Upper Airway Obstruction

What is Upper Airway Obstruction?

The upper airway, which includes the nose, mouth, throat, and voice box, plays an essential role in breathing. The throat or “pharynx” is subdivided into three areas: the nasopharynx near your nose, the oropharynx near your mouth, and the hypopharynx that leads to the voice box or “larynx”. This in turn is divided into three areas as well: supraglottis, glottis and subglottis, located above, around, and below the vocal cords respectively. The most narrow part of the adult airway is the glottis (the area around the vocal cords), while in children, it’s the cricoid (a ring-shaped cartilage in the neck).

Blockage or narrowing of the airways, known as upper airway obstruction, can interfere with breathing. Recognizing the symptoms that indicate airway blockage is very important due to the serious complications that can develop if not promptly treated. The level at where the obstruction is happening can often be determined by the type of noisy breathing one experiences. Noisy breathing produced above the voice box is called “stertor”, while noisy breathing from the voice box or below is referred to as “stridor”. “Stridor” can be further divided into inspiratory (occurring during inhalation, happens at supraglottis), expiratory (occurring during exhalation, at glottis level) and biphasic (occurring during both, at subglottis or windpipe level).

Upper airway obstruction can either be partial (incomplete blockage) or complete (total blockage), and it can develop slowly over time (chronic) or happen suddenly (acute). It is necessary to get a good evaluation of the patient’s history and a thorough examination to understand the cause and urgency of treatment for the obstruction. If left unattended, upper airway obstruction can have major or even deadly long-term effects.

What Causes Upper Airway Obstruction?

Upper airway obstruction, which refers to a blockage in the upper part of your airway, can result in noisy breathing. There are two types of sounds you might hear: stertor and stridor.

Stertor is caused by a blockage in your mouth or nose area and is usually congenital (present at birth) or acquired (developed later in life). Blockages in newborns can cause symptoms right after birth because they mainly breathe through their noses for a few months. This is due to conditions like pyriform aperture stenosis and bilateral choanal atresia, which are rare but do cause upper airway obstruction at birth.

Bilateral choanal atresia causes immediate distress in newborns, but crying can relieve it as it helps them to breathe through their mouths. Other possible causes of obstruction in older children or adults include nasal turbinate hypertrophy often due to allergies, nasal polyps, foreign objects in the nose, deviated septum, and adenoidal hypertrophy. Conditions involving the mouth like retrognathia, glossoptosis, macroglossia, and lymphovascular malformation can also lead to obstruction. If you’re older, causes also extend to angioedema, Ludwig angina (a floor-of-mouth abscess caused by dental infection), oral cancer, tonsillar hypertrophy, and abscesses in the area around the throat. Penetrating neck injury, burns, or caustic injury can also cause swelling that leads to stertor.

A very common cause of stertor in children is adenotonsillar hypertrophy, leading to obstructive sleep apnea (OSA). OSA is when your breathing often stops and starts in sleep. Symptoms of OSA in children include noisy breathing, frequent night awakenings, hyperactivity, poor concentration in school, and bedwetting. It’s important to have sleep studies in children suspected of OSA. During a sleep study, the number of times breathing stops (apnea) or decreases (hypopnea) during each hour of sleep is recorded. This count is known as the Apnea-Hypopnea Index (AHI). Adults also can have OSA with different severity grading.

Stridor is a high-pitched sound associated with obstruction at the level of the voice box or larynx. Congenital causes in neonates include laryngomalacia and unilateral or bilateral vocal cord palsy. Acquired causes in childhood include recurrent respiratory papillomatosis (RRP), subglottic stenosis secondary to intubation, epiglottitis, tracheobronchitis, and foreign body inhalation. A build-up of subglottic stenosis or subglottic hemangioma can lead to a barking cough.

In children, accidental inhalation of items like peanuts, buttons, and beads can cause stridor. However, in adults, sudden onset stridor is usually worrying as it may be a sign of laryngeal cancer. This may require urgent evaluation as it may indicate a rapidly progressing airway emergency. In adults, other causes of stridor can be infections such as epiglottitis or supraglottis, immune system diseases, diseases following prolonged intubation or trauma, and bilateral vocal cord palsy. Burn injuries to the airway are also important causes of upper airway obstruction.

