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UPPER AIRWAY MANAGEMENT:

UPPER AIRWAY MANAGEMENT:. DR. MARION COUCH DEPT. OF OHNS UNC 2005. OBJECTIVES:. LEARN HOW TO PERFORM A SURGICAL AIRWAY BE ABLE TO DIAGNOSE A DANGEROUS AIRWAY LEARN AN ALGORITHM FOR MANAGEMENT OF THE AIRWAY RESPECT THE AIRWAY. INDICATIONS FOR TRACHEOSTOMY:. UPPER AIRWAY OBSTRUCTION

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UPPER AIRWAY MANAGEMENT:

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  1. UPPER AIRWAY MANAGEMENT: DR. MARION COUCH DEPT. OF OHNS UNC 2005

  2. OBJECTIVES: • LEARN HOW TO PERFORM A SURGICAL AIRWAY • BE ABLE TO DIAGNOSE A DANGEROUS AIRWAY • LEARN AN ALGORITHM FOR MANAGEMENT OF THE AIRWAY • RESPECT THE AIRWAY.

  3. INDICATIONS FOR TRACHEOSTOMY: • UPPER AIRWAY OBSTRUCTION • NEED FOR PULMONARY TOILET • PROLONGED INTUBATION • NEUROLOGIC DISORDERS • NEED TO PROTECT THE AIRWAY • REDUCE THE ‘DEAD SPACE’ • REDUCE ASPIRATION • TRAUMA

  4. INDICATIONS: • HEAD AND NECK SURGERIES • IATROGENIC • INFLAMMATION • INFECTION

  5. CONTRAINDICATIONS: • IF YOU BE ASSURED THAT ORAL OR NASOTRACHEAL INTUBATION IS POSSIBLE FOR A SHORT DURATION OF TIME • BETTER SAFE THAN SORRY.

  6. PRE-OPERATIVE: • SPEECH CONSULTATION • NURSING CONSULTATION • SOCIAL WORK CONSULTATION • TELEPHONE, BG&E, MEDIC ALERT • MEETING WITH OTHER PATIENTS OR A SUPPORT GROUP • SUCTION MACHINE, SUPPLIES.

  7. PERCUTANEOUS TRACH: • MINIMALLY INVASIVE • NO SHARPS • COST EFFECTIVE • TIMELY INTERVENTION • EDUCATIONAL OPPORTUNITY • SAFE WITH BRONCHOSCOPE.

  8. TOTAL LARYNGECTOMY: • WHAT’S THE DIFFERENCE BETWEEN THIS AND A TRACHEOSTOMY???

  9. TECHNIQUES: • SKELETONIZE LARYNX: • TRANSECT STRAP MM LOW IN NECK • EXPOSE THYROID GLAND • REMOVE ONE LOBE IF NEEDED • LEAVE PARATHYROID GLANDS

  10. TECHNIQUE: • IDENTIFY POSTERIOR BORDER OF THYROID CARTILAGE ON BOTH SIDES • ROTATE LARYNX TO EXPOSE ATTACHMENT OF INFERIOR CONSTRICTOR MM. • INCISE MM ALONG POSTERIOR BORDER OF THYROID ALA

  11. TECHNIQUE: • THE THYROHYOID MEMBRANE IS EXPOSED • SUPERIOR HORN OF THYROID CARTILAGE IS ISOLATED AND MUCOSA IS DISSECTED FROM THE THYROID CARTILAGE • LIGATE SUPERIOR LARYNGEAL NEUROVASCULAR BUNDLE

  12. TECHNIQUE: • GRASP HYOID BONE WITH ALLIS CLAMP AND CAUTERIZE ON HYOID BONE SUPERIOR AND LATERAL SURFACE • AVOID HYPOGLOSSAL NERVE • MOBILIZE LARYNX FROM SURROUNDING TISSUE

