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1600 SECTION 19: Eye, Ear, Nose, Throat, and Oral Disorders TABLE 246-3 Physical Findings, Pathology, and Management of Neck Masses in Adults Disorder Physical Finding Pathology Management Ranula Sublingual area swelling Mucus retention cyst due to ductal obstruc tion of the sublingual gland Surgical excision Laryngeal papillomas Sessile, warty-appearing lesions on the soft palate or tonsillar pillars Human papillomavirus type 6 or 11 infection Surgical excision Palatine torus Boney smooth painless mass of the hard palate Exostoses of the palate No treatment needed in most cases Mandibular torus Boney smooth painless growth of the mandible under the tongue Exostoses of the mandible No treatment needed in most cases Branchial cleft cysts Painless, fluctuant masses close to the angle of the mandible Incomplete obliteration of the branchial apparatus during development Antibiotics if infected, surgical excision Thyroglossal duct cysts Soft, mobile, subhyoid bone midline mass Remnant of the thyroid anlage Antibiotics if infected, surgical excision Lymphoma Multiple, rubbery low-neck masses, night sweats, fever, malaise Malignant process Biopsy, referral to ENT and oncology Acute retroviral syndrome Generalized adenopathy, unprotected sex by history Human immunodeficiency virus infection Antiretroviral medication Squamous cell carcinoma Firm, possibly fixed cervical lymph node Oral lesion metastatic to cervical node Biopsy, referral to ENT and oncology Parotid tumors Nonpainful masses under or anterior to the ear Benign or malignant process Biopsy, referral to ENT and oncology as needed Sialadenitis Tender swelling in area of parotid, submandibular, or sublingual salivary gland Salivary gland infection Antibiotics, salivary stimulants. See Chapter 243, “Face and Jaw Emergencies” Thyroid enlargement Diffuse nodular thyroid enlargement or solitary nodular thyroid Benign or malignant process See Chapter 228, “Hypothyroidism and Myxedema Crisis,” and Chapter 229, “Hyperthyroidism and Thyroid Storm” Abbreviation: ENT = otorhinolaryngology. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Complications of Airway Devices Casey D. Bryant TRACHEOSTOMY TUBES AND CANNULAS A tracheostomy is an opening between cartilaginous rings in the trachea and the skin, with a tracheostomy tube placed into the stoma to facilitate ventilation. Tracheostomy is usually performed as an elective or semielective procedure and is not an emergency procedure. Most tracheostomies are performed on chronically ill patients requiring prolonged mechanical ventilation. There are many types of tracheostomy tubes available, including those made of plastic, silicone, nylon, and metal. Tracheostomy tubes vary in diameter, total length, the length before and after the curve, and the presence or absence of a cuff ( Figure 247-1). The size of the tracheostomy tube is usually defined by the inner diameter, ranging in adults from 5 to 10 mm and in pediatric patients from 2.5 to 6.5 mm. Most pediatric and adult tracheostomy tubes have a 15-mm standard respiratory connection that may be used with ventilator tubing or a bag-valve device. Fenestrated tracheostomy tubes have an opening along the dorsal surface of the body of the tube. The fenestration allows the passage of air through the tracheostomy tube to the vocal cords so the patient can speak.

