insert your text here n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Insert Your Text Here PowerPoint Presentation
Download Presentation
Insert Your Text Here

Loading in 2 Seconds...

play fullscreen
1 / 75

Insert Your Text Here - PowerPoint PPT Presentation


  • 172 Views
  • Uploaded on

Insert Your Text Here. ENT Emergencies. Ashutosh Kacker, MBBS, MS, MD, FACS Associate Professor Department of Otorhinolaryngology Weill Medical College of Cornell University New York-Presbyterian Hospital—Weill Cornell Center. Foreign Bodies of the Upper Aerodigestive Tract. Background.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Insert Your Text Here' - berget


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
ent emergencies

ENT Emergencies

Ashutosh Kacker, MBBS, MS, MD, FACS

Associate Professor

Department of Otorhinolaryngology

Weill Medical College of Cornell University

New York-Presbyterian Hospital—Weill Cornell Center

background
Background
  • Majority occur in children under age 5
  • 4300 deaths in the US in 2003 (national safety council)
  • Most deaths occur before arrival in the hospital
  • Up to 2% mortality reported
  • Vegetable matter in 70-80% of cases (peanut most common)
background1
Background
  • Suffocation and aspiration is the 3rd leading cause of death in children under one
  • 4th leading cause of death in children ages 1 to 6
background2
Background
  • Most common age – 1-3 years old:
    • Oral exploration of environment
    • Lack molars
    • Poor swallow coordination
background3
Background
  • 1897 – Gustav Killian - 1st reported endoscopic foreign body removal
  • Early 1900’s - Chavalier Jackson:
    • Invented the science of upper airway endoscopy
    • Hollow tubes with distal illumination
    • Techniques for safe removal of airway foreign bodies
  • 1970’s - development of the Hopkins rod telescope - magnified endoscopic view of the airway
  • Combine with endoscopic instruments  increased safety and precision
history
History
  • Choking, coughing, or gagging episode
  • Shortness of breath
  • Respiratory distress
  • Drooling or cough
laryngeal foreign bodies
Laryngeal Foreign Bodies
  • 8-10% of airway foreign bodies
  • Highest risk of death before arrival to the hospital
  • Additional history/physical:
    • Complete airway obstruction
    • Hoarseness
    • Stridor
    • dyspnea
tracheal foreign bodies
Tracheal Foreign Bodies
  • Additional history/physical:
    • Complete airway obstruction
    • Audible slap
    • Palpable thud
    • Asthmatoid wheeze

Jackson and Jackson

bronchial foreign bodies
Bronchial Foreign Bodies
  • 80-90% of airway foreign bodies
  • Right main stem most common (controversial)
  • Additional history/physical:
    • Diagnostic triad (<50% of cases):
      • unilateral wheezing
      • decreased breath sounds
      • cough
    • Chronic cough or asthma, recurrent pneumonia, lung abscess
esophageal foreign bodies
Esophageal Foreign Bodies
  • Complete esophageal obstruction with overflow of secretions leading to drooling
  • Odynophagia
  • Dysphagia
  • In young infants respiratory symptoms including stridor, croup, pneumonia– caused by compression of the tracheal wall
  • Typically at level of cricopharyngeus muscle
diagnostic tests
Diagnostic Tests
  • High KV ap and lateral views of the larynx:
    • Radio-opaque laryngotracheal object
  • AP and lateral views of the chest:
    • Radio-opaque object
    • Hyperinflation or collapse of involved lung
  • Decubitis films:
    • Involved lung may not collapse when dependent
  • Inspiratory/expiratory films:
    • Involved lung may remain hyperinflated on expiration
  • Fluoroscopy
    • Differential dynamic inflation of lungs
  • CT/ MR complications
decision for surgery
Decision for Surgery
  • 3 factors to consider:
    • History
    • Physical exam
    • Radiology
  • Negative bronchoscopy – 20-50%
  • Stool’s rule:
    • If 2/3 factors are positive  OR for bronchoscopy and possible removal
decision for surgery1
Decision for Surgery
  • Even et al., Journal of Ped Surg 2005:
    • Positive history but negative physical and radiology  foreign body in 45%
    • Doubtful history  foreign body in 9.5% (regardless of radiology findings)
    • Increased yield of physical exam and radiology findings after 24 hours
decision for surgery2
Decision for Surgery
  • Aydogen et al., Int Journal Ped Oto 2006:
    • Review of 1887 bronchoscopies for suspicion of foreign bodies over 31 years
    • 79.1% with positive bronchoscopy
    • Positive history  93% with foreign body
    • Negative history  28.1% with foreign body
    • Foreign body  93.2% with positive history
management
Management
  • Complete airway obstruction:
    • < 1 year – back or chest thrusts
    • Small children – abdominal thrusts
    • Larger children – heimlich maneuver
  • Partial airway obstruction:
    • OR for endoscopic removal
    • Wait appropriate NPO times to avoid aspiration of stomach contents
slide21

