Complete ENT (Otorhinolaryngology) question bank — ear, nose, throat, larynx, airway & head-neck — in explanation-first exam-topper style, with 72 diagrams.
12chapters144questions77High-Yield
THE CONCEPT
Tracheostomy is a surgical opening (stoma) in the anterior wall of the trachea (usually through the 2nd–4th tracheal rings) to establish an airway, bypassing the upper airway — one of the oldest life-saving procedures.
Tracheostomy (anterior neck)
thyroid cartilage
cricothyroid membrane
cricoid cartilage
thyroid isthmus(over rings 2–4)
ring 1
tube throughrings 2–4
Opening made through the 2nd–4th tracheal rings, below the isthmus —
avoiding the 1st ring & cricoid (subglottic stenosis)
A tracheostomy is an opening made in the anterior tracheal wall — usually through the 2nd–4th tracheal rings, below the thyroid isthmus — to establish an airway. The first ring and the cricoid cartilage are avoided because injury there risks subglottic stenosis.
Prolonged ventilation/respiratory failure — the commonest modern indication (ICU; long-term ventilation, weaning).
Bronchial toilet & airway protection — when the patient cannot clear secretions (coma, bulbar/neuromuscular disease, aspiration risk).
As part of major head-and-neck surgery (elective).
TECHNIQUE & LANDMARKS
The technique (surgical): supine with the neck extended, a midline incision, the strap muscles separated in the midline, the thyroid isthmus retracted/divided, and a window made in the trachea (usually the 2nd–4th rings — avoiding the 1st ring and cricoid, which risk subglottic stenosis), then the tube inserted and secured. The cricoid cartilage is the key landmark, and the thyroid isthmus overlies the 2nd–4th rings.
COMPLICATIONS & CARE
WHY THE 2ND–4TH RINGS ARE CHOSEN
A frequently-tested technical point is why the tracheostomy opening is made specifically through the 2nd–4th tracheal rings, avoiding both the 1st ring and the cricoid above and going no lower below. The choice reflects a balance of hazards. Going too high — through the first ring or the cricoid — risks damaging the cricoid, the only complete cartilage ring and the narrowest part of the airway, and predisposes to subglottic stenosis, a difficult late complication. Going too low increases the risk of injuring the large vessels at the root of the neck (the innominate artery) and makes the tube more likely to erode into them, and places the stoma awkwardly deep. The 2nd–4th rings sit in a 'safe' zone — low enough to avoid the cricoid, high enough to avoid the great vessels — with the thyroid isthmus, which overlies these rings, retracted or divided to reach them. Understanding this explains the emphasis on identifying the cricoid as the key landmark before creating the opening.
WHY PROLONGED VENTILATION IS NOW THE COMMONEST INDICATION
It is worth appreciating how the main reason for performing a tracheostomy has shifted over time, because it reflects changes in medicine. Historically, tracheostomy was chiefly an emergency operation to relieve upper-airway obstruction — from diphtheria, epiglottitis or advanced laryngeal disease. With vaccination (against Hib and diphtheria), antibiotics and earlier cancer treatment, such obstructive emergencies have become far less common. Meanwhile, the growth of intensive care means that large numbers of patients now require prolonged mechanical ventilation, for which a tracheostomy is preferred over long-term translaryngeal intubation — it is more comfortable, allows easier weaning and mouth care, reduces laryngeal injury from a prolonged endotracheal tube, and facilitates secretion clearance. Consequently, facilitating and weaning from prolonged ventilation, and managing secretions in critically ill or neurologically impaired patients, is now the commonest indication. Recognising this shift explains why most tracheostomies today are performed in the ICU rather than as airway emergencies.
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DANGER / REMEMBER: Complications are timed: immediate (haemorrhage, apnoea, pneumothorax, injury to the recurrent laryngeal nerve/oesophagus, air embolism, tube misplacement); intermediate/early (tube blockage from crusting/secretions, tube displacement, surgical emphysema, infection, aspiration); and late (tracheal stenosis, tracheo-oesophageal/tracheo-innominate fistula, granulations, difficult decannulation, persistent stoma). Care requires humidification, regular suction and inner-tube cleaning, correct cuff care, and emergency equipment (a spare tube and tracheal dilators) at the bedside.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Acute upper-airway obstruction is a life-threatening reduction/blockage of airflow in the upper airway (nose to trachea), requiring rapid assessment and intervention — a medical emergency.
Features are inspiratory stridor (the key sign), dyspnoea, accessory-muscle use, suprasternal/intercostal recession and tracheal tug, with restlessness, tachypnoea and tachycardia — and later cyanosis, exhaustion, drowsiness and bradycardia (pre-terminal). Jackson's grading (I–IV) describes severity: I — stridor/recession on exertion; II — at rest but comfortable; III — with restlessness/dyspnoea/cyanosis; IV — exhaustion, cyanosis, coma → asphyxia.
MANAGEMENT
WHY THE SITE OF OBSTRUCTION SHAPES THE PICTURE
A useful way to approach acute upper-airway obstruction is to recognise that the level of the obstruction shapes both the clinical picture and the treatment. Obstruction at or above the larynx tends to produce inspiratory stridor, a change in the voice and difficulty swallowing (with drooling), whereas a lower, tracheal obstruction may give a more biphasic noise. Recognising the level helps identify the cause — a toxic child sitting forward and drooling points to supraglottic epiglottitis, a barking cough to subglottic croup, and sudden choking to a foreign body — and thus directs specific treatment (antibiotics and airway control, steroids and adrenaline, or foreign-body removal respectively). Whatever the level, however, the overriding priority is the same: assess the severity, avoid distressing the patient, and be prepared to secure the airway before decompensation. This combination of localising the obstruction while never losing sight of airway safety is the essence of managing these emergencies.