ve a 15-mm standard respiratory connection that may be used with ventilator tubing or a bag-valve device. Fenestrated tracheostomy tubes have an opening along the dorsal surface of the body of the tube. The fenestration allows the passage of air through the tracheostomy tube to the vocal cords so the patient can speak. Irritation from the fenestration may promote growth of granulation tissue, which may extend into the fenestration, leading to bleeding, obstruction, and difficulty removing the tracheostomy tube. If any dif ficulty is encountered removing a fenestrated tracheostomy tube, obtain surgical consultation. CHAPTER Obturator Inner cannula Outer cannula with cuff FIGURE 247-1. Common components of most tracheostomy tube sets. Most adult tracheostomy tubes have a removable inner cannula, which allows secretions to be cleared from the lumen without remov ing the entire tube from the trachea. In assessing an adult tracheostomy patient, remove and examine the inner cannula for crusting or obstruc tion. Both disposable and reusable inner cannulas may be cleaned by using a small brush dipped in a solution of hydrogen peroxide and then rinsing the cannula with warm tap water. If the correct size of disposable inner cannula is not available, use the existing inner cannula temporar ily, or change the entire tracheostomy tube. Pediatric tracheostomy tubes never have an inner cannula because of the small inner diam eter; the entire tube must be removed for cleaning.  COMPLICATIONS OF TRACHEOSTOMIES Complications due to the surgery are grouped according to the timing since the tracheotomy and the technique. Timing is divided into intra operative, early, and late, with 1 week typically being used in the medical literature as the cutoff between early and late complications. Summed complication rates are 10.0% for percutaneous technique and 8.7% for Tintinalli_Sec19_p1523-1606.indd 1600 8/2/19 3:08 PM

tomy and the technique. Timing is divided into intra operative, early, and late, with 1 week typically being used in the medical literature as the cutoff between early and late complications. Summed complication rates are 10.0% for percutaneous technique and 8.7% for Tintinalli_Sec19_p1523-1606.indd 1600 8/2/19 3:08 PM CHAPTER 247: Complications of Airway Devices 1601 open tracheostomy.1 Bleeding, obstruction, dislodgement, and infection are all potential early complications. Late complications may include granulation, stenosis (subglottic, glottic, tracheal), persistent stoma, fistula formation (tracheocutaneous, tracheoesophageal, or tracheoin nominate), and any of the early complications listed. 1-5 Patients with tracheostomy tubes can develop respiratory distress due to obstruction, dislodgement (decannulation), bleeding, and infection. Figure 247-2 is a step-by-step approach to assess and treat respiratory distress. In the ED, the provider must be proficient in the following skills (as outlined in the sections that follow): replacement of an uncuffed with a cuffed tracheostomy tube for mechanical ventilation, replacement of a tracheostomy tube after accidental decannulation, correction of a tube obstruction, and control of bleeding or infection at the tracheostomy site. It is important to determine a few key elements about the trache ostomy: When and why was the procedure performed? What type of tracheostomy tube is the patient using currently? And can the patient be orally intubated if needed? Patients who have undergone a laryngectomy or who have tumors or scarring that occlude the upper airway cannot be orally intubated. Tracheostomy Tube Obstruction Mucous plugging is a major cause of respiratory failure in tracheostomy patients and may occur at all levels of the respiratory system. If the tracheostomy is patent and is in the airway, leave it in place. If the tracheostomy tube is obstructed, mucous plugging is commonly the cause. Secretions may act as a ballvalve mechanism, allowing air in but restricting exhalation. Suctioning may relieve the obstruction. Preoxygenation and placement of sterile saline solution into the trachea will aid in suctioning. Prolonged use of large suction catheters without preoxygenation will cause hypoxemia. If mucous plugging of the tracheostomy tube cannot be relieved by suctioning, the inner cannula and, occasionally, the entire tracheostomy tube may need to be removed and cleaned. Tracheostomy Dislodgement It is possible for the tracheostomy tube to become dislodged from the trachea but still be in the neck. In this case, a suction catheter cannot be passed through the tube, and on radiographs, the tracheostomy tube may be seen to extrinsically com press the trachea (Figure 247-3). In this circumstance, remove the entire tracheostomy tube. It may be difficult to accurately identify the actual FIGURE 247-2. Steps in assessing a tracheostomy patient with respiratory distress. Tintinalli_Sec19_p1523-1606.indd 1601 8/2/19 3:08 PM

