Hoarseness, Stridor & Tracheostomy (2022-2023) PDF

Hoarseness, stridor and tracheostomy DR. Abdulsalam Muhammad ENT-Surgeon Duhok Medical College 2022-2023 Definition Hoars YSPLOM O Hoarseness = dysphonia: is a change in the q...

Hoarseness, stridor and tracheostomy DR. Abdulsalam Muhammad ENT-Surgeon Duhok Medical College 2022-2023 Definition Hoars YSPLOM O Hoarseness = dysphonia: is a change in the quality of voice. It indicate laryngeal pathology. Most common cause in adult is viral laryngitis (with URTI) In children is vocal cord nodule vivallnmn.si 2 History 1-Onset: Sudden like in shouting 00 Gradual which indicates either inflammatory or neoplastic diseases 2- Progression: relentless progressive hoarseness may indicate neoplastic disease 3- Duration: Persistent hoaresness more than 3 week should be referred for an otolaryngologist for further evaluation (alarming symptom) 3 Benign Laryngeal lesions that can cause hoarseness 1-Vocal cord nodule Usually affects children or individuals who use their voices professionally. History of voice abuse common, such as frequent shouting in a young child. Bilateral, pale lesions at the junction of the anterio one third and posterior two thirds of the vocal cords. Vocal cord nodule con…. Treatment 1- voice therapy 2- surgical treatment so microlaryngeal surgery CO2 laser 2-Vocal cord polyp Usually unilateral pedunculated lesions. in Associated with smoking and voice abuse. Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds. Treatment: surgical excision Vocal cord granuloma trauminfection 2 Asked Arise posteriorly, adjacent to the vocal process. Frequent history of intubation trauma (intubation granuloma). The initial focus of treatment should be on conservative voice therapy, combined with F aggressive antireflux therapy. 8 Antibiotics and systemic steroids may be of use. Microlaryngoscopy is rarely required to exclude malignancy.  She Neurological diseases of the larynx can present with Hoarseness  Nerve supply of the larynx : 1- Superior laryngeal nerve Internal branch External branch i 2-the recurrent laryngeal nerve 10 Nerve supply of the larynx : The recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx except the cricothyroid muscle and it is sensory nerve for glottis and Subglottis 11 Unilateral RLN paralysis The left recurrent laryngeal nerve is more affected than the right due to longer and convoluted course. 12 Aetiology of unilateral recurrent laryngeal nerve palsy Iatrogenic is the most common cause as in Thyroid, Esophageal, Cervical spine and Thoracic surgeries Left vocal cord paralysis dysphonia voice become weak with use (tired with speaking) Examination of the larynx: The cord is in paramedian position due to unopposed action of the cricothyroid muscle. Treatment : Expectant therapy if there is no underlying malignancy (in ideopathic cases) Because compensation can occur by the other normal vocal cord within 6- 18 months decreasing the degree of hoarseness. 15 Surgical treatment : Idea is to approximate the vocal cord to allow contact with the opposite cord during phonation and swallowing, and to improve ability to cough Injection laryngoplasty Laryngeal framwork surgery (medialization laryngoplasty) 16 Stridor Stridor (noisy respiration), is a hallmark symptom of upper airway obstruction (UAO). The timing of the stridor with respiration can frequently indicate where the obstruction lies: Lesion at the glottis and supraglottis gives rise to inspiratory stridor Subglottic lesion can present with biphasic stridor Intrathoracic airway obstruction gives rise to expiratory stridor. Causes of upper airway obstruction 1- congenital like congental laryngeal cyst or laryngomalacia 2- inflammatory like epiglottitis. 3- neoplastic as laryngeal cancer. 4- traumatic like maxillofacial trauma, bilateral RLN palsy. 5- foreign body Assessment of patient with UAO 1- History: Onset, symptoms of upper airway disease like hoarseness, dysphagia. History of trauma or foreign body ingestion or inhalation. 