WHY EARLY RECOGNITION IS EVERYTHING
The most important principle in acute upper-airway obstruction is that outcome depends on recognising the deterioration early and securing the airway before the patient decompensates. A partially obstructed airway can be maintained for a time by increased respiratory effort, but this compensation is finite: a patient who looks to be coping may tire suddenly, and the transition from compensated obstruction to exhaustion, cyanosis and arrest can be rapid. This is why the clinician watches for the warning signs of decompensation — rising respiratory rate then falling effort, restlessness giving way to drowsiness, and the ominous quietening of a previously loud stridor (which signals reduced airflow, not improvement) — and intervenes before these appear. Preparing early, calling for senior anaesthetic and ENT help, and having a plan (and the equipment) for a surgical airway ready in case intubation fails, are all part of this anticipatory approach. In airway emergencies, waiting to see whether the patient will settle is dangerous; erring on the side of securing the airway early saves lives.
THE BOTTOM LINE
Acute upper-airway obstruction is an emergency with many causes whose management rests on assessing severity, avoiding distressing the patient, treating the cause, and above all securing the airway early — by intubation or, if that fails, a surgical airway — before decompensation.
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DANGER / REMEMBER: Management: ABC and oxygen; do not distress a child; identify and treat the cause (nebulised adrenaline/steroids, antibiotics, remove a foreign body); and secure the airway if severe — endotracheal intubation, or if impossible/obstructed, a surgical airway (cricothyroidotomy in an emergency, or tracheostomy). Heliox can temporise.
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CLINICAL PEARL: Acute upper-airway obstruction = an emergency; causes = infective (epiglottitis, croup, Ludwig's), foreign body, trauma, tumour, allergic (angioedema), bilateral cord palsy. Signs: inspiratory stridor, recession (suprasternal/intercostal), tracheal tug, restlessness → cyanosis/exhaustion (pre-terminal). Jackson's stages I–IV. Manage: ABC + O2, don't distress a child, treat the cause (adrenaline/steroids/antibiotics/remove FB), secure the airway (intubation; if failed → cricothyroidotomy/tracheostomy).
Jackson's stages: I stridor/recession on exertion; II at rest but comfortable; III + restlessness/dyspnoea/cyanosis; IV exhaustion/cyanosis/coma → death. Rx: ABC + O2, don't distress child, treat cause (adrenaline/steroids/antibiotics/remove FB), secure airway — intubation; if failed → cricothyroidotomy (emergency)/tracheostomy. Heliox temporises.
Jackson's stages I–IV grade severity (I exertion → IV asphyxia); stage III–IV need urgent airway.
Manage: ABC + oxygen; don't distress a child; treat the cause (adrenaline/steroids/antibiotics/remove FB).
Secure the airway if severe: intubation; if impossible → cricothyroidotomy (emergency) or tracheostomy.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Acute epiglottitis is a rapidly progressive, life-threatening bacterial infection and inflammation of the epiglottis and supraglottic structures → swelling → airway obstruction. It is classically caused by Haemophilus influenzae type b (Hib) — now rarer since the Hib vaccine, so relatively more common in adults.
Acute epiglottitis — 'thumb sign'
normal
epiglottitis
thin epiglottis
swollen ('thumb')
→
In acute epiglottitis the epiglottis becomes swollen and cherry-red; on a lateral neck X-ray this appears as the rounded 'thumb sign', in contrast to the thin normal epiglottis. Imaging is done only when the airway is safe — the diagnosis is clinical.
CLINICAL FEATURES (rapid, over hours)
The child looks toxic/ill with a high fever.
The '4 D's': dysphagia, drooling, dyspnoea and dysphonia (a muffled 'hot-potato' voice).
Severe sore throat/odynophagia; sits upright, leaning forward (the tripod/sniffing position), reluctant to lie down.
Soft inspiratory stridor with little or no cough (unlike croup), progressing rapidly to obstruction.
KEY CAUTION, DIAGNOSIS & MANAGEMENT
WHY YOU MUST NOT EXAMINE THE THROAT
The single most important — and potentially life-saving — rule in acute epiglottitis is that the throat must not be examined and the child must not be upset or lain down, and understanding the reason is essential. The child with epiglottitis is maintaining a precarious airway past a grossly swollen epiglottis, and is instinctively sitting upright and still to keep it open. Attempting to examine the throat with a tongue depressor, forcing the child to lie down, or provoking crying and struggling can trigger laryngospasm or cause the swollen epiglottis to prolapse over the laryngeal inlet, converting a partial obstruction into complete, fatal obstruction in moments. This is why the classic teaching is emphatic: leave the child undisturbed on the parent's lap, give oxygen non-threateningly, summon senior anaesthetic and ENT help, and secure the airway in the controlled setting of an operating theatre before any examination. The instinct to look in the throat, so natural with a sore throat, must be actively suppressed here — a point examiners test repeatedly.
WHY THE HIB VACCINE CHANGED THE DISEASE
An important epidemiological concept is how the Haemophilus influenzae type b (Hib) vaccine has transformed acute epiglottitis, because it explains the changing pattern of the disease. Classically, epiglottitis was a disease of young children caused overwhelmingly by Hib, and was a feared paediatric airway emergency. Since the widespread introduction of Hib immunisation, the incidence in children has fallen dramatically, so that a paediatric case is now uncommon in vaccinated populations. As a result, a relatively greater proportion of the cases now seen occur in adults (in whom the presentation may be a little less fulminant but is still dangerous) and, in children, other organisms and unvaccinated individuals account for more of the residual cases. This means clinicians must still recognise the condition — now more likely in an adult or an unvaccinated child — and it underlines the value of maintaining high vaccination coverage. The story of epiglottitis is a striking example of a vaccine changing the face of a once-common emergency.
