An episode of acute upper airway obstruction was caused by a lingual haematoma, when a patient with end stage renal failure suffered a hypocalcaemic fit and bit his tongue. The large haematoma and profuse bleeding caused the patient to obstruct and become hypoxic, and rendered laryngoscopy and intubation impossible, requiring an urgent tracheostomy to secure the airway.
Fourth branchial pouch anomalies are extremely rare and only a few such cases showing sinuses and cystic masses have been reported in the literature. We describe a patient who presented on the third day of life with cystic neck swelling of fourth branchial pouch origin giving rise to respiratory obstruction and stridor. Despite repeated aspiration of the cystic mass to relieve respiratory obstruction, rapid recurrence of the mass continued to cause stridor and ultimately required surgical excision. The clinical, radiological, and histopathological findings of this unusual condition are discussed with a review of the literature.
Every body has to eat to survive but it becomes a matter of great concern, when the life provider food becomes an asphyxiating agent. In this case, a 60-year-old woman choked herself while swallowing biscuits. On autopsy examination, biscuits were found lodged in larygo-pharynx. Brain showed marked dystrophy and loosened lusterless white matter. On histopathologic examination, brain tissue had numerous eosinophilic globules representing astrocytic processes called "Rosenthal fibers"; hence, it was diagnosed as a case of Alexander dystrophy. It is a disease of white matter, where there is a progressive degeneration of the white matter of the brain because of imperfect growth or development of the myelin sheath. The histopathology of brain showed Rosenthal fibers in abundance. This is one of the rarest disease in which choking can occur because of lack of nervous and muscular coordination and weakness. Its specific relation to choking is documented in this report.
We describe a child who presented with intermittent respiratory obstruction especially in supine position. Examination revealed a fleshy post nasal mass extending up to the oropharynx. The mass was removed surgically and histopathology revealed an antrochonal polyp. Patient was relieved of his symptoms and has been well ever since.
There have been fourteen cases of solitary fibrous tumour reported as originating from the paranasal sinuses. Here we report a case of solitary fibrous tumour that involved the right nasal cavity with extension into the oropharynx causing stertor and intermittent respiratory obtruction. Histopathology examination revealed the tumuor cells expressed CD34 turnout marker.
Neonatal stridor resulting from intrinsic or extrinsic aberration in the upper respiratory tract often poses not only a diagnostic problem, but also a difficult airway and a dilemma as to the necessity / timing of surgical intervention. A 45 day old female child with increasing stridor since birth was managed by emergency intubation and CT scan followed by excision biopsy of the cystic left sided parapharyngeal mass via a transcervical approach. On histopathology, the excised specimen was reported as cystic salivary choristoma.
A pyolaryngocele is an uncommon complication of a laryngocele that has become infected. We present a case of a pyolaryngocele that was probably due to repeated injections in the neck veins. The pathogenesis, clinical features and management are discussed in detail.
Mandibular distraction osteogenesis (MDO) is increasingly used for neonates and infants with upper airway obstruction secondary to micrognathia. This systematic review was conducted to determine the effectiveness of MDO in the treatment of airway obstruction. The databases searched included PubMed, Embase, Scopus, and grey literature sources. The inclusion criteria were applied to identify studies in children with clinical evidence of micrognathia/Pierre Robin sequence (PRS) who had failed conservative treatments, including both syndromic and non-syndromic patients. Overall 66 studies were included in this review. Primary MDO for the relief of upper airway obstruction was found to be successful at preventing tracheostomy in 95% of cases. Syndromic patients were found to have a four times greater odds of failure compared to those with isolated PRS. The most common causes of failure were previously undiagnosed lower airway obstruction, central apnoea, undiagnosed neurological abnormalities, and the presence of additional cardiovascular co-morbidities. MDO was less effective (81% success rate) at facilitating decannulation of tracheostomy-dependent children (P<0.0001). Failure in these patients was most commonly due to severe preoperative gastro-oesophageal reflux disease, swallowing dysfunction, and tracheostomy-related complications. The failure rate was higher when MDO was performed at an age of ≥24 months. More studies are needed to evaluate the long-term implications of MDO on facial development and long-term complications.
From August till November 1998, the Paediatric and Anaesthetic Units of Hospital Kuala Terengganu managed three patients from Kuala Terengganu District who were ventilated for respiratory diphtheria. Their ages were 5, 4 and 7 years old and their immunisation for diphtheria were not complete. All three patients presented with respiratory distress and were ventilated for upper airway obstruction. Their treatment included intravenous penicillin and diphtheria antitoxin. One patient died of cardiogenic shock with secondary pneumonia. Pharyngeal and tonsillar swabs of all three patients grew toxigenic Corynebacterium diphtheriae biotype mitis. There were 765 throat cultures taken from contacts. The confirmed positive cultures grew 2 toxigenic and 3 non-toxigenic Corynebacterium diphtheriae biotype mitis and surprisingly, 10 non-toxigenic biotype gravis. A prevalence study is needed to document the endemicity of diphtheria in Kuala Terengganu and to determine the carrier rate of both biotypes. Steps have been taken to increase the immunisation coverage in children. The giving of regular booster doses of diphtheria toxoid to the adult population should be considered.