Compression of the windpipe can occur as a congenital or acquired condition. Some neonates are born with vascular or aortic anomalies that cause windpipe compression. In adults, a slow-growing goiter or other cancers of the head and neck can also cause compression of the windpipe.

Risk Factors and Frequency for Upper Airway Obstruction

There are various reasons for upper airway obstruction, and the frequency of this problem can vary greatly depending on the cause. Here are some common causes of upper airway obstruction and the statistics associated with them.

• In 2000, the Centers for Disease Control and Prevention reported 160 children, all 14 years old or younger, died from choking incidents. Additionally, there were around 17,537 visits to emergency departments for nonfatal choking incidents that year.
• Surgery for enlarged tonsils and adenoids, medically termed adenotonsillar hypertrophy, is common. The rates for these surgeries can be anywhere from 19 to 118 out of every 10,000 children, depending on the country.
• Obstructive sleep apnea, a condition that can cause the upper airway to become blocked during sleep, affects 26% of the adult population in the United States.
• Every year, over 650,000 cases of head and neck cancers are diagnosed globally, leading to 330,000 deaths. These cancers make up 3% of all cancer cases in the United States. Men are more commonly affected than women.

Signs and Symptoms of Upper Airway Obstruction

When dealing with kids who might have obstructive sleep apnea (OSA), the questions need to be directed to the adult with them. You might ask if they snore with pauses in their breathing, or if they seem overly tired or hyperactive during the day. Parents might report that their child often breathes through their mouth. Other signs of OSA in kids can be overactive behavior and bedwetting.

Adults who may have OSA might have different experience. They might say they wake up a lot during the night, and still feel tired the next day, even though they were in bed the whole night. They might be overweight, have excessive sleepiness during the day, and their sleeping partner often reports loud snoring.

Quick recognition and treatment is vital for someone experiencing a sudden blockage in the upper airway. A delay could lead to difficulty in breathing and can quickly worsen to severe inability to breathe without prompt medical intervention. It’s crucial to check their airway, breathing, and circulation (ABCs) while keeping the patient safe. Approach might vary based on the patient’s symptoms.

Patients at risk of blockage in the upper airway need a thorough Ear, Nose, and Throat (ENT) examination quickly, while ensuring it’s safe to conduct. Often, taking medical history and performing the examination can be done simultaneously.

All patients should have a general examination, such as noting their body shape, facial characteristics (especially any features indicating a certain syndrome), and difficulty in breathing. Their mental status, tobacco use, or signs of drug or alcohol abuse should also be evaluated.

• For kids, signs of breathing difficulty may include using extra muscles to breathe, nasal flaring, pulling in between the ribs and in the neck, and grunting. If they’re not breathing adequately, their breathing may be shallow, heart rate slow, and they may become lethargic. Kids not reacting normally or resisting examination or treatments like injections might be very ill. In case of a certain condition affecting the throat called epiglottitis, the child might have a painful throat, changed voice, and excess salivation. In severe cases they might lean forward and extend the neck to keep their airway open.
• Adults might breathe rapidly or tell you they can’t breathe properly, which might even hinder their ability to complete sentences. In a condition called recurrent respiratory papillomatosis, a person may have long-term voice changes and shortness of breath that becomes progressively worse until it causes a noise during inhaling. They might also report sudden worsening of longstanding symptoms.

Nasal examination should be performed to check for a deviated septum, enlarged nasal structures, or nasal polyps. To test if the nasal passage is open, you can ask the patient to breathe out onto a cold metal spatula. This will cause misting if the passageway is clear. The mouth must also be thoroughly examined for any small lower jaw, swelling of the lips, inability to open the mouth, swelling of the floor of the mouth or tongue, or abnormal mass. Any neck or facial swelling or signs of abscess must also be checked.

Additional examinations such as a heart and lung evaluation should be performed where appropriate. Vital signs such as the pulse, breathing rate, blood pressure, and oxygen level in blood should be evaluated. Any noisy breathing and how they sound while speaking should be noted.

Testing for Upper Airway Obstruction

To diagnose the common and urgent causes of an upper airway blockage, your doctor will need to perform some tests after doing an initial exam and taking your medical history.

One of these tests is a Flexible Laryngoscopy. This involves using a special flexible instrument to look into your throat and voice box. This test is very useful when checking the movement of the voice cords and diagnosing common conditions such as laryngomalacia in kids (a condition where the voice box has not developed fully) or a voice box tumor in adults.

