UPPER AIRWAY
MANAGEMENT:
DR. MARION COUCH
DEPT. OF OHNS
UNC
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 PREOPERATIVE 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