2- Examination: Generally observe for: Dyspnea, Tachypnoea, Restlessness, Color like cyanosis. Vital signs should be checked, Neck examined for bruises Subcutaneous emphysema or haematoma Treatment ABC (Airway, Breathing, Circulation) Medical Alternative airway 1- IV line Nonsurgical: 2- humidified oxygen oral airway 3- steroid nasalpharyngeal airway 4- antiobiotics endotracheal intubation Surgical Cricothyroidotomy Tracheostomy Cricothyroidotomy Tracheostomy Tracheostomy Tracheostomy: is a creation of opening in the anterior wall of the trachea through neck incision The primary objective of a tracheostomy is to provide a secure airway. The only contraindication is high innominate artery. Indications of tracheostomy (1) bypassing an upper airway obstruction (Laryngeal foreign body, edema, tumor. epiglottitis, maxilo-fascial truama….) (2) providing a means for assisting mechanical ventilation (ie, chronic ventilator dependence > 3 weeks) (3) enabling more efficient bronchial toilet (4) temporarily securing an airway in patients undergoing major head and neck surgery (as part of another surgery) Surgical technique of tracheostomy The skin incision The strap muscles are then separated and then retracted laterally with appropriate retractors The thyroid isthmus either retracted or divided Trachea opened between the 2nd and 3rd tracheal rings and the tube inserted. Avoid cricoid and 1st ring because it leads to subglottic stenosis All otherwinsexcept 1ˢᵗ  areouay Types of tracheostomy tubes 1- metal tube 2- non metal tube from different material like pvc, silicon Non metallic tube with: 1. Outer tube 2. Inner tube 3. Introducer without cuff The introducer helps to facilitate insertion of the tube  The inner tube project 2-3 mm beyond the outer tube So that the secretion or crust will collect in the lumen of the inner tube which can be removed for cleaning without disturbing the main tracheostomy The cuff is used to prevent aspiration of food or blood And to prevent leakage of air during anesthesia or prolonged mechanical ventilation Metal tracheostomy tube Less commonly used (from silver or gold) It has no cuff Can not be fenestrated It comes in set of Outer tube Inner tube Introducer  Tracheostomy care Good nursing care is of extreme importance in postoperative period. Wound care. Checking the fixation of the tube. Deflation of the cuff intermittently to prevent tracheal necrosis (every 2 hour for 10 min or every 1 hour for 5 min). Suction of the secretion under aseptic technique (every 15 min in first day) Tracheostomy can be changed every 1 month but with good wound care nothing will happen up to 2-3 months. If the tracheostomy has been dysfunctional after 2-3 days, it means the nurse didn't take a good care for tube and the surgeon will not change it because it's very difficult, after 5-7 days surgeon can change it easily. Complications Immediate: Anaesthetic complications; Haemorrhage is the most common complication: thyroid veins; jugular veins (fatal); arteries. Air embolism; occurs if large neck veins are opened during the procedure, air can be sucked into the venous system. Apnoea. Cardiac arrest. Local damage: thyroid cartilage; cricoid cartilage; RLN. Intermediate: Displacement of the tube, can be avoided by proper selection and fixation of the tube by sutures and by tapes. Surgical emphysema; The wound should not be closed tightly (just approximation of the edges). Pneumothorax/pneumomediastinum; Infection: perichondritis; antibiotics are given if there is infection of the lower airway at time of tracheostomy. Tube obstruction by secretions or crusts; Tracheal necrosis; Tracheoarterial fistula; Most common in irradiated neck due to pressure of the cuff or tip of the tube. Tracheo-oesophageal fistula; due to necrosis of the posterior wall of the trachea. Dysphagia due to presence of the tracheostomy tube impairs the movement of the larynx and pressure of the cuff on the esophagus. Long term: Stenosis; due to damage of the cricoid cartilage or first tracheal cartilage Decannulation problems; Tracheocutaneous fistula; if tracheostomy persists for several months Disfiguring scar. Decanulation (tracheostomy weaning) Is a stepwise process Down size the tube With or without fenestration Closure of the tube with 24 hour observation If the patient tolerate closure, the tube removed and the stoma should be occluded with airtight dressing. Criteria: the cause is treated (Ca larynx, foreign body… ) patients should be fully conscious positive cough reflex no dysphagia, no granuloma by laryngoscope normal chest (no infection) Thank you