To determine the severity of an airway blockage, the doctor may also check your oxygen saturation levels. This is typically done using a small device that clips onto your finger.

Imaging studies using ultrasound or MRI are often performed on children, as these methods don’t use radiation. However, young children often need to be asleep for an MRI, so a CT scan may be used instead when the situation is urgent or when surgery might be needed. CT scans are often used in specific situations, such as when the doctors suspect a foreign object have been breathed into the lungs or when diagnosing a retropharyngeal abscess (a deep neck infection).

If your doctor suspects that you have Obstructive Sleep Apnea (OSA), a condition that causes repeated pauses in breathing during sleep, they may recommend a sleep study or polysomnography. This measures the number of apneic and hypopneic episodes (pauses in breathing or shallow breathing) you have per hour, as well as the lowest level your oxygen saturation drops to during sleep.

Treatment Options for Upper Airway Obstruction

If someone is having trouble breathing due to a blocked airway, they need to get immediate medical attention. A device can be used to monitor their oxygen levels, and oxygen might be given via a mask. A healthcare professional can do some tests if the patient seems stable, and medicines may be provided. If the patient seems unstable, a quick examination and health history will be taken. If this occurs outside a hospital, it’s necessary to call for an ambulance. If the person is unconscious, checking their pulse and following basic lifesaving steps is crucial before the ambulance arrives. If this happens within a hospital setting, a medical emergency team would be alerted.

If a child has possibly inhaled a foreign body and is facing breathing trouble, they need urgent medical care in an operating room. Trained medical professionals will provide them with anesthesia and operate to remove the foreign object. In adults, the presentation can vary, leading to different actions needed. If there’s a blockage near the mouth or throat, and there’s the possibility that it will soon fully block the airway (like with Ludwig’s angina, a bacterial infection that causes swelling), a tube might be guided into the airway to keep it open with the patient awake. After the airway is secured, the patient will be put to sleep, and the dental abscess drained. The tube might need to be kept in for a couple of days.

In critical situations where placing a tube in the airway is too difficult, a fast procedure called a cricothyroidotomy might be performed. In this procedure, a tiny incision is made between the thyroid and cricoid cartilage and a small tube is inserted to keep the airway open. In some cases, a tracheostomy might be necessary. This is often performed under local anesthesia with experienced staff present and involves making a direct opening in the windpipe (trachea).

Some adults might experience a blockage in their upper airway due to a chronic condition called Obstructive Sleep Apnea (OSA). Initial management could involve lifestyle changes like losing weight, followed by a therapy called Continuous Positive Airway Pressure (CPAP). There are also other medical devices that can help, too, such as oral devices that move the jaw or position the tongue forward, improving the airway. In severe cases, a nerve stimulator can be used. Surgery could also be considered for certain patients who aren’t responding well to other treatments.

In children with OSA, the most common cause is enlarged tonsils and adenoids for which surgery is performed to reduce the bulk of the tissue. Infact, when children with enlarged tonsils and adenoids breathe irregularly during sleep, it often leads to the same rate of surgery as for recurrent infections.

What else can Upper Airway Obstruction be?

Upper airway obstruction can be caused by various conditions, which can either be congenital (present at birth) or acquired later in life. These causes can also differ among infants, children and adults. Here are some examples:

Congenital Causes:

• Midfacial hypoplasia caused by craniofacial syndromes such as Apert and Crouzon syndromes.
• Conditions causing micrognathia or retrognathia like Pierre Robin Sequence, which can cause upper airway obstruction.
• Rare cases include bilateral choanal atresia or lymphovascular malformation of the tongue or neck.
• Congenital subglottic stenosis, especially common in babies with Trisomy 21.
• Congenital laryngeal web, a rare but important cause of obstruction in newborns.

Acquired Causes in Children:

• Acute: Common causes include neck abscesses or croup due to infection. However, an inhaled foreign body can also obstruct the upper airway. Burns or injuries from caustic substances though less common, are worth mentioning.
• Chronic: The most common cause is Adenotonsillar hypertrophy. Other possible causes are bilateral vocal cord palsy, subglottic hemangioma or stenosis, or recurrent respiratory papillomatosis. Acquired subglottic stenosis is also possible, especially if the child has had previous long-term or repeated intubations.

