Airway Endoscopy The Basics Neonatal Progressive Acute Quiz

Transcription

1 Endoscopy of the Airway Dave Albert

2 Airway Endoscopy The Basics Neonatal Progressive Acute Quiz

3 The laws of Poiseuille and Bernoulli French physician,physicist mathemetician and Dutch Swiss mathemetician physician and physicist

4 Basics of Endoscopy Team Anaesthetist Nurse Surgeon Equipment Hopkins rod endoscopes Video/still digital recording Microdebrider rather than laser Balloon Spontaneous respiration

5 Flexible Endoscopy Good screening procedure Good for dynamic conditions May miss :- Cricoarytenoid Cleft larynx fixation Subglottic pathology

6 Rigid Endoscopy Precarious airways - Can Can more control probe treat arytenoids etc endoscopically

7 FESS Style Endoscopy

8 Four Shot Views

9 Dynamic View

10 Traditional Microlaryngobronchoscopy

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13 NEONATAL

14 Laryngomalacia: History Stridor cry Not Quiet usually with at musical : cyanotic normal present rest/asleep feeding quality and episodes: growth/weight : at birth crying unusual affected if (first severe week)

15 Laryngomalacia: Examination Inspiratory stridor crying Recession Check for with cutaneous haemangiomata signs of syndromes: small jaw, wide spaced eyes, low set ears etc

16 Laryngomalacia: Endoscopy to confirm diagnosis of laryngomalacia to exclude co-existent airway pathology Fibre- o ptic in office screening? Now minimal standard of care MLB under GA for full assessment

17 When to perform rigid endoscopy laryngomalacia in suspected Intubation history Traumatic birth Stridor from day 1 Cyanotic episodes Biphasic stridor Severe recession Other congenital abnormalities Abnormal neurology Aspiration Failure to thrive

18 Posterior Laryngomalacia Prolapse of arytenoid laryngeal lumen into Trim or snip if: Failure to thrive Severe airway difficulties eg desaturation

19 Aryepiglottoplasty: Surgery Mucosal excision

20 Aryepiglottoplasty Sheffield snip NOT LASER!! Laryngomalacia

21 Vocal cord palsy

22 Vocal cord palsy? second most common cause of neonatal stridor However, often more an incoordination Within 1s with first t month breath and often Bilateral paralysis: Stridor, cyanosis, apnea Unilateral paralysis: dysphonia. Both: feeding problems, sternal recession

23 Treatment Conservative or Tracheostomy Also: Lateralisation: Laser Posterior open or arytenoidectomy Re-inervation cricoid graft? endoscopic endoscopic Voice vs airway

24 Prolonged Intubation

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28 Subglotic edema - endoscopic

29 Endoscopic Cut edges procedure of cricoid

30 Cricoid Split: open procedure

31 Subglottic stenosis

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33 Staging-Sizing using ET tube

34 My current guidelines Grade I Conservative II Endoscopic if soft LTR once established III L TR CTR if cords severe and clear of IV LTR CTR if clear of cords/ t tube

35 LTR Graft placement

36 Cricotracheal resection

37 T-Tube In Situ

38 Webs

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40 Tracheal Stenosis

41 vs Vc nodules intracordal cyst

42 Valecullar cyst

43 Cleft larynx

44 Laryngeal Cleft Type I Type -To VC s - Involving cricoid - II Type III Type IV above thoracic - below thoracic outlet outlet

45 Endoscopic repair

46 Open Repair

47 Trache Oesophageal Fistula

48 Choanal atresia Choanal atresia

49 P resentation Bilateral choanal atresia A neonatal respiratory emergency Immediate management with taped- in oral airway Urgent CHARGE work- up and?ct scan Trans- nasal correction in first week of life Choanal atresia

50 4 of the 6 'C-H-A-R-G- E' features. C H A R G E oloboma eart tresia etarded enital ar disease choanae growth hypoplasia anomolies and and/or development deafness

51 P resentation Unilateral choanal atresia Non- urgent presentation with unilateral discharge and obstruction nasal Routine CT scan Elective correction 1-5 years Choanal atresia

52 Differential diagnosis Neonatal rhinitis Masses Post nasal Teratoma space Anterior nasal space Glioma Midline nasal dermoid Meningocoele Mid nasal and pyriform aperture stenosis (Foreign body if unilateral) Choanal atresia

