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Treatment of Pediatric Airway Disorders: Beyond Tracheostomy Meredith N. Merz, M.D. Nationwide Children’s Hospital Department of Pediatric Otolaryngology.

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Presentation on theme: "Treatment of Pediatric Airway Disorders: Beyond Tracheostomy Meredith N. Merz, M.D. Nationwide Children’s Hospital Department of Pediatric Otolaryngology."— Presentation transcript:

1 Treatment of Pediatric Airway Disorders: Beyond Tracheostomy Meredith N. Merz, M.D. Nationwide Children’s Hospital Department of Pediatric Otolaryngology April 6, 2011

2 Objectives 1. Identify the most common causes of stridor in the pediatric population. 2. Discuss diagnostic techniques in a child with stridor. 3. Understand the pathogenesis of acquired subglottic stenosis and the difference between congenital and acquired stenosis. 4. Discuss treatment options for the most common airway disorders in children.

3 Laryngeal Function Three Main Functions:Three Main Functions: 1. Acts as an airway from pharynx into trachea and lungs 2. Instrument of phonation 3. Protects the lower airways Closure of glottis during swallowingClosure of glottis during swallowing Epiglottis folds posteriorly over glottisEpiglottis folds posteriorly over glottis CoughCough

4 Infant Larynx Larynx is more rostralLarynx is more rostral Epiglottis apposes the soft palateEpiglottis apposes the soft palate Hyoid bone is impacted on thyroid cartilageHyoid bone is impacted on thyroid cartilage Vocal cords are oriented transverselyVocal cords are oriented transversely Epiglottis is short and curled in on itselfEpiglottis is short and curled in on itself Arytenoids are anteriorly oriented and involve half the length of the vocal foldsArytenoids are anteriorly oriented and involve half the length of the vocal folds

5 Infant Larynx Bosma JF. Anatomy of the Infant Head. Baltimore, Johns Hopkins University Press, 1986, pp

6 Stridor Harsh sound caused by turbulent airflowHarsh sound caused by turbulent airflow Implies partial airway obstructionImplies partial airway obstruction Location of lesion determines character of stridorLocation of lesion determines character of stridor oSupraglottic oExtrathoracic oIntrathoracic

7 Physics Review… Poiseuille’s LawPoiseuille’s Law Q = [πd 4 (P1-P2)] / 128ν Flow within a system is related to the radius of the tube to the fourth power Resistance is related to the inverse of the radius to the fourth power Bernouilli’s Law:Bernouilli’s Law: W = PAv As velocity increases through a constant area the pressure on the wall of the lumen decreases A region of anatomic narrowing is predisposed to collapse further with increased turbulent airflow

8 Effect of Airway Narrowing

9 Localizing Stridor Supraglottic obstructionSupraglottic obstruction oWith inspiration the loosely supported supraglottic structures collapse. Increased turbulence causes increased constriction oStridor is inspiratory and high pitched Extrathoracic obstructionExtrathoracic obstruction oAirway is affected equally by inspiration and expiration oStridor is biphasic, often accompanied by increased work of breathing Intrathoracic obstructionIntrathoracic obstruction oRelative positive pressures of expiratory forces narrow the airway lumen, resulting in increased constriction oStridor is expiratory and “musical”; Wheeze

10 Airway Evaluation- History Age at onsetAge at onset Onset: acute, chronic, progressiveOnset: acute, chronic, progressive Prior respiratory problemsPrior respiratory problems Birth historyBirth history Prior intubationPrior intubation GERD symptomsGERD symptoms Wheezing episodesWheezing episodes Feeding problems:Feeding problems: oFTT, weight gain Choking episodesChoking episodes Aggravating factorsAggravating factors

11 Airway Evaluation- Initial Examination InspectionInspection oGeneral appearance and position, color, retractions, level of consciousness AuscultationAuscultation oMouth/Nose, Neck and Chest RepositioningRepositioning oProne/Supine, lateral, jaw thrust Is there acute distress?Is there acute distress? oNasal flaring oTachypnea oCyanosis oRetractions oTripod position

12 Flexible Nasopharyngoscopy Gold Standard for office evaluationGold Standard for office evaluation Assess nares/ choanaeAssess nares/ choanae Assess adenoid and lingual tonsilAssess adenoid and lingual tonsil Assess laryngeal structuresAssess laryngeal structures Assess TVC mobilityAssess TVC mