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Neck & Airway TABLE OF CONTENTS:

1. Angioedema

2. Post-tonsillectomy Bleed

3. Deep Neck Space Infections

4. Epiglottitis & Supraglottitis

5. Aerodigestive Tract Foreign Bodies

6. Adult Tracheostomy Consult

7. Tracheostomy Tube Exchange

8. Tracheostomy Bleed

9. Sialadenitis

10. Sentinel Bleed and Carotid Blowout

TRACHEOSTOMY ON-CALL CONSULT PODCAST EPISODES:

1. Tracheostomy Hemorrhage

2. Ludwig’s Angina

Overview
Angioedema, swelling underneath the skin or mucosa similar to hives from extravasation of intravascular fluid, can present with rapidly progressive swelling of the lips, tongue, face, supraglottis, or larynx with resultant airway compromise. The underlying etiology may be inherited or acquired C1 esterase inhibitor deficiency, a drug or allergic reaction, or idiopathic. Swelling most often involves the face but may also affect distant sites such as the genitals or bowels with sudden cramping abdominal pain a possible presenting symptom. The responsible biochemical pathway may be classified as histaminergic or bradykinin-mediated with the former being much more common. Histaminergic reactions may additionally involve pruritus, urticaria, or hives. Understanding these separate biochemical pathways is important due to differences in the treatment algorithms and expected response. Standard medical treatment uses antihistamines, steroids, epinephrine, and trigger avoidance, although bradykinin-mediated cases will typically require directed therapies at the qualitative or quantitative C1 esterase inhibitor deficiency as it is refractory to these conventional treatments. History suggestive of bradykinin-mediated angioedema including family history is important as these cases may be more likely to progress and require airway intervention. Patients with recurrent angioedema benefit from allergic work-up and trigger avoidance. The primary role of the Otolaryngologist in managing angioedema involves airway management upon presentation and throughout medical treatment.

Differential Diagnostic Considerations for Angioedema

• Contact Dermatitis

• Cheilitis Granulomatosa

• Systemic Capillary Leak Syndrome

• Epiglottitis

• Urticaria

• Idiopathic Edema

• Hypothyroidism

• Superior Vena Cava Syndrome

• Anaphylaxis

• Insect Bite

• Subcutaneous Emphysema

• Cluster Headache

• Quincke’s Disease

• Cellulitis

• Dermatomyositis

• Lemierre’s Syndrome

Key Supplies for Angioedema Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Topical combination anesthetic/decongestant spray such as lidocaine/oxymetazoline spray

• Flexible endoscope (preferably videoendoscopy via portable unit or tower to record exam)

• Antifog solution (Fred)

• Equipment for fiberoptic bronchoscope awake intubation

• Ensure airway cart is immediately available with supplies for bag valve mask, cricothyroidotomy kit, and surgical airway instruments

Management

• See all consultations for suspected angioedema immediately as the edema may progress rapidly.

• While talking to the consulting team, recommend placement of IV, oxygen, telemetry, NPO status, and placement of airway cart by patient’s room. Suggest IV steroids (dexamethasone or similar) and antihistamines.

Airway Evaluation and Management

Airway evaluation and potential treatment takes precedence. Signs of impending airway compromise include, but are not limited to, muffled voice, significant lip, tongue, or oral cavity edema, stridor, stertor, distress, anxiety, disorientation, tachypnea, retractions, cyanosis, tripod or sniffing positioning, and drooling or inability to manage secretions.

If patient is showing signs of airway distress

• Immediately activate the OR, notify senior resident/attending, Anesthesia, and OR charge, mobilize help in obtaining airway adjuncts and supplies for intubation or an emergent surgical airway if needed.

• Consider oxygen via nasal cannula, nasal trumpet, facemask, non-rebreather, or heliox. If available, consider THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange).

• In the patient with significant distress, nasopharyngoscopy may be reserved for the OR, although in all but the most extreme cases, fiberoptic airway evaluation may be completed in the Emergency Department and can be performed with a video bronchoscope to facilitate immediate transition to intubation if necessary.

• Ideally the airway should be secured in the OR. Generally, video or videobronchoscopic intubation is preferred; however, if the patient is not a good candidate or has acute decompensation, an awake or emergent tracheostomy may be required and should be undertaken with great care, as surrounding edema can distort anatomy and make tracheostomy more challenging.

• If the airway is obtained in the OR, consider performing direct laryngoscopy to confirm underlying etiology of airway compromise and extent of angioedema. Stored images of the airway are helpful in tracking progress as the patient progresses through medical treatment.

• If the airway is secured outside the OR (e.g., ER or ICU) direct laryngoscopy is not typically performed for angioedema unless high concern for other process that would require surgical intervention and is usually delayed at least 24 hours.

• If signs of infection, consider alternative diagnosis such as epiglottitis or deep neck space infection and appropriate antimicrobial treatment.

If patient is showing signs of a stable airway

• Complete history with attention to the timeline, symptom progression, preceding illnesses, past medical history, and similar past events in the patient or family members (family history critical to identify bradykinin-mediated variant).

• Do not significantly delay airway exam for history.

• Obtain a complete list of active or recent medications.

  • Attention to ACE inhibitors and ARBs, NSAIDS, and estrogens (may worsen or increase attack frequency if C1 esterase inhibitor deficiency).

  • Additional attention to anticoagulants (coumadin, aspirin, apixaban, etc.) that may be important if tracheostomy is required.

• Complete head and neck exam focusing on the airway, oral cavity, oropharynx, and neck, and pay particular attention to maximal incisor opening, dentition status, tongue size and modified Mallampati score, and neck range of motion for intubation considerations.

• Ensure airway supplies are readily accessible before exam.

• Flexible nasopharyngoscopy (preferably video).

  • If significant supraglottic edema, proceed with steps as above for impending airway compromise with plan for intubation or surgical airway if needed in the OR.

  • If supraglottic or tongue edema is mild, recommend admission to ICU for close airway observation with airway supplies including trach tray at bedside in case of acute decompensation.

Labs

• Once a stable airway is confirmed or obtained, consider the following labs:

  • CBC, CMP, ESR and CRP, C1 esterase inhibitor levels, and C4 complement levels. Consider serum tryptase if within an hour or so of symptom onset. (Elevated levels are associated with anaphylaxis and help rule out C1 esterase inhibitor deficiency as the underlying cause.)

  • If C1 esterase inhibitor and C4 complement levels are low, consider additional complement studies including C1q levels and C1-esterase inhibitor function studies.

  • Hereditary angioedema expected lab findings

    • Type I: C1 esterase inhibitor level and function low, C4 low.

    • Type II: C1 esterase inhibitor level normal or high, C1 esterase inhibitor function low, and C4 levels low.

    • Type III: C1 esterase inhibitor level and function normal, but F12 gene mutation leading to increased activation by plasmin, worsened with estrogen exposure (e.g., contraceptives or pregnancy).

    • Acquired C1-INH Deficiency: Low C1-INH function and low C1q.

Imaging

• Angioedema is a clinical diagnosis; imaging is reserved for cases where the diagnosis is in doubt or the patient is not responding to treatment as anticipated.

Medical Treatment

• Histaminergic Angioedema:

• IV steroids.

• IV H1 and H2 blockers such as diphenhydramine and cimetidine.

• Nebulized or systemic epinephrine may be administered if severe or progressing.

• Humidified oxygen.

• Elevate head of bed.

  • Consider treatment as below for bradykinin-mediated angioedema if recalcitrant or severe.

• Bradykinin-Mediated Angioedema:

  • Unless known history prior to presentation, most patients will undergo the treatments above for histaminergic angioedema (these may be less effective or ineffective for bradykinin-mediated angioedema). Consider the treatments below if unresponsive; these treatments are usually ordered by the Emergency Department or ICU provider.

    • Fresh frozen plasma.

    • C1 esterase inhibitor concentrate.

    • Icatibant: Bradykinin receptor antagonist, very expensive and typically reserved for severe cases with proven hereditary angioedema or refractory ACE related angioedema, used by some hereditary angioedema patients as a self-injection at home.

    • Ecallantide: Kallikrein inhibitor, also expensive, may be used both prophylactically and for treatment in severe cases.

    • Acquired C1 esterase inhibitor deficiency patients should be worked up for underlying neoplastic or autoimmune conditions.

    • May be considered for prophylactic rituximab if recalcitrant disease and recurrent attacks despite treatment of underlying disorder if present.

Disposition and Follow-up

• Admission required for patients with concern for airway involvement or progression.

  • ICU if intubated or if airway involvement requiring close observation.

  • If not intubated, ensure a closely monitored environment, as airway inflammation and edema can acutely worsen requiring airway securement.

  • If symptoms stable or improving and minimal airway compromise, may consider regular floor (hospital dependent based on available resources and skill sets), although consider continuous pulse oximetry/capnography and escalation of care if any signs of worsening.

• If intubated, extubate per usual ICU protocol (e.g., check endotracheal tube cuff leak prior to extubation, etc.).

• Consider referral to an Allergist for follow-up.

• Primary Care follow-up after discharge.

• Otolaryngology follow-up on an as-needed basis in most cases.

References
1. LoVerde, D., Files, D.C., Krishnaswamy, G. (2017). Angioedema. Crit Care Med. 45(4):725-735.
2. Memon, R.J., Tiwari, V. (2021). Angioedema. In: StatPearls. Treasure Island, FL: StatPearls Publishing; August 11.
3. Tuchman, J.B., Mehta, D.K. (2013). Complex Upper Airway Problems. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 896-907). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
Post-tonsillectomy hemorrhage usually represents a surgical emergency. Hemorrhage can either occur within the first 24 hours following surgery (primary post-tonsillectomy hemorrhage) or in a delayed fashion, most commonly 7-10 days following surgery (secondary hemorrhage). Secondary bleeds are the most common, occurring in 0.1-4.8% of cases. Hemorrhage after transoral robotic surgery (TORS) for oropharyngeal cancer can present similarly in both an acute or delayed fashion and occurs after roughly 5% of TORS cases; in most cases, concomitant ligation of branches of the external carotid artery is performed at or near the time of TORS, which has been shown to reduce the severity of the bleeding, although not the overall postoperative bleed rate.

Key Supplies for Post-Tonsillectomy Bleed Consultation

• Headlight

• Tongue depressor or retractor

• Kidney basin

• Suction with Yankauer tip

• Benzocaine (Hurricane®) or Cetacaine® spray (be aware of risk for methemoglobinemia)

• Silver nitrate

• Ice water

• Tonsil sponges

• Curved ring forceps

• Airway cart if active bleeding or airway concerns

Initial Management

When initially consulted for post-tonsillectomy hemorrhage, the first concern is to verify the patient’s ABCs (Airway, Breathing, Circulation). It is important to ask the Emergency Department to urgently obtain sufficient IV access to allow resuscitation and deliver fluids to the patient. In cases of more severe bleeding, it is recommended to obtain a blood type and screen.

Physical exam is crucial to determine whether the patient is actively bleeding (bleeding typically occurs from either the inferior or superior tonsillar poles). Attention to the patient’s airway, vital signs, and pulse oximetry is paramount. Young children may not alert caregivers of bleeding and may simply swallow blood as it accumulates if bleeding is relatively mild, and so physical exam is important.

Generally, a child who is actively bleeding (visible hemorrhage or fresh clot in the tonsillar fossa) will require surgical control of hemorrhage. A select group of adults and adolescents without brisk bleeding may be able to tolerate a trial of bedside cautery. Prior to cauterization, gargling ice water may be helpful in slowing down bleeding. All patients should be considered to have a full stomach if sedation or general anesthesia are considered. If proceeding with bedside cauterization, topical anesthetic (e.g., benzocaine or Cetacaine® spray) can be used prior to cauterization with silver nitrate. Prior to cauterization, compression with gauze or a tonsil ball soaked in oxymetazoline and local anesthetic may help with hemorrhage control and local anesthesia. When performing these procedures, it is important to be cognizant of airway stability. It is also important to avoid run-down of silver nitrate onto the larynx, which may cause laryngeal burns or edema.

Should conservative bedside measures fail, the patient will require treatment in the OR for control of oropharyngeal hemorrhage. If the patient is not actively bleeding at the time they are seen or the bleeding is stopped at bedside, observation in the Emergency Department or admission for observation may be appropriate. Factors to consider include the severity of bleeding, patient age and comorbidities, hemoglobin level, reliability of patient to follow directions, and distance the patient lives from the Emergency Department.

Operative Management

In the case of brisk or persistent bleeding in the Emergency Department, or if the patient is unable to cooperate with bedside hemostasis, the OR should be immediately prepared as the patient is rolled back. The patient should be kept upright and given a basin or suction until the time of anesthesia induction to allow expectoration of blood as it accumulates. In some cases, it is possible to hold pressure on the bleeding area with a tonsil sponge on a clamp, but in many cases, patients cannot tolerate this. Informed consent should be obtained whenever feasible.

Approaches to securing the airway in these patients vary depending on the situation and the comfort of the Anesthesia team. In the OR, children should generally undergo rapid sequence intubation given the risk of emesis and aspiration. For mild to moderate bleeding or clot, adults may be intubated with videolaryngoscope by the Anesthesia team. The adult patient who is vigorously bleeding but actively protecting his/her airway may be managed with awake fiberoptic intubation. Having operative laryngoscopes and a direct laryngoscopy setup available is also a potential option for rapid transoral intubation by the Otolaryngology team (in this case, ensure that the endotracheal tube will fit through the laryngoscope beforehand). In rare situations, emergent cricothyroidotomy or awake tracheostomy may be required for airway control. Regardless of approach to securing the airway, several suctions, good lighting, and several airway management and rescue options should be ready for use. Keep in mind, patients with postoperative oropharyngeal hemorrhage do not generally die from exsanguination but from airway compromise. Ultimately, airway management in this setting is nuanced and requires the best collective judgment of the Otolaryngology and Anesthesia teams.

Intraoperative technique for hemorrhage control includes use of suction cautery, bipolar cautery, silver nitrate, pillar suturing, and figure-8 suturing. More extreme measures may include cervical approach for ligation of feeding vessels or endovascular procedures.

The stomach should be suctioned clear with a large-bore sump tube at the end of the case; irrigation and suctioning through the tube may be necessary to clear clots from the stomach.

Example Operative Note

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

After written informed consent was obtained, the patient was brought back to the operating room by Anesthesia and placed supine on the operating room table. A surgical pause was performed. Rapid sequence intubation was performed, and the patient was orotracheally intubated without difficulty. The bed was turned 90 degrees. A Crowe-Davis retractor was placed with good visualization of the oropharynx. Eschar was noted in the [left/right] tonsil bed, partially dislodged, with [a small amount of/brisk/pulsatile] bleeding. After a clot was removed, the [left/right] [superior/inferior] tonsillar pole was found to be bleeding more briskly and was controlled with bipolar cautery set at 20. The [left/right] tonsil fossa was examined with no evidence of blood or clot. Valsalva to 30 was performed with no bleeding. The stomach was suctioned with an orogastric tube. The patient was taken out of suspension and the Crowe-Davis retractor was removed. The patient was turned back to Anesthesia in stable condition. The patient was extubated uneventfully.

References
1. Christian, J.M., Felts, C.B., Beckman, N.A., et al. (2020). Deep Neck and Odontogenic Infections. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 141-154). Philadelphia, PA: Elsevier.
2. Jeyakumar, A., Miller, S., Mitchell, R.B. (2013). Adenotonsillar Disease in Children. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1430-1444). Baltimore, MD: Lippincott Williams & Wilkins.
3. Mitchell, R.B., Archer, S.M., Ishman, S.L., et al. (2019). Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery, 160(1_suppl), S1–S42.

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Overview
Deep neck space infections occur across all age groups with various etiologies, although are most commonly caused by an infection of the upper aerodigestive tract (e.g., odontogenic, oropharyngeal, sinonasal). Additional causes include foreign body, malignancy with secondary infection, suppurative lymphadenitis or infection of a congenital tract or fistula (i.e., branchial cleft, thyroglossal duct cyst), or iatrogenic after surgery to the head and neck, trachea, or esophagus. The location of the causative infection typically determines the presentation as well as the offending flora, which is polymicrobial in most cases. Knowledge of the anatomical layers of the cervical fascia is important for understanding tracts of spread and the presenting symptoms. Symptoms primarily depend on the involved space(s) and may include dysphagia/odynophagia (parapharyngeal, retropharyngeal), nuchal rigidity (prevertebral), trismus (masticator space with pterygoid involvement), otalgia, dysphonia, and neck pain.

The first concern when evaluating a patient with a potential deep neck space infection is ensuring/establishing a safe airway followed by prevention of disease progression with secondary complications such as Lemierre’s syndrome (septic thrombophlebitis of the internal jugular vein with septic pulmonary emboli), mediastinitis, cavernous sinus thrombosis, or Ludwig’s angina (firm floor of mouth cellulitis/edema involving the submandibular and sublingual spaces), among others. Mainstays of treatment include securing a safe airway, broad antibiotic coverage (which may be narrowed based on culture data), potential surgical drainage and wound care, and serial exam to ensure improvement. In addition, it is crucial to distinguish these conditions from necrotizing fasciitis – a life-threating, rapidly progressive infection that results in progressive destruction of soft tissue as well as thrombosis of associated vasculature and that requires emergent surgical debridement. Findings concerning for necrotizing fasciitis include, but are not limited to, overlying rapidly progressing erythema and edema, severe pain, fever, crepitus, skin bullae, or ecchymosis. In some cases, symptoms of sepsis including tachycardia, fever, and hypotension may develop.

Layers of Cervical Fascia

Superficial Layer of the Cervical Fascia

• Extends from top of head to thorax.

• Continuous with platysma, superficial musculoaponeurotic system, and temporoparietal fascia superiorly.

Deep Cervical Fascia (comprised of three layers)

• Superficial Layer of Deep Cervical Fascia

  • Surrounds neck from nuchal line posteriorly, envelops sternocleidomastoid and trapezius muscles, muscles of mastication, and the submandibular and parotid glands.

• Middle Layer of Deep Cervical Fascia (comprised of two divisions)

  • Muscular division: Envelops strap muscles (omohyoid, sternohyoid, thyrohyoid, sternothyroid).

  • Visceral division: Envelops thyroid, trachea, esophagus, and pharyngeal constrictor muscles; creates buccopharyngeal fascia.

• Deep Layer of Deep Cervical Fascia (comprised of two layers)

  • Alar fascia: Starts at cranial base and fuses with middle layer of deep cervical fascia in the upper mediastinum.

  • Prevertebral fascia: Starts at cranial base and extends to coccyx.

  • Both layers are anterior to the vertebral bodies and envelop the paraspinous muscles.

• Carotid sheath fascia is created by all three layers of the deep cervical fascia.

Deep Neck Spaces

Parapharyngeal Space

The parapharyngeal space is shaped as an inverted pyramid with base of the pyramid at the skull base and apex at the hyoid bone. The space is divided into pre- and post-styloid compartments and can be thought of as a central space in the neck as it directly abuts the peritonsillar, masticator, parotid, retropharyngeal, and submandibular space with the carotid sheath running through it. Parapharyngeal space infections can both originate from and spread to any of these bordering spaces. An infection in the oropharynx, particularly the tonsil, is one of the most common sources of parapharyngeal space infection. Symptoms reflect this and can be nonspecific (most commonly throat pain, trismus, malaise, and fever) but may less commonly present with neurovascular complications, especially with post-styloid involvement such as mycotic aneurysm, cranial nerve neuropathy, or Horner’s syndrome.

Carotid Sheath Space

The carotid sheath, comprised of all three layers of deep cervical fascia, runs the length of the neck and contains the carotid, internal jugular, vagus nerve, and sympathetic nerve plexus. Infections in this space are most commonly caused by spread from the parapharyngeal space, although rarely IV drug use can lead to an isolated carotid space infection. Involvement of the carotid sheath can present with insidious development of systemic symptoms or fevers weeks after the suspected causative infection and without trismus or other common deep neck space infection symptoms or obvious abnormalities on physical exam, making the diagnosis a challenge. Sentinel bleeding from the oropharynx, nasopharynx, or even ear is thought to occur before many cases of carotid aneurysm rupture and any history of bleeding or neck hematoma on exam should prompt immediate evaluation for this rare but devastating complication.

Retropharyngeal Space

The retropharyngeal space, bounded by the buccopharyngeal fascia anteriorly and the alar fascia posteriorly, extends the length of the neck from skull base to tracheal bifurcation. Its contents include lateral fat pads and lymph nodes that receive drainage from the posterior pharyngeal wall, nasopharynx, middle ear, and nasal cavity. Infections of the retropharyngeal space can be caused by spread from the aforementioned drainage pathways, parapharyngeal space, trauma, recent upper aerodigestive tract surgery, foreign bodies (e.g., fish bone, barbecue brush wire), suppurative retropharyngeal lymph nodes, or spread from a pharyngeal infection. Any patient with fluid/abscess in the retropharyngeal space deserves immediate evaluation, IV antibiotics, and observation in the hospital with possible surgical drainage depending on the clinical picture. Although observed sometimes in children, most adults require surgical drainage, either transoral or transcervical.

Prevertebral and Danger Space

Directly posterior to the retropharyngeal space and separated by the alar fascia is the danger space. Bounded by the alar fascia and prevertebral fascia, the danger space receives its name because infections in this neck space have no barrier of spread to the chest and can rapidly lead to mediastinitis or acute necrotizing mediastinitis, which carries a high mortality rate even with appropriate antibiotic coverage and treatment. The prevertebral space is directly posterior to the danger space and extends the length of the spine from skull base to coccyx. The prevertebral space is unique in that most infections occur secondary to vertebral body infections, commonly from spinal hardware, trauma, or tumors.

Submandibular and Sublingual Spaces

These spaces, partially separated by the mylohyoid muscles (with communication around the posterior muscle edge), are commonly involved with periodontal infections while sialadenitis is a less common etiology. Ludwig’s angina, a bilateral submandibular space infection usually due to 2nd or 3rd mandibular molar infections, can rapidly progress to fatal airway obstruction secondary to posterior and superior tongue displacement. Anatomically, infection can spread from the submandibular space to nearby deep neck spaces through the buccopharyngeal gap, created by the styloglossus muscle traversing the pharyngeal constrictors. Oral exam frequently reveals an odontogenic source, oral airway obstruction, and a “woody” induration of the floor of mouth. Airway exam should include nasopharyngoscopy to evaluate the base of tongue, oropharynx, supraglottis, and larynx. A definitive airway should be secured if Ludwig’s angina is suspected as cases can progress to complete airway obstruction rapidly. Adjuncts until a definitive airway is secured/needed include nasal or oral airways, supplemental oxygen, and heliox (recommended by some sources, although rarely used in the authors experience). THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) is another recent adjuvant therapy to provide additional airway management time. Most often, videobronchoscopic nasal intubation is the preferred method for definitive airway, although this should only be attempted with a team and equipment ready for an emergent surgical airway. In patients with advanced infection and impending airway distress, awake tracheostomy can be considered. Incision and drainage of any abscess (intraorally for mild disease and transcervical for more severe), drain placement, extraction of the offending tooth (if odontogenic), and broad-spectrum antibiotics are the mainstays of treatment.

Masticator Space

This space contains the muscles of mastication as well as the mandible, inferior alveolar nerve, and internal maxillary artery. Infections of the masticator space predominantly originate from 3rd molar infections. Exam findings are non-specific, most commonly posterolateral oral swelling and tenderness with trismus (involvement of pterygoids). Amalgam artifact can inhibit CT visualization of this space making MRI necessary at times. Drainage may be performed intraorally or externally.

Pretracheal Space

The pretracheal space extends from the thyroid cartilage to the mediastinum. Infection of this space is most commonly iatrogenic following surgical perforation of the anterior esophageal wall but may also be caused by foreign bodies, intubation trauma, or more rarely, thyroid abscess or suppurative thyroiditis. Due to its location, airway edema or compression is possible.

Parotid Space

The parotid space is formed by the superficial layer of the deep cervical fascia wrapping around the parotid gland. This fascia is deficient at the stylomandibular tunnel allowing communication between the parapharyngeal space and the parotid space. This communication more commonly allows spread of parotid tumors into the parapharyngeal space but may also allow infection to spread between these spaces. Primary infections of this space are most commonly related to sialadenitis and may require drainage in addition to the conservative treatments of parotid massage, warm compress, sialagogues, hydration, and antibiotics.