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55 T rans nasal approach with 120 telescope

56 Adrenaline and dilators Choanal atresia

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58 T rans nasal approach with 120 dilatation telescope -

59 T rans nasal approach with 120 drilling telescope -

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61 Stents Bilateral cases External bridge piece to avoid damage to columella 6 weeks Only dilate if needed 4.5 Portex for term Unilateral Avoid Intranasal Choanal atresia

62 Mitomycin Sub-cytotoxic dose inhibits fibroblasts 2 mg/ml applied topically for 4 minutes Topical Mitomycin as an Adjunct to Choanal Atresia Repair - Arch Otolaryngol. 2002;128: S urgical Management of Choanal Atresia Improved Outcome Using Mitomycin ( 0.4 mg/ml ) Arch Otolaryngol. 2001;127: The expression of mrna for some extracellular matrix proteins (elastase, hyaluronidase, and procollagen) was downregulated in the mitomycin test groups Laryngoscope. 113(2): , February 2003 Choanal atresia

63 Pyriform Stenosis

64 PROGRESSIVE

65 Definition: JRRP Juvenille Recurrent Mean age at diagnosis 3years More aggressive than adult disease Average lifetime procedures = 21 Respiratory Usually larynx If extends below larynx tends to be younger Papillomatosis With rare dysplasia and progression to carcinoma

66 HPV types 6 11 Benign genital warts/jrrp In JRRP, 11 associated with disease Eleven Ξ Heaven more severe Cervical cancer

67 Juvenille respiratory papilloma

68 Cidofovir 5mg/ml 3ml = 15mg Risk/Benefit

69 Subglottic Haemangioma

70 Subglottic Haemangioma Presentation weeks stridor, peaks feeding difficulties, FTT at 6 Usual site subglottis is Occasionally and glottis left in lateral trachea

71 Subglottic Haemangioma 50% of patients with SGH have associated head and neck cutaneous haemangioma Diagnosis at endoscopy Can be biopsied safely as capillary not cavernous haemangioma

72 Management C utaneous usually regress by 6-8 years S ubglottic involute sufficiently so that most are asymptomatic by 2-3 years Observation 50-70% will need a tracheostomy until about months Medical treatments 18 Surgical treatments

73 Management Interferon Steroids Propranalol Tracheostomy aser KTP/C0 L 2 Steroid injection Open excision Microdebrider

74 First GOS patient: SGH,trachy after debulk, July 2008

75 Propranolol Week1 1mg/kg/day divided into 3 doses. Week 2: 2 mg/kg/day divided into 3 doses Up to 9/12 adjust by weight F rom 9/12 no weight adjustment? 12/12 ½ dose every week.

76 Subglottic Haemangioma Endoscopic resection haemangioma of

77 Tumours RRP commonest Chondroma Squamous Ca 2 nd Rhabdomyosarcoma Lymphoma RRP Vascular - disappears

78 Tracheobronchomalacia

79 Collapse and increasing obstruction on expiration intra thoracic obstruction with Extra-thoracic Intra-thoraci c + ve + ve + ve + ve + ve + ve

80 Primary Tracheobronchomalacia Cartilage to muscle Ratio should be 2:

81 Secondary Tracheobronchomalacia Compression

82 Tracheobronchomalacia Diagnosis Cyanotic episodes MLB Cough Avoid physical or (underdiagnosis) airway splinting Aspiration Expiratory Coughing (overdiagnosis) Bronchography stridor

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84 Tracheobronchomalacia Prognosis Treatment Usually months improves by 18 Aortopexy Can be severe (fatal) Bronchopexy Stents

85 Cystic Hygroma

86 ACUTE

87 Acute Epiglottitis H. Infuenzae type b A ge 3 6 years Sore throat, Upright position, drooling, neck fever extended Intubate in OT

88 Laryngotracheobronchitis (Croup) Parainfluenza virus Ages 3 months to 3 years Barking cough Progresses slowly Rarely requires intubation

89 Retropharyngeal Abscess

90 Bacterial tracheitis Staph Aureus H. Flu

91 Laryngeal FB

92 Bronchial Foreign bodies

93 Expiration Inspiration