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DANGER / REMEMBER:Do not examine the throat, lie the child down, use a tongue depressor, or otherwise distress the child — this may precipitate complete obstruction. A lateral neck X-ray (only when the airway is safe) shows the 'thumb sign', but the diagnosis is clinical. Management: secure the airway first in a controlled environment (theatre, with an anaesthetist/ENT surgeon — intubation, or tracheostomy if needed) — the most important step — then IV antibiotics (a 3rd-generation cephalosporin, ceftriaxone/cefotaxime), oxygen, steroids and IV fluids; rifampicin prophylaxis for contacts, and the Hib vaccine prevents it.
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CLINICAL PEARL: Acute epiglottitis = rapidly progressive bacterial supraglottic infection (classically Hib — now rarer/more adult) → airway obstruction. The child is toxic, high fever, with the 4 D's (dysphagia, drooling, dyspnoea, dysphonia), sits upright/tripod, muffled voice, soft stridor, NO cough. Do not examine the throat/lie the child down/use a tongue depressor (may obstruct). Lateral X-ray = 'thumb sign'. Manage: secure the airway first (controlled, theatre, intubation) + IV cephalosporin (ceftriaxone) + steroids. Hib vaccine prevents it.
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KEY POINTS / NUMBERS (viva)
Acute epiglottitis = rapidly progressive bacterial supraglottitis; classic Haemophilus influenzae type b (Hib) — now rarer (vaccine), relatively more in adults; also Strep/Staph.
Toxic child, high fever, 4 D's (dysphagia, drooling, dyspnoea, dysphonia), sits upright (tripod), muffled voice, soft stridor, NO cough.
DON'T examine the throat / lie the child down / use a tongue depressor — may precipitate complete obstruction.
Lateral neck X-ray = 'thumb sign' (only if airway safe); diagnosis is clinical.
Secure the airway first (controlled, theatre, intubation) + IV cephalosporin (ceftriaxone) + steroids; Hib vaccine prevents.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Croup is a common viral infection of the larynx, trachea and bronchi (subglottic) in young children → subglottic oedema → inspiratory stridor and a characteristic barking cough. It is usually mild and self-limiting (in contrast to epiglottitis).
Croup — 'steeple sign' (AP)
subglotticnarrowing
Tapering air column below the cords (steeple/pencil)
In croup, viral inflammation causes subglottic oedema that tapers the air column below the vocal cords — the 'steeple' (or pencil) sign on an AP neck X-ray — producing the characteristic barking cough and inspiratory stridor.
CAUSE & FEATURES
It is caused by the parainfluenza virus (commonest; also RSV, influenza) in children aged about 6 months–3 years, developing gradually over days after a URI:
A barking (seal-like) cough — characteristic, with inspiratory stridor and hoarseness.
Low-grade fever and coryza (preceding URI); worse at night.
The child is usually not toxic (less ill than in epiglottitis) and can swallow (no drooling); the onset is gradual.
Severity is judged by recession and, in severe cases, cyanosis.
DIAGNOSIS & MANAGEMENT
Diagnosis is clinical; an AP neck X-ray shows the 'steeple sign' (subglottic narrowing). Management: most (mild) cases need only supportive care (reassurance, humidified air, fluids); steroids (oral/IM dexamethasone or nebulised budesonide) reduce the oedema and are the mainstay (given even in mild cases); nebulised adrenaline is used for moderate-severe croup (rapid, temporary relief — observe for rebound); with oxygen and, rarely, intubation for severe disease.
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CLINICAL PEARL: Croup (acute laryngotracheobronchitis) = viral (parainfluenza) subglottic infection in young children (6 months–3 years) → subglottic oedema → barking cough + inspiratory stridor + hoarseness, gradual onset, low fever, NOT toxic (contrast epiglottitis). AP X-ray = 'steeple sign'. Manage: supportive + steroids (dexamethasone — mainstay) + nebulised adrenaline for moderate-severe; mostly self-limiting.
WHY DEXAMETHASONE IS GIVEN EVEN IN MILD CROUP
A practical point worth understanding is why a dose of corticosteroid (dexamethasone) is now given even in mild croup, not just severe cases. Although mild croup is self-limiting and most children recover with simple supportive care, a single dose of an oral or intramuscular steroid reduces the subglottic oedema, shortens the illness, lessens the severity, reduces the chance of the child deteriorating and needing to return to hospital, and reduces the need for adrenaline or admission. Because the treatment is a single, cheap, safe dose with a favourable risk-benefit balance, it is recommended across the severity range rather than reserved for severe cases. Nebulised adrenaline, by contrast, is kept for moderate-to-severe croup, where its rapid but temporary effect buys time — with the child observed afterwards because the oedema (and stridor) can rebound as it wears off. Appreciating this explains the modern, steroid-led approach to a condition that was once managed largely with humidified air alone.