Key Supplies for Deep Neck Space Infection Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Tongue depressor

• Flexible laryngoscope (preferably videoendoscopy via portable unit or tower to record exam)

• If planning bedside needle aspiration or incision and drainage

  • Alcohol pads or betadine swabs

  • 27-gauge needle and 1% lidocaine with 3cc syringe

  • 18-gauge needle and 10cc control syringe for aspiration

  • +/- use of portable ultrasound for image guided needle aspiration

  • 15-blade scalpel

  • Mosquito or Carmalt forceps

  • Culture trap or swab (for both aerobic and anaerobic cultures)

  • Saline irrigation and syringe for irrigation

  • Suction

  • Cotton tip applicators

  • Strip gauze

  • 4x4 gauze

  • Paper tape

Management

• For all patients, airway evaluation comes first. If there are signs of impending airway compromise (e.g., stridor, tripod positioning by patient, desaturation, etc.):

  • Activate OR, notify your senior resident/attending and Anesthesia without delay.

  • Mobilize support in obtaining airway adjuncts, supplies for intubation, and emergent surgical airway.

  • If possible, an immediate flexible laryngoscopy is helpful in further determining airway status/site of obstruction and whether intubation would be possible, but airway securement should not be delayed in the emergent setting.

• If the patient is stable, obtain a complete history including: Symptom progression, surgical history (especially recent procedures to the airway or esophagus), dental pain or recent dental work, drug use, recent infection of the head and neck (e.g., sinusitis, otitis media, cellulitis, etc.), past medical history, especially HIV or immunosuppression, tuberculosis, diabetes, and any steroid use; pay attention to any “muffling” or inability to complete full sentences due to dyspnea.

• Complete head and neck physical exam with attention to oral exam, including Stenson’s and Wharton’s ducts, dental exam, and detailed cranial nerve exam.

• Fiberoptic nasopharyngeal airway exam is required in most cases, and certainly if there is any dyspnea/stridor, dysphagia, or dysphonia.

  • Neck range of motion is particularly important and may be significantly reduced, particularly with retropharyngeal infections.

• Labs including CBC and CMP with consideration for blood cultures and wound cultures (if drainage completed) and specific infectious etiologies (e.g., HIV) depending on clinical context.

• Imaging can be quite helpful but should never delay securing an airway if there is impending or active airway distress.

  • CT neck with contrast is preferred in most cases; most modern Emergency Departments can obtain a CT rapidly, and this can provide invaluable information if it is necessary to proceed to the OR.

  • Plain films of the neck can be considered in an unstable patient with suspected retropharyngeal abscess or supraglottitis but are of less value in the modern setting given access to CT scanners.

  • Chest radiograph for patients with dyspnea with careful attention to air in the mediastinum, deviation of the trachea, etc.

  • Ultrasound can be helpful for some neck space infections and may assist in needle aspiration/decompression.

  • MRI is uncommonly used due to the length of the scan and the need for extended supine positioning in patients who may have airway compromise but can be helpful in stable patients with contrast allergies or if dental artifact obscures the CT.

• Low threshold for securing an airway with intubation (either oral or nasal fiberoptic depending on clinical scenario) or awake tracheostomy if intubation is not possible.

• Some patients may be observed with medical trial before airway intervention but should be in a closely monitored environment, including consideration of continuous pulse oximetry and capnography, with airway equipment ready in case of decompensation.

• At a minimum, admission with close airway observation is indicated in most cases, typically ICU or step-down unit depending on institutional capabilities and the patient’s situation.

• Patients are often managed primarily by an ICU team or Medicine team with Otolaryngology and Infectious Disease consultations.

• Antibiotics:

  • Initiate empiric broad spectrum antibiotics.

  • For adults without severe complications or disease, consider ampicillin-sulbactam or clindamycin.

  • If severe disease, options include ceftriaxone with clindamycin, ceftriaxone with metronidazole, or penicillin G with gentamicin and clindamycin.

  • Consider MRSA coverage for at-risk patients with options of clindamycin or vancomycin (dosage dependent on weight and renal function with serum trough levels drawn per local protocol).

  • Consider antipseudomonal coverage for nosocomial infections with piperacillin-tazobactam or ciprofloxacin.

  • Consider scheduled steroids if airway concerns, most commonly dexamethasone, but be aware of subsequent impacts to WBC trends after steroid administration and worsening of blood sugar control in diabetics.

• Keep all patients NPO during medical trials and have a low threshold to repeat CT neck with contrast if the patient is clinically not responding or deteriorating to assess for the development or progression of a drainable abscess.

• General indications for surgical drainage:

  • Abscess, particularly when discrete and <2-3 cm (distinct from phlegmon in that the infection is walled off, phlegmon may spread along tissue planes and are not encapsulated and thus more amenable to medical treatment).

  • Airway compromise.

  • Failure to respond to medical therapy after 48 hours.

  • Concern for developing complications (Lemierre’s, Mediastinitis, necrotizing fasciitis, etc.) or disease progression.

• Surgical drainage is most commonly performed in the OR depending on the clinical scenario and location of the abscess. Almost always, a passive drain or strip gauze packing is placed to allow continued egress of purulence from the wound and facilitate healing. Large volume irrigation intraoperatively is crucial. Discussion of specific surgical approaches for drainage are beyond the scope of this review, but more information can be found in the included references.

Convalescence

• With improving clinical course, patients may be transitioned from IV to oral antibiotics, typically guided by culture data; the Infectious Disease team may assist with determining the course of outpatient antibiotic therapy.

• Close follow-up with Otolaryngology after discharge.

• Consider repeat imaging once the infection has resolved if suspicion for underlying predisposing pathology such as neoplasm or congenital cyst or tract. For patients with poor dental hygiene, consider dental follow-up to prevent further infections.

References
1. Aynehchi, B.B., Har-El, G. (2013). Deep Neck Infections. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 794-814). Baltimore, MD: Lippincott Williams & Wilkins.
2. Christian, J.M., Felts, C.B., Beckman, N.A., et al. (2020). Deep Neck and Odontogenic Infections. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 141-154). Philadelphia, PA: Elsevier.
3. Vieira, F., Allen, S.M., Stocks, R.M., et al. (2008). Deep neck infection. Otolaryngol Clin North Am. 41(3):459-483, vii.

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Overview
Epiglottitis is defined by acute inflammation of the epiglottis and surrounding supraglottis associated with infection (most cases), thermal or chemical inhalation, caustic ingestion, or foreign bodies. The incidence of epiglottitis in children has decreased dramatically since the widespread implementation of a conjugate vaccine for Haemophilus influenzae type b (Hib). Prior to this vaccine, epiglottitis was seen more commonly in children and was characterized by more isolated inflammation of the epiglottis. In adults, the incidence has remained stable with common isolated pathogens including Haemophilus influenzae, Streptococcus pyogenes and pneumoniae, Staphylococcus aureus, and rarely Candida species in immunosuppressed patients. A viral prodrome or cough may be observed before rapid progression of obstructive airway symptoms and odynophagia. Patients may appear toxic and anxious and may assume the “sniffing position,” with the head hyperextended and nose pointed superiorly in an effort to maintain a patent airway or the “tripod position” by leaning forward to manage secretions. The clinical triad of the ‘‘three Ds’’ (drooling, dysphagia, distress) constitutes the classic presentation of epiglottitis in both adults and children.

Croup and epiglottitis may be difficult to differentiate in young children but dysphagia/odynophagia, preferred upright or tripod positioning, and drooling are all findings that strongly suggest epiglottitis. Lateral neck x-ray to assess epiglottis thickness (i.e., thumb sign) is sometimes used as a screening tool in the ER setting, with the AP radiograph useful to assess for croup. This may be a reasonable adjunct for evaluating a relatively stable pediatric patient with suggestive findings. For children, laryngeal exam via nasopharyngeal endoscopy or direct laryngoscopy in the OR is required for diagnosis but ideally should take place with preparations for securing an airway. In general, nasopharyngeal endoscopy in the ER is not recommended in children, as lack of easy cooperation and laryngospasm and acute decompensation are more likely to occur than in adults. Nasopharyngoscopy is not strictly contraindicated in children but should be performed by the most experienced Otolaryngology provider available, if at all. Stable adults may carefully undergo videolaryngoscopy (or without video if not available) in the ER setting; however, unstable patients should be urgently transported to the OR, where an airway (generally intubation with flexible videobronchoscopic or videolaryngoscopic or surgical if required) can be secured if needed. While many cases present early and can be managed with IV antibiotics, steroids, and close airway monitoring, delayed presentation in adults or children may require emergent intubation or a surgical airway. Consequently, upon consultation, the first step is to assess the status of the airway and ensure NPO status, as rapid disease progression may require rapid action to secure the airway. Once diagnosed, antibiotic treatment is highly effective, and inflammation generally resolves within a few days.

Key Supplies for Epiglottitis and Supraglottitis Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Flexible endoscope (preferably videoendoscopy via portable unit or tower to record exam)

• Antifog solution (Fred)

• Ensure airway cart is immediately available with supplies for bag valve mask, needle cricothyroidotomy, and surgical airway

• Recommend flexible bronchoscope available for intubation if necessary

Management

• See all consultations for suspected epiglottitis or supraglottitis emergently.

• While talking to the consulting team, recommend placement of IV, oxygen, telemetry, NPO status, and placement of airway cart by patient’s room.

• Airway evaluation and management takes precedence. Signs of impending airway compromise include:

  • Stridor.

  • Distress, anxiety, or disorientation.

  • Muffled voice and inability to complete full sentences.

  • Tachypnea.

  • Retractions.

  • Cyanosis.

  • Sniffing or tripod positioning.

  • Drooling or inability to manage secretions.

If patient is showing signs of airway distress

• Immediately activate OR, notify senior resident/attending, Anesthesia, and OR charge, mobilize help in obtaining airway adjuncts and supplies for intubation or an emergent surgical airway if needed.

• Consider oxygen via nasal cannula or facemask, heliox, or THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange).

• Keep patient as calm as possible to discourage airway decompensation; depending on circumstances, may need to avoid provoking maneuvers (e.g., tongue blade exam) in children that may precipitate airway compromise. IV placement should be discussed but should not delay travel to OR to secure airway and should not be done in ER if there is concern for provoking airway compromise.

• In the patient with significant distress, nasopharyngeal scope is not generally recommended as this may delay treatment and precipitate airway compromise.

• Ideally the airway should be secured in the OR. Generally nasal videobronchoscopic intubation is preferred; however, if a patient is not a good candidate or has acute decompensation, an emergent tracheostomy may be required. Avoid cricothyrotomy in pediatric patients given their anatomy.

• After airway is secured, perform direct laryngoscopy.

• Evaluate for abscess, which may require incision and drainage.

• Obtain cultures if possible.

If patient is showing signs of a stable airway

• Complete history including timeline, symptom progression, preceding illness, past medical history. Do not significantly delay airway exam to obtain a lengthy history.

• Complete head and neck exam focusing on the airway, oral cavity, oropharynx, and neck.

• Ensure airway supplies are readily accessible before exam.

• Flexible nasopharyngoscopy:

  • If supraglottic inflammation is significant, proceed with steps as above for impending airway compromise with plan for intubation or surgical airway if needed in the OR.

  • If supraglottic inflammation is mild, recommend admission to ICU for close airway observation with airway supplies including trach tray at bedside in case of acute decompensation.

• Once a stable airway is confirmed or obtained, consider the following labs:

  • CBC, CMP, and CRP for all patients.

  • If intubated, culture of the epiglottic surface should be taken.

  • Blood cultures should be ordered in all cases where patients appear toxic and considered in all pediatric cases.

Imaging

• Should only be completed in cases of stable airway. Provider should accompany the patient.

• AP and lateral neck x-ray:

  • Sensitive but low specificity.

  • Quick to perform, does not require patient to lie down.

  • “Thumb sign” on lateral neck x-ray may indicate edematous epiglottis.

• CT neck with contrast:

  • Sensitive and specific but requires supine positioning, which can lead to rapid decompensation in the scanner.

  • Better for evaluation of epiglottic abscess, which is more common in adults.

  • CT should only be considered in patients with a very stable airway, or after the airway has been more definitely secured.

• Chest x-ray: Should be ordered in all cases after airway is secured or patient is in closely monitored environment; concomitant pneumonia may be identified.

Medical Treatment

• Initiate empiric parenteral antibiotics.

  • In adults consider third-generation cephalosporin (such as ceftriaxone) +/- vancomycin for MRSA coverage.

  • If allergic to cephalosporins, consider levofloxacin or ertapenem with vancomycin.

  • In immunosuppressed patients with signs of candidiasis on exam, consider IV fluconazole or micafungin, usually after consultation with Infectious Disease.

