ENT/HEAD & NECK

Ear, nose and throat

emergencies

Learning objectives
After reading this article, you should be able to:
C
list the main causes of stridor in adults and children
C
state the difference in presentation between croup and
epiglottis
C
outline the key points in the management of epiglottitis, croup,
inhaled foreign body and the bleeding tonsil

Joanna Makepeace
Anil Patel

Abstract
An airway emergency, including any lesion causing upper airway compromise, is potentially life-threatening in both adults and children. Stridor,
acute epiglottitis, inhaled foreign body and bleeding tonsils, all require
a prompt, methodical approach. Clear communication and cooperation
between anaesthetic and surgical teams is vital.

Fibreoptic nasendoscopy can be helpful in assessing the airway

in adults. A CT of the neck/thorax may also be indicated to locate
the exact site and extent of the obstruction. Careful planning with
the ENT surgeons is needed at all stages of management.

Keywords Bleeding tonsil; croup; ENT emergency; epiglottitis; foreign

body; stridor

Croup
Royal College of Anaesthetists CPD matrix: 2A01, 3A01, 3A02, 3D00

Laryngotracheobronchitis (croup) is the most common cause of

stridor in children, usually presenting between 6 months and 2
years of age. It is due to viral infection of the larynx, trachea and
bronchi, secondary to parainfluenza, respiratory syncitial, and
influenza viruses.

Any lesion that compromises the upper airway may be lifethreatening, and a prompt but methodical approach is needed
to manage these situations. Most importantly, good communication between the anaesthetists and all medical personnel
involved is vital.
The Certificate of Completion of Training (CCT) in Anaesthesia (2010 curriculum) states that the trainee: Explains the
principles of the recognition and appropriate management of
acute ENT emergencies, including bleeding tonsils, epiglottitis,
croup, and inhaled foreign body.

Clinical presentation
 Gradual onset of a barking cough.
 Children rarely appear toxic (as with epiglottitis).
Management
 As for Stridor.
 Nebulized budesonide 2 mg may also help.
 Monitor after treatment, as mucosal swelling may recur.
 Intubation is only required for severe cases, and should be
managed as for epiglottitis.

Stridor
Stridor is a harsh, predominantly inspiratory noise, caused by
partial upper airway obstruction. It is a medical emergency which
may necessitate urgent tracheal intubation or tracheostomy. The
initial management is the same irrespective of the cause (Table 1).

Acute epiglottitis
Epiglottitis is an acute inflammation and swelling of the epiglottis
and other supraglottic structures, which causes obstruction of the
laryngeal inlet. It is a medical emergency as it can precipitate
complete occlusion of the upper airway. The cause is usually
bacterial, the predominant agent being Haemophilus influenzae
type b (Hib), followed by group A Streptococcus pneumoniae,
Haemophilus parainfluenzae, Streptococcus aureus and b-haemolytic streptococci. It is now becoming rare in children since
the introduction of the Hib vaccine in October 1992 in the UK. It
is often streptococci that are responsible for the epiglottitis in
vaccinated children who develop the condition. Its incidence in
adults has increased, however, because of the frequent use of
antibiotics in childhood.

Management
 Administer 100% oxygen via a face-mask, with the patient
sitting upright.
 Nebulized epinephrine 1 mg (1 ml) of 1:1000 made up to
5 ml with 0.9% saline (repeated every 30 min, with ECG
monitoring).
 Intravenous dexamethasone 0.1 mg/kg, 6-hourly. This will
help reduce airway oedema, but may take 4e6 hours to work.
 Consider inhaled heliox (70% helium, 30% oxygen). Its
density is less than that of air, promoting laminar flow
within the airway.

Clinical presentation
 Most commonly children aged 2e5 years, (but may occur
in adults).
 Acute onset of fever, sore throat and rapid deterioration of
the airway.
 The child is unwell, with drooling, dysphagia and stridor.
 Laryngotracheobronchitis (croup) is the main differential
diagnosis.

Joanna Makepeace FRCA is a Locum Consultant Anaesthetist at Barnet

and Chase Farm Hospitals, London, UK. Conflicts of interest: none
declared.
Anil Patel FRCA is a Consultant Anaesthetist at the Royal National
Throat, Nose and Ear Hospital, London, UK. Conflicts of interest: none
declared.

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2014 Published by Elsevier Ltd.

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Further management
 Laryngeal and blood cultures before commencing
antibiotics.
 Intravenous cefotaxime 50 mg/kg every 8e12 hours.
 Normal visualization of the glottis and presence of a leak
around the tube indicates oedema has settled.
 Extubation is normally within 36 hours.

Causes of stridor
Acute

Chronic

Infection
Epiglottitis, retropharyngeal
abscess, croup

Malignancy
Supraglottic tumours, base
of tongue tumours, laryngeal
papillomatosis
Subglottic stenosis
Following prolonged intubation
Laryngomalacia

Foreign bodies
Aspiration of coin, peanut, etc
Airway oedema
Anaphylaxis, following
instrumentation of the
airway, drug reaction
(e.g. angiotensin-converting
enzyme inhibitors)
Acute exacerbation of chronic
condition

Adults with epiglottitis

Initial management should follow that for stridor, and should
also include intravenous antibiotics and a plan for securing the
airway. There are a number of techniques for anaesthetic management, none of which are ideal, and they are all associated
with difficulties.
Anaesthetic management
 Inhalation induction is slow and may be difficult, resulting
in worsening obstruction and breath-holding.
 Rapid-sequence induction using intravenous induction
agents and muscle relaxants can be used.
 Tracheostomy under local anaesthesia may be difficult to
perform in a patient with severe respiratory distress.
 Awake fibreoptic intubation may precipitate complete
airway obstruction.

