Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Impending upper-airway obstruction
Inspiratory stridor, increasing work of breathing, inability to lie flat or handle secretions, hypoxaemia, exhaustion, cyanosis or altered consciousness indicates a critically narrowed laryngeal airway.
Action: Call senior anaesthesia and ENT immediately, keep the patient upright and calm with high-concentration oxygen and suction, avoid unplanned sedation or paralysis, move to the best controlled location and agree awake endoscopic intubation, tracheostomy and front-of-neck rescue options before instrumentation; do not send an unstable patient to CT.
Synopsis
Recognise glottic, supraglottic and subglottic cancer, distinguish stable hoarseness from impending obstruction, investigate safely and choose treatment that balances cure with voice, swallowing and airway function.
Glottic cancer classically causes persistent progressive hoarseness early; supraglottic cancer more often causes sore throat, dysphagia, odynophagia, referred otalgia, aspiration or a neck node.
First-line diagnostic assessment is flexible nasendoscopy by a trained clinician, but a severely compromised patient needs a controlled airway plan before repeated examination or transfer.
The diagnostic reference standard is direct laryngoscopy with biopsy and histology once the airway is secure; do not biopsy a precarious obstructing lesion in an uncontrolled setting.
Key red flags
Stridor at rest, drooling, severe recession, silent airflow, fatigue, cyanosis or reduced consciousness requires an immediate controlled airway response.
Threatened airway
Stridor at rest, inability to speak normally, secretion intolerance, recession, orthopnoea, cyanosis or exhaustion requires immediate airway action.
Investigation priorities
01
First-line flexible nasendoscopyFirst stepFirst line
Visualise supraglottis, glottis, subglottic inlet, pooling, tumour and vocal-cord movement and assess airway calibre.
02
First-line contrast CT neck and chest for stagingFirst line
Critical airwaySecure oxygenation without losing spontaneous ventilation
The patient has rest stridor, severe work of breathing, secretion intolerance, hypoxaemia or exhaustion.
Call senior ENT, anaesthesia and critical care, keep upright and calm, give oxygen, attach monitoring and prepare suction and difficult-airway equipment while identifying prior tracheostomy or laryngectomy anatomy.
Agree the planned and rescue airway before drugs or transfer; a controlled awake approach, rigid endoscopic debulking, tracheostomy or front-of-neck access may be selected according to level and anatomy.
Stable suspected cancerVisualise, image and biopsy
Persistent hoarseness or another suspicious laryngeal symptom is present without immediate compromise.
Key medicines
Dexamethasone as an airway bridgeFor significant tumour-associated upper-airway oedema, a specialist may give dexamethasone 8 mg intravenously initially and continue 4 to 8 mg every 6 to 12 hours for the shortest effective period while definitive airway treatment proceeds; follow the local airway protocol.
Nebulised adrenaline as a temporary bridgeIn a monitored resuscitation area, use the locally approved nebulised adrenaline regimen for acute upper-airway oedema only after senior airway review; repeat dosing and concentration must follow that protocol.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.