Unusual cause acute airway obstruction

Unusual cause acute airway obstruction

Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2017) xxx–xxx Contents lists available at ScienceDirect Egyptian Journal of Ear, Nose...

745KB Sizes 8 Downloads 116 Views

Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Egyptian Journal of Ear, Nose, Throat and Allied Sciences journal homepage: www.ejentas.com

Case report

Unusual cause acute airway obstruction R. Vengatesh ⇑, N. Sanjeevan, Nik Fariza Husna Nik Hassan Department of Otorhinolaryngology-Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kubang Kerian, Kota Bharu 16150, Malaysia

a r t i c l e

i n f o

Article history: Received 23 October 2016 Accepted 3 January 2017 Available online xxxx Keywords: Airway obstruction Laryngopharyngeal reflux

a b s t r a c t Upper airway obstruction is one the most feared condition in Otolaryngology. Acute upper airway obstruction usually requires prompt tracheostomy as a lifesaving act. Through assessment and appropriate diagnosis and management of underlying cause are mandatory and at times even can avoid tracheostomy and its potential complications. We describe a case of severe laryngopharyngeal reflux (LPR) in 63-year-old man, causing acute stridor and airway obstruction lead to emergency tracheostomy. According to our literature review this may be the first case of LPR implicated in acute airway obstruction. Ó 2017 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).

1. Introduction Acute airway obstruction is a life threatening condition. The precise diagnosis and management can be challenging even to experienced physicians. The limitation of time can hamper proper history and examination. Often the history had to be taken from third source. There several conditions lead to airway obstruction, some of them are reversible. Tracheostomy is the gold standard in the treatment of upper airway obstruction. However, tracheostomy has its own complications both short and long term. Identifying reversible and medically treatable airway obstruction is prudent. Laryngopharyngeal reflux is a common condition defined as the retrograde flow of stomach content to the larynx and pharynx whereby this material comes in contact with the upper aerodigestive tract.1 This occurs when the sphincters or muscular rings of the upper or lower esophagus do not function adequately allowing the stomach contents and acid to trickle up to the larynx causing inflammation and edema. LPR presents with variety of symptoms. Symptoms based grading of LPR is called Reflux Symptom Index (RSI).2 LPR can cause the following sings on endoscopic findings subglottic oedema, ventricular obliteration, Erythema, vocal cord edema, diffuse laryngeal oedema and posterior commissure hypertrophy, presence of granulation tissue and thick endolaryngeal mucous. These signs are graded using reflux finding score.2 Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences. ⇑ Corresponding author. E-mail address: [email protected] (R. Vengatesh).

Airway obstruction is a life threatening emergency. It causes severe distress to patients and relatives. Patients often display agitated and restless behavior. Airway obstructions can occur to any age group and has a broad spectrum of causes. Airway obstructions are classified as partial or complete and can occur at any level from the larynx up to the bronchioles. The Causes include foreign bodies, severe allergic reactions, infections, structural abnormalities of the airway, trauma and etc. Symptoms and onset reflect the level of obstruction and severity.

2. Case summary 62 year-old male presented to emergency department with 3 day history of worsening stridor and respiratory distress. He complained of hoarseness for the last 6 months but did not consider medical help. He has a past history of Tracheostomy inserted for prolong ventilation. The tracheostomy was successfully decannulated 6 months ago after a thorough evaluation of his larynx and trachea to make sure there was no subglottic stenosis and vocal cord palsies. On examination on presentation, patient was in acute airway distress with inspiratory stridor. 70 degree rigid endoscopy was performed and revealed very narrow rima glottis and very edematous vocal cords. No appreciable vocal cords movements were noted and minimal movement of the false cords seen. He was admitted with close observation. He was started on intravenous Dexamethasone 8 mg, eight hourly. His symptoms noted to show remarkable improvement with the steroids. However, there was still audible stridor and hoarseness.

http://dx.doi.org/10.1016/j.ejenta.2017.01.001 2090-0740/Ó 2017 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Vengatesh R., et al. Unusual cause acute airway obstruction. Egypt J Ear Nose Throat Allied Sci (2017), http://dx.doi.org/ 10.1016/j.ejenta.2017.01.001

2

R. Vengatesh et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2017) xxx–xxx

Fig. 1. Vocal cord oedema seen over bilateral vocal folds.