Table 1

Initial




management
Seek senior anaesthetic, paediatric and ENT input.
Try to keep the child and parents calm.
Complete airway obstruction may be provoked by:
pharyngeal examination, intravenous cannulation, or
excessive excitement.

Inhaled foreign body

This is the most common indication for bronchoscopy in children
aged 1e3 years old. The effects of foreign body aspiration depend
on the nature, duration, degree and site of the foreign body.
 Larynx and trachea: acute dysponea, stridor, coughing and
cyanosis. This may necessitate the Heimlich manoeuvere
to dislodge the obstruction.
 Bronchus: wheezy, coughing and dyspnoeic with evidence
of decreased air entry on the side of the obstruction.
Chest radiographs may not reveal the lesion as most foreign
bodies are radiolucent, so a positive history and clinical symptoms of aspiration may be the only guide to the diagnosis.
If the obstruction does not pose a functional problem, the
child may present much later with mucosal irritation, oedema
and pneumonitis distal to the obstruction. Peanuts may cause
intense bronchial inflammatory reactions.
The removal of the foreign body requires rigid bronchoscopy
under general anaesthetic, either by inhalational or intravenous
induction. It is important that the anaesthetist and surgeon
discuss the manner in which the foreign body is to be removed.

Anaesthetic
 Urgent transfer to the operating theatre/anaesthetic room.
 A senior surgeon competent at performing paediatric tracheostomy should be present.
 Inhalational induction with 100% oxygen and either sevoflurane or halothane, with the child in a sitting position,
(this may be slow and challenging).
 Intravenous cannulation once the child is anesthetized.
 Intubation is difficult e anatomy of the airway is distorted
due to oedema (Figure 1).
 Glottic opening may be identified by the presence of air
bubbles emerging from the laryngeal inlet.
 Oral tracheal tubes that are 0.5e1.5 mm (ID) smaller than
normal should be available.

Management
Pre-induction
 Child should be adequately fasted.
 Premedication with sedative agents is usually not advised.
 Intravenous cannulation.
 Atropine 20 mg/kg (maximum 600 mg) will reduce secretions and reflex bradycardia associated with airway
instrumentation.
Induction and maintenance
 100% oxygen and either sevoflurane or halothane, (induction may be slow).

Figure 1 Cherry-red epiglottitis.

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 Usually venous or capillary zone bleeding, rather than

arterial.

 Lidocaine spray to the vocal cords may reduce the risk of

laryngospasm on surgical instrumentation.
 Ventilating bronchoscope is inserted with the child
breathing spontaneously. Ayres T-piece is connected to
the side-arm of the bronchoscope, allowing the passage of
oxygen and sevoflurane.
 Ideally, spontaneous ventilation should be maintained to
minimize the risk of distal displacement of the foreign
body. However, this can be difficult to sustain in practice
and intermittent positive pressure ventilation may be
required.
 Anaesthesia should be sufficient to prevent moving,
coughing and laryngospasm. Sevoflurane may be changed
to isoflurane once depth is achieved, or maintenance may
be in the form of a propofol infusion.

Management
General
 Wide-bore intravenous access.
 Adequate fluid resuscitation and blood if indicated.
 Coagulation screen should also be performed to rule out
undiagnosed bleeding diathesis.
Anaesthetic
Intravenous or gaseous induction is used for bleeding tonsils. For
a rapid-sequence induction use the following procedure:
 Check previous chart for airway difficulties and endotracheal tube (ETT) size.
 An ETT size 1.0 mm smaller may be required because of
airway oedema.
 The patient may not tolerate lying supine.
 Preoxygenation, induction and cricoid pressure may be
applied with patient sitting.
 Direct laryngoscopy may be difficult due to blood pooling
in the pharynx, so adequate suction must be ready.
 Insert a wide-bore oral-gastric tube at the beginning and
the end of the procedure to decompress the stomach and
evacuate swallowed blood.
 Extubate fully awake.

Postoperative care
 Intravenous dexamethasone 0.1 mg/kg, 6-hourly, is
administered in the postoperative period, together with
antibiotics if an infection is suspected.

Bleeding tonsil
Although the number of tonsillectomies performed has recently
reduced, around 50,000 tonsillectomies are still carried out in
England every year, making it one of the most common ENT
procedures in children. Postoperative tonsillar haemorrhage occurs in approximately 1% of children and 3% of adults. Of these,
less than a quarter will require surgical intervention.

Conclusion
Airway emergencies pose many challenges to the anaesthetist
and surgeon. A prompt and coordinated management plan
should be formulated and undertaken, with clear communication
between all members of the team at all times. This is vital when
dealing with such life-threatening emergencies.
A

Clinical presentation
 There may be large volumes of swallowed blood, leading
to hypovolaemia
 Extent of loss revealed only when the haemoglobin levels
are measured.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:5

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2014 Published by Elsevier Ltd.