UPPER AIRWAY MANAGEMENT: DR. MARION COUCH DEPT. OF OHNS UNC 2005
Mar 29, 2015
UPPER AIRWAY MANAGEMENT:
DR. MARION COUCHDEPT. OF OHNSUNC 2005
OBJECTIVES: LEARN HOW TO PERFORM A
SURGICAL AIRWAY BE ABLE TO DIAGNOSE A
DANGEROUS AIRWAY LEARN AN ALGORITHM FOR
MANAGEMENT OF THE AIRWAY RESPECT THE AIRWAY.
INDICATIONS FOR TRACHEOSTOMY:
UPPER AIRWAY OBSTRUCTION NEED FOR PULMONARY TOILET PROLONGED INTUBATION NEUROLOGIC DISORDERS NEED TO PROTECT THE AIRWAY REDUCE THE ‘DEAD SPACE’ REDUCE ASPIRATION TRAUMA
INDICATIONS: HEAD AND NECK SURGERIES IATROGENIC INFLAMMATION INFECTION
CONTRAINDICATIONS: IF YOU BE ASSURED THAT ORAL OR
NASOTRACHEAL INTUBATION IS POSSIBLE FOR A SHORT DURATION OF TIME
BETTER SAFE THAN SORRY.
PRE-OPERATIVE: SPEECH CONSULTATION NURSING CONSULTATION SOCIAL WORK CONSULTATION
TELEPHONE, BG&E, MEDIC ALERT MEETING WITH OTHER PATIENTS OR
A SUPPORT GROUP SUCTION MACHINE, SUPPLIES.
PERCUTANEOUS TRACH:
MINIMALLY INVASIVE NO SHARPS COST EFFECTIVE TIMELY INTERVENTION EDUCATIONAL OPPORTUNITY SAFE WITH BRONCHOSCOPE.
TOTAL LARYNGECTOMY: WHAT’S THE DIFFERENCE BETWEEN
THIS AND A TRACHEOSTOMY???
TECHNIQUES: SKELETONIZE LARYNX:
TRANSECT STRAP MM LOW IN NECK
EXPOSE THYROID GLAND•REMOVE ONE LOBE IF NEEDED•LEAVE PARATHYROID GLANDS
TECHNIQUE: IDENTIFY POSTERIOR BORDER OF
THYROID CARTILAGE ON BOTH SIDES
ROTATE LARYNX TO EXPOSE ATTACHMENT OF INFERIOR CONSTRICTOR MM.
INCISE MM ALONG POSTERIOR BORDER OF THYROID ALA
TECHNIQUE: THE THYROHYOID MEMBRANE IS
EXPOSED SUPERIOR HORN OF THYROID
CARTILAGE IS ISOLATED AND MUCOSA IS DISSECTED FROM THE THYROID CARTILAGE
LIGATE SUPERIOR LARYNGEAL NEUROVASCULAR BUNDLE
TECHNIQUE: GRASP HYOID BONE WITH ALLIS
CLAMP AND CAUTERIZE ON HYOID BONE SUPERIOR AND LATERAL SURFACE
AVOID HYPOGLOSSAL NERVE MOBILIZE LARYNX FROM
SURROUNDING TISSUE
TECHNIQUE: TRANSECT TRACHEA (USUALLY
ABOUT 4TH RING) DISSECT ALONG THE PARTY WALL
AND SEPARATE TRACHEA FROM ESOPHAGUS
SECURE ANTERIOR TRACHEAL WALL TO SKIN WITH HEAVY SUTURE
INTUBATE TRACHEA WITH TUBE
TECHNIQUE: ENTER PHARYNX ON SIDE OPPOSITE
TUMOR MAY ENTER IN VALLECULA IF LARYNGEAL
TUMOR MAY ENTER IN PYRIFORM SINUS IF B.O.T.
TUMOR GRASP EPIGLOTTIS WITH ALLIS USE METZENBAUM SCISSORS TO
ENLARGE CUTS
TECHNIQUE: ALWAYS LOOK TO PRESERVE AS
MUCH MUCOSA AS POSSIBLE ON THE TUMOR-FREE SIDE OF LARYNX!!!!
CUT MUCOSA WITH CARE WATCH WHERE TUMOR IS LOCATED
AT ALL TIMES
TECHNIQUE: JOIN SUPERIOR DISSECTION WITH
INFERIOR DISSECTION REMOVE LARYNX MAY PASS NASOGASTRIC TUBE CLOSE WITH 3-0 VICRYL SUTURES CONNELL STITCH TO INVERT
MUCOSA IN THE BAR, OUT THE DOOR……
TECHNIQUE: SECOND LAYER CLOSURE USING
CONSTRICTOR MUSCLES IRRIGATE WOUND TRY A BLUE HAWAIIAN:
METHYLENE BLUE AND WATER INTO PHARYNX – CHECK FOR LEAKS
NOW FOR STOMA: HALF MATTRESS SUTURES
STOMA: SOME SURGEONS USE ENTIRE
TRACHEAL RING AND SUTURE TO SKIN
MAY ALSO BEVEL TRACHEA TO CREATE WIDE STOMA BIRD GRATE IS GOAL!!