A NOTE ON RECOGNISING THE UNWELL CHILD
Although croup is usually benign, an important skill is recognising the minority of children who are becoming seriously unwell and need more than reassurance. Most children with croup have a barking cough and mild stridor but are otherwise comfortable and can be managed at home or with a single dose of steroid. However, the clinician must watch for features of significant obstruction: stridor at rest, marked chest-wall recession, restlessness or agitation, a rising respiratory and heart rate, and — as a late and worrying sign — drowsiness, pallor or cyanosis and a quietening of the stridor as air movement falls. Such children need urgent treatment (nebulised adrenaline and steroids), oxygen, close observation and, rarely, intubation. It is also important to reconsider the diagnosis if the picture does not fit — a very toxic, drooling child is more likely to have epiglottitis or another serious infection. Being able to distinguish the well child with mild croup from the deteriorating one is the key clinical judgement, ensuring safe management of a common condition.
THE BOTTOM LINE
Croup is a common viral subglottic infection causing a barking cough and stridor in young children that is usually mild and self-limiting, treated with a single dose of steroid and, for moderate-to-severe cases, nebulised adrenaline, while watching for the few who deteriorate.
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KEY POINTS / NUMBERS (viva)
Croup = viral (PARAINFLUENZA commonest; also RSV/influenza) laryngotracheobronchitis; subglottic; children 6 months–3 years; gradual onset over days post-URI.
Barking (seal-like) cough (characteristic) + inspiratory stridor + hoarseness; low-grade fever, coryza; worse at night; NOT toxic; can swallow (no drooling). AP neck X-ray = 'steeple sign' (subglottic narrowing).
Rx: mild → supportive (humidified air, fluids, reassurance). STEROIDS (oral/IM dexamethasone or nebulised budesonide) = mainstay, even mild. Nebulised ADRENALINE for moderate-severe (rapid, temporary — observe for rebound); oxygen; rarely intubation. Mostly self-limiting.
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KEY POINTS TO REMEMBER
Croup = viral (parainfluenza) subglottic infection in young children (6 months–3 years); subglottic oedema.
Barking (seal-like) cough + inspiratory stridor + hoarseness; gradual onset, low fever, NOT toxic, can swallow (contrast epiglottitis).
AP neck X-ray = 'steeple sign' (subglottic narrowing); diagnosis clinical.
Steroids (dexamethasone/budesonide) are the mainstay, even in mild cases.
Nebulised adrenaline for moderate-severe (temporary, observe for rebound); mostly self-limiting.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
An inhaled foreign body is aspiration of an object into the larynx, trachea or bronchi — a common paediatric emergency (especially toddlers). It can cause acute obstruction (if laryngeal/tracheal — life-threatening) or chronic problems (if bronchial).
Inhaled foreign body
trachea
carina
FB in RIGHTmain bronchus
Right bronchus is wider, more vertical & more in line with the
trachea → foreign bodies lodge here more often
An inhaled foreign body lodges most often in the right main bronchus, because it is wider, more vertical and more directly in line with the trachea than the left. A laryngeal or tracheal foreign body, by contrast, can cause acute complete obstruction.
COMMON OBJECTS, SITE & FEATURES
Common foreign bodies are peanuts/nuts (commonest, especially under 3 years), seeds, small toys, beads and pins. A laryngeal/tracheal object can cause acute complete obstruction (choking, asphyxia), while a bronchial object lodges more often in the right main bronchus (wider, more vertical, more in line with the trachea). Features:
Bronchial (may follow a symptom-free interval): persistent cough, wheeze, recurrent/non-resolving pneumonia, unilateral decreased breath sounds, and obstructive emphysema (ball-valve) or collapse.
INVESTIGATION & MANAGEMENT
WHY THE RIGHT MAIN BRONCHUS IS FAVOURED
A classic anatomical point is why an inhaled foreign body lodges more often in the right main bronchus than the left, and it follows directly from the anatomy of the airway. The right main bronchus is wider, shorter and more vertical (more in line with the trachea) than the left, which branches off at a sharper angle. An object falling down the trachea therefore tends to continue on the straighter, more direct path into the right bronchus. This is a useful and frequently-examined fact, and it has practical value: in a child with a suspected inhaled foreign body and unilateral chest signs, the right side is the more likely location, guiding the bronchoscopist. (In very young children the difference in bronchial angles is less marked, so the lateralisation is less pronounced.) The same anatomical principle explains why aspiration pneumonia also tends to favour the right lung.
WHY THE HISTORY OF CHOKING IS SO IMPORTANT
The most valuable single clue in diagnosing an inhaled foreign body is the history of a witnessed choking or coughing episode, and understanding why explains the whole diagnostic approach. Many inhaled objects — particularly organic ones like peanuts — are radiolucent and do not show on an X-ray, and after the initial choking there may be a symptom-free interval during which examination and even imaging can appear near-normal, only for the child to later develop a persistent cough, wheeze or recurrent pneumonia. In this setting, a clear history that the child was seen to choke while eating nuts or playing with a small object is often the strongest evidence, outweighing a normal X-ray, and should prompt bronchoscopy. Conversely, an inhaled foreign body must be actively considered — and the history specifically sought — in any child with an unexplained persistent respiratory problem or a non-resolving pneumonia. Trusting the history of choking, even when investigations are unremarkable, prevents dangerous delay in removing the object.
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DANGER / REMEMBER: A history of a witnessed choking episode is the key clue. Investigation: examination (unilateral signs), X-ray (a radio-opaque object, or indirect signs — air trapping/collapse/mediastinal shift; many objects are radiolucent), and bronchoscopy (diagnostic and therapeutic). Management: for acute complete obstruction (choking) — back blows and chest/abdominal thrusts (Heimlich), and if these fail, laryngoscopy/an emergency airway; the definitive treatment is rigid bronchoscopy under GA to remove the object, with antibiotics/physiotherapy for complications.
