Managing Common Otolaryngologic Emergencies

Emerg Med 37(5):18-47, 2005

In the first installment of this two-part article, the authors review the critical considerations in responding to esophageal and tracheobronchial foreign bodies, caustic ingestions, angioedema, trauma to the larynx or upper aerodigestive tract, peritonsillar abscesses, and stridor in children.

By Giovana R. Thomas, MD, Sandeep Dave, MD, Alexis Furze, David Lehman, MD, Jose Ruiz, MD, Mark Checcone, MD, and Thomas Balkany, MD

Otolaryngologic emergencies represent between 30% and 80% of presentations seen by emergency department physicians in the United States. Since many of these disorders may involve upper airway compromise that can lead to respiratory failure and subsequent cardiopulmonary arrest, swift recognition and acute management of these problems are crucial. In this first part of a two-part series, we will present a practical approach to the management of common otolaryngologic emergencies involving the neck and upper airway and pediatric stridor.
 

ESOPHAGEAL FOREIGN BODIES

In decreasing order of frequency, the most common esophageal foreign bodies include coins, sharp objects (such as needles and pins), fish and chicken bones, metal objects, food, seeds, plastic material, magnets, and jewelry rings (see the radiographic image below). The majority of children who ingest these objects are five years old or younger. Meat and vegetable matter impaction is more common in adults. Drooling, vomiting, odynophagia, and airway obstruction may be seen with esophageal foreign body impaction, but the signs and symptoms can also be subtle. In long-standing esophageal foreign body impaction, fever and other symptoms of respiratory infection may occur.

Esophageal foreign body. This x-ray reveals a butterfly-shaped earring at the crico-pharyngeus, the entrance to the esophagus.

Radiologic evaluation should consist of anteroposterior (AP) and lateral airway and chest films to rule out the possibility of multiple foreign bodies. A barium swallow will show the site of the obstruction as well as the presence of coexisting pathology such as a stricture or mass in adults.

Rigid endoscopy has been the standard technique for evaluating and removing objects from the esophagus. However, a flexible endoscope may be an effective and safe device for removing foreign bodies from the upper gastrointestinal tract within the first 24 hours. Enzymatic degradation (with papain or a meat tenderizer, for example), muscle relaxants, and Foley catheter retrieval have been used with variable success.

Potential complications of esophageal foreign body impaction include deep neck abscess, esophageal perforation with mediastinitis, and hemorrhagic gastritis. With disk battery ingestion, urgent esophagoscopic removal is essential in all cases because of the risk of alkaline leakage and resultant tissue destruction.
 

CAUSTIC INGESTIONS

Generally speaking, caustic ingestions are intentional in adults and accidental in children. The majority of cases involve liquid and solid alkali such as those used in disinfectants and pipe drain cleaners. Mucosal injury from caustic ingestions can range from minimal mucosal erythema to frank transmural necrosis of the esophagus and stomach with viscous perforation. Alkaline agents may cause liquefactive necrosis and significant tissue damage. In contrast, mucosa damaged by a strong acid forms a coagulum that limits the degree of injury. Therefore, it is paramount to identify the ingested agent as quickly as possible, its pH and concentration, physical form, the time of ingestion, and the volume swallowed.

Signs and symptoms of caustic ingestion may range from oral erythema and ulceration to hoarseness and stridor. Patients may also present with drooling, tongue edema, dysphagia, chest or back pain, vomiting, or hematemesis. Fiberoptic laryngoscopy should be used to evaluate the airway in patients with oral mucosal burns, tongue edema, hoarseness, stridor, or dyspnea. If edema and exudate are severe and the larynx cannot be visualized, an emergent tracheotomy or cricothyrotomy is indicated. Early signs and symptoms after caustic substance ingestion may not be consistent with the extent of damage, and endoscopy is the only reliable method to assess esophageal injury.

The most common complication from strong alkali burns is esophageal fibrosis and, with deeper injuries, esophageal strictures. Because large volumes of caustic agents may have been swallowed, endoscopy within the first 24 hours is advised for any adult regardless of the absence of presenting symptoms. In the pediatric population, however, endoscopy can be reserved for children with significant oral burns, dysphagia, or stridor. Emetics and buffers should not be used because of the risk of vomiting and subsequent aspiration.

The use of corticosteroids and antibiotics is controversial. However, steroids may be indicated in patients with mild to moderate caustic ingestion. When large amounts of caustic material have been ingested, patients have developed severe esophageal stenosis even while receiving steroids.
 

TRACHEOBRONCHIAL FOREIGN BODY ASPIRATION

Without medical intervention, foreign body aspiration has a high mortality rate in children. Food items are the most common type of material aspirated, and peanuts are the most frequently aspirated food in the United States. Presenting signs and symptoms of tracheobronchial foreign body aspiration may include choking, severe coughing, wheezing, labored breathing, decreased breath sounds, and apnea. Loss of voice, stridor, tachypnea, and chest retractions may indicate airway obstruction.

Fever and signs of lung infection, atelectasis, or abscess may occur if the patient presents with a missed or delayed diagnosis of foreign body aspiration. Anteroposterior and lateral chest x-rays should be taken as an adjunct to the physical examination in the emergency department. Inspiratory and expiratory chest films may aid in the diagnosis by showing hyperinflation on expiratory films or atelectasis on inspiratory films. For younger children who cannot cooperate, lateral decubitus films should be obtained. In bronchial obstruction, the dependent lung will remain inflated.

Despite these techniques, typical signs of foreign body aspiration on chest x-ray will be absent in 24% to 33% of patients with endoscopy-verified foreign body aspiration. Fluoroscopic evaluation is of little benefit. The gold standard for diagnosis and management is rigid bronchoscopy under general anesthesia. Rigid or flexible bronchoscopy has been recommended for all patients with a strongly suggestive history and signs and symptoms of foreign body aspiration regardless of radiologic findings. Approximately 80% to 90% of airway foreign bodies will be found in the bronchi.
 

ANGIOEDEMA

Angiotensin-converting enzyme (ACE) inhibitors, used in the treatment of hypertension, are among the most common causes of angioedema that may lead to acute onset of upper airway obstruction. Food allergies, insect bites, antibiotics, and infection are less common predisposing factors. Hereditary angioedema caused by C1 esterase deficiency is rare and accounts for less than 1% of cases reported in the literature.

Angioedema is characterized by nonpitting, painless edema of the skin and mucous membranes. The condition occurs in 1% to 25% of patients taking ACE inhibitors, and the effects can be seen as early as one day after the start of therapy. Signs and symptoms of angioedema may include lip and tongue swelling, dyspnea, stridor, respiratory failure, cough, dysphagia, drooling, and pruritus. Lip and tongue swelling is the symptom seen most consistently in a majority of patients.

Emergency medical management should consist of upper airway evaluation by an otolaryngologist. Patients with respiratory symptoms should also receive 0.5 ml epinephrine (1:1000) subcutaneously, which can be repeated every 15 to 20 minutes. In addition, antihistamines and high-dose steroids (0.5 mg/kg intravenously) should be started in all patients until the edema has resolved. The inciting agent, of course, must be discontinued.

Endotracheal intubation and cricothyrotomy is required in approximately 10% of patients for respiratory distress and airway compromise. Fluid resuscitation and therapy with vasopressors may be required if the patient is hemodynamically unstable.
 

LARYNGEAL AND UPPER AERODIGESTIVE TRACT TRAUMA

Acute laryngotracheal trauma is a rare injury. Blunt and penetrating traumatic injuries to the anterior neck can occur from motor vehicle accidents, assaults, gunshot wounds, stabbing, strangulation, or blows to the neck. Perforation of the mucous membrane often follows these injuries due to compression of laryngeal cartilage against the vertebral bodies.

The mortality rate associated with injuries of the upper aerodigestive tract approaches 20% and is most often due to damage to major vascular structures, the esophagus, and the cervical spine, and to disruption of the airway. The diagnosis of aerodigestive trauma is based on clinical examination. Signs and symptoms include cervical subcutaneous emphysema (53% of patients), hoarseness (47%), neck tenderness (27%), and stridor (20%). In fact, the absence of clinical findings reliably excludes aerodigestive trauma in most cases.

The presence of hoarseness or stridor along with neck crepitus is an important indicator of potential upper aerodigestive tract injury. Loss of anatomic landmarks such as the thyroid cartilage notch, in association with the signs and symptoms mentioned above, is characteristic of laryngotracheal injuries. Injuries can range from mild (edema, lacerated mucosa, vocal cord hematoma) to severe (complete tracheal transection, bilateral recurrent nerve transection, comminuted fracture). Other associated soft tissue and bony injuries around the chin and mandible can also occur in these patients.

Proper airway management is of vital importance in the treatment of laryngeal trauma. Endotracheal intubation should be performed on any patient with expanding hematomas encroaching on the trachea, depressed mental status, respiratory compromise, or cardiovascular collapse. In the presence of large and significant laryngotracheal injuries with airway distress, orotracheal intubation may be difficult; a surgical airway should be created if orotracheal intubation fails.

In blunt and penetrating neck trauma, chest and neck radiographs should be obtained for all patients who are hemodynamically stable. Spiral computed tomography (CT) scan is a sensitive diagnostic test and the most useful modality in stable patients with suspected laryngotracheal injuries and gunshot wounds; it may indicate the trajectory of the bullet and identify patients who may benefit from further endoscopic or contrast swallow studies. However, a CT scan may not reveal the sites of mucosal perforations. For this purpose, fiberoptic or rigid endoscopy is recommended.

Endoscopy and swallow studies are used to evaluate the pharynx and cervical esophagus. Corticosteroids, inhalation of vasoactive substances, and humidification may be sufficient therapy for limited laryngeal mucosal hematomas and edema. Major dislocations in fractures of the cartilaginous and bony laryngeal framework require repositioning and fixation of the fragments.

In penetrating neck injuries, management will depend on the anatomic level of involvement (see algorithm below). Zone I describes the areas between the sternal notch and the cricoid cartilage; zone II between the cricoid cartilage and the lower border of the mandible; and zone III between the lower border of the mandible and the base of the skull. Injuries to zones I and III require complete diagnostic evaluation before surgical exploration is undertaken. Vascular injury should be suspected in the presence of active bleeding, absent pulse, bruit, expansile or pulsatile hematoma, or contralateral central neurologic deficit. Angiography combined with transcatheter embolization may be necessary to manage vascular injuries in zones I and III.

Physical examination alone is sufficient to assess vascular injury in asymptomatic patients sustaining injuries in zone II. One exception is patients with transcervical gunshot wounds—that is, wounds that cross the midline. These patients should undergo complete diagnostic evaluations. Management, however, should be prioritized to achieve airway patency and to tamponade hemorrhage. Patients with persistent shock, profuse bleeding, airway compromise, or evolving stroke should undergo immediate neck exploration.
 

PERITONSILLAR ABSCESS

Peritonsillar abscess most commonly occurs in adolescents and young adults. The diagnosis is made clinically, based on such symptoms as fever, odynophagia, dysphagia, trismus, and sore throat. Streptococcus is the organism most often cultured, although polymicrobial flora have been reported. Dyspnea and stertor may be present, but airway compromise in older children and adults is uncommon. Patients usually report having had a sore throat that failed to resolve and instead progressed to worsening unilateral symptoms.

Physical examination reveals trismus, drooling, and a muffled "hot potato" voice. Classic findings include unilateral peritonsillar and soft palate swelling, with deviation of the uvula to the contralateral side. Tonsillar erythema and exudates may be absent. If limited neck motion is observed and peritonsillar aspiration fails to reveal purulent collection, a CT scan and flexible laryngoscopy are warranted to exclude a parapharyngeal abscess (see image below).

Peritonsillar abscess. This axial CT scan with contrast shows fluid collection in the peritonsillar area in a child.

Treatment begins with intravenous (IV) hydration and antibiotics. Ampicillin/sulbactam or clindamycin is acceptable. In addition, IV steroids are recommended if there are no contraindications. A single dose of 8 to 12 mg of dexamethasone appears to decrease trismus and discomfort. Next, topical anesthesia with cetacaine and infiltrative anesthesia with lidocaine and epinephrine are administered. A 25-gauge needle can be used to inject 1 to 2 ml of lidocaine and epinephrine submucosally at the superior tonsillar pole and the area of greatest fluctuance. A submucosal bleb with mucosal blanching signifies an injection of proper depth and effectiveness.