tube may be seen to extrinsically com press the trachea (Figure 247-3). In this circumstance, remove the entire tracheostomy tube. It may be difficult to accurately identify the actual FIGURE 247-2. Steps in assessing a tracheostomy patient with respiratory distress. Tintinalli_Sec19_p1523-1606.indd 1601 8/2/19 3:08 PM 1602 SECTION 19: Eye, Ear, Nose, Throat, and Oral Disorders tracheal stoma when replacing the tube (see later section, “Changing a Tracheostomy Tube”). A nasopharyngoscope or flexible bronchoscope should be inserted into the visible stoma in an attempt to identify the tracheal opening. If the opening still cannot be identified, obtain surgi cal consultation. If the patient cannot maintain the airway, oral intuba tion will be necessary. Tracheostomy Site Infection Indwelling tracheostomy tubes become contaminated with normal and/or pathogenic flora. Surgical site infec tion is more common in patients treated with the open technique versus the percutaneous technique. 6 This is believed to be due to a smaller incision, less tissue dissection, and less tissue exposure. 7 Stomal skin infec tion, tracheitis, and bronchitis can be recurring problems. Infections may be polymicrobial, and antimicrobial therapy is indicated in the setting of clinical disease. Treatment should focus on control of the source of infection with antimicrobial therapy guided by local antibiogram data and prior patient culture data, if available. 8 Dressing changes with gauze soaked in 0.25% acetic acid 9 or using silver-containing products are effective for local wound infections.10 Tracheostomy Site Bleeding Bleeding can occur at any time after a tracheostomy. Granulation tissue, bleeding from proximal areas such as epistaxis, erosion of the thyroid vessels or thyroid gland, the tracheal wall (frequently from suction trauma), and the innominate artery are all potential sources of hemorrhage. Slow bleeding originating from the stoma may be controlled by packing the site with saline-soaked gauze or with a hemostatic product. If this is ineffective, remove the tube and examine the stoma and tracheal wall. Local bleeding can be controlled with silver nitrate. 10 Electrocautery should be done by a surgeon. If bleeding is brisk from a stomal site, replace the tracheostomy tube with a cuffed endotracheal tube, with the cuff below the bleeding site. Tracheoinnominate Artery Fistula Tracheoinnominate artery fistula is a rare but life-threatening complication of tracheostomy. Cuff pressure >25 mm Hg, tracheostomy below the third tracheal ring, radiation treatment, chronic steroid use, and deformed neck or chest are all risk fac tors. Bleeding results from vessel erosion caused by either direct pressure of the tip of the tracheal cannula against the innominate artery or from a cuff with inappropriately high pressures due to overinflation. Most patients with a tracheoinnominate artery fistula present within the first 3 weeks after tracheostomy, with the peak incidence between the first and second week. Some patients may have a sentinel arterial bleed or hemoptysis. Bleeding may be mild or severe and should be thoroughly investigated because of the potential for sudden massive hemorrhage. 11,12 Immediate surgical consultation is required, and operative repair can be lifesaving. If a patient presents with massive bleeding, resuscitation and operative planning should begin immediately. Hemorrhage control should first be attempted by hyperinflating the cuff. If bleeding persists, slowly withdraw the tube while exerting pressure against the anterior trachea. If these initial maneuvers do not control the bleeding, then have an assistant remove the tracheostomy tube simultaneously while the patient is being orotracheally intubated.

rst be attempted by hyperinflating the cuff. If bleeding persists, slowly withdraw the tube while exerting pressure against the anterior trachea. If these initial maneuvers do not control the bleeding, then have an assistant remove the tracheostomy tube simultaneously while the patient is being orotracheally intubated. The cuffed endotracheal should be placed distal to the source of bleeding. 11,12 Hemorrhage control is then attempted by placing a finger into the stoma, dis secting along the trachea, and then compressing the innominate artery against the posterior manubrium. This is known as the Utley maneuver. 13,14 Tamponade of the hemorrhage should be maintained during transport to the operating room.14 Tracheal Stenosis Tracheal stenosis may present weeks to months after decannulation and results from mucosal necrosis and subsequent scar ring. Risk factors for tracheal stenosis in adults are intubation duration of more than 1 week, obesity, and having an endotracheal tube larger than 7.5 mm. 5 Signs and symptoms include dyspnea, wheezing, stridor, and the inability to clear secretions. A chest radiograph may demonstrate the narrowed tracheal airway. Medical treatment includes placing the patient in an upright position, humidified oxygen, nebulized racemic epinephrine, and steroids. If an airway needs to be established, airway adjuncts such as a bougie or fiberoptic scope may prove helpful, and a smaller tracheostomy or endotracheal tube should be considered. 15 Operative treatment involves rigid bronchoscopy with laser excision of the scar bands, and stenting or tracheal reconstruction in more severe cases.  MECHANICAL VENTILATION WITH A TRACHEOSTOMY TUBE If the patient requires mechanical ventilation, an uncuffed tracheostomy tube will result in a large air leak, and it will be difficult to ventilate the FIGURE 247-3. A. Patient with a large goiter and a No. 4 Shiley tracheostomy tube with the tip of the tube outside the trachea and compressing the tracheal wall. B. Same patient with a longer No. 6 Shiley tracheostomy tube with the tip of the tube correctly placed inside the trachea. Tintinalli_Sec19_p1523-1606.indd 1602 8/2/19 3:08 PM