An interesting case is described here in which partial airway obstruction resulted in sleep apnoea and which was relieved by adeno-tonsillectomy. Enlarged tonsils and adenoids causing upper airway obstruction represent one facet of a continuum of hypoventilation - sleep disorders and clinical examination with x-rays will help in determining patients at risk of developing these syndromes.
Six children who survived severe acute bronchiolitis in infancy and early childhood continued to have persistent symptoms of breathlessness, cough and wheeze resistant to bronchodilator therapy. Hyperinflation of the chest, widespread crepitations and rhonchi were persistent clinical features. Failure to thrive was a problem in most. At presentation clinical measles was diagnosed in one child and adenovirus titres were raised in another; the aetiological agents in the others were not known. Lung biopsy from the child with measles showed features of severe bronchiolitis. The clinical and radiological features and course of the illness were consistent with those of bronchiolitis obliterans. Although illness was prolonged the long term prognosis was satisfactory with the majority of children showing improved chest signs, growth and general health after four to eight years of follow up.
Airway assessment is important in emergency airway management. A difficult airway can lead to life-threatening complications. A perfect airway assessment tool does not exist and unanticipated difficulty will remain unforeseen. Current bedside clinical predictors of the difficult airway are unreliable but airway ultrasound can be used as an adjunct to predict difficult laryngoscopy. We report a case of a 60-year-old man presenting to the emergency department with shortness of breath, hoarseness of voice and stridor. Airway ultrasound revealed a large laryngeal mass narrowing the upper airway, extending to bilateral vocal cords with heterogenous echogenicity. In view of impending complete upper airway obstruction, acute respiratory distress and airway ultrasound findings, urgent emergency tracheostomy was chosen as definitive airway over endotracheal intubation or surgical cricothyroidotomy. Point of care ultrasound (POCUS) was used to evaluate this patient with severe upper airway obstruction. A laryngeal mass was detected by ultrasound and this pointed towards the presence of a difficult airway. POCUS was a good non-invasive tool used for airway assessment in this uncooperative and unstable patient. Ultrasound predictors of the difficult airway include the inability to visualize the hyoid bone, short hyomental distance ratio, high pretracheal anterior neck thickness and large tongue size. Besides airway assessment, ultrasound can also help to predict endotracheal tube size, confirm intubation and guide emergency airway procedures such as cricothyroidotomy and tracheostomy. Point of care ultrasound of the upper airway can be used in airway assessment to identify distorted airway anatomy, pathological lesions and guide treatment decisions.
Acute airway obstruction in pregnancy remains a challenge to manage. Failure of appropriate and timely airway management may lead to maternal morbidity and mortality such as aspiration pneumonitis or worst hypoxaemic cardiopulmonary arrest. 1 As pregnancy may exacerbate asthma attacks, parturient presenting with wheezing or shortness of breath will commonly be treated as suffering from an asthmatic attack. 2 However, it is important to note other possible differential diagnoses. Thyroid disease is relatively common in women of childbearing age. The thyroid gland undergoes several changes during pregnancy, which may lead to altered function as well as gland enlargement and cause upper airway obstruction and symptoms similar to a bronchial asthma attack. 3 4 With that in mind, we report a case of a parturient with long-standing goitre in her second trimester who presented to our institution with acute respiratory symptoms and cardiopulmonary arrest.
We present two interesting cases of isolated left subclavian artery from the pulmonary artery with symptoms of upper airway obstruction. The first patient had tetralogy of Fallot, pulmonary artery sling, bilateral superior caval veins, and left bronchial isomerism, suggesting heterotaxy syndrome. The second patient had a right aortic arch, isolated left subclavian artery, and bilateral arterial ducts. These two cases are interesting because of their rarity and uncommon presentation.
Intubations are important live saving skills to maintain adequate ventilation and oxygenation. Common indications include impending upper airway obstruction, respiratory failure and impaired conscious level. Oral myiasis is an infrequently found disease which is characterised by ectoparasitic infestation of body tissues by fly maggots.We present a case report and share valuable experiences on a patient with massive airway myiasis causing upper airway obstruction which require emergency intubation.
Lipoblastomas are benign tumours of immature fat cells presenting in infancy. A lipoblastoma within the airway lumen causing airway compromise is an extremely rare occurrence. We present a 6 hours of life girl who had airway compromise due to a lobulated mass at the base of the tongue. The mass was excised after emergency endotracheal intubation.
The use of ultrasonography in acute and critical care medicine is becoming increasingly common. However, use of an airway ultrasound as an adjunct to determine the type of intervention needed and assess complications is not common practice. We report a 56-year-old male who presented to the Emergency Department of the Sungai Buloh Hospital, Selangor, Malaysia, in 2015 with hoarseness, stridor and impending respiratory failure. A point-of-care ultrasound performed to assess the neck and vocal cords indicated a heterogeneous echogenic mass in the larynx, thus ruling out a cricothyroidotomy. The patient was therefore referred for an emergency tracheostomy. This case highlights the importance of point-of-care airway ultrasonography in the assessment of patients with stridor. This imaging technique not only helps to detect the cause of the stridor, but also to determine the feasibility of a cricothyroidotomy in emergency cases.