There is no significant difference in outcome between needle aspiration and incision and drainage. If needle aspiration is performed, an 18-gauge needle should be used. A rare but serious complication is inadvertent puncture of the carotid artery. Always pointing the needle medially and not allowing the tip to pass a plane lateral to the teeth can easily avoid this complication. Needle aspiration should begin at the site of greatest fluctuance and proceed from medially to laterally along the soft palate, and then superiorly to inferiorly along the anterior tonsillar pillar until purulence is found.

The needle can be safely inserted to a depth of 1 to 2 cm, and multiple aspiration attempts can be made. If no purulence is aspirated, the patient may have an early phlegmon and multiple aspirations may be therapeutic. However, if neck swelling, erythema, fluctuance, or limited neck motion is observed, the presence of a parapharyngeal abscess should be excluded.

After aspiration, the patient can swish and spit half-strength hydrogen peroxide; substantial relief of symptoms is expected within 30 minutes. The patient should be discharged on 7 to 10 days of oral antibiotics and re-evaluated in 2 to 3 days in order to ensure resolution of the infection. Patients with chronic tonsillitis or those who have had a previous episode of peritonsillar abscess may benefit from tonsillectomy, and an outpatient otolaryngology consult is recommended. Finally, younger children and patients with airway compromise should undergo drainage in the operating room.
 

INFECTIOUS ETIOLOGIES OF PEDIATRIC STRIDOR

The most common causes of pediatric stridor can be characterized etiologically as infectious, acquired, or congenital. Prompt diagnosis and management of pediatric airway disease is essential. Dyspnea, vocal changes, dysphagia, cyanosis, drooling, and use of accessory respiratory muscles may be present in a child with stridor. However, the presence of fever supports an infectious etiology. When fever is absent, acquired and congenital etiologies should be considered.

Radiologic and endoscopic evaluations are adjuncts to a thorough history and physical examination and are critical for the diagnosis of certain pediatric airway conditions. Also, the patient's age and the duration of symptoms can help determine the cause of airway obstruction.

Infectious etiologies of pediatric stridor include laryngotracheobronchitis, acute supraglottitis, adenotonsillar hypertrophy, and retropharyngeal and parapharyngeal abscess.

Laryngotracheobronchitis. More commonly referred to as croup, laryngotracheobronchitis is the most common cause of pediatric stridor, occurring most often in children aged 1 to 3 years. The condition can occur in children as young as 6 months of age, but it is rare. Therefore, for patients with croup-like symptoms who are younger than 1 year of age, acquired or congenital causes of airway obstruction should be considered. The most common etiologic organisms are parainfluenza viruses types 1 and 2.

Laryngotracheobronchitis is characterized by low-grade fever and hoarseness of gradual onset following an upper respiratory tract infection. A barking cough and varying degrees of biphasic stridor are often present, both of which may be relieved by the supine position. The history and physical examination should suggest the diagnosis. However, if the airway is stable, AP and lateral neck radiographs should be obtained; narrowing of the subglottis ("steeple sign") is diagnostic.

Treatment may include observation, hydration and humidified oxygen, nebulized racemic epinephrine, and corticosteroids. Endotracheal intubation should be reserved for those cases in which airway obstruction is imminent and medical therapy has failed. Antibiotics are reserved for suspected bacterial superinfection.

Acute supraglottitis. This condition, also known as epiglottitis, occurs in children aged 2 to 6 years. It is characterized by an acute onset (within hours) of high fever, stridor, odynophagia, dysphagia, drooling, and a muffled voice. The organism responsible for most cases of epiglottitis in pediatric patients has been Haemophilus influenzae type B (Hib), although infections with Streptococcus pneumoniae, other Streptococcus species, Staphylococcus aureus and Moraxella catarrhalis have also been seen.