Patient with a large goiter and a No. 4 Shiley tracheostomy tube with the tip of the tube outside the trachea and compressing the tracheal wall. B. Same patient with a longer No. 6 Shiley tracheostomy tube with the tip of the tube correctly placed inside the trachea. Tintinalli_Sec19_p1523-1606.indd 1602 8/2/19 3:08 PM CHAPTER 247: Complications of Airway Devices 1603 patient. In this case, the uncuffed tube should be exchanged for a cuffed tube.15 If a tracheostomy tube is not readily available, an endotracheal tube may be inserted into the stoma to maintain airway security. If the stoma cannot be cannulated, the patient may be orotracheally intubated to secure the airway—unless the patient has a contraindication to attempted orotracheal intubation (see the later section, “Laryngectomy Patients”).  CHANGING A TRACHEOSTOMY TUBE The amount of difficulty encountered when changing a tracheostomy tube depends on when the procedure was performed and on patient anatomy. If the tracheostomy is <7 days old, the tract will not be mature and manipulation may easily create a false passage within the soft tissue of the neck. In addition, a tract may easily collapse at any time in patients with obese necks or neck masses. If the situation is not emergent and the tracheostomy is <7 days old, tra cheostomy tubes should be changed by a surgeon familiar with the procedure. An uneventful tracheostomy change depends on adequate preparation and is best accomplished with an assistant. The spontaneously breathing, stable patient can easily breathe through a patent stoma without the tube in place, so there is no reason to rush through this procedure. The needed equipment is listed in Table 247-1. 16,17 If a cuffed tube is used, test the balloon before use and make sure the balloon is completely deflated before insertion. A cricoid hook can be used to lift and stabilize the trachea. The dilator is particularly useful if a larger tube is to be inserted, but if dilation is needed and time permits, obtain surgical consultation. Dilation may require injection of local anesthesia. Become familiar with the cricoid hook and tracheal dilator before using them. To minimize soft tissue damage, try to use an obturator whenever a tracheostomy tube is replaced. When the obturator is placed within the outer cannula, the tube presents a solid, rounded end that is less likely to damage the neck soft tissue during tube insertion ( Figure 247-1). After placement, quickly remove the obturator and place the inner can nula, because the patient cannot breathe through the tracheostomy tube when the obturator is in place. After gathering the necessary equipment, place the patient in the supine position and use a shoulder roll to extend the neck. Remove the old tube and gently suction and examine the stoma. In most cases, the opening in the trachea and the posterior tracheal wall can be seen. Gently direct the fresh tube with the balloon deflated into the opening, curving it downward into the trachea ( Figure 247-4). The movement should be smooth and gentle. If resistance is met, the tube is likely caught on the cartilaginous tracheal wall. Remove the tube and reexamine the stoma, and again place the tube directly into the tracheal opening. If the tube still cannot be placed, consider placing a smaller tracheostomy tube. However, when placing a smaller tube, one must ensure that the tube is long enough for the patient’s neck. 17 Another helpful method is to place a small suction catheter or nasogastric tube into the trachea and thread the tracheostomy tube over the catheter using a modified Seldinger technique. Once the tube is in place, verify correct tube position by attaching an end-tidal carbon dioxide detector or by passing a suction catheter into the tube.

hod is to place a small suction catheter or nasogastric tube into the trachea and thread the tracheostomy tube over the catheter using a modified Seldinger technique. Once the tube is in place, verify correct tube position by attaching an end-tidal carbon dioxide detector or by passing a suction catheter into the tube. If a suction catheter is placed, it should easily pass beyond the length of the tracheostomy tube without resistance. If there is a question about placement, pass a nasopharyngoscope or flexible bronchoscope through the tube for direct visualization of placement. Patients with accidental decannulation who are not in distress can have the tracheostomy tube replaced as described. If the tube has been out for several hours, the stoma may begin to close and dilation may be needed before tube insertion. In these cases, and if the stoma is small or the tracheostomy is