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CLINICAL PEARL: Inhaled foreign body = paediatric emergency (toddlers; peanuts commonest). Larynx/trachea → acute choking/asphyxia (emergency); bronchus → the right main bronchus (wider/vertical) — cough, wheeze, recurrent/non-resolving pneumonia, unilateral signs. A history of choking is the key clue. X-ray (air trapping/collapse; often radiolucent). Manage: choking → back blows/thrusts (Heimlich); definitive = rigid bronchoscopy under GA.
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KEY POINTS / NUMBERS (viva)
Inhaled foreign body = paediatric emergency (toddlers); peanuts/nuts commonest (esp <3 y); also seeds, toys, beads, pins.
Larynx/trachea → acute choking, cyanosis, complete obstruction/asphyxia (penetration syndrome). Bronchus → RIGHT main bronchus more common (wider, more vertical, in line with trachea); may have symptom-free interval then persistent cough, wheeze, recurrent/non-resolving pneumonia, unilateral ↓ breath sounds, obstructive emphysema/collapse.
History of witnessed choking = key. Ix: X-ray (radio-opaque FB or indirect — air trapping/collapse/mediastinal shift; often radiolucent), CT, bronchoscopy (diagnostic + therapeutic). Rx: choking → back blows + chest/abdominal thrusts (Heimlich) → laryngoscopy/emergency airway if fails; DEFINITIVE = rigid bronchoscopy under GA; antibiotics/physio for complications.
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KEY POINTS TO REMEMBER
Inhaled foreign body = paediatric emergency (toddlers); peanuts commonest.
Larynx/trachea → acute choking/asphyxia (emergency); bronchus → right main bronchus (wider/vertical) more common.
History of a witnessed choking episode is the key clue; X-ray often shows only indirect signs (radiolucent objects).
Manage: choking → back blows/thrusts (Heimlich); definitive = rigid bronchoscopy under GA.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Cricothyroidotomy is an emergency surgical airway created through the cricothyroid membrane (between the thyroid and cricoid cartilages) — the fastest surgical airway in a 'can't intubate, can't oxygenate' emergency.
Cricothyroidotomy
thyroid cartilage
cricothyroidmembrane (incise)
cricoid cartilage
Fastest surgical airway: horizontal incision through the
cricothyroid membrane in 'can't intubate, can't oxygenate'
Temporary — convert to formal tracheostomy within 24–48 h
Cricothyroidotomy is the fastest surgical airway in a 'can't intubate, can't oxygenate' emergency: a horizontal incision is made through the cricothyroid membrane between the thyroid and cricoid cartilages. It is a temporary measure, converted to a formal tracheostomy within 24–48 hours.
TECHNIQUE & ROLE
Technique: identify the cricothyroid membrane (just below the laryngeal prominence), make a horizontal stab incision through it, and insert a tube/cannula (surgical cricothyroidotomy; or a needle cricothyroidotomy with jet insufflation as a temporary measure, preferred in children). It is quick and superficial (avoiding the vascular thyroid isthmus and major vessels of a formal tracheostomy), but is a temporary measure — converted to a formal tracheostomy within 24–48 hours (prolonged use risks subglottic stenosis). It is avoided (needle preferred) in children under about 12.
A NOTE ON WHY IT IS ONLY TEMPORARY
An important principle is that a cricothyroidotomy, although life-saving, is only a temporary airway that should be converted to a formal tracheostomy (or the patient otherwise definitively managed) within a day or two. The reason is that the cricothyroid membrane lies immediately adjacent to the cricoid cartilage and the subglottis — the narrowest part of the airway — so a tube left in this position for a prolonged period can cause inflammation and scarring that leads to subglottic stenosis, a serious and difficult-to-treat narrowing. This is why the cricothyroidotomy is regarded as an emergency bridge: it secures oxygenation immediately when intubation has failed, but the definitive airway is then relocated to the safer lower position of a standard tracheostomy once the crisis is controlled and the situation allows. Understanding this distinction — emergency and temporary at the cricothyroid membrane, definitive and durable at the lower trachea — clarifies the role of each surgical airway.
THE BOTTOM LINE
Cricothyroidotomy is the fastest emergency surgical airway, made through the cricothyroid membrane in a 'can't intubate, can't oxygenate' crisis, and is a temporary bridge to a formal tracheostomy.
A further practical point is that reliable identification of the cricothyroid membrane is the crux of the procedure: it is found in the midline as a soft depression just below the prominence of the thyroid cartilage and above the firm cricoid ring, and being able to locate it quickly and confidently by palpation — even in a difficult neck — is the skill that makes this emergency airway feasible under pressure.
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KEY POINTS TO REMEMBER
Cricothyroidotomy = emergency surgical airway through the cricothyroid membrane; fastest surgical airway ('can't intubate, can't oxygenate').
Technique: horizontal stab through the membrane + tube/cannula (surgical); or needle cricothyroidotomy with jet insufflation (temporary; preferred in children).
Quick and superficial (avoids the vascular isthmus/vessels of a formal tracheostomy).
Temporary — convert to a formal tracheostomy within 24–48 h (prolonged use → subglottic stenosis); avoid surgical form in children <12.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; ATLS.
THE CONCEPT
Tracheostomy tubes vary by material and features, chosen according to the patient's needs (ventilation, speech, duration, secretions).
Types of tracheostomy tube
Cuffedseal: ventilation,anti-aspiration
Uncuffedchildren /long-term
Fenestratedenables speech,aids weaning
Inner cannularemovable —easy cleaning
Tracheostomy tubes vary by feature: a cuffed tube seals the airway for ventilation and against aspiration; an uncuffed tube suits children and long-term use; a fenestrated tube allows airflow to the larynx for speech and weaning; and an inner cannula can be removed for cleaning to prevent blockage.