Children with epiglottitis appear toxic and often assume a classic sitting position with the chin up and the mouth open ("sniffing" position) to maximize airflow. Any attempt to visualize the airway or perform invasive procedures, such as obtaining a blood culture or establishing IV access, may provoke respiratory arrest and should be deferred until the airway has been stabilized. The diagnosis is often made clinically, but a lateral neck x-ray may be performed under close supervision. If it reveals a "thumbprint," that is considered diagnostic.

Treatment includes urgent intubation, preferably in the operating room. Antibiotic therapy should include ampicillin/sulbactam or a third-generation cephalosporin.

Bacterial tracheitis. A variant of croup usually caused by S. aureus, bacterial tracheitis is characterized by croup-like symptoms but with a higher fever than in croup itself and a more rapid onset of severe stridor and respiratory distress. Unlike children with epiglottitis, these patients can lie flat and do not drool. Lateral and AP neck x-rays demonstrate irregular subglottic narrowing and may reveal intraluminal crusts or membranes.

Treatment includes endoscopy to confirm the diagnosis and remove any crusting within the airway. Antibiotic therapy should include coverage for S. aureus. To prevent development of subglottic stenosis, intubation should be avoided except in severe cases of airway obstruction.

Adenotonsillar hypertrophy. Although adenotonsillar hypertrophy usually presents as chronic airway obstruction, acute airway obstruction may occur as a result of edema caused by an upper respiratory tract infection such as infectious mononucleosis. This is especially evident in patients with craniofacial abnormalities (as in Down syndrome, for example). Symptoms may include dyspnea, sore throat, dysphagia, and drooling.

Treatment includes antibiotics and corticosteroids. Airway stabilization is usually achieved with placement of a nasal trumpet, but intubation may be necessary in some cases.

Retropharyngeal and parapharyngeal abscess. Deep neck space abscesses in children are characterized by high fever, odynophagia, dysphagia, and torticollis, but the clinical picture may be limited or changing. A polymicrobial flora that includes S. aureus, streptococcal species, and anaerobes is common. Dyspnea may occur in the form of stertor or stridor. Pharyngeal erythema or exudates and cervical adenopathy may be present.

If the airway is stable, an inspiratory lateral neck x-ray in full extension may demonstrate abnormal widening of the pre-vertebral soft tissue space, but a CT scan with contrast is recommended to confirm the presence and extent of the abscess. If dyspnea is present, a flexible laryngoscopy to determine the extent of airway compromise prior to CT is reasonable, and endotracheal intubation or tracheotomy should be considered. An otolaryngology consultation is always required for these cases.

There has been considerable debate on the timing of surgical drainage of deep neck space abscesses in children. When there is no clearly defined abscess, nonoperative management can be initiated. Treatment includes administration of IV antibiotics, with surgical intervention reserved for cases of airway compromise or failure to respond to antibiotics.
 

ACQUIRED ETIOLOGIES

Acquired etiologies for pediatric stridor include acquired vocal cord paralysis (VCP), acquired subglottic stenosis, and respiratory papillomatosis.

Acquired VCP. This condition can be unilateral or bilateral. Acquired unilateral VCP is usually idiopathic, but birth trauma and previous cardiac surgery with injury to the recurrent laryngeal nerve are not uncommon. Unilateral VCP can result in severe respiratory distress in newborns and in small children; therefore, recognition of this problem is critical. A thorough history and physical examination should be performed, with particular attention paid to any associated central nervous system and cardiovascular anomalies.

Unilateral VCP is characterized by hoarseness or a weak cry and choking spells secondary to aspiration. Diagnostic modalities include fiberoptic examination, electromyography (in the older child), imaging studies, and rigid endoscopy. Symptoms are usually self-limiting.

Acquired bilateral VCP is most commonly caused by trauma, whether due to delivery, surgery, or a motor vehicle collision. It is often characterized by significant airway distress and biphasic stridor requiring tracheotomy. Vocal cord lateralization procedures with partial arytenoidectomy afford the highest rate of decannulation among primary procedures for bilateral pediatric VCP.

Acquired subglottic stenosis. This diagnosis should be considered in any patient with stridor and a history of prior intubation. Its incidence in intubated infants has been found to range from 1% to 10%. Although it usually presents as chronic airway obstruction, acute airway obstruction may occur in the presence of edema caused by an upper respiratory tract infection. Varying degrees of biphasic stridor are characteristic, and the condition may masquerade as croup. An otolaryngologist should evaluate patients who present with a prolonged episode (lasting more than two weeks) or recurrent episodes of croup to rule out subglottic stenosis. In addition, children younger than one year of age who present with croup-like symptoms may actually have an underlying, undiagnosed subglottic stenosis.

A lateral neck x-ray will demonstrate subglottic narrowing and, if intubation is necessary, a smaller endotracheal tube may be needed to bypass the stenotic segment. Endoscopy is essential to confirm the diagnosis. Laryngotracheal reconstruction has become the standard of care for long-term treatment of symptomatic subglottic stenosis in children.

Respiratory papillomatosis. This is the most common laryngeal tumor in children. Human papilloma virus types 6 and 11 have been implicated as the cause of the disease, for which there is no definitive cure. Patients with respiratory papillomas may present with hoarseness, weak cry, and signs of partial airway obstruction such as stridor, tachypnea, chest retractions, and nasal flaring. In addition, patients may have a chronic cough, paroxysms of choking, recurrent respiratory infections, or failure to thrive.

Flexible laryngoscopy should be performed. The diagnosis is usually made with visualization of wart-like lesions concentrated at the level of the true vocal folds (see image below) and confirmed by biopsy. A tracheotomy should be avoided to prevent distant spread of the disease; intubation is preferred in the setting of acute airway compromise. Surgical debulking of the lesions in the operating room remains the mainstay of treatment for recurrent respiratory papillomatosis. Several methods have been employed, including physical debridement with forceps, carbon dioxide laser vaporization, and use of a laryngeal microdebrider.

Laryngeal papilloma. Endoscopy reveals the characteristic wart-like lesions of laryngeal papilloma.

CONGENITAL ETIOLOGIES

Congenital causes of pediatric stridor include laryngomalacia, tracheomalacia, and subglottic hemangioma.

Laryngomalacia. The most common cause of pediatric stridor, laryngomalacia is characterized by a congenitally flaccid supraglottis. Airway symptoms begin shortly after birth, worsen through six months of age, and usually resolve without therapy by 12 to 18 months of age. Rarely, symptoms can persist up to five years of age. However, in 10% of affected infants, upper airway obstruction is severe enough to cause apnea or failure to thrive, making surgical intervention necessary.

Symptoms include intermittent inspiratory stridor that improves with the prone position but worsens with feeding, crying, and the supine position. Severe laryngomalacia may result in apnea, cyanosis, feeding problems, failure to thrive, and cor pulmonale. Flexible laryngoscopy in the awake patient is essential for diagnosis. Gastroesophageal reflux therapy is usually beneficial.

Tracheomalacia. This condition can result from a primary congenital deformity of the supporting tracheal rings or from a secondary extrinsic compression of the trachea by a vascular anomaly. Tracheomalacia is also seen occasionally in infants following long-term endotracheal intubation or tracheostomy.

Children with mild tracheomalacia may have no symptoms apart from a characteristic barking or seal-like cough. In more severe cases, stridor is often the first physical sign and may appear within a few days of birth. Primary tracheomalacia is usually self-limiting. Signs and symptoms will resolve in most children by two years of age, and the majority of children demonstrate clinical improvement by 6 to 12 months of age. However, treatment of secondary tracheomalacia is directed at the underlying compressive lesion. Bronchoscopy is the diagnostic study of choice to confirm the diagnosis and assess the severity of the airway collapse.

Subglottic hemangioma. Although subglottic hemangioma usually presents as chronic airway obstruction, acute obstruction may occur in the presence of edema caused by an upper respiratory tract infection. Most patients present by six months of age with stridor and croup-like symptoms. Cutaneous hemangiomas may be present in up to 50% of patients.

Because subglottic hemangiomas do eventually spontaneously regress, treatment must be supportive of the child's airway until involution has occurred. Most subglottic hemangiomas begin to regress after the child is one year old. Endoscopy is required for diagnosis and a smaller endotracheal tube may be needed to bypass the obstruction if intubation is necessary.

Next month: Emergencies of the nose, face, and ear.

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