the patient’s only airway, surgical consultation is recommended for tube replacement. LARYNGECTOMY PATIENTS It is impossible to orally intubate patients who have had a laryngec tomy. The only access to the tracheobronchial tree is through the tra cheostoma in the neck. Occasionally, laryngectomy patients will have a laryngectomy tube in the stoma, similar in appearance to a tracheostomy tube. Laryngectomy patients can be distinguished from tracheostomy patients by history and physical examination and by the fact that lar yngectomy patients are unable to phonate or breathe when the laryn gectomy tube is occluded. Laryngectomy patients can be emergently intubated by placing an endotracheal tube into the tracheostoma. Do not advance the tube too far, because the adult carina may be only 4 to 6 cm from the tracheostoma. FIGURE 247-4. Insertion (A) and placement (B) of the tracheostomy tube. Cuffed tubes should be inserted with the cuff deflated. TABLE 247-1 Equipment Needed to Change a Tracheostomy Tube •   Suction device with both a Yankauer tip and suction catheters that fit inside the tracheostomy tube •  Good  lighting directed into the tracheostoma •  An  appropriate-size tracheostomy tube with obturator in place •  Another  tracheostomy tube one size smaller than planned •  Tracheostomy  tube tie •  Cricoid  hook and tracheal dilator (if physician is familiar with their use) Tintinalli_Sec19_p1523-1606.indd 1603 8/2/19 3:08 PM

ting directed into the tracheostoma •  An  appropriate-size tracheostomy tube with obturator in place •  Another  tracheostomy tube one size smaller than planned •  Tracheostomy  tube tie •  Cricoid  hook and tracheal dilator (if physician is familiar with their use) Tintinalli_Sec19_p1523-1606.indd 1603 8/2/19 3:08 PM 1604 SECTION 19: Eye, Ear, Nose, Throat, and Oral Disorders  AIRWAY STENTS There are many different airway stent configurations and materials, 19 and a detailed discussion on all of the possible configurations is outside the scope of this chapter. In the event of any suspected complication, consultation with an expert in the type and anatomic arrangement of the airway stent is recommended. 20 It is important to note that the airway stents may be solid or hollow, may be secured within the lumen or externally, and may or may not communicate via tracheostomy.19 Complications associated with airway stents include dislodgement, granulation tissue, mucous plugging, bleeding, and crusting. A solid airway stent renders the patient tracheostomy dependent until the stent is removed because the solid stent blocks the airway above the level of the tracheostomy ( Figure 247-5). In the event of respiratory failure or distress, focus should be placed on establishing an adequate airway via the tracheostomy in place (see algorithm, Figure 247-2). Although stents may be secured by a variety of methods, dislodgement is a known complication of these devices. If an airway stent becomes dislodged but the tracheostomy tube remains in position, airway security is typically not an issue. Consult the appropriate specialist for extrusion or dislodgement of a stent. In the case of patients with hollow endoluminal stents, endotracheal intubation can be performed if needed by passing the endotracheal tube through the hollow stent from above. In this scenario and if patient stability allows, one should look for a stent card or other sources of documentation regarding the appropriate size of endotracheal tube to place. In the emergency situation, additional smaller endotracheal tubes should be available. The assistance of a specialist is certainly recom mended if patient stability permits. The mainstay of treatment for symptomatic tracheal stenosis is surgical resection and anastomosis. When surgical treatment is not possible, the option exists for insertion of airway stents as a bridge to surgery, as a treatment for patients who are not surgical candidates, and in cases where there is a long segment of stenosis. 19 Dumon and Montgomery T-tube configurations are the most commonly used silicone stents. The Dumon tube also has bronchial options and is secured endoluminally via studs. The Montgomery T-tube is a modification of a tracheostomy tube and does not have an inner cannula.22 Humidification and suctioning of the T-tube are essential to prevent mucous plugging and crusting, which are the most common complications of these devices. 21 Airway obstruction should be addressed by first suctioning both the upper and lower limbs of the T-tube ( Figure 247-6). If suctioning both limbs of the T-tube does not relieve the obstruction, the T-tube should be removed and the trachea cannulated with an appropriately sized tracheostomy tube or an endotracheal tube. Do not try to use a bag-valve device through the T-tube because most tubes do not take a standard 15-mm connector. Removal requires a strong, steady pull on the T-tube and should only be attempted if the operating surgeon is unavailable or the patient is in airway distress.  SPEECH DEVICES The Passy-Muir valve is a one-way valve that fits directly over the opening of an uncuffed tracheostomy tube and allows the patient hands-free speech.