Management

urgent or emergent situations

  • Actual or potential airway obstruction
  • Aspiration of dried beans or peas
  • Ingestion of disc batteries
  • Signs or symptoms of a perforation
operative considerations
Operative Considerations
  • Endoscopic foreign body forceps:
    • Peanut grasper
    • Alligator
  • bronchoscope size
    • Practice on duplicate foreign body if known
  • Ventilation port
  • Anesthetic technique
anesthetic technique
Anesthetic technique
  • Spontaneous ventilation
  • Neuromuscular blockade- short acting, medium actng
  • Newer agents (combination of inhahation and intravenous medications
  • Avoid vigorous positive pressure ventilation
  • Topical lidocaine
  • Role of intubation
operative considerations1
Operative Considerations
  • Flexible suction catheter via suction port
  • Suction secretions around foreign body
  • Orient graspers for removal
  • Attempt retraction of foreign body into bronchoscope
  • If not possible  remove as one unit
  • Repeat bronchoscopy to assess for multiple objects
difficult objects
Difficult Objects
  • Embedded in tissue or granulation:
    • Afrin (avoid epinephrine)
    • Debride granulation
    • Flexible biopsy forceps
    • Fogarty Catheter
    • Wait 72 hours
    • Thoracotomy
  • Unable to pass through larynx:
    • Tracheotomy incision
    • Break object and remove pieces
complications
Complications
  • Higher risk of complications when object present for > 24 hours
    • Atelectasis
    • Pneumonia
    • Pneumothorax
    • Pneumomediastinum
    • Laryngeal edema
postoperative management
Postoperative Management
  • Uncomplicated removal  discharge home without medication
  • Traumatic bronchoscopy – steroids +/- racemic epinephrine and observation
  • Pneumonia – antibiotics, chest PT, and observation
  • Atelectasis – chest PT +/- nebulizers and observation
prevention
Prevention
  • Parental education
  • Physician awareness
  • Timely bronchoscopy
prevention1
Prevention
  • Milkovitch et al., Int Journal Ped Oto 2003:
    • RAM consulting group
    • 7000 data points since 1988
    • 51 children’s hospitals
    • 15 countries
    • Injury prevention criteria:
      • Spherical objects 38.10mm diameter
      • Non-spherical objects 44.50mm diameter
conclusions
Conclusions
  • Airway foreign bodies are a relatively common cause of morbidity and mortality
  • A high index of suspicion should be present in order to make the diagnosis
  • Proper instrumentation and technique are essential for effective and a-traumatic removal of foreign bodies
  • Cooperation/communication between the surgeon and anesthesiologist allows for a safe environment for treatment and avoidance of an airway catastrophe