• Given the relative rarity of this condition, it may be best to enlist the help of Infectious Disease for input regarding optimal medical therapy.

• May consider corticosteroids; however, data regarding benefit are inconsistent.

Disposition

• Admit to ICU.

• If intubated, extubate per ICU protocol (e.g., check endotracheal tube cuff leak prior to extubation, etc.).

• If not intubated, ensure close monitoring as airway inflammation and edema can acutely worsen requiring airway securement.

References
1. Allen, C.T., Nussenbaum, B., Merati, A.L. (2020). Acute and Chronic Laryngopharyngitis. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 897-905). Philadelphia, PA: Elsevier.
2. Guerra, A.M., Waseem, M. Epiglottitis. (2020). In: StatPearls. Treasure Island, FL: StatPearls Publishing; August 10.
3. Tibballs, J., Watson, T. (2011). Symptoms and signs differentiating croup and epiglottitis. J of Paediatr Child Health. 47(3):77-82.
4. Villari, C.R., Statham, M.M. (2013). Infection, Infiltration, and Benign Neoplasms of the Larynx. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 978-988). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
Foreign body impaction or aspiration requiring Otolaryngology consultation is most commonly seen in pediatric patients, and most frequently involves organic material in the airway and inorganic material with esophageal impactions. All cases require airway evaluation for patency as foreign bodies can lodge in the pharynx or larynx, and esophageal foreign bodies can create pressure and edema that encroach on the posterior trachea leading to airway obstruction, or even erosion into the airway. Furthermore, a co-existing airway foreign body is not uncommon in the setting of a seemingly isolated esophageal foreign body. Most aspiration events lodge the aspirated material in the primary bronchi, right more common than left, unless they are larger in size and obstruct more proximally in the trachea or upper airway. After removal of the foreign body, checking for a second foreign body or secondary aerodigestive injury is critical.

A thorough history that explores the mechanism and nature of the foreign body is important in these cases. If the patient or family member can provide an identical item for study, that can be helpful in instrument selection for removal. Diagnosis is primarily clinical; however, radiographs should be obtained if the patient is clinically stable as they may help localize the foreign body even if it is radiolucent. In many cases the foreign body may be radiopaque (e.g., coin, watch battery, chicken bone); however, a “negative scan” does not rule out the presence of a foreign body because radiolucent material may be missed. It is also prudent to look for indirect signs of foreign bodies including unilateral lung hyperinflation, atelectasis, focal consolidation, surrounding edema, or air in soft tissue surrounding the esophagus or trachea. Persistent sensation of a foreign body that is not visualized by viewing the surface of the mucosa may require a CT to evaluate for embedded fish bone, glass, etc.; this sensation may persist even after the foreign body migrates or is removed secondary to focal mucosal irritation. More proximal foreign bodies in the cooperative older child or adult may be managed in the ER setting; however, those near or below the glottis or at or below the cricopharyngeus will likely require treatment in the OR setting.

Key Supplies for Aerodigestive Tract Foreign Body Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Rigid or flexible endoscope and tower for recording

• If available, flexible bronchoscope with working side channel with grasping instruments

• Antifog solution (Fred™)

• Suction with Yankauer tip

• McGill forceps, Carmalt forceps, and curved Kelly clamp

• Topical anesthetic/decongestant spray (e.g., lidocaine/oxymetazoline spray)

• Ensure airway cart is immediately available with supplies for bag valve mask and surgical airway

Management by Subsites

When managing foreign bodies of the aerodigestive tract, consider approaching these by the suspected site(s) of involvement: oral cavity and oropharynx, tongue base and vallecula, piriform sinus and hypopharynx, supraglottis, glottis, subglottis, trachea, and bronchi.

Oral Cavity/Oropharynx

Oral cavity and oropharynx foreign bodies are often successfully removed by the patient prior to presentation or by the ER provider. In some cases, focal mucosal injury from a prior foreign body that has since migrated distally or has been expelled may induce symptoms that make the patient and provider concerned that it is still present. Small and sharp items, such as fish bones, may also firmly lodge in the oral cavity or oropharynx mucosa making them difficult to immediately visualize. Common areas of the oral cavity and oropharynx that are not easily visualized by other providers include the retromolar trigone, tonsillar fossa, glossotonsillar sulcus, posterior pharyngeal wall, and tongue base/vallecula. In these areas, it is important to examine the painful area as well as the opposing mucosal surface for a potential foreign body. Occasionally, the foreign body will be on the opposite surface from where the patient is experiencing pain. Loupes or a high resolution flexible nasopharyngoscope can be useful to visualize small, difficult to see items, and reflections from a headlight may indicate the location of small foreign bodies.

Tongue base/Vallecula

Foreign bodies at the tongue base/vallecula can sometimes be treated in the Emergency Department (patient tolerance dependent, with great care not to dislodge more distally); however, more distal foreign bodies generally require operative intervention. Mucosal irritation can sometimes be mistaken for a foreign body up to 72 hours after injury; however, in all cases a foreign body must be ruled out. Fish bones, toothpicks, wire brush bristles, etc. are very common foreign bodies at the tongue base/vallecula. The vallecula is optimally visualized by having the patient maximally protrude the tongue while using a flexible nasopharyngoscope through the nose or mouth. “Helping” the patient by gently pulling their tongue forward with gauze may enhance visualization. Depending on the patient’s anatomy, the tongue base and vallecula may be assessed transorally with a good headlight, or more commonly with a flexible scope either through the nose or mouth. One to two puffs of topical anesthetic spray can help with patient tolerance. If there is no concern for airway distress, a lidocaine nebulizer can be very effective at topically anesthetizing the upper aerodigestive tract to allow for good exam and foreign body removal, especially in patients with a strong gag reflex. Foreign bodies that are easily accessible in the tolerant adult patient may be removed in the ER setting; however, in adults who are not tolerant of exam and instrumentation, or when concern for impending airway compromise is present, management in the OR setting is recommended. A portable rigid scope or taping a flexible scope to McGill forceps can be helpful to both visualize and grasp the foreign body. For children, OR removal is strongly recommended. For all patients, avoid use of blind finger sweep as foreign bodies can be pushed distally, and sharp edges may injure the examiner.

Piriform Sinus/Hypopharynx/Supraglottis/Glottis/Subglottis/Trachea/Bronchi

Foreign bodies located more distally are more difficult for the patient to localize, are more challenging to visualize with awake endoscopy, and are more concerning from an airway perspective. Cases of suspected or confirmed foreign bodies involving the supraglottis, glottis, subglottis, or trachea generally require acute intervention. In the stable patient, AP and lateral neck and chest x-rays may be useful to help localize the foreign body. In many cases, flexible nasopharyngoscopy can visualize a foreign body involving the hypopharynx, glottis, immediate subglottis, or esophageal introitus; however, removal in the ER is difficult and the likelihood that the foreign body could be dislodged and move distally is high with manipulation and therefore is generally not advisable. For smaller, biodegradable foreign bodies in adults, time and plenty of fluids may dislodge the foreign body and the patient will swallow it. For larger (or compositionally harmful) foreign bodies, you will likely have to take the patient to the OR. Contact your senior resident, the attending on-call, OR staff, and Anesthesia team as quickly as possible. Regardless of whether an object is visualized on plain film or endoscopy, stories concerning for foreign body aspiration in children generally necessitate an exam in the OR. As a rule of thumb, if any one or more of the three key data elements (history, exam, imaging) is concerning, endoscopy is generally indicated. Assessing these patients quickly when consulted is highly important, as clinical status can rapidly change if the object is obstructing the airway or changes position to cause more complete airway obstruction.

Operating Room Setup

No matter if a child or adult, when proceeding to the OR for airway exam and potential foreign body removal, it is important to ensure that you are set up with all supplies needed to ventilate, expose, examine, and retrieve the foreign body prior to starting the case. When contacting the OR, communicate that you will be performing a microlaryngoscopy, rigid bronchoscopy, possible flexible bronchoscopy, esophagoscopy, retrieval of foreign body, and proceed as indicated. If there is a possibility that the foreign body has fragmented, you should request a flexible bronchoscope to allow inspection of the more distal airways. Depending on the clinical status of the patient, you may want to have a tracheostomy tray in the room as well. You will need your institution’s airway/microlaryngoscopy/laryngoscopy cart or instrument pans, appropriate laryngoscopes, the endoscopy tower, topical lidocaine, the 0-degree 4 mm Hopkins rod telescope, McGill forceps, a range of age appropriate bronchoscopes and esophagoscopes (see table below), the foreign body graspers, the peanut graspers, the coin graspers, and suction, etc. If the patient is an infant, consider having tracheoscopes available as well. Have suspension ready if the foreign body is at or above the glottis. Check the lenses and light prisms in everything that has a lens to ensure nothing is broken or cracked before you need it, and remember to focus and white balance your cameras. Confirm that telescopes, suctions, foreign body instruments, and bronchoscopes match in terms of length and diameter. Keep in mind that bronchoscopes and tracheoscopes must be size 3.5 or larger to fit foreign body forceps. If the child is too small to use a 3.5 rigid scope, consider using the laryngoscope and optical foreign body instruments by themselves. Ensure accordion ventilation connectors are available for the bronchoscope. Communicate with the Anesthesia team that the patient’s respiratory status could change quickly and dramatically and ask them to keep the patient breathing spontaneously and to avoid paralysis. Discuss timing of IV access, communicate that the Otolaryngology team will be managing the airway, and again, ensure that you are set up with all supplies needed to expose, examine, ventilate, and retrieve the foreign body prior to starting the case. It is helpful to run through the case in your head, imagining all the instruments and tools you will need, verifying that you have them in working order before the case. Calculate max lidocaine dosage and inform the circulating nurse and surgical tech of this volume and record it somewhere in the OR. If you are confident the foreign body is esophageal, discuss with the Anesthesia team the option to intubate before retrieving the foreign body.

General Guidelines for Operative Procedure

• Patient masked down by Anesthesia and handed off to Otolaryngology team; bed generally turned 90 degrees; IV access either before or after mask induction depending on preoperative discussion.

• Size appropriate Phillips, Macintosh, or Miller blade or Parsons laryngoscope used to visualize pharynx, larynx, and esophageal inlet with tooth guard.

• Many foreign bodies will lodge post cricoid and can be removed with McGill forceps at this point.

• Anesthetize glottis with topical lidocaine.

• Pause to allow for lidocaine to take effect, mask ventilate.

• Re-expose larynx, and advance rigid bronchoscope through vocal cords with care to avoid injury to cords. Remove laryngoscope once rigid bronchoscope is through the cords. Connect circuit to bronchoscope; can provide some ventilation during exam.

• Can also place small cuffless endotracheal tube transnasally or transorally, positioned just above glottis to aid in oxygenation. This will not be useful once the bronchoscope is through the vocal cords.

• Examine subglottis, trachea, carina, and as far into bronchi as safely possible. If foreign body is visualized, record images, and prepare optical forceps to retrieve object. Turn the head to the right to visualize the left mainstem, and vice versa.

• With the appropriate optical forceps (peanut, coin, etc.), the object is grasped, and the entire rigid bronchoscope, forceps, and object are removed as a single unit.

• After removal, examine for a “second foreign body” in the trachea/bronchi and esophagus, suction any secretions/blood, look for any aerodigestive tract injuries secondary to the foreign body or its removal, and record images of the airway and esophagus.

Esophageal Foreign Bodies

Overview
Generally, non-food foreign bodies located in the proximal esophagus are frequently managed by Otolaryngology, while food boluses impacted in the esophagus are generally treated by GI unless there are airway issues; however, this division of labor varies by institution. For foreign bodies located in the esophagus, evaluate for airway symptoms as anterior pressure on the trachea and associated edema can cause airway issues. As alluded to earlier, a second foreign body is also possible. Radiographs are particularly important for esophageal foreign bodies. In children, esophageal foreign bodies are frequently inorganic objects (e.g., coins) and usually no underlying esophageal dysfunction is present. Common locations for the foreign body to lodge include at or just below the cricopharyngeus, at the aortic arch, at the level of the left mainstem bronchus, and at the lower esophageal sphincter. It is particularly important to evaluate for possible signs of button battery ingestion. In contrast to coins, a button battery will have a step off sign on lateral projection and halo sign on AP. Button battery ingestion is considered an operative emergency and generally requires expeditious removal, as coagulative necrosis begins soon after mucosal contact (discussed in greater detail below).

