1. UPPER AIRWAY MANAGEMENT:
DR. MARION COUCH
DEPT. OF OHNS
UNC
2005

2. 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.

3. 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

4. INDICATIONS:
HEAD AND NECK SURGERIES
IATROGENIC
INFLAMMATION
INFECTION

5. CONTRAINDICATIONS:
IF YOU BE ASSURED THAT ORAL OR NASOTRACHEAL INTUBATION IS POSSIBLE FOR A SHORT DURATION OF TIME
BETTER SAFE THAN SORRY.

6. 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.

13. PERCUTANEOUS TRACH: MINIMALLY INVASIVE NO SHARPS COST EFFECTIVE
TIMELY INTERVENTION
EDUCATIONAL OPPORTUNITY
SAFE WITH BRONCHOSCOPE.

18. TOTAL LARYNGECTOMY:
WHAT’S THE DIFFERENCE BETWEEN THIS AND A TRACHEOSTOMY???

22. TECHNIQUES: SKELETONIZE LARYNX: TRANSECT STRAP MM LOW IN NECK
EXPOSE THYROID GLAND
REMOVE ONE LOBE IF NEEDED
LEAVE PARATHYROID GLANDS

26. 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

28. 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

29. TECHNIQUE:
GRASP HYOID BONE WITH ALLIS CLAMP AND CAUTERIZE ON HYOID BONE SUPERIOR AND LATERAL SURFACE
AVOID HYPOGLOSSAL NERVE
MOBILIZE LARYNX FROM SURROUNDING TISSUE

32. 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

34. 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

37. 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

38. 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……

41. 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

43. STOMA: SOME SURGEONS USE ENTIRE TRACHEAL RING AND SUTURE TO SKIN
MAY ALSO BEVEL TRACHEA TO CREATE WIDE STOMA
BIRD GRATE IS GOAL!!

44. NEED FOR RECONSTRUCTION:
3 CM

45. COMPLICATIONS: PHARYNGOCUTANEOUS FISTULA STOMAL STENOSIS
PHARYNGEAL STENOSIS
HYPOTHYROIDISM
HYPOPARATHYROIDISM
STOMAL RECURRENCE
HEMATOMA

46. COMPLICATIONS: DYSPHAGIA DUE TO CRICOPHARYNGEAL MUSCLE HYPERTROPHY
AIRWAY OBSTRUCTION
CAROTID ARTERY EXPOSURE
FISTULA
WOUND BREAKDOWN

47. MANAGEMENT OF FISTULA:
CREATE MEDIAL CONTROLLED FISTULA AND USE PACKING
OTHER INSTITUTIONS LEAVE DRAINS IN PLACE, OFF SUCTION
CAROTID PROTECTION

48. 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

49. 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

50. 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

51. PEARLS:
FEEDING CAN BE DONE THROUGH A TUBE THAT EXTENDS FROM TEP OR VIA A NG TUBE.
COMFORT OF PATIENT

52. 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.

53. PEARLS:
ALWAYS CONSIDER BIOPSYING A PERSISTENT FISTULA TO RULE OUT TUMOR
NO DATA FOR GIVING PATIENT ANTIBIOTICS WHILE DRAINS ARE IN PLACE

54. FOR ALL OF ONCOLOGY: NATIONAL COMPREHENSIVE CANCER NETWORK
STAGING
ALGORITHMS
EVIDENCE-BASED TREATMENT

55. 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.

59. PERITONSILLAR ABSCESS:
SEE TRISMUS, FEVER, OTALGIA, ODYNOPHAGIA.
“HOT POTATO” VOICE, DROOLING.
MANAGEMENT CONTROVERSIAL:
NEEDLE ASPIRATION
INCISION & DRAINAGE
QUINSY TONSILLECTOMY

60. MANAGEMENT: AUGMENTIN OR CLINDAMYCIN CLOSE FOLLOW-UP
MOST ARE TREATED AS OUTPATIENTS BUT MONITOR AIRWAY CLOSELY

63. EPIGLOTTITIS: MEDICAL EMERGENCY
DROOLING, HIGH FEVER, STRIDOR, ODYNOPHAGIA.
DO NOT MANIPULATE PATIENT OR AIRWAY!!!!
AFTER INTUBATION, SWAB EPIGLOTTIS, DRAW BLOOD CULTURES

68. Haemophilus influenzae type B infection: RARE!

69. TREATMENT OF EPIGLOTTITIS:
AMPICILLIN
CHLORAMPHENICOL
OR CEPHALOSPORINS
PROTECT AIRWAY

70. ADULT EPIGLOTTITIS OR SUPRAGLOTTITIS:
LESS CONCERN ABOUT LARYNGOSPASM SO EXAMINE AIRWAY
SMOKING CRACK OR IMMUNOCOMPROMISED
FACULTATIVE ANAEROBES OR PAE.
ANTIBIOTICS, PROTECT AIRWAY, CONSIDER STEROIDS.

71. LUDWIG’S ANGINA SUBMANDIBULAR SPACE
SUBLINGUAL SPACE
SUBMAXILLARY SPACE (INFERIOR)
INFECTION SPREADS FROM DIGASTRIC MUSCLE FROM THE SUBMENTAL AREA TO THE SUBMAXILLARY COMPARTMENT

72. 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

73. AIRWAY MANAGEMENT: JAW THRUST ORAL AIRWAY, NASAL TRUMPETS MASK AIRWAY
ORAL OR FIBEROPTIC INTUBATION
JET VENTILATION
SURGICAL AIRWAY – CRICOTHYROIDOTOMY OR TRACH