Acquired Causes in Adults:

• Acute: There are many infectious causes including Ludwig’s angina, Peri-tonsillar abscesses, and parapharyngeal abscesses. Other causes can be Supraglottitits, recurrent respiratory papillomatosis and laryngeal cancer.
• Chronic: The most common cause is Obstructive Sleep Apnea (OSA). Other potential causes are tuberculosis, sarcoidosis, granulomatosis with polyangiitis, and Behçet’s disease. Nasal or nasopharyngeal obstruction can also be caused by allergic rhinitis, nasal polyposis, nasal foreign bodies, septal deviation or adenoidal hypertrophy.

What to expect with Upper Airway Obstruction

If left untreated, upper airway obstruction, which is a blockage in the upper part of your respiratory system, can cause breathing difficulties and eventually lead to failure of the respiratory system and heart. This can be life threatening. The most common chronic condition causing this kind of obstruction is Obstructive Sleep Apnea (OSA).

In children, if OSA is not treated, it may result in failure to grow and develop properly, behavioral issues such as excessive activity (hyperactivity), underperformance in school, and heart diseases. In adults, untreated OSA could lead to problems like excessive daytime sleepiness (somnolence), metabolic dysfunction which can cause issues like diabetes, and an increased risk of developing heart diseases.

Possible Complications When Diagnosed with Upper Airway Obstruction

If an upper airway blockage isn’t treated in time, it can lead to some serious outcomes. The first signs are respiratory trouble, which can make the person’s heart rate slower and cause fatigue. If left unchecked, the individual could lose consciousness, and their heart and lungs could stop working. When the blockage is caused by something they inhaled, it’s even more dangerous and could cause immediate death. Even small objects that get into the lungs can cause problems like lung collapse, lung infection, or accumulation of air in the chest.

It’s key to be aware of these potential problems, particularly with a common cause of upper airway blockages, known as OSA, or Obstructive Sleep Apnea. If children with OSA are not treated, they can develop a serious heart and lung condition. In adults, untreated OSA can lead to heart disease, metabolic syndrome (a combo of high blood pressure, high sugar levels, excess body fat around the waist, and abnormal cholesterol levels), difficulty functioning during the day, sleepiness, metabolic issues, and an increased risk of heart disease and car accidents.

The main goals of treating OSA are to reduce the side effects caused by it, improve the quality of sleep, and reduce the amount and severity of the apnea events. This often requires a team of doctors, usually led by a lung specialist. The first steps of the treatment usually involve losing weight and using a device that helps breathing during the night. This device, known as CPAP (continuous positive airway pressure), is shown to significantly improve the severity of the condition, daytime sleepiness, blood pressure, and reduce car accidents compared to no treatment.

Common Side Effects:

• Respiratory distress
• Slowed heart rate
• Fatigue
• Loss of consciousness
• Cardiorespiratory arrest
• Inhaled foreign bodies causing lung collapse, pneumonia, pneumothorax
• Cor pulmonale in children with OSA
• Heart disease in adults with OSA
• Metabolic syndrome with OSA
• Impaired daytime function and sleepiness
• Metabolic dysfunction with OSA
• Increase risk of cardiovascular disease and car accidents with OSA

Preventing Upper Airway Obstruction

Research has indicated that the majority of items that children accidentally inhale are usually organic, like food. In these cases, the child might be eating and walking at the same time, which increases the chance of them accidentally inhaling their food. Parents should be reminded to make their kids sit down while eating. Additional vigilance is needed when little children play with toys. The toys should be safe for their age group, and parents should ensure that the toys don’t have easily removable small parts that a child could inhale.

Babies, up to age 2, often explore their world by mouthing objects, and they require careful supervision. If they happen to inhale a foreign object, it’s crucial to recognize this immediately and quickly get medical help by calling 911.

For adults dealing with Obstructive Sleep Apnea (OSA), a sleep disorder where breath stops intermittently during sleep, lifestyle changes can be beneficial. These changes can include losing weight, changing sleeping positions and avoiding alcohol before bedtime. Everyone needs to be aware of the risk factors associated with the development of cancers in the head and neck regions. These risks include smoking, excessive drinking, and being infected with the Human Papillomavirus (HPV).