In contrast to children, adult esophageal foreign bodies are more likely to be food matter and are more likely to occur in the setting of anatomic abnormality or dysmotility that renders the patient susceptible. In both age groups, the cervical esophagus just distal to the cricopharyngeus muscle is the most common location for the object to become lodged; however, the compression site of the aorta and left main bronchus are all possible locations. Sharp objects such as animal bones and safety pins represent unique situations where timely treatment and removal can prevent serious morbidity. Finally, if there is concern for esophageal perforation, appropriate antibiotics, proton pump inhibitors, serial chest films, possible water-soluble oral contrast study, Thoracic Surgery consultation, CT of the chest, and early intervention are generally necessary.

Operating Room Setup and Procedure

Essentially the same as for airway foreign bodies, with the addition of rigid esophagoscopes, which are necessary for foreign body removal beyond the cricopharyngeus muscle. If a known proximal esophageal foreign body is present, this is addressed in the same fashion as an airway foreign body, with attention given to the proximal esophagus upon initial exposure. If the location of the object is unknown, it is prudent to first examine the airway thoroughly. This not only allows for airway foreign bodies to be addressed first, but often, the patient can be intubated after the airway is cleared and focus is turned to the esophagus.

Button Batteries

Overview
Button or disk battery ingestion or intranasal placement occurs most frequently in toddlers and most commonly involves hearing aid batteries or toy batteries. Smaller hearing aid batteries often pass through the GI tract without causing substantial damage due to their small size. Larger button batteries, on the other hand, most commonly become lodged in the upper cervical esophagus. Severe mucosal damage can occur in as little as 1 hour and esophageal perforation in as little at 6 hours with potentially fatal sequelae. Erosion adjacent to major vessels such as the aortic arch may also lead to fatal aorto-enteric fistulae. Identification and localization can usually be achieved with plain film radiography and differentiated from coins by carefully looking for a subtle step off on lateral view or potentially a double-ring or halo sign on AP, reflecting the battery’s bilaminar construction. Theories of the mechanism of damage have evolved over time. Spent or “dead” batteries still frequently retain enough charge to cause damage and independently can cause pressure necrosis, mercury poisoning, or leakage of alkaline contents leading to a liquefactive necrosis in the GI system. Current evidence suggests that ingestion of honey or sucralfate in the field may buffer the battery and reduce injury. Intraoperatively, the site should be copiously irrigated with dilute acetic acid after battery removal. Battery ingestions should be reported to the National Battery Ingestion Hotline at 800-498-8666.

Example Operative Note
Direct Laryngoscopy/Esophagoscopy with Foreign Body Removal

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was induced with inhaled anesthetic, remained spontaneously breathing, paralysis was avoided, and mask ventilation was conducted easily.  The patient was then rotated 90° for direct laryngoscopy. A Dedo laryngoscope was used to perform a standard direct laryngoscopy, taking care to avoid damage to the teeth, lips, and gums. The patient's bilateral tonsils, tongue, and the remainder of the oral cavity exam were normal. The supraglottic and glottic structures were visualized with a grade 1 view with no evidence of damage or foreign body presence. The vocal cords were anesthetized with __cc of 1% lidocaine. An uncuffed endotracheal tube was inserted through the nose, positioned above the glottis, and connected to oxygen. The rigid bronchoscope was introduced and brought through the vocal cords. The immediate subglottis and trachea were without lesion and normal in appearance. The carina and the primary bronchi were also well appearing, and no foreign body was identified in the visualized airway. At this time, the patient was intubated with a cuffed/uncuffed ___ ETT. Attention was then turned to the esophagus where, after examination of the upper esophagus with a rigid cervical esophagoscope, a fish bone was noted lodged in the inferior portion of the cricopharyngeus muscle/upper esophagus. The bone was removed with graspers with minimal bleeding. The esophagus was inspected distally to the lower esophageal sphincter with a thoracic esophagoscope following removal with no additional foreign bodies visualized and no additional damage. The esophagoscope was withdrawn atraumatically. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

References
1. Schoem, S.R., Rosbe, K.W., Bearelly, S. Aerodigestive Foreign Bodies and Caustic Ingestions. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 3184-3194). Philadelphia, PA: Elsevier.
2. Cohen, S., Avital, A., Godfrey, S., et al. (2009). Suspected foreign body inhalation in children: what are the indications for bronchoscopy? J Pediatr. 155(2):276-280.
3. Fidkowski, C.W., Zheng, H., Firth, P.G. (2010). The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 111(4):1016-1025.
4. Kimball, S.J., Park, A.H., Rollins, M.D., et al. (2010). A review of esophageal disc battery ingestions and a protocol for management. Arch Otolaryngol Head Neck Surg. 136(9):866-871.
5. Lerner, D.G., Brumbaugh, D., Lightdae, J.R., et al. (2020). Mitigating risks of swallowed button batteries: new strategies before and after removal. J Pediatr Gastroenterol Nutr. 70(5):542-546.

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While tracheostomies are frequently performed by other specialties, the Otolaryngologist is the definitive expert in management of tracheostomies, surgical airways, and associated complications. This chapter covers the initial tracheostomy consultation for adult patients. Other chapters in this survival guide cover tracheostomy tube exchange and tracheostomy-related complications.

Overview
Most commonly, ICU teams may place a tracheostomy consultation for long-term (beyond 7 days) intubated adult patients. Prolonged intubation (beyond 7-10 days) has been associated with increased rates of glottic/subglottic stenosis and ventilator-associated pneumonia. In most cases, it is reasonable to consider a tracheostomy if the patient is not progressing toward extubation after 7 days. Placement of a tracheostomy improves pulmonary toilet, as it allows for direct tracheal suctioning. Notably, tracheostomies do not directly minimize the risk of aspiration, and in some cases, the placement of a tracheostomy can worsen dysphagia. Nevertheless, it can be helpful in patients with aspiration as direct suctioning can mitigate some of the complications of aspiration. Tracheostomy placement also facilitates sedation weaning, starting physical rehabilitation/mobilization sooner, hospital discharge in ventilator-dependent patients, and may facilitate ventilator weaning as well. Additional indications for placement of a tracheostomy include upper airway masses, swelling, upper airway or craniofacial trauma, laryngotracheal stenosis, severe neurologic deficit, or recalcitrant obstructive sleep apnea.

Management

A detailed history and physical exam should be performed with attention to underlying etiology of ventilator requirement, intubation and reintubation history, prior airway exams and access, anatomic abnormalities, and prior respiratory and upper airway procedures. Additionally, ventilator settings at the time of exam (positive end expiratory pressure and FiO2) and pulmonary reserve will be important in determining how long a patient can safely be off ventilator support. Overall hemodynamic stability is important, and note should be made of pressor requirements and need for anticoagulants. These factors are important to consider not only when considering initial tracheostomy placement but also during tracheostomy tube exchange. Peak ventilatory pressures may also be important; pressures above 40 cm H2O may cause air leaks around an appropriately inflated tracheostomy tube cuff and impair ventilation. Active pneumonia or acute respiratory distress syndrome and overall lung status is a significant consideration when considering a tracheostomy and the optimal timing of the procedure. While it is preferable not to keep patients intubated for more than 7-10 days if not progressing toward extubation, overall clinical status must be considered, and delay of tracheostomy may be wise until improved hemodynamic stability in certain circumstances.

• Perform a complete head and neck physical exam.

  • Focus on oral exam (dental status, tongue size and position, and mouth opening) to estimate intubation access for patients who are not already intubated, and neck exam for surgical landmarks (hyoid, thyroid notch, thyroid gland, cricoid, depth of trachea, and distance from sternal notch to cricoid).

  • Note the patient’s BMI and body habitus.

  • Palpate for a thyroid goiter or vascular anomaly such as high riding innominate artery.

  • Patients with previous sternotomy may have an abnormal venous plexus at or above the sternal notch.

  • If feasible and safe for the patient, neck extension can be tested. Relative contraindications to neck extension such as cervical spine trauma, severe cervical stenosis, cervical spinal fusion, and trisomy 21 are relevant for surgical positioning and determination of percutaneous or open tracheostomy.

  • Although most intubated patients cannot answer questions, their neck can be examined for evidence of prior tracheostomy scars or neck incisions related to thyroid or airway surgery that may be pertinent in planning. This can be coupled with a careful review of the chart and discussion with next of kin (if available) to maximize knowledge before the procedure.

• Ensure basic preoperative labs have been obtained including CBC, BMP, and coagulation panel. (Anticoagulation is not a contraindication to tracheostomy placement but warrants a meticulous operative approach with particular attention given to hemostasis and careful postoperative care).

• Preoperative imaging is usually reserved for select cases. In many cases, particularly in ICU patients, there may be imaging of the neck/chest already available for review. A review of available imaging is useful to look for evidence of a high riding innominate artery. Consider open versus percutaneous tracheostomy as described below and according to your institutional and Otolaryngology departmental preferences.

Open Tracheostomy

• Advantages: Better exposure, easier control of bleeding, usually performed in the comfortable and controlled surgical environment of the OR (although this can also be performed in the ICU setting in many institutions), allows for superior cricoid traction to expose trachea that otherwise might be substernal (patients who cannot extend neck), ideal for patients without palpable landmarks, and can create Bjork flap, place stay sutures, and “defat” the neck of the obese patient, which can be helpful for tube exchanges or in case of accidental decannulations as well as potentially improved protection of the innominate artery. Generally, this is a “safer” option if concerns related to the ease of the surgical procedure.

• Disadvantages: Requires OR time (unless performed in the ICU), larger incision, requires transport of clinically ill patient that may result in pulmonary decompensation or derecruitment of the lungs prior to starting the procedure as patient is switched between machinery.

Percutaneous Tracheostomy

• Advantages: Generally no need for OR (usually performed at bedside if patient is in ICU), only need sedation, this may be the “safer” option for a patient who does not pose significant surgical challenges but who is critically ill or relatively unstable, as it can be done in the ICU with minimal disruption to ongoing care.

• Disadvantages: Difficult to perform in patients without palpable landmarks, potentially more difficult tracheostomy changes (no stay suture placement) can fracture trachea or pierce posterior tracheal wall (possible with open tracheostomy as well, although potentially higher risk with percutaneous tracheostomy), bleeding less easy to control, requires visualization by bronchoscopy, risk of injuring innominate vessels. Most importantly, this requires additional personnel, as someone is required to drive the bronchoscope during the procedure. In almost all cases, an ultrasound is also required to evaluate the neck prior to beginning the procedure.

Example Operative Note (open tracheostomy)

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

DICTATION OF EVENTS: The patient and surgical site were correctly identified preoperatively. The patient was then brought to the operating room and placed on the operating table in the supine position. The surgical site was prepped and draped in a sterile fashion. A preoperative time-out was completed verifying the correct patient, procedure, site, positioning and equipment.
 
After the time-out, the thyroid and cricoid cartilage were palpated and the skin and subcutaneous tissue in this area was anesthetized with ___ ml 1___% lidocaine with ___ epinephrine. A 2cm transverse incision was made over the 2nd tracheal ring. Monopolar/electrocautery and blunt dissection were used to identify the strap muscles, which were then retracted laterally. Palpation confirmed no high-riding innominate artery. The thyroid isthmus was divided and thoroughly cauterized with monopolar electrocautery. Dissection was continued down to the cricoid cartilage and trachea.  The endotracheal tube and cuff were advanced after communication with the anesthesia team. A cricoid hook was used to retract the cricoid cartilage superiorly. Prior to entry into the trachea, FiO2 was confirmed to be 30% or lower. Next, a transverse incision was made between the second and third cartilaginous tracheal rings using a #15 blade. A Bjork flap was developed with lateral tracheal ring incisions using curved Mayo scissors. The Bjork flap was then retracted inferiorly and secured to the subcutaneous tissue with _-0 _ stitch. Hemostasis was achieved with electrocautery. After coordination with the Anesthesia team, the endotracheal tube cuff was deflated and the tube was retracted above the tracheostomy site. A ___-0 cuffed ___ tracheostomy tube was placed and connected to the anesthesia machine. Positional confirmation with end-tidal CO2 and condensation within the circuit were noted. The tracheostomy tube was sutured in placed with ___-0 ___ suture in 4 corners. The cuff was inflated with _cc or [air/water]. The obturator was kept with the patient. Next, the patient was turned over to the care of anesthesia. The patient tolerated the procedure well and was taken to the intensive care unit in stable condition.