tracheotomy
Tracheotomy
  • Tracheostomy vs Tracheotomy
introduction
INTRODUCTION
  • Ancient Egypt – 3500 BC
    • Earliest Recorded Surgical Tracheotomy
  • Chevalier Jackson – Early 20th Century
    • Modern Surgical Tracheotomy
  • Percutaneous Tracheotomy – 1950s and 1960s
    • High Rate of Complications
  • Ciaglia et al - 1985
    • Modern Percutaneous Dilatational Tracheotomy
introduction1
INTRODUCTION
  • Expanding Indications
    • Upper Airway Obstruction - Prolonged Ventilation
    • Pulmonary Toilet - Airway Protection
  • Modern Trends
    • Shorter Interval Between Intubation and Tracheotomy
    • Performance at the Bedside Instead of the OR
    • Percutaneous Versus Surgical
materials and methods
MATERIALS AND METHODS
  • Surgical Tracheotomy
    • Local Injection / Shoulder Roll
    • Midline Vertical Incision
    • Division of Midline Raphe
    • Retraction or Division of Thyroid Isthmus
    • Cricoid Hook Stabilization
    • Horizontal Inter-Tracheal Incision
    • Dilation of Stoma
    • 6.0 DCT (Female) and 8.0 DCT (Male) Shiley
percutaneous tracheotomy
PERCUTANEOUS TRACHEOTOMY
  • Procedure :
    • Percutaneous Needle Placement into the Trachea
    • Passage of Guide Wire
    • Serial Dilation (Seldinger Technique)
    • Placement of Tracheotomy Tube
    • ? Bronchoscopic Guidance
    • ? Forceps Dilation (Griggs Method)
    • ? Airway Management
percutaneous tracheotomy1
PERCUTANEOUS TRACHEOTOMY
  • Contra-Indications
    • Medical Factors
      • High Ventilation/ Oxygen Requirements
      • Difficult Intubation / Non-Intubated
      • Emergency Tracheotomy
      • Coagulopathy
      • Age less than 18
    • Anatomic Factors
      • Short or Obese Neck – Poor Landmarks
      • Tracheotomy Site Infection / Mass or Goiter
      • Unstable Cervical Spine
      • History of Previous Tracheotomy
      • Sonographically Detected Excess Vascularity
percutaneous tracheotomy2
PERCUTANEOUS TRACHEOTOMY
  • Potential Advantages
    • Technical Ease - Less Invasive
    • Shorter Procedure Time - Multiple Specialists
    • Less Cost - Bedside
  • Complications : Percutaneous versus Surgical
  • Conflicting Reports in Literature
materials and methods1
MATERIALS AND METHODS
  • Percutaneous Tracheotomy
    • Pre-Operative Bedside Neck Sonogram
    • Local Injection / Shoulder Roll
    • Direct Laryngoscopy - Withdrawal of ETT to Sub-Glottis
    • 2-3 cm Midline Vertical Incision
    • Midline Needle Puncture of Trachea
    • Passage of Guide Wire
    • Dilation and Placement of Tracheotomy Tube
    • 6.0 DCT (Female) and 8.0 DCT (Male) Shiley
materials and methods2
MATERIALS AND METHODS