THE TYPES
Cuffed — an inflatable cuff seals the airway (for positive-pressure ventilation and to prevent aspiration; deflate periodically to avoid pressure necrosis).
Uncuffed — for children, or long-term use when ventilation/aspiration protection is not needed.
Fenestrated — a hole in the outer tube allows airflow to the larynx → enables speech and aids weaning/decannulation (with the inner tube removed and cuff deflated).
With an inner cannula — a removable inner tube for easy cleaning (prevents blockage); and metal (Jackson's/silver) — reusable, for long-term/permanent use.
A NOTE ON MATCHING THE TUBE TO THE NEED
The key concept in choosing a tracheostomy tube is that the tube is matched to the patient's specific requirements, which change over the course of care. Early on, a ventilated patient needs a cuffed tube to allow positive-pressure ventilation and to protect against aspiration; as the patient improves and weaning begins, the emphasis shifts toward restoring speech and preparing for decannulation, favouring cuff deflation and a fenestrated tube that lets air pass up to the larynx. Throughout, an inner cannula that can be removed and cleaned helps prevent the tube blocking with secretions. Thus the same patient may progress through different tube types as their condition evolves. Recognising that tube selection is a dynamic decision — driven by the need for ventilation, aspiration protection, speech and the stage of weaning — rather than a single fixed choice, is the essence of understanding tracheostomy tubes and is what examiners are really testing.
THE BOTTOM LINE
Tracheostomy tubes are chosen to match evolving needs — cuffed for ventilation, uncuffed for children/long-term, fenestrated for speech and weaning, with an inner cannula to prevent blockage.
A further point is that the size of the tube also matters, being chosen to fit the trachea comfortably — large enough to ventilate and suction effectively but not so large as to cause mucosal pressure damage — and that adjustable-flange tubes are available for patients with deep or fat necks in whom a standard tube would not seat correctly.
It is also worth noting that the choice between a metal (silver) tube and a modern plastic one depends on the situation: durable reusable metal tubes such as Jackson's are used for long-term or permanent tracheostomies, whereas plastic tubes, being lighter and available with cuffs and inner cannulae, suit the acute and ventilated setting.
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KEY POINTS TO REMEMBER
Cuffed: seals the airway for ventilation and against aspiration (deflate periodically — pressure necrosis).
Uncuffed: for children or long-term use without ventilation/aspiration needs.
Fenestrated: hole allows airflow to the larynx → speech and weaning/decannulation.
Inner cannula (removable for cleaning — prevents blockage); metal (Jackson's) for long-term/permanent; adjustable-flange for deep necks.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
The complications of tracheostomy are usefully divided by timing.
BY TIMING
Immediate (operative): haemorrhage, apnoea (loss of hypoxic drive), pneumothorax/pneumomediastinum, injury to the recurrent laryngeal nerve/oesophagus/cricoid, air embolism, and tube misplacement.
Intermediate (early, hours–days): tube blockage (crusting/secretions — a leading cause of death; humidify and suction), tube displacement, surgical emphysema, wound infection, secondary haemorrhage, aspiration and tracheitis.
Late (weeks later): tracheal stenosis (at the stoma/cuff site), tracheo-oesophageal fistula, tracheo-innominate artery fistula (torrential, often fatal haemorrhage — rare), granulation tissue, difficult decannulation, a persistent tracheocutaneous fistula and an unsightly scar.
A NOTE ON THE MOST IMMEDIATELY DANGEROUS COMPLICATIONS
Among the many complications, two deserve special emphasis because they are immediately life-threatening and central to safe tracheostomy care: tube blockage and tube displacement. A tracheostomy tube can rapidly become blocked by inspissated (dried) secretions or a crust, especially if the inspired air is not humidified, cutting off the airway — which is why humidification, regular suction and cleaning of the inner cannula are so important. Equally, the tube can become displaced or fall out, particularly in the first days before the tract has matured, leaving the patient without an airway. Both are true emergencies, which is the reason a spare tube of the same and a smaller size, along with tracheal dilators, must always be kept at the bedside so the airway can be re-established at once. Recognising blockage and displacement as the immediate killers, and having the equipment and drills ready to deal with them, is the practical heart of tracheostomy safety.
THE BOTTOM LINE
Tracheostomy complications are grouped by timing, with tube blockage and displacement the immediate killers, prevented by humidification, suction and a bedside spare tube.
A further point is that a rare but catastrophic late complication, the tracheo-innominate artery fistula, deserves special mention: erosion of the tube into the innominate artery causes torrential, usually fatal haemorrhage, and a herald bleed (a small sentinel bleed from the tracheostomy) should therefore never be ignored, as it may warn of this impending catastrophe.
It is also worth noting that many of these complications are preventable with good technique and diligent nursing care, which is why structured tracheostomy care — with trained staff, clear protocols and appropriate equipment at the bedside — is now emphasised as a way of reducing avoidable harm and deaths.
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DANGER / REMEMBER: Prevention/care: humidification, regular suction, inner-tube cleaning, correct cuff pressure, and a bedside spare tube and tracheal dilators.
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KEY POINTS TO REMEMBER
Immediate: haemorrhage, apnoea, pneumothorax, RLN/oesophageal injury, air embolism, tube misplacement.
Early: tube blockage (crusting — leading cause of death), displacement, surgical emphysema, infection, secondary haemorrhage, aspiration.
