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  • • Obstruction may be caused by structural/anatomic abnormalities (tumors, foreign bodies, infections) or functional abnormalities (vocal cord dysfunction, muscle tension dysphonia).
  • • Symptoms include cough, stridor, shortness of breath, globus sensation, hoarseness.
  • • Pulmonary function testing including flow volume loops showing truncation.
  • • Laryngoscopy reveals cause of mechanical or anatomical obstruction.
  • • Bronchoscopy may be necessary if obstruction occurs in the subglottic large airway including trachea and main bronchi.

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In this chapter the large airways will be considered to include the pharynx, larynx, trachea, and main bronchi. Obstruction of the large airways should be considered when patients present with symptoms and signs of obstructive airways disease but do not have findings consistent with asthma or chronic obstructive lung disease or have these conditions but demonstrate a pronounced worsening of symptoms not controlled with standard medication. In the young age groups, foreign bodies and congenital webs are the most common abnormalities; whereas in the elderly population, tumors both benign and malignant and laryngeal manifestations of systemic diseases such as sarcoidosis or collagen vascular diseases are of greatest concern.

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There are both acute and chronic causes of upper airway obstruction. Acute causes include aspiration of a foreign body as well as causes associated with direct blunt trauma such as fractures of the laryngeal cartilages, arytenoid cartilage dislocation, hematoma formation, and bilateral vocal cord paralysis. These injuries may be overlooked if the patient is intubated following massive trauma (eg, trauma resulting from motor vehicle accidents or falls). Only after the patient is extubated may such injuries be appreciated. The physician should be alert to evaluating these patients by laryngoscopy during intubation and soon after extubation. Intubation and various invasive surgical and medical procedures of the head and neck area lead to vocal cord paralysis and/or obstruction due to hematoma or formation of infectious abscess. There are a variety of drugs that lead to upper airway obstruction including the sedative hypnotics such as benzodiazepines that produce somnolence, respiratory depression, reduction in upper airway muscle tone, reduced cough response, and a blunted respiratory drive to hypoxia and hypercarbia. Use of the anticoagulants warfarin and heparin may put patients at risk for formation of hematoma secondary to relatively minor trauma.

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Large airway obstruction caused by bacterial infection is seen in children and is less common in adults. Noniatrogenic infections including tracheitis and supraglottitis are commonly due to Staphylococcus aureus and Streptococcus species. Adult croup may be due to viral rather than bacterial sources. Retropharyngeal abscesses and dental, sublingual, submandibular, and other oral cavity infections are commonly due to Streptococcus or oral anaerobic species. Miscellaneous causes for acute upper airway obstruction include thermal injuries, systemic anaphylaxis, and rapid thyroid enlargement such as during pregnancy or postradiation therapy edema.

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Chronic or slowly progressive causes of airflow obstruction include vocal cord polyps or granulomas and tumors of the aerodigestive tract, particularly invasive malignancies such as squamous cell carcinomas, lymphomas, or thyroid cancers. Children, in ...

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