NEED FOR RECONSTRUCTION: 3 CM
COMPLICATIONS: PHARYNGOCUTANEOUS FISTULA STOMAL STENOSIS PHARYNGEAL STENOSIS HYPOTHYROIDISM HYPOPARATHYROIDISM STOMAL RECURRENCE HEMATOMA
COMPLICATIONS: DYSPHAGIA DUE TO
CRICOPHARYNGEAL MUSCLE HYPERTROPHY
AIRWAY OBSTRUCTION CAROTID ARTERY EXPOSURE
FISTULA WOUND BREAKDOWN
MANAGEMENT OF FISTULA: CREATE MEDIAL CONTROLLED
FISTULA AND USE PACKING OTHER INSTITUTIONS LEAVE DRAINS
IN PLACE, OFF SUCTION CAROTID PROTECTION
NEED FOR EMERGENT TOTAL LARYNGECTOMY? DATA NOT COMPELLING ENOUGH TO
PROCEED WITHOUT PROPER PRE-OPERATIVE PLANNING.
ESTABLISH AIRWAY ETT, TRACH, SHAVE TUMOR
GET TISSUE DIAGNOSIS SCAN, STAGE PATIENT DISCUSS WITH PATIENT
PEARLS: ENTER PHARYNX ON SIDE OPPOSITE
OF TUMOR. SAVE AS MUCH MUCOSA AS
POSSIBLE WITHOUT COMPROMISING TUMOR MARGINS.
IF TUMOR IS IN PYRIFORM SINUS – THINK FLAP RECONSTRUCTION
PEARLS: A DEAVER RETRACTOR INSERTED
THROUGH MOUTH INTO VALLECULA CAN HELP FIND PHARYNGEAL MUCOSA FOR ENTRY INTO PHARYNX.
TRACHEOESOPHAGEAL PUNCTURE MAY BE PERFORMED AFTER REMOVAL OF LARYNX USUALLY 1.5 CM FROM SUPERIOR EDGE
PEARLS: FEEDING CAN BE DONE THROUGH A
TUBE THAT EXTENDS FROM TEP OR VIA A NG TUBE. COMFORT OF PATIENT
PEARLS: IF DOING T.L. FOR B.O.T. TUMOR,
RESECT LARYNX AND PROCEED CEPHALD. EXPOSE TONGUE TUMOR AND RESECT WITH 2 CM. MARGINS.
USE FROZEN –SECTIONS TO CONFIRM NEGATIVE MARGINS.
PEARLS: ALWAYS CONSIDER BIOPSYING A
PERSISTENT FISTULA TO RULE OUT TUMOR
NO DATA FOR GIVING PATIENT ANTIBIOTICS WHILE DRAINS ARE IN PLACE
FOR ALL OF ONCOLOGY: NATIONAL COMPREHENSIVE CANCER
NETWORK WWW.NCCN.ORG STAGING ALGORITHMS EVIDENCE-BASED TREATMENT
FOREIGN BODIES: USUALLY DOWN RIGHT MAIN STEM
BRONCHUS. MUST REMOVE QUICKLY. CHEST X-RAYS. AVOID THORACOTOMY. DON’T LET CHILDREN EAT PEANUTS
UNTIL THEY CAN SPELL THEM.
PERITONSILLAR ABSCESS: SEE TRISMUS, FEVER, OTALGIA,
ODYNOPHAGIA. “HOT POTATO” VOICE, DROOLING. MANAGEMENT CONTROVERSIAL:
NEEDLE ASPIRATION INCISION & DRAINAGE QUINSY TONSILLECTOMY
MANAGEMENT: AUGMENTIN OR CLINDAMYCIN CLOSE FOLLOW-UP MOST ARE TREATED AS
OUTPATIENTS BUT MONITOR AIRWAY CLOSELY
EPIGLOTTITIS: MEDICAL EMERGENCY DROOLING, HIGH FEVER, STRIDOR,
ODYNOPHAGIA. DO NOT MANIPULATE PATIENT OR
AIRWAY!!!! AFTER INTUBATION, SWAB
EPIGLOTTIS, DRAW BLOOD CULTURES
Haemophilus influenzae type B infection: RARE!
TREATMENT OF EPIGLOTTITIS:
AMPICILLIN CHLORAMPHENICOL OR CEPHALOSPORINS PROTECT AIRWAY
ADULT EPIGLOTTITIS OR SUPRAGLOTTITIS: LESS CONCERN ABOUT
LARYNGOSPASM SO EXAMINE AIRWAY
SMOKING CRACK OR IMMUNOCOMPROMISED
FACULTATIVE ANAEROBES OR PAE. ANTIBIOTICS, PROTECT AIRWAY,
CONSIDER STEROIDS.
LUDWIG’S ANGINA SUBMANDIBULAR SPACE
SUBLINGUAL SPACE SUBMAXILLARY SPACE (INFERIOR)
INFECTION SPREADS FROM DIGASTRIC MUSCLE FROM THE SUBMENTAL AREA TO THE SUBMAXILLARY COMPARTMENT
LUDWIG’S ANGINA DENTAL ABSCESS WOODY OR BRAWNY EDEMA CAN NOT OPEN MOUTH NASOTRACHEAL INTUBATION OR
TRACHEOTOMY I & D OR ANTIBIOTICS
STREP, FACULTATIVE ANAEROBES, STAPH
AIRWAY MANAGEMENT: JAW THRUST ORAL AIRWAY, NASAL TRUMPETS MASK AIRWAY ORAL OR FIBEROPTIC INTUBATION JET VENTILATION SURGICAL AIRWAY –
CRICOTHYROIDOTOMY OR TRACH