Prevent with humidification, suction, inner-tube cleaning, correct cuff pressure, and a bedside spare tube + dilators.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Decannulation is the removal of a tracheostomy tube once it is no longer needed — when the upper airway is patent and the patient can breathe and protect the airway.
PREREQUISITES & PROCESS
Prerequisites: the original indication has resolved, the upper airway is patent (adequate laryngeal function, no obstruction), the patient can cough/clear secretions and swallow, and is off ventilation. The process is gradual: assess (endoscopy to confirm a patent airway/cord mobility), then downsize the tube, deflate the cuff, use a fenestrated tube/speaking valve, and perform a tube-occlusion (capping/spigot) trial — if capping is tolerated for about 24 hours, the tube is removed and the stoma covered (it heals/closes spontaneously).
A NOTE ON WHY DECANNULATION IS DONE GRADUALLY
The important principle underlying decannulation is that it is done gradually and by stages rather than by simply pulling the tube out, and understanding why makes the process logical. Removing the tube abruptly risks discovering too late that the upper airway is not adequately patent or that the patient cannot manage their secretions, leaving them in respiratory difficulty with a stoma that has begun to close. The staged approach — confirming a patent airway by endoscopy, downsizing the tube, deflating the cuff, then capping the tube for a trial period — tests at each step whether the patient can breathe and clear secretions through the normal upper airway while the tracheostomy is still in place as a safety net. Only when the patient comfortably tolerates the tube being capped is it removed. This cautious, reversible sequence ensures that decannulation is safe and that the tube is not removed prematurely — a particular concern in children, in whom difficult decannulation is more common.
THE BOTTOM LINE
Decannulation is a staged, reversible process of confirming a patent airway and capping the tube before removal, done cautiously because premature removal — especially in children — is dangerous.
A further point is that in children decannulation is often more difficult than in adults, because problems such as tracheomalacia, suprastomal granulation tissue, subglottic stenosis or simple psychological dependence on the tube may only become apparent when removal is attempted, which is why a careful endoscopic assessment of the airway usually precedes decannulation in a child.
It is also worth noting that once the tube is removed the stoma usually closes and heals on its own within days, needing only a simple occlusive dressing, though occasionally a persistent tracheocutaneous fistula remains and requires surgical closure.
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DANGER / REMEMBER:Difficult decannulation — especially in children (tracheomalacia, granulations, subglottic stenosis, psychological dependence) — may need endoscopy/dilatation.
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KEY POINTS TO REMEMBER
Decannulation = removing the tracheostomy tube when no longer needed (patent upper airway, patient can breathe/protect airway).
Prerequisites: original indication resolved, patent upper airway, adequate cough/swallow, off ventilation.
Difficult decannulation (esp children): tracheomalacia, granulations, subglottic stenosis, dependence — may need endoscopy/dilatation.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Both cause paediatric stridor but differ greatly — a classic and important differentiation.
COMPARISON
Feature
Croup
Epiglottitis
Cause
Viral (parainfluenza)
Bacterial (Hib)
Site
Subglottic
Supraglottic
Onset
Gradual (days)
Rapid (hours)
Cough
Barking (seal-like)
Little/none
Fever/toxicity
Low, not toxic
High, toxic
Drooling/dysphagia
No
Yes
Voice
Hoarse
Muffled
X-ray
Steeple sign (AP)
Thumb sign (lateral)
Management
Steroids ± adrenaline
Secure airway + antibiotics
The key contrasts: epiglottitis = toxic, drooling, no cough, don't examine the throat, secure the airway; croup = barking cough, not toxic, steroids.
A NOTE ON WHY THE DISTINCTION MATTERS
This differentiation matters because the two conditions, though both presenting with stridor in a child, demand completely different responses — and confusing them can be fatal. Mistaking epiglottitis for croup risks fatal underestimation: attempting to examine the throat or manage the child casually can precipitate complete airway obstruction, when what is needed is urgent, controlled airway management and antibiotics. Conversely, treating croup as epiglottitis leads to unnecessarily aggressive intervention. The distinguishing features are therefore highly practical: the toxic, drooling, quiet child sitting forward with a high fever and no cough has epiglottitis and needs the airway secured, whereas the less-ill child with a barking cough, hoarse voice and gradual onset after a cold has croup and responds to steroids. Being able to tell them apart quickly at the bedside, and to act accordingly, is one of the most important skills in paediatric airway emergencies — which is exactly why the comparison is such a favourite examination topic.
THE BOTTOM LINE
Croup and epiglottitis both cause paediatric stridor but differ in cause, onset and toxicity, and distinguishing them is vital because epiglottitis is an airway emergency while croup responds to steroids.
A further point is that the changing epidemiology has made croup by far the commoner of the two in vaccinated populations, so that a child presenting with stridor is now much more likely to have croup than epiglottitis — but the clinician must never let this lull them into missing the occasional, dangerous case of epiglottitis, particularly in an unvaccinated child or an adult.
It is also worth noting that a further practical distinguishing feature is the child's posture and behaviour: the child with epiglottitis characteristically sits still and upright, quiet and anxious, to protect the airway, whereas the child with croup is usually more active and troubled chiefly by the barking cough.
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KEY POINTS TO REMEMBER
Croup: viral (parainfluenza), subglottic, gradual, barking cough, not toxic, can swallow, steeple sign, treated with steroids ± adrenaline.
Epiglottitis: bacterial (Hib), supraglottic, rapid, no cough, toxic, drooling/dysphagia, muffled voice, thumb sign, secure airway + antibiotics.
Epiglottitis clues: toxic, drooling, sits upright, no cough, don't examine the throat.