 

References
1. Mitchell, R.B., Hussey, H.M., Setzen, G., et al. (2013). Clinical consensus statement: Tracheostomy care. Otolaryngol Head Neck Surg. 148(1):6-20.
2. Kraft, S.M., Schindler, J.S. (2020). Tracheotomy. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.
3. Durbin Jr., C.G. (2010). Tracheostomy: why, when, and how? Respir Care. 55(8):1056-1068.

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Overview
Although most tracheostomy tube exchanges are uneventful, care and planning are integral to prevent avoidable morbidity and mortality or emergency situations. Each tracheostomy tube exchange should be approached with a well thought out plan and the necessary equipment to regain control of the airway in the event of complications. The first tracheostomy tube exchange is commonly performed by the service that originally placed the trach on postoperative day 5-14, depending on the institutional protocol and patient-specific situation. That said, there are no strict guidelines when a trach needs to be exchanged, and ventilator-dependent patients can remain with their initial trach for longer if there are no strong indications for changing it. An AAO-HNS consensus statement recommends that an experienced physician make the first change on day 10-14 for trachs placed percutaneously but allows for surgical trachs with favorable anatomy to be changed as early as day 3-7 to facilitate discharging a patient. It is crucial to have a more senior resident walk you through your first several tracheostomy tube exchanges to avoid preventable complications. Calling ahead to inform Nursing staff, ICU teams, and Respiratory Therapy also makes tracheostomy tube exchanges safer and more efficient. Having Respiratory Therapy at the bedside for ventilator-dependent patients is integral for continued optimal ventilation if settings require adjusting.

Key Supplies for Tracheostomy Tube Exchange Consultation

• Nurse or Respiratory Therapist to help you

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Appropriate tracheostomy tubes* (recommend having target size and one size smaller)

• Lubricant

• Suture removal kit

• 10 mL syringe

• Suction with Yankauer tip and flexible inline suction

• Nasal speculum or tracheostomy spreader

• Retractors: Two army/navy or band retractors

• Cricoid hook

• Trach ties (Velcro® or Dale collar)

• Consider changing tracheostomy tube over bougie if necessary

• Flexible fiberoptic endoscope (preferably videoendoscopy via portable unit or tower to record exam or allow others to see properly positioned tracheostomy tube on completion of the procedure)

• Antifog solution (Fred™)

*Specific brands are named in this chapter, not as endorsements for any product, but to make this information practical and applicable to junior residents. It is crucial to understand the various types of tracheostomy tubes available at your institution including their advantages and disadvantages. It is important to compare various tracheostomy tubes based on their outer diameter (size of tract) and their inner diameter (correlation of effective airway size) with other tubes (see Airway Size Guide below). A patient requiring ventilator support with a significant secretion burden may benefit from a dual cannula tracheostomy tube with removable inner cannula to allow for inner cannula cleaning and rapid removal if obstructed with mucus plug. Common examples of dual cannula tubes available are various Shiley™ and Portex® models. Patients trending towards ventilator weaning, decannulation, or requiring only intermittent ventilation may benefit from a Bivona® or other similar tracheostomy tube with single cannula and “tight to shaft” cuff potentially allowing for easier breathing and talking around the tube. Other options as patients progress toward decannulation include simply downsizing their tracheostomy tube instead of exchanging for a tight to shaft option (especially as different models and brands have different curvature and may fit differently in their stoma and trachea). Patients with no positive pressure ventilation needs and no immediate plans for return to the OR can be exchanged to a cuffless trach to minimize the tracheal lumen obstruction and improve their tolerance of capping or Passy Muir® valve. Ultimately a joint decision should be made that allows for the best care of the patient after comprehensive consideration of their pulmonary status and future operative needs.

Steps of Tracheostomy Tube Exchange

• Ensure assistance from other residents or Nursing staff and Respiratory Therapist according to institutional policies and the clinical scenario. Patients with ventilator demands should preferably be exchanged with a physician or Respiratory Therapist optimizing their ventilatory settings to assist with pre-oxygenation and management of derecruitment following exchange.

• Place an abdominal pad on the patient’s chest and lay out the following items: tracheostomy tube (test the balloon if using cuffed tube) with the obturator inside, empty 10 mL syringe (for cuff inflation or syringe with sterile water if applicable), nasal speculum, and new inner cannula if applicable. If using a water or saline-cuff tube (choice of water or saline is based partially on institutional preference with some believing that saline leads to earlier cuff breakdown), ensure that the cuff inflates circumferentially when testing it (cuff often sticks to shaft and inflates partially on first test). Remove all air from the cuff, pilot balloon, and tube. (Most tubes ship with a small amount of air that will affect your measurement of cuff inflation volume.) Use gloved hand to massage tube from tip towards flange to get tube as close to the shaft as possible. Prepare the flexible scope (use antifog) and place it at the foot of the patient’s bed (or on Mayo stand or bedside table if available) for easy access. Have nasal speculum and other retractors immediately available at bedside. Ensure good lighting (headlight can be very helpful). Know where endotracheal tubes are kept on the floor.

• Increase FiO2 to 100% if otherwise clinically safe to do so and consider pre-oxygenating according to the clinical scenario.

• Using a flexible tracheostomy suction to clear the airway before the tracheostomy tube exchange may be helpful.

• Patient positioning: Lay the patient flat (flatten the bed) and remove any pillows. Extend the patient’s neck if possible/safe; a shoulder bump may be helpful for obese patients.

• While a colleague holds the tracheostomy in place, cut the sutures securing the tracheostomy tube to the skin.

• Have both a flexible suction and Yankauer suction set up. Remove the tracheostomy tie or collar and have an assistant hold the trach until it is time to remove. Verbally prepare the patient (e.g., “we are going to remove the tube now, you will probably cough,” etc.).

• Deflate the balloon completely. This may cause patients to cough significantly as any secretions sitting above the cuff will fall into the airway.

• Use the help of the Respiratory Therapist to disconnect from the vent when the time comes. You may have to move more quickly if the patient is requiring ventilation support. Note the derecruitment during the tracheostomy tube exchange may require time to recover during even a relatively rapid exchange and that confirming positioning after placement can allow the provider to comfortably allow ventilator management to re-recruit.

• Remove the tracheostomy tube. Using your headlight and the nasal speculum, get a good view of the tracheostomy tract. Use Yankauer suction to clear the path of secretions. Place the new tracheostomy tube, remove the obturator, place the inner cannula, if applicable, inflate the new balloon. Connect the ventilator if needed. If the anatomy is difficult, or if you’re having a hard time visualizing, use the retractors to visualize the tracheostomy tract. Visualization of the tract is important to avoid placing the new tracheostomy tube in a false passage, one of the most common and potentially devastating complications. If helpful, a bougie, the flexible scope, or a suction catheter can be used in a Seldinger fashion to identify the airway and then slide the tracheostomy tube into the airway. Identifying granulation tissue at the stoma site is best done at this time and can provide identification of future treatment needs to optimize the tracheostomy site.

• Patients react differently to tracheostomy tube exchanges. Some handle it very well, others are coughing, choking, or gasping. Continue to communicate with them and help them remain calm. If they are coughing up mucus, suction with flexible or Yankauer suction.

• After the new tracheostomy tube is in place, confirm appropriate placement within the trachea with the flexible endoscope. The tracheostomy tube should sit easily in a neutral position without abutting the tracheal wall.

• Secure the trach tube in place with new trach collar. The collar should be relatively tight, but you should be able to fit two fingers under the collar; this may be modified for patients with a recent free flap or pec flap based on pedicle or anastomosis location. Place any needed stomal dressings while your assistant holds the tube.

• Confirm that the patient is comfortable and moving air well. If the new tracheostomy tube is a different size or type, it may initially be irritating to the trachea and cause coughing for several minutes to hours. If the patient is moving air, oxygen saturation is normal, and placement has been confirmed with a scope, reassure the patient that the adjustment period is normal and will improve.

Additional Tips

• In all cases, a second set of hands is helpful; some institutional protocols require more than one person to be available during a tracheostomy tube exchange.

• When documenting a note regarding the tracheostomy tube exchange, describe the new trach type and how it sits in the trachea. Tracheostomy tube exchange before the stoma is fully healed is a billable code (CPT 31502).

• Some patients will have metal tracheostomy tubes or tracheostomy tubes with which you are unfamiliar. Compare the outer diameters for fit and the inner diameters for airway sizing needs prior to undertaking a tracheostomy tube exchange. Sizes of uncommon tubes can generally be found quickly on the internet.

• Unless ventilatory needs necessitate, it is not recommended to replace the initial tracheostomy tube with one of a wider diameter. Upsizing a tracheostomy tube in a well-formed stoma may require serial dilations and more force than the typical exchange and may cause significant pain and lead to bleeding; it should only be undertaken with experience and with appropriate indications and equipment.

Tracheostomy Tubes

• Shiley™

  • Some models have inner cannula which can be exchanged.

  • Very useful for patients with large secretion burden.

  • Rigid shaft, more right angled.

  • Cuffed and cuffless options.

  • Cuff is floppy and takes up more space when deflated, more difficult to talk/breathe around.

  • Proximal and distal XLT to extend more horizontally or vertically based on patient anatomy.

  • Air cuff allows direct measurement of cuff pressure.

• Bivona®

  • No inner cannula (tracheostomy tubes without inner cannulas are at risk for plugging as they lack an inner cannula that can be removed and cleaned, may necessitate emergent decannulation in the case of thick mucus plugs).

  • Flexible shaft, more of a smooth curvature.

  • Cuff is “tight to shaft” when deflated.

  • Smaller profile within the airway, easier to talk/breathe around.

  • Fill cuff with sterile water, not air or saline in common models (some air cuff models available).

  • Smaller external flange, less peristomal irritation.

  • Available in adjustable length.

  • Water cuff pressures cannot be measured directly.

• Portex®

  • Inner cannula can be exchanged.

  • Some models have integral suction port for subglottic suctioning.

  • Some models have adjustable flange lengths (can be customized to better fit the patient’s anatomy).

  • Flange is clear allowing some stoma visualization without decannulation.

  • Thermosensitive PVC allows some softening of the tube as it warms to body temperature.

  • Can be connected to ventilator with or without the inner cannula.

  • Inner cannula diameter is narrower than corresponding Shiley™ and Bivona® models.

• Jackson

  • Metal tracheostomy with inner cannula.

  • Small outer diameter, as metal is thinner than plastic used for more common plastic models.

  • Reusable; patients will clean Jackson tracheostomy tubes.

  • Twist and lock mechanism for inner cannula may not be familiar for Nursing staff, and hospital worker education around this may be required.

Additional manufactures and models exist with varying inner, outer, and length dimensions and curvature that will influence how the tube sits in the patient’s neck as well as the airway resistance. Always refer to online documentation for tube specifics prior to making clinical judgements about tubes with which you are unfamiliar.

Example Procedure Note
Procedure: Tracheostomy tube exchange
A routine tracheostomy tube exchange was performed at the bedside. Consent was obtained from the patient or family prior to proceeding. Universal protocol was followed throughout. The patient was placed in the supine position with the neck extended. The original tracheostomy tube was examined, and the stoma appeared to be healing well with no signs of infection, bleeding, irritation, or wound breakdown. A fiberoptic exam was performed through the lumen of the existing tube, which demonstrated that the current tracheostomy tube was well positioned in the center of the airway. There were no signs of granulation tissue or airway irritation. A suction catheter was used to clear the tracheostomy tube and trachea or secretions. The sutures securing the tracheostomy tube to the skin were cut, and the trach ties were undone. The balloon on the existing trach was deflated. The existing trach was gently removed, and a ___ was used as a retractor to maintain patency of the stomal opening. The tract was examined and appeared to be healing appropriately. A new ___-sized tracheostomy tube was placed through the stoma. The fiberoptic scope was placed through the lumen of the new tube to confirm positioning. The tube appeared to be in good position, without abutting the walls of the trachea. The balloon on the trach was inflated with approximately ___cc’s of ___. The tube was secured with Velcro® ties. The patient tolerated the procedure well with no desaturations or complications.

References
1. Mitchell, R.B., Hussey, H.M., Setzen, G., et al. (2013). Clinical consensus statement: Tracheostomy care. Otolaryngol Head Neck Surg. 148(1):6-20.
2. Kraft, S.M., Schindler, J.S. (2020). Tracheotomy. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.
3. Durbin Jr., C.G. (2010). Tracheostomy: why, when, and how? Respir Care. 55(8):1056-1068.