requires a strong, steady pull on the T-tube and should only be attempted if the operating surgeon is unavailable or the patient is in airway distress.  SPEECH DEVICES The Passy-Muir valve is a one-way valve that fits directly over the opening of an uncuffed tracheostomy tube and allows the patient hands-free speech. When the patient inhales, the valve opens and allows air to pass into the trachea and lungs. 23 Speech is created when the patient exhales with enough force to close the Passy-Muir valve. The exhaled air is directed around the tracheostomy tube and through the vocal cords (Figure 247-7). Because the patient exhales around the tracheostomy tube, a Passy-Muir valve should never be used with a cuffed tube. If a patient with a Passy-Muir valve develops signs of airway obstruction or an inability to speak, the speaking device should be removed from the tracheostomy tube so that air can pass freely during both inhalation and FIGURE 247-5. Relation of the tracheostomy tube to the laryngeal stent. The stent lies within the lumen of the trachea, superior to the tracheostomy tube. FIGURE 247-6. Suctioning is required of both the upper and lower limbs of the Montgomery T-tube. If necessary, the entire T-tube can be removed. FIGURE 247-7. The Passy-Muir valve is a one-way valve that fits directly on the open ing of the tracheostomy tube. Speech is created when the patient exhales as air is passed up through the vocal cords and out of the mouth. Tintinalli_Sec19_p1523-1606.indd 1604 8/2/19 3:08 PM

ecessary, the entire T-tube can be removed. FIGURE 247-7. The Passy-Muir valve is a one-way valve that fits directly on the open ing of the tracheostomy tube. Speech is created when the patient exhales as air is passed up through the vocal cords and out of the mouth. Tintinalli_Sec19_p1523-1606.indd 1604 8/2/19 3:08 PM CHAPTER 247: Complications of Airway Devices 1605 exhalation. If this does not relieve symptoms, check the tracheostomy tube itself for obstruction. A tracheoesophageal prosthesis allows speech in postlaryngectomy patients. This one-way valve is surgically placed between the posterior wall of the tracheal stoma and the anterior wall of the cervical esopha gus. To speak, patients exhale while occluding the stoma with their thumb or finger, thus forcing the exhaled air into the esophagus. The air vibrates the esophagus (as a belch does), and the resultant tone is used to provide speech (Figures 247-8 and 247-9). The most common complication associated with tracheoesophageal prosthetic valves is leakage, either around the valve or through the valve lumen. Both types of leakage may be confirmed by looking at the prosthesis while the patient drinks a colored liquid (e.g., grape juice). Leakage commonly occurs due to enlargement of the tracheoesophageal fistula. 24,25 Leakage increases the risk of aspiration pneumonia. A temporary solution to a leaking valve begins with removal of the entire prosthesis and replacement with a larger Foley catheter into the tracheoesophageal fistula. This will prevent the tracheoesophageal fistula from closing completely as the fistula contracts in size. Leakage through a voice prosthesis is predominantly due to valve damage caused by fungal colonization or contact of a duckbill-style device against the posterior esophageal wall and is treated by replacement of the prosthesis with a temporary FIGURE 247-9. Tracheoesophageal prosthesis in place in a laryngectomy patient. The prosthesis is in place, and the tag is usually held with tape. Finger occlusion of the tracheos toma with exhalation leads to increased airway pressure, which opens the one-way valve and allows air to enter the esophagus. This vibrates and allows the patient to speak. FIGURE 247-8. Tracheoesophageal prosthesis. The bobbin-shaped device is placed with the smaller flange in the esophagus and the tagged flange in the posterior tracheostoma. tube (usually a Foley catheter). Once a Foley catheter is placed and secured, the patient is unable to speak. Arrange otolaryngologist followup the next day. Do not inflate the balloon on the Foley catheter, as this will interfere with swallowing. Another common complication with tracheoesophageal prostheses is valve aspiration or valve extrusion. Aspiration results in persistent cough, dyspnea with discomfort, and even respiratory distress. If there is suspicion of aspiration or if the prosthesis is dislodged, obtain a chest radiograph to visualize the radiopaque valve and consult an otolaryngologist. The tracheoesophageal puncture tract will close quickly, typically within 24 to 48 hours after the tube is dislodged. A Foley or red rubber catheter inserted into the tract will maintain its patency. Do not attempt temporary catheter placement if the tract is <2 weeks old because a false passage may result. Specialty Consultation Whenever a patient presents to the ED with a complication due to an airway device, the provider should be able to troubleshoot many of the common problems. If there is concern, it is advisable to consult the appropriate specialist. Acknowledgment: The author gratefully acknowledges John Gaillard for his contribution to this chapter in the previous edition. REFERENCES The complete reference list is available online at www.TintinalliEM.com.

hoot many of the common problems. If there is concern, it is advisable to consult the appropriate specialist. Acknowledgment: The author gratefully acknowledges John Gaillard for his contribution to this chapter in the previous edition. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec19_p1523-1606.indd 1605 8/2/19 3:08 PM Tintinalli_Sec19_p1523-1606.indd 1606 8/2/19 3:08 PM