Thyroid Notch

Cricoid Cartilage

Crico-

Sternal

Distance

Sternal Notch

materials and methods3
MATERIALS AND METHODS

Needle Placement

Guide Wire

Placement

Tracheotomy Tube Placement

Serial Dilation

results
RESULTS
  • Percutaneous Complications
    • Difficult Cannulation, Broken Trach, Re-Intubation and Replacement of Trach
    • ETT Balloon Puncture, Difficult Dilation
    • Post-Operative Stomal Bleeding, Packing
    • Loss of Airway, Re-Intubation, Difficult Cannulation with Placement in False Passage
    • Loss of Airway, Re-Intubation
    • Loss of Airway, Re-Intubation, Cardiac Arrest, Death
    • Loss of Airway, Re-Intubation
  • Surgical Complications
    • Low Trachea with Difficult Cannulation
discussion
DISCUSSION
  • Massick et al - Prospective Study of 100 Patients
    • Similar Intra-Operative but Higher Post-Operative Complications in Percutaneous Group
  • Dulguerov et al – Meta-Analysis of 1817 Patients
  • Freeman et al – Meta-Analysis of 236 Patients
  • Percutaneous – Faster Procedure, Less Blood Loss, Less Cost
discussion1
DISCUSSION
  • Controversies in Percutaneous Tracheotomy
    • Airway Management
    • Bronchoscopy
    • Ultra-Sound
    • Contra-Indications
discussion2
DISCUSSION
  • Trend Towards Higher Complications in 1st Half of Percutaneous Series Versus Surgical
  • Equal Rates of Complications Between 2nd Half of Percutaneous Series Versus Surgical
  • Percutaneous - Less Blood Loss, Shorter Procedure, Trend Towards Easier Procedure
slide55
Learning Curve
  • Higher Complication Rates in Male Gender? and in Subjectively Difficult Procedures
  • Trend Toward Higher Complications in Older Age and More Blood Loss
  • No Correlation Between Complications and Duration of Intubation and Duration of Procedure
slide56
Early complications
  • Early bleeding:
  • Plugging with mucus:.
  • Tracheitis:
  • Cellulitis:
  • Displacement
  • Subcutaneous emphysema:
  • Atelectasis
slide57
Late complications
  • Bleeding
  • Tracheomalacia
  • Stenosis
  • Tracheoesophageal fistula
  • Tracheocutaneous fistula
  • Granulation
  • Scarring
  • Failure to decannulate:
decannulation
Decannulation
  • Criteria
    • Stable respiratory status
    • No ventilatory support needed
    • No Obstruction of upper airway
    • Downsizing, capping and decannulation
peri tonsillar abscess
Peri-tonsillar Abscess
  • Peritonsillar abscess, also called “quinsy” or (PTA), is a complication of tonsillitis and consists of a collection of pus beside the tonsil and the superior constrictor muscles
slide61

It takes about 2–8 days before the formation of abscess. Progressively worsening unilateral sore throat and pain during swallowing usually are the earliest symptoms.

slide62

As the abscess develops, persistent pain in the peritonsillar area, fever, malaise, headache and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and halitosis are also common

signs
Signs
  • Chills
  • Difficulty and pain with opening the mouth
  • Drooling
  • Facial swelling
  • Fever
  • Headache
  • Hoarseness (occasionally)
  • Sore throat (may be severe)
  • Tender glands of the jaw and throat
clinical exam
Clinical exam
  • Trismus
  • Unilateral Palate edema with bulge
bacteriology
Bacteriology
  • group A beta-hemolytic streptococcus.
treatment
Treatment
  • I & D of PTA
  • Quinsy Tonsillectomy
complications1
Complications
  • Airway obstruction
  • Cellulitis of the jaw, neck, or chest
  • Endocarditis (rare)
  • Fluid around the lungs (pleural effusion)
  • Inflammation around the heart (pericarditis)
  • Pneumonia
anatomy physiology of epistaxis
Anatomy/Physiology of Epistaxis

Anatomy

Nasal cavity

Vascular supply

Physiology

Vascular nature

Mucosa

slide71

Kiesselbach’s Plexus/Little’s Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus:

-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

anterior vs posterior epistaxis
Anterior vs.PosteriorEpistaxis

Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe

Posterior: older population, usually from Woodruff’s plexus, more serious.

etiology
Etiology

Trauma (most common)

Iatrogenic

Post-surgical

Infectious/Inflammatory

Dessication

Neoplasm

Coagulopathy

Hypertension

Arteriosclerosis

non surgical treatments
Non-surgical treatments

Control of hypertension

Correction of coagulopathies/thrombocytopenia

FFP or whole blood/reversal of anticoagulant/platelets

Pressure/Expulsion of clots

Topical decongestants/vasocontrictors

Cautery (AgNO3 vs. TCA vs. Bipolar vs. Bovie)

Nasal packing (effective 80-90% of time)

Greater palatine foramen block

nasal packs
Nasal packs

Anterior nasal packs

Traditional

Recent modifications

Posterior nasal packs

Traditional

Recent modifications