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Overview
Most tracheostomy bleeds originate from the stomal region or are related to suctioning trauma and are self-limiting. Timing can be of importance during the workup, as fresh trach bleeds of significant volume or persistence commonly originate from the thyroid gland, anterior jugular veins, or other etiologies, whereas more remote bleeds from tracheostomy generally suggest either granulation tissue, suctioning trauma, or more sinister origins. More serious causes of bleeding such as tracheoinnominate fistula must always be considered and ruled out. Although tracheoinnominate fistula makes up less than 1% of all trach bleeds and 10% or less of severe bleeds, a true tracheoinnominate fistula can be fatal, and only 25% who make it to the OR will survive. Upon consultation, the status of bleeding (active bleeding or previously bleeding) as well as volume of blood loss and time since tracheostomy should first be determined. In cases of substantial bleeding (whether active or previously), the patient should be evaluated immediately. Of note, tracheoinnominate fistulas may present with a “sentinel bleed,” which is a self-limiting initial episode of bleeding that is later followed by an episode of massive bleeding. Additional helpful information obtained from the patient’s history include timing and reason for tracheostomy, tracheostomy type and size, anticoagulation status, ability to intubate/ventilate from above, and relevant comorbidities such as pulmonary disease and coagulopathies.

One common point of confusion within the hospital system is differentiating a laryngectomy stoma from a tracheostomy. Clear communication surrounding this point is important when managing an acute airway, particularly in the context of an airway bleed, so that appropriate measures can be taken to protect the airway. Most importantly, you cannot intubate, oxygenate, or ventilate through the mouth or nose in a patient with a total laryngectomy. This point should be clearly communicated to Anesthesia, the ER, or other potential members of the acute airway team.

Key Supplies for Tracheostomy Bleed Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Flexible endoscope

• Antifog solution (Fred™)

• Suction with Yankauer tip x2 and inline suction

• Army/navy or band retractors

• Nasal speculum or tracheostomy spreader

• Cricoid hook

• Endotracheal tubes (cuffed, sizes 6 and 7)

• Replacement tracheostomy tubes (Shiley™ and Bivona® of the same size or smaller, cuffed and uncuffed nonfenestrated)

• Bougie for potential trach change assistance

• Trach ties or Dale collar

• Empty syringe

• Gauze, Surgicel®/Fibrillar™, silver nitrate

• Tranexamic acid (TXA) or topical 1:1,000 epinephrine

• Of note, if individual items are not readily available, a trach tray often will have many of these items above and may be easier to locate

Management

It is prudent to see all tracheostomy bleed consultations as soon as possible. Bleeding at the trach site can lead to aspiration and pulmonary compromise. If you are called for a large volume bleed or hemorrhage, go to the patient’s room as quickly as possible and inform your senior resident as you make your way to the room. When talking to the team about the patient, ask for a crash cart, endotracheal tubes, and supplies mentioned above to be set up while you make your way to the patient.

Large Volume Bleeding

• Upon arrival, assess patient status and ABCs (Airway, Breathing, Circulation), consider type and cross in the event transfusion may be required.

• Set up one or two large suctions if possible.

• If large volume active hemorrhage, compression to stop bleeding while transport to OR.

• If patient has a cuffed tracheostomy in place, consider overinflating the cuff, which in many cases will compress the vessel temporarily.

• If the patient does not have a cuffed tracheostomy tube in place, place one or a cuffed endotracheal tube (usually size 7 will work), then overinflate the cuff. Doing a trach change during massive bleeding can be challenging, and a second set of hands is helpful. In this situation, a trach change over a catheter can be extremely helpful.

• If overinflating the cuff is not helpful, it is possible that the cuff is not directly sitting over the bleeding site within the trachea. Manipulating the tracheostomy tube either slightly deeper or shallower may place the cuff over the bleeding site. The cuff may need to be inflated within the stoma tract to compress the vessel. It is also possible, often in a recently placed tracheostomy, that the bleed is from the surrounding tissue between the skin and tracheostomy (most commonly a ruptured anterior jugular vein or thyroid gland) in which case it can be packed with gauze if transport to the OR is required and the bleeding cannot be controlled at bedside.

• If the above fails to stop the bleeding, finger compression can be effective but partially obstructs the airway. Insert digit via tracheal stoma and compress innominate or other offending vessel against sternum anteriorly (hook around anteriorly with your finger). The patient can be ventilated from above with mask, endotracheal tube, or laryngeal mask airway if there is no anatomic difficulty preventing this and skilled colleagues are available.

• Arrange for definitive treatment, have a colleague work on arranging for immediate OR or Interventional Radiology transfer for exploration and ligation of bleeding artery versus endovascular management.

• The patient should ultimately be orotracheally intubated; however, this is preferably done in a more controlled setting in the OR when possible. Remember, patients with laryngectomies cannot be orotracheally intubated.

• Be on guard for tracheoinnominate or other tracheoarterial fistulas in all patients, especially those with neuromuscular hypotonia, kyphosis, long-term ventilation/high airway pressures (often necessitates high pressure within cuff, tracheal mucosal breakdown), sepsis, radiation, steroids, malnutrition, or diabetes.

• Tracheoinnominate fistulas can occur early after tracheostomy placement but peak incidence is 2-3 weeks postoperatively.

• Preserving the integrity of the tracheal mucosa and tracheal cartilage with appropriate tube size and length, neutral tracheostomy tube positioning, minimizing cuff pressure, good patient nutrition, and close monitoring in patients with predisposing conditions can minimize risk of tracheoinnominate fistula.

• Early bleeding from a damaged anterior jugular vein or thyroid gland bed from a recent tracheostomy are far more common and can frequently successfully be managed with thoughtful care that may include stomal packing around the tracheostomy tube with hemostatic agents such as Surgicel® or bipolar cauterization which may require temporary decannulation with or without orotracheal intubation. Decannulation in the setting of active bleeding should only be cautiously considered by experienced providers, with assistance, and with all supplies necessary for airway securement and with appropriate precautions for prevention of airway fire.

Low Volume or Self-Limited Bleeding

• Bleeding is generally from tissue breakdown/irritation at the stomal site, or suctioning trauma of the posterior tracheal wall or carina, or in the setting of anticoagulation or coagulopathy. Granulation tissue can be a common source of bleeding and can be treated at bedside with silver nitrate.

• Inflate cuff to prevent blood from running down the trachea.

• Scope through the tracheostomy tube and examine the entirety of the trachea itself, carina, and proximal bronchi, preferably with a videolaryngoscope for best visualization and for others to observe. Sometimes pulling the tracheostomy tube back slightly will help expose the area of erosion within the trachea.

• If posterior or lateral tracheal wall irritation/erosion is noted, can address by repositioning tracheostomy tube, exchanging for a tracheostomy tube that will be better contoured for the patient’s airway, or establishing a plan with Nursing and Respiratory Therapy for suctioning that avoids trauma.

• If proximal anterior erosion, consider CT angiogram of the neck to evaluate fat plane between trachea and innominate artery.

• Knowledge of tracheostomy tubes available can be very useful in these situations, see previous chapter entitled “Tracheostomy Tube Exchange” for additional tracheostomy tube comparisons and details.

• If airway is clear, turn attention to stoma. If patient can tolerate temporary decannulation, can cautiously remove trach, and examine the external stoma, tract, and tracheal wall concealed by tracheostomy tube. A flexible scope is helpful for this task.

• If stomal bleeding is seen:

  • Address as needed with pressure, gauze, or Surgicel®/Fibrillar™. If placing hemostatic agent (such as Surgicel®) within the stoma, leave a tail externally over the skin to discourage the packing from falling into the airway and allowing for easy removal if necessary.

  • Do not remove scab/clotted blood over wounds/breakdown.

  • It is important to chart these items and communicate to Nursing and Respiratory Therapy that they are in place, as to avoid being dislodged into the airway.

  • Tranexamic acid (TXA) can be a useful adjunct.

  • Granulation tissue can be addressed with silver nitrate or cautery.

  • In the setting of exuberant granulation tissue, repeated treatments over time may be necessary. A dilute betadine treatment (10% povidone-iodine solution diluted 1:20 in normal saline soaked on a trach or drain sponge, left in place under the trach flanges for approximately 10 minutes twice daily) can be helpful in some cases where an overlying stomal infection/inflammation and granulation are the source of persistent bleeding. There are case reports of interstitial pneumonitis following aspiration of betadine; however, this has generally been seen with higher concentration/undiluted betadine and is rare.

Example Procedure Note
Procedure: Tracheostomy bleeding control
I was called to the bedside of the patient for tracheostomy bleeding. Upon arrival, the vital signs of the patient were ___. He/she appeared stable/unstable. I proceeded to inflate the cuff of the tracheostomy tube, and examined the full length of the tracheal mucosa, carina, and proximal primary bronchi using a flexible fiberoptic laryngoscope. The tracheal mucosa was noted to be intact, without erosion, erythema, or bleeding. The carina was normal in appearance with well-appearing mucosa. No pooling of blood or excessive secretions were noted in the primary bronchi. The tracheostomy tube was withdrawn slightly, and the same findings noted. The scope was removed atraumatically and attention was turned to the stoma. Minor mucosal bleeding was noted just within the proximal tracheostomy tract. This was controlled with Surgicel® and application of pressure. The tracheostomy tube was replaced, trach collar attached, and the patient tolerated the procedure well. Oxygen saturation remained greater than 90% throughout the duration and the patient was left in stable condition.

References
1. Mitchell, R.B., Hussey, H.M., Setzen, G., et al. (2013). Clinical consensus statement: Tracheostomy care. Otolaryngol Head Neck Surg. 148(1):6-20.
2. Kraft, S.M., Schindler, J.S. (2020). Tracheotomy. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.
3. Durbin Jr., C.G. (2010). Tracheostomy: why, when, and how? Respir Care. 55(8):1056-1068.
4. Ridley, R.W., Zwischenberger, J.B. (2006). Tracheoinnominate fistula: Surgical management of an iatrogenic disaster. J Laryngol Otol. 120(8):676.80.

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Overview
Acute sialadenitis represents acute inflammation of one or more of the major salivary glands and, while usually medically managed, is a common consultation for Otolaryngologists. Sialadenitis has many causes including autoimmune processes, salivary outflow obstruction, granulomatous diseases, and various infections both viral and bacterial. Hospitalized patients may suffer from sialadenitis secondary to dehydration. Common symptoms include swelling and tenderness of the involved gland(s), while bacterial sialadenitis commonly presents additionally with fever, leukocytosis, and purulent drainage from the duct of the affected gland (most commonly the parotid). Bacterial or suppurative sialadenitis occurs most commonly in the setting of dehydration, malnutrition, or postoperatively in elderly patients with Staphylococcus aureus and Streptococcus pneumoniae being the most common isolated bacteria, although most cases are polymicrobial. Viral causes of sialadenitis most commonly include influenza, adenoviruses, and Epstein-Barr virus (EBV). While the incidence of mumps-induced parotitis has decreased dramatically after implementation of the measles, mumps, and rubella (MMR) vaccine, this cause should still be on the differential diagnosis for patients with multiple gland involvement who have not been immunized.

Sialoliths may lead to sialadenitis with or without infection by causing salivary duct obstruction. Sialoliths are predominantly found in the submandibular duct due to the longer course of the submandibular duct as well as the higher viscosity of the mucus-rich saliva. Acute suppurative sialadenitis of the salivary glands can lead to abscess formation that may require drainage and may be difficult to distinguish on palpation alone making imaging with CT or ultrasound necessary. In addition to abscess identification, both CT and ultrasound have a high sensitivity for detection and localization of sialoliths. The physical exam for sialadenitis remains imperative for diagnostic purposes. Importantly, massaging the gland and visualizing saliva pass through the duct lumen is important both for diagnostic purposes and for therapeutic purposes for bacterial infections or in cases of small sialoliths.

Key Supplies for Sialadenitis Consultation

• Appropriate PPE including masks, eye protection, gloves, and gown

• Headlight

• Tongue depressors

• Culture swabs

• If drainable abscess, for ultrasound-guided fine needle aspiration:

  • Alcohol swab (for skin cleansing)

  • 1% lidocaine with 1:100,000 epinephrine

  • 18- and 27-gauge needles

  • 10cc syringe

  • Ultrasound with ultrasound gel

Management

• Complete medical history with attention to similar previous episodes (suspect sialolithiasis or juvenile recurrent parotitis in pediatric patients), history of risk factors such as autoimmune conditions, immunosuppression, sicca, current medications (many can cause xerostomia), and recent surgeries.

• Full head and neck physical exam with detailed cranial nerve exam (facial nerve paralysis is highly suspicious for underlying parotid malignancy, rarely Heerfordt syndrome presents with uveitis, facial paralysis, and parotid swelling), bimanual massage may express purulence from the associated duct as well as palpation of the ducts for sialoliths. If purulence is expressed, collect, and send for aerobic and anaerobic bacterial cultures.

• Basic lab analysis including CBC and BMP. If suspecting autoimmune or specific infectious causes can consider targeted labs such as HIV, ESR, CRP, ANCA, RF, Ro/SS-A, La/SS-B, IgG to B. henselae, PPD, etc.

• Imaging in cases where abscess is suspected or failure to improve after antibiotic and supportive care trial.

  • CT with contrast: Sensitive and specific, may show sialolithiasis as well as abscess.

  • Ultrasound: Slightly less sensitive than CT for abscess and sialolithiasis but good first line imaging in children or in uncomplicated cases.

  • Sialogram: Contraindicated in acute sialadenitis as can worsen inflammation.

• If inflammation alone without signs of infection:

  • Conservative medical management with massage of the gland as frequently as tolerated, warm compress, analgesics, sialogogues (bitter or acidic drops such as lemon or orange juice or candies), and hydration.

• If suspected bacterial sialadenitis (purulence expressed from involved gland, leukocytosis, or fever):

  • Conservative management as above except no gland massage in neonates (may lead to septicemia).

  • Initiate empiric beta-lactamase resistant anti-staphylococcal antibiotics, for adults consider clindamycin or amoxicillin-clavulanate; can also consider vancomycin if risk of MSRA (history of prior MRSA, nursing home patient, or hospitalized patient).

  • Response to antibiotics is expected within 2-3 days, consider imaging versus change in antibiotics if unimproved.

• In cases of sialolithiasis:

  • Submandibular duct calculi within 2 cm of Wharton’s duct may be removed with manual massage, papillary dilation, or intraoral excision with or without sialodochoplasty. Large sialoliths (>3-4 mm) may require surgical removal.

  • Calculi >2 cm from duct papilla may require sialendoscopy (stones 3-4 mm in size may be mechanically removed with baskets or graspers, >4 mm in size typically need lithotripsy followed by endoscopic removal versus surgical excision).

  • Parotid duct calculi are generally orally accessible if in segment medial to masseter muscle.

• If imaging reveals an abscess, can trial medical therapy or proceed directly to needle aspiration with incision and drainage; drain placement reserved usually for cases without improvement after needle aspiration.

• Patients with systemic symptoms such as fever, malaise, and significantly elevated WBC should be admitted with IV antibiotics.

• Close follow-up with primary care.

  • ENT follow-up in cases of recurrent disease for consideration of gland excision or sialendoscopy.

  • Rheumatology referral if suspicion of underlying autoimmune condition.

References
1. Abdel Razek, A.A.K., Mukherji, S. (2017). Imaging of sialadenitis. Neuroradiol J. 30(3):205-215.
2. Jackson, N.M., Mitchell, J.L., Walvekar, R.R. (2020). Inflammatory Disorders of the Salivary Glands. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 1157-1170). Philadelphia, PA: Elsevier.
3. Roland, L.T., Skillington, S.A., Ogden, M.A. (2017). Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis. Laryngoscope. 127(11):2510-2516.
4. Walvekar, R.R., Bowen, M.A. (2013). Nonneoplastic Disease of the Salivary Glands. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 702-716). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
Bleeding or hemorrhage in patients with head and neck cancer is a relatively frequently encountered consultation at tertiary care centers. In most cases, bleeding may be limited or spontaneously resolve, but patients should be thoroughly evaluated to determine the site and source of bleeding as limited sentinel bleeding can be a sign of a more sinister developing problem. While large volume head and neck bleeds from carotid artery injury (i.e., carotid blowout) is relatively uncommon, this catastrophic complication may be heralded by a lower volume or sentinel bleed and thus should be considered in all cancer patients with predisposing tumors or prior radiation treatment. Risk factors for major head and neck bleeding include those that compromise the vasa vasorum and adventitia of the carotid and other vessels such as prior radiation therapy, prior surgical intervention nearby (e.g., neck dissection), residual or recurrent cancer, infection, and mucocutaneous fistula. A true carotid blowout carries a high mortality rate even if occurring in the hospital setting and is almost universally fatal if occurring outside the hospital setting.

Carotid blowouts may be categorized as threatened (evidence on imaging or exam of risk of a blowout without any bleeding), impending (self-limited bleed), and as an active blowout. In addition to carotid blowout, significant or even fatal bleeding may occur from the lingual artery, other branches of the external carotid, the jugular vein, or from a tumor directly. Principles of management for these consultations includes appropriate triage (to include verification of a patient’s resuscitation status), thorough exam, identifying the patients at risk for potentially catastrophic bleeding, and prophylactic treatment of these patients. Treatment typically involves securing an airway, tamponading acute bleeding if possible, and addressing problematic arterial bleeds with endovascular embolization or stenting. In some cases, especially in major venous bleeding, emergent surgical ligation may be employed. Tracheoinnominate fistula with tracheostomy or laryngectomy stoma bleed is covered in the previous chapter, “Tracheostomy Bleed.”

Key Supplies for Sentinel Bleed and Carotid Blowout Consultation

• Headlight

• Appropriate PPE including mask, eye protection, gloves, and gown

• Flexible endoscope (preferably videoendoscopy via portable unit or tower to record exam)

• Suction with Yankauer tip x2

• Tongue depressor

• Airway cart, complete with cuffed endotracheal tube assortment, and tracheostomy tray

• Throat packing supplies (Kerlix™ rolls x4, Kelly/tonsil clamp)

• Ability to quickly activate the rapid response system to readily have help if you need it

Management

Large Volume Bleeding

• Upon consultation, ensure large bore IV access x2, airway/crash cart availability, telemetry, and pulse oximetry. Notify embolization team of possible emergent case.

• Upon arrival, assess patient status and ABCs (Airway, Breathing, Circulation).

• In acute upper aerodigestive hemorrhage, mortality is primarily related to asphyxiation from blood within the airway rather than hypovolemic shock; therefore, a priority is placed to securing an airway early. If bleeding is from a presumed upper aerodigestive source (i.e., per mouth):

  • Identify specific location of bleeding, if possible.

  • Set up two large bore suctions.

  • Arrange for airway securement.

    • Ensure airway cart is available and stays with patient.

    • Ensure patient is positioned upright with suctions to aid in protecting airway.

    • Patients with an unstable airway should be orotracheally or nasotracheally intubated; however, this is preferably done in a more controlled setting in the OR when possible.

    • If patient is unable to protect airway and actively decompensating, intubation at bedside may be necessary.

    • If unable to secure airway via orotracheal intubation, surgical cricothyrotomy or tracheostomy should be performed for definitive airway control.

    • Once airway is secured, place a throat pack to compress bleeding source, packing should be tight and initial rolls should go down to hypopharynx if possible, usually takes 3-4 Kerlix™ rolls.

    • Consider going to the OR for direct laryngoscopy versus transfer to Interventional Radiology for embolization.

• If bleeding is external: Compression to stop bleeding while arranging for definitive treatment; may be best accomplished by a gloved finger with precise pressure as indiscriminate pressure with dressings may simply hide the bleeding, avoid indiscriminate clamping.

• Treat hypotension typically in concert with Anesthesia or Emergency Department assistance; may require blood products, crystalloids, colloids, and vasopressors.

• Have a colleague work on arranging for immediate OR or Interventional Radiology transfer for exploration or ligation as indicated based on the involved vessels, patient stability, and facility capabilities.

• Labs:

  • Type and cross patient or activate massive transfusion protocol as indicated.

  • Obtain coagulation panel, correct anticoagulant status if indicated and possible.

Low Volume or Self-Limited Bleeding

• Assess all patients. Consulting providers may have low concern or underestimate the potential severity and contact you just as a courtesy call; however, these patients should still be evaluated urgently.

• Obtain complete history with attention to previous oncologic history and treatment as well as anticoagulant medications.

• Complete head and neck physical exam with nasopharyngoscopy. Try to identify source of bleeding, which may not be actively bleeding at time of exam. Signs of potential sources may include granulation tissue, areas of erosion, or inflammation.

• Labs:

  • CBC with consideration of type and screen.

  • CMP with attention to renal function.

• Imaging:

  • CT angiography:

    • Evaluate for arterial wall necrosis, wall irregularity or stenosis, pseudoaneurysm formation, viable tumor burden, exposed artery, and active contrast extravasation.

  • MRI angiography:

    • Rarely obtained due to length of study and need for extended supine positioning.

    • Can be considered in stable patients under special circumstances.

• Consider Interventional Radiology consultation.

  • Diagnostic and therapeutic angiography may be employed at discretion of the interventional radiologist with additional testing.

  • Contralateral carotid artery system angiography to determine patency of circle of Willis and if carotid sacrifice is possible.

    • Balloon occlusion testing: If patient exhibits no clinical signs (neurologic exam performed during occlusion testing at set time intervals) or angiographic signs (<20% decrease in cerebral blood flow) of compromise, carotid embolism or ligation can be considered; stroke after carotid ligation is still possible in a proportion of people who “pass” the balloon occlusion test.

  • Stenting: May be employed to allow patency of injured artery (especially if common or internal carotid) while addressing bleeding. Length of artery injury and remainder vessel quality may not make this a viable option in many patients. Endovascular stenting, particularly for the common or internal carotid artery, is generally not a durable solution to the issue and should be seen as a bridge to more definitive management (e.g., surgical reconstruction of artery or coverage with vascularized tissue), as stent exposure and rebleeding is common over time.

  • Embolization: If source is from the external carotid system or sufficient contralateral internal carotid flow, may be accomplished with wire vascular plugs, microparticles, wire coils, or permanent balloon (rarely).

• For all patients at risk of bleeding, notify patient’s care team about the possibility of re-bleeding and the steps to be taken in the event of bleeding:

  • Apply localized pressure to bleeding area.

  • Call for aid and immediately notify Otolaryngology team.

  • Have embolization team on standby if indicated.

Disposition

• If patient is extremely low risk for recurrent bleeding based on history, exam, and imaging (e.g., minor granulation tissue tracheostomy bleeding), may consider overnight observation and discharge to home after discussion of return precautions.

• If patient is at moderate to high risk of recurrent bleeding or blowout based on history, exam, or imaging:

  • Consider admission to floor or ICU as indicated based on the overall risk and site of bleeding (intraoral bleeding may warrant higher level of care if concern of airway compromise with recurrence).

  • Consider prophylactic treatment measures whether surgical or with Interventional Radiology endovascular treatments.

• Discharge is typically feasible after treatment and post-treatment observation period of variable lengths based on what vessels are involved and the intervention taken (i.e., internal carotid artery embolization would generally warrant at minimum overnight observation, while endovascular embolization of a branch of the external carotid artery may permit same day discharge in select situations).

Follow-up and Patient Instructions

• Close follow-up with Otolaryngology typically within 1 week for most patients.

• Discuss return precautions and plan if re-bleeding.

• If carotid blowout or other terminal bleed is possible and unable to be prophylactically treated (e.g., terminal patient with large segment carotid encasement that is not amenable to stenting), prepare patient and family members for possible blowout with plan in place in case of terminal bleeding; have dark towels available, apply gentle pressure while attempting to keep patient calm.

• Goals of care conversation +/- palliative care conversation should be undertaken as indicated based on the situation to determine the patient’s and family’s wishes should bleeding occur. This should occur before bleeding if a patient is deemed high risk or in the “threatened bleeding category,” as well as after stabilization from a sentinel or major bleed.

References
1. Medina, J.E., Vasan, N.R., (2013). Neck Dissection. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1807-1838). Baltimore, MD: Lippincott Williams & Wilkins.
2. Mydlarz, W.K., Eisele, D.W. (2020). Complications of Neck Surgery. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 1831-1839). Philadelphia, PA: Elsevier.
3. Suárez, C., Fernández-Alvarez, V., Hamoir, M., et al. (2018). Carotid blowout syndrome: Modern trends in management. Cancer Manag Res. 10:5617-5628.
4. Manzoor, N.F., Pezaee, R.P., Ray, A., et al. (2017). Contemporary management of carotid blowout syndrome using endovascular techniques. Laryngoscope. 127(2):383-390.

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