcus aureus in the wound. Intravenous tazocin and clindamycin were commenced, and the patient returned to intensive care intubated. The patient was extubated after 36 h following clinical improvement and discharged the following day with no further episodes of neck swelling or long-term sequelae. Ludwig’s angina was the initial diagnosis in this patient, but given that the infection was unilateral, it did not fit the classical diagnostic criteria of bilateral neck swelling. Ludwig’s angina is a life-threatening cellulitis, usually originating in the submandibular space. This condition typically occurs secondary to odontogenic infections [1], with the most common pathogens identified as Streptococcus viridans, S. aureus and Staphylococcus epidermidis, and group B streptococcus [1, 2]. Other recognised causes include parapharangeal abscesses, mandibular fractures, oral piercings, submandibular gland sialadenitis and oral malignancy [1]. Those suffering from dental caries and systemic illnesses such as diabetes mellitus, malnutrition, alcoholism and immunosuppression are also at risk [2, 3]. Ludwig’s angina often begins as a mild infection which rapidly progresses to bilateral swelling of the neck and floor of the mouth with associated trismus, tongue elevation, and stridor, ultimately leading to airway compromise and asphyxia [1–4]. The presence of cellulitis helps to differentiate this condition from others such as haematoma [5]. Without treatment, Ludwig’s angina carries a high mortality of 50 %, although this figure is markedly reduced to 10 % by antibiotics and supportive treatment [1, 2, 6, 7]. * Philip Rubin Philip.Rubin@cddft.nhs.uk

Epidemiological survey of head and neck injuries and trauma in the United States.

Head and neck trauma results in a range of injuries, spanning minor lacerations to life-threatening airway compromise. Few studies provide in-depth analysis of injuries to the head and neck (HN). We aim to (1) describe HN injury prevalence in the US and (2) investigate patient disposition and the outcome of mortality. Case series with chart review. Nationwide emergency department (ED) sample. The 2011 database was queried for encounters with a primary diagnosis of HN injury, as categorized by the Barell Injury Matrix. Weighted estimates for demographics, injury category, and mechanism were extracted. Predictors of mortality and admission were determined by multivariable regression. We identified 131 million ED encounters. A weighted total of 5,418,539 visits were related to primary HN injuries. Average age was 30 (SE = 0.4), and 56.8% were male. Sixty-four percent of injuries were attributed to fall or blunt trauma. Open wounds comprised 41.8% of injuries. The most common procedure was laceration repair (70%). The majority of patients (97%) were discharged home. Mortality rate was less than 1%. Predictors of admission and mortality (P < .05) included multiple trauma, vessel trauma, and burns. Other risk factors included foreign-body, older age, and male gender. Primary HN injuries commonly present to emergency rooms in the US. The majority of HN injuries are non-life threatening and do not require admission to the hospital or result in death. These data have implications for HN injury surveillance and may be used to risk-stratify patients who present with injuries in the acute care setting.

Incidence, predictors and clinical characteristics of orolingual angio-oedema complicating thrombolysis with tissue plasminogen activator for ischaemic stroke

BackgroundOrolingual angio-oedema is a recognised complication of tissue plasminogen activator (tPA) for ischaemic stroke. We investigated its incidence, clinical characteristics and relationship with other factors in patients receiving tPA at...

Fibrovascular Polyps of the Hypopharynx and Esophagus

Objectives: Fibrovascular polyps of the hypopharynx and esophagus are rare, and the majority of the literature is comprised of case reports. The goals of this study are: 1) Present one of the largest series of patients from a single institution that presented with fibrovascular polyps; 2) Describe their presentation focusing on airway management and clinical demographics; 3) Discuss our surgical management and demonstrate how it has evolved from open to endoscopic approaches. Methods: A retrospective review was conducted with four patients that presented to a tertiary medical center with fibrovascular polyps between 1990 and 2012. Patient demographics, clinical presentations, surgical approaches, and diagnostic studies were analyzed. Results: The average age at presentation was 72 years (range 59 to 85 years). Among the four patients, two presented with airway compromise requiring tracheotomy. All patients had removal of the polyp shortly after presentation; two underwent transcervical approaches with lateral pharyngotomy/esophagotomy; and the other two had endoscopic removal. The polyps arose from the hypopharynx in three patients and upper esophagus in one. Three patients had complete resolution of their symptoms and remained disease free. One patient had recurrence of the polyp two years later and is currently being observed. Conclusions: Fibrovascular polyps are rare tumors of the hypopharynx/esophagus that occur among older patients. Although benign, they can cause life threatening airway compromise that may necessitate tracheotomy. We present four cases of fibrovascular polyps and discuss our evolving surgical management. We demonstrate that endoscopic removal is a viable option for these tumors.

Lung Squamous Cell Carcinoma Arising in a Patient with Adult-onset Recurrent Respiratory Papillomatosis

A 75-year-old male was admitted to our hospital in December 2011 with a mass in the right upper pulmonary lobe. He was incidentally diagnosed as having tracheal papillomas 10 years ago. Bronchoscopy revealed multiple polypoid papillomas in the dorsal lesion of the trachea. Polymerase chain reaction amplification detected human papillomavirus type 11 DNA in the papilloma tissues. A computed tomography scan demonstrated the occlusion of the right superior segment bronchus with distal consolidation. Furthermore, F-18 fluoro-2-deoxy-D-glucose positron emission tomography and computed tomography showed intense tracer uptake in the right superior segment of the lung. He underwent a right upper lobectomy. The tumor was seen as a rounded nodule, ≈ 2 cm in diameter. Histological examination of the tumor revealed squamous papilloma with papillary and solid architecture surrounded by accumulation of acute inflammatory cells. Furthermore, in a part of the tumor, squamous cell carcinoma was also present. The lymph nodes were free of tumor. After the surgery, he continued to undergo endoscopic microwave resection. Recurrent respiratory papillomatosis is a rare disease that can cause life-threatening airway compromise and malignant transformation. The present case indicates that F-18 fluoro-2-deoxy-D-glucose positron emission tomography and computed tomography is indispensable for early detection of lung cancer arising in a patient with recurrent respiratory papillomatosis.

Obstruction iatrogène sévère de la voie aérienne par un lymphangiome lingual

Lymphangioma of the tongue is a rare and benign tumour involving congenital and cystic abnormalities derived from lymphatic vessels. Treatment modalities include surgery and a large number of different intralesional injections of sclerosing agents. Presently, OK-432 (Picibanil(®)) is the preferred sclerosant and when administered intralesionally will result in inflammation, sclerosis, and cicatricial contraction of the lesion. We report a case of microcystic lymphangioma of the tongue in a 5-year-old boy treated with an intralesional injection of OK-432. In the immediate postoperative period, the patient suffered severe diffuse swelling, progressive upper airway obstruction with inspiratory stridor, and respiratory distress requiring emergency fiberoptic nasotracheal intubation. Although OK-432 injections are found to be safe and effective as a first line of treatment for lymphangiomas, local swelling with potentially life-threatening airway compromise should be anticipated, especially when treating lesions near the upper airway.

Management of Anterior Mediastinal Masses in Children

Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons. We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications. There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26). Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.