  13. TECHNIQUE: • TRANSECT TRACHEA (USUALLY ABOUT 4TH RING) • DISSECT ALONG THE PARTY WALL AND SEPARATE TRACHEA FROM ESOPHAGUS • SECURE ANTERIOR TRACHEAL WALL TO SKIN WITH HEAVY SUTURE • INTUBATE TRACHEA WITH TUBE

  14. TECHNIQUE: • ENTER PHARYNX ON SIDE OPPOSITE TUMOR • MAY ENTER IN VALLECULA IF LARYNGEAL TUMOR • MAY ENTER IN PYRIFORM SINUS IF B.O.T. TUMOR • GRASP EPIGLOTTIS WITH ALLIS • USE METZENBAUM SCISSORS TO ENLARGE CUTS

  15. TECHNIQUE: • ALWAYS LOOK TO PRESERVE AS MUCH MUCOSA AS POSSIBLE ON THE TUMOR-FREE SIDE OF LARYNX!!!! • CUT MUCOSA WITH CARE • WATCH WHERE TUMOR IS LOCATED AT ALL TIMES

  16. TECHNIQUE: • JOIN SUPERIOR DISSECTION WITH INFERIOR DISSECTION • REMOVE LARYNX • MAY PASS NASOGASTRIC TUBE • CLOSE WITH 3-0 VICRYL SUTURES • CONNELL STITCH TO INVERT MUCOSA • IN THE BAR, OUT THE DOOR……

  17. TECHNIQUE: • SECOND LAYER CLOSURE USING CONSTRICTOR MUSCLES • IRRIGATE WOUND • TRY A BLUE HAWAIIAN: • METHYLENE BLUE AND WATER INTO PHARYNX – CHECK FOR LEAKS • NOW FOR STOMA: • HALF MATTRESS SUTURES

  18. STOMA: • SOME SURGEONS USE ENTIRE TRACHEAL RING AND SUTURE TO SKIN • MAY ALSO BEVEL TRACHEA TO CREATE WIDE STOMA • BIRD GRATE IS GOAL!!

  19. NEED FOR RECONSTRUCTION: • 3 CM

  20. COMPLICATIONS: • PHARYNGOCUTANEOUS FISTULA • STOMAL STENOSIS • PHARYNGEAL STENOSIS • HYPOTHYROIDISM • HYPOPARATHYROIDISM • STOMAL RECURRENCE • HEMATOMA

  21. COMPLICATIONS: • DYSPHAGIA DUE TO CRICOPHARYNGEAL MUSCLE HYPERTROPHY • AIRWAY OBSTRUCTION • CAROTID ARTERY EXPOSURE • FISTULA • WOUND BREAKDOWN

  22. MANAGEMENT OF FISTULA: • CREATE MEDIAL CONTROLLED FISTULA AND USE PACKING • OTHER INSTITUTIONS LEAVE DRAINS IN PLACE, OFF SUCTION • CAROTID PROTECTION

  23. NEED FOR EMERGENT TOTAL LARYNGECTOMY? • DATA NOT COMPELLING ENOUGH TO PROCEED WITHOUT PROPER PRE-OPERATIVE PLANNING. • ESTABLISH AIRWAY • ETT, TRACH, SHAVE TUMOR • GET TISSUE DIAGNOSIS • SCAN, STAGE PATIENT • DISCUSS WITH PATIENT

  24. PEARLS: • ENTER PHARYNX ON SIDE OPPOSITE OF TUMOR. • SAVE AS MUCH MUCOSA AS POSSIBLE WITHOUT COMPROMISING TUMOR MARGINS. • IF TUMOR IS IN PYRIFORM SINUS – THINK FLAP RECONSTRUCTION

  25. PEARLS: • A DEAVER RETRACTOR INSERTED THROUGH MOUTH INTO VALLECULA CAN HELP FIND PHARYNGEAL MUCOSA FOR ENTRY INTO PHARYNX. • TRACHEOESOPHAGEAL PUNCTURE MAY BE PERFORMED AFTER REMOVAL OF LARYNX • USUALLY 1.5 CM FROM SUPERIOR EDGE

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