Croup clues: barking cough, hoarse, not toxic, gradual onset after a cold.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Jackson's stages (Chevalier Jackson) are a clinical grading of the severity of upper-airway obstruction, guiding the urgency of intervention.
THE STAGES
Stage I — stridor and suprasternal recession only on exertion/crying; the patient is otherwise comfortable.
Stage II — stridor and recession at rest, but the patient is comfortable/not distressed (compensated).
Stage III — stridor + recession at rest + signs of hypoxia/distress: restlessness, dyspnoea, accessory-muscle use, sweating, tachycardia (decompensating).
Stage IV — exhaustion, cyanosis, drowsiness/coma and feeble respiration → asphyxia and death if untreated.
Significance: it helps decide when to intervene (secure the airway before stage IV); stages III–IV need an urgent airway.
A NOTE ON ITS PRACTICAL USE
The value of Jackson's staging is that it turns the assessment of a struggling airway into a clear, graded scale that guides the timing of intervention. Rather than relying on a vague impression of how badly the patient is breathing, the clinician can place them on a defined scale from stridor on exertion alone (stage I) to exhaustion and impending asphyxia (stage IV), and track their progress up or down that scale over time. Crucially, the staging emphasises that the airway should be secured before the patient reaches the decompensated, pre-terminal stages (III–IV) — waiting for cyanosis and exhaustion is waiting too long. It also warns against false reassurance: a patient in stage II may look comfortable at rest yet be one step from decompensation. Used this way, the staging is not merely a descriptive classification but a practical prompt to intervene early and to monitor for deterioration, which is why it remains a useful bedside tool in airway obstruction.
THE BOTTOM LINE
Jackson's stages grade upper-airway obstruction from exertional stridor to impending asphyxia, prompting the airway to be secured before the decompensated stages III–IV.
A further point is that the staging applies to obstruction from any cause — infective, foreign body, tumour or trauma — giving a common language for describing severity and communicating urgency between clinicians, so that a report of a patient in 'stage III obstruction' immediately conveys the need for prompt airway intervention regardless of the underlying diagnosis.
It is also worth noting that, being a purely clinical bedside grading requiring no equipment, Jackson's staging is especially valuable in resource-limited and pre-hospital settings, where it allows rapid assessment and triage of a patient with airway obstruction without the need for investigations.
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KEY POINTS TO REMEMBER
Jackson's stages grade upper-airway obstruction severity to guide intervention.
I: stridor/recession on exertion only (comfortable at rest). II: at rest but comfortable (compensated).
III: at rest + restlessness, dyspnoea, accessory muscles, cyanosis (decompensating). IV: exhaustion, cyanosis, coma → death.
Intervene before stage IV; stages III–IV need an urgent airway.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Percutaneous dilatational tracheostomy is a bedside technique (especially in the ICU) to create a tracheostomy without an open surgical dissection, using the Seldinger technique.
METHOD & COMPARISON
Method: a needle is inserted into the trachea (usually between the 1st–2nd or 2nd–3rd rings) under bronchoscopic guidance, a guidewire is passed, and the tract is progressively dilated (a tapered dilator/forceps) before the tube is railroaded over it. Advantages: it is done at the bedside (no transfer to theatre), is quick, with a smaller wound, less bleeding/infection and is cost-effective in the ICU.
A NOTE ON WHY IT SUITS THE ICU BUT NOT EMERGENCIES
The key to understanding percutaneous tracheostomy is recognising why it is ideal for the controlled ICU setting but unsuitable for an airway emergency. Its great advantage is that it can be performed at the bedside in a stable, already-intubated patient — avoiding the cost, delay and risk of transferring a critically ill patient to an operating theatre — which is exactly the situation of the many ICU patients needing a tracheostomy for prolonged ventilation. However, the technique relies on the airway already being secured by an endotracheal tube (which supports oxygenation while the tract is dilated) and on being able to control the situation with bronchoscopic guidance. In a patient with acute upper-airway obstruction who cannot be intubated — the very situation where an emergency airway is needed — these prerequisites are absent, so an open surgical approach (or cricothyroidotomy) is required instead. Grasping this explains why the percutaneous method has become routine in intensive care yet has no place in the crash airway.
THE BOTTOM LINE
Percutaneous dilatational tracheostomy is a bedside Seldinger technique ideal for ICU patients on prolonged ventilation but unsuitable for airway emergencies or children, where open surgery is preferred.
A further point is that, despite its bedside convenience, percutaneous tracheostomy is not risk-free — complications such as bleeding, posterior tracheal wall injury and tube misplacement can occur — which is why it is performed by trained operators, usually with bronchoscopic guidance to confirm correct needle placement and to protect the back wall of the trachea during dilatation.
It is also worth noting that percutaneous and open surgical tracheostomy are complementary rather than competing techniques, each with its place: the percutaneous method for stable, intubated ICU patients, and the open method for emergencies, children and patients with difficult neck anatomy or bleeding tendencies.
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DANGER / REMEMBER: Disadvantages/contraindications: it needs an intubated/controlled airway (it is not for emergency obstruction or for children), and is difficult with a short/fat neck, a goitre, coagulopathy or in an emergency — for which open surgical tracheostomy is preferred. It is widely used for prolonged ventilation in the ICU.
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KEY POINTS TO REMEMBER
Percutaneous dilatational tracheostomy = bedside tracheostomy without open dissection (Seldinger technique), esp in ICU.
Advantages: bedside (no theatre), quick, smaller wound, less bleeding/infection, cost-effective.
Needs a controlled/intubated airway — NOT for emergency obstruction or children; open surgical tracheostomy preferred for emergencies/difficult anatomy.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.