LPR causing airway obstruction was made. However unable to assess the vocal cord mobility as patient was under general anesthesia. Patient was started on IV Esomeprazole, IV ranitidine and Syrup Magnesium Trisilicate. Post-operative day 5 laryngoscopic evaluation showed improvement and patent rima glottis. Other findings were Pseudo sulcus, and edematous bilateral vocal cord with minimal but normal movement. Arytenoids were swollen with presence pachydermia. A functional endoscopic evaluation of swallowing (FEES) was also performed and showed premature spillage, weak pharyngeal contraction, delayed swallowing at pharyngeal stage, No aspiration. A scope via the tracheostomy was normal. Patient was discharged home with a double lumen tracheostomy, Esomeprazole 40 mg OD, ranitidine150 mg BD and given out patient consultation. On 4 week follow up laryngoscopy showed marked improvement of laryngeal edema and good mobility of vocal cords. After period of 24 h spigotting tracheostomy was removed. Patient was advised to continue with anti-reflux medication and life style modification. Arrangements were made for a consultation with gastroenterology department. 3. Discussion

Fig. 2. Pachydermia seen over bilateral vocal folds.

The next day patient underwent tracheostomy and direct Laryngosco-bronchoscopy under general anesthesia. Tracheostomy was uneventful, Intra operatively noted Vocal Cords severely edematous, infraglottic oedema, Obliteration of ventricle, pachydermia and a mobile arytenoid (See Figs. 1 and 2). Subglottis was normal but trachea appears unhealthy and irregular with thick endotracheal secretion (Fig. 3). Post-operative diagnosis of severe

This case report illustrates a serious complication of LPR that has not been previously recognized as a complication. The tracheostomy was done in view of the preoperative diagnosis, of bilateral vocal cord paralysis. Patient had a previous history of cerebrovascular accident; therefore we attributed the vocal cord paralysis as the continuation or worsening of cerebrovascular disease. Severe LPR reflux theoretically can cause upper airway obstruction. In isolated supraglottic stenosis, this can be a diagnosis and should be thought of although rare.3 The edema can involve the entire larynx. Our literature search did not reveal documented reports. There could be many reasons such as difficulty in establishing the diagnosis in acute setting and lack of vigorous follow ups. In our case the diagnosis was only came to light in post tracheostomy period and by performing repeated direct laryngoscopy. The bilateral vocal cord mobility was obscured by very edematous cords. In hindsight our patient could have been managed medically without tracheostomy. Most likely he wouldn’t have encountered complete airway obstruction as feared. Dramatic improvement to intravenous steroid suggested reversible edema and adds weight to conservative management. The trigger for the edema in this case was LPR that could have been managed with aggressive medical

Fig. 3. Mucosa within the trachea appearing unhealthy and irregular with thick endotracheal secretion.

Please cite this article in press as: Vengatesh R., et al. Unusual cause acute airway obstruction. Egypt J Ear Nose Throat Allied Sci (2017), http://dx.doi.org/ 10.1016/j.ejenta.2017.01.001

R. Vengatesh et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2017) xxx–xxx

therapy. Lack of this knowledge at the time of presentation lead us towards the safe option of securing the airway. Tracheostomies do have their complications of their own. Studies have shown that emergency tracheostomy can post much severe complications compared to an elective tracheostomy. Complications include infection 12%, dysphagia 6%, emphysema 6%, immediate haemorrhage 4%, Aspiration 6%, Tube obstruction 4% and etc.4 however we are fortunate enough that our patient did not develop such complications. Thus, avoidance of tracheostomy whenever possible may prove beneficial to the patient. Authors understand the difficulties in managing acute upper airway obstruction and the priority of securing the airway. In critical but stable patient, ascertain the etiology of airway obstruction may identify reversible causes like LPR. The clinical acumen is paramount in making such decisions. Patient should be nursed in appropriate setting. Facilities and trained personals should be available for emergency scenarios. Patient’s factors including neck anatomy and obesity do play a role in concluding such decision. 4. Conclusion

3

as the potential cause of airway obstruction in high risk patients with convincing history for LPR. If an accurate diagnosis of LPR related acute airway obstruction can be made, it’s possible to treat the patient with appropriate medical management. This can avoid a tracheostomy. There are few conditions that cause acute airway obstruction can be managed without tracheostomy. Conflict of interest There is no conflict of interest.

References 1. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. 2005;294(12):1534–1540. 2. Postma GN, Halum SL. Laryngeal and pharyngeal complications of gastroesophageal reflux disease. GI Motility Online. 2006. 3. Krishna PD, Malone JP. Isolated adult supraglottic stenosis: surgical treatment and possible etiologies. Am J Otolaryngol. 2006;27(5):355–357. 4. Hamid AA, Sattar F, Din SE, Khan NS, Ullah Z. Complications of tracheostomy. J Postgraduate Med Inst (Peshawar-Pakistan). 2011;18(3).

Based on the experience gained from this case we conclude that LPR can cause acute airway obstruction. LPR should be considered

Please cite this article in press as: Vengatesh R., et al. Unusual cause acute airway obstruction. Egypt J Ear Nose Throat Allied Sci (2017), http://dx.doi.org/ 10.1016/j.ejenta.2017.01.001