UCLA Head & Neck Surgery Resident Lecture Series Marc Cohen, M.D.
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UCLAHead&NeckSurgeryResidentLectureSeriesMarcCohen,M.D.
Alittlehistory…
Videotutorial
Alittlehistory…
Alittlehistory…
By1910,intubationforanesthesiahadbecomeanacceptedpractice
DuringWWI,MagillandMacintoshmadeprofoundimprovements
In1970,high‐volume,lowpressurecuffswereintroduced
Prolongedintubationvs.tracheotomy?
Inthe1960’s,longtermintubationforthemanagementofprematureLBWinfantswasrecommended
Until….Subglotticstenosiswasrecognized
Indicationsforendotrachealintubation
1.Temporaryreliefofupperairwayobstruction
2.Assistedventilationforrespiratoryfailure 3.Pulmonarytoilet
Whatarethepotentialcomplicationsofendotrachealintubation? Edema
Granuloma
Healedfibrousnodule
Interarytenoidadhesion
Posteriorglotticstenosis
Subglotticstenosis
Healedfurrows
Ductalcysts
Hematoma
Laceration
Subluxationofarytenoidcartilage
Lossofmobilityofcricoarytenoidjoint
Vocalcordparalysis
Nasogastrictubesyndrome
Pathogenesis
Pressure‐InducedInjuries
Vulnerablestructures• Medialsurfacesofarytenoids• Vocalprocesses• Cricoarytenoidjoints• Cricoidcartilage• Posteriorglottic/Interarytenoidregion
Pathogenesis
Supraglotticstructuresmaybecomeedematous,butrarelysustainseriousdamage
Trachealinjurieshavealsobecomelesssignificantduetolowpressurecuffs Althoughthereispotentialforinjuryifthecuffisinflatedtoohigh
Pathogenesis
ThemicrocirculationofthemucosaandmucoperichondriumisinterruptedwhenpressurefromtheETTexceedscapillarypressure
IschemiaNecrosisEdema,Hyperemia,Ulceration,andErosion
Factorsforsusceptibility
Extrinsicfactors DiameterofETT Durationofintubation Traumaticormultipleintubations
Patientfactors Poortissueperfusion(i.e.sepsis,organfailure,etc) LPR Abnormallarynx Woundhealing,keloid
Movement Duringventilatoruse Duringsuctioning Duringcoughing Duringtransport
“LaryngealBedsore”
Superficialulcerationcanoccurwithinhoursofintubation Usuallyhealswithoutscarring
AsETTpressurecontinues,migrationofinflammatorycellsensues Ifepithelialerosionsareincomplete,epitheliummaybereplacedbysquamousmetaplasia
Furtherpressurecausesulcerationthroughmucosatocartilage Causesperichondritisanddestructivechondritis Asopposedtosuperficialdamage,deeperulcerationhealsbysecondaryintentionandfibrosis
Edema
3locations1. Reinke’sspace Usuallypersistsafterextubation
2. Ventricularmucosa,seenas“protrusion” Usuallyresolvesafterextubation
3. Subglottis Usuallyresolvesafterextubation
Edema
Granulationtissue
Seenwithin48hours Proliferateatperipheryofulceratedareas
Pathogenesis
Granulationtissue
Flapsofgranulationtissue Canmovewithinspiration/expiration
Inspiratorystridor Notrecommendedtoexcisebothsides
MostcaseswillresolvewithoutanyinterventiononceETTisremoved
Granulationtissue
Incompleteresolutionofgranulationtissuecanyield: Postintubationgranuloma Healedfibrousnodule
Interarytenoidadhesion
Posteriorglotticstenosis
Formswhenscarcontractsafterwideulcerationwithnointactmedianstripofmucosa
Vocalcordsunabletoabduct Glottisremainspartlyclosed Inspiratorystridor Voiceisusuallyunaffected Treatment:deepverticaldivisionwithlaseror11
bladedowntolevelofcricoid Re‐stenosisislikely Costalcartilagegraftmaybenecessary(endoscopicallyoropen)
Posteriorglotticstenosis
Subglotticstenosis
Manycauses Ininfants,mostcommonfactorsrelatedtoacquiredSSareETTsizeandLPRduringlong‐termintubation
Presentationinaninfant: Failedextubation Recurrentoratypicalcroup Slowlyprogressiveairwayobstruction DifficultypassingETT Postanesthesiastridor
Cotton‐MyerGradingSystem
GradeI‐<50%obstruction GradeII–51‐70%obstruction GradeIII–71‐99%obstruction GradeIV–Nodetectablelumen
Ruleofthumb: Subglotticdiameter<4.0mminafull‐terminfantisthelowerlimitofnormal(<3.0mminapreterminfant)
Subglotticstenosis
Whenrepeatedattemptsatextubationfail: ReintubatewithsmallerETT Racemicepinepherine Dexamethasone Ifthesemaneuversfail: Cricoidsplitwith/withoutcartilagegraft Tracheostomy
DuctalCysts
Resultfromretentionofmucusinobstructed,dilatedductsofsubmucosalmucousglands
Mostaresmallandrequirenotreatment Whenlargeandcauseobstruction,endoscopicremovalisrequired
Ductalcysts
Arytenoiddislocation
MayoccurduringpassageofanETT Leftarytenoidisusuallyaffectedsinceintubationoccursfromrightsideofmouth
Patientwillcomplainofhoarseness,throatdiscomfort,odynophagia,andcough
Microlaryngoscopyandclosedreductionshouldbeperformedearly
Arytenoiddislocation
Nasogastrictubesyndrome
OccurswhenNGTrestscentrally,ratherthanlaterally
Anteriorwallofhypopharynx/posteriorwallofcricoidbecomesulcerated
Resultsinperichondritis,chondritis,necrosis
Canprogresstosudden,life‐threateningbilateralvocalcordparalysisduetomyositisofPCAmuscles
Diabeticsandrenaltransplantswhoareinrenalfailureareespeciallyvulnerable
Warningsigns:hoarseness,otalgia,andodynophagia
Treatment:removeNGT,abx,G‐tube,andpossibletracheostomy
Timelineofpostextubationobstruction Immediate:flapsofgranulationtissue,laryngealspasm
Minutestohours:flapsofgranulationtissue,subglotticedema,granulationtissue,LPR
Daystoweeks:persistentedemaorgranulationtissue,granuloma
Months:posteriorglotticstenosis,subglotticstenosis
Totrachornottotrach?
Oneschoolofthoughtisthatanyonewhoisintubatedlongerthan7daysshouldundergotracheotomy
NewerrecommendationsareforDLafter7days–ifnoevidenceofsignificantlaryngealpathology,keepthepatientintubatedunlessplanforlong‐termtracheostomy
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