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BACKGROUND

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Maintaining a safe airway is one of the primary concerns when managing patients with otolaryngology problems. This includes not only ensuring adequate size and patency of the airway but also protecting against aspiration of blood, food, and secretions into the airway.

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Although loss of a secure airway is one of the most feared complications in otolaryngology patients, other disorders of the head and neck can have significant morbidity if not appropriately addressed. The head and neck have an abundant vascular supply and blood loss can be brisk and substantial. Seemingly minor trauma can lead to significant cosmetic deformity if not promptly and appropriately treated. Localized infections can spread to the bloodstream or track along fascial planes to become life-threatening. The close proximity of head and neck structures to the brain facilitates easy intracranial spread of otolaryngologic disease or infection, often with devastating results. The majority of conditions that require otolaryngology referral can be safely and effectively managed in the outpatient setting. However, when significant risk of complication exists, admission for inpatient management is warranted. It is also common for patients that are already hospitalized to develop or have coexisting head and neck conditions.

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AIRWAY

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INFANT WITH NOISY BREATHING

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A rapid preliminary assessment of the infant who presents with noisy breathing is essential to determine the degree of respiratory distress. The presence of retractions, increased work of breathing, vital sign instability, and oxygen desaturations provide a more accurate indicator of the patient’s respiratory status than the extent of the noisy breathing. A patient that is tiring will often be less noisy as obstruction worsens and airflow decreases. In such cases, the airway must be urgently secured in a controlled fashion. However, the majority of infants can be safely evaluated without intubation.1,2

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The history and physical examination should guide the initial management and workup of an infant with noisy breathing. The history alone may suggest the diagnosis in more than 80% of cases. A few components of the history are particularly important: onset of noisy breathing (e.g. immediately following delivery, 6 to 8 weeks of age, later in infancy); quality of noisy breathing (e.g. stertor, inspiratory stridor, expiratory stridor, biphasic stridor, wheezing); quality of the cry (e.g. normal, weak, absent); and aggravating or alleviating factors (e.g. supine positioning, crying, feeding).2 A thorough physical examination is then undertaken paying particular attention to the general state of the child and auscultation of the neck and chest to determine in which phase of respiration the noisy breathing is occurring. Flexible fiberoptic laryngoscopy can often confirm the diagnosis by allowing examination of the entire upper airway as well as visualization of the larynx.2

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In a stable patient, the next step in the evaluation should include radiographic examination of the airway with a chest radiograph and high-kilovolt anteroposterior and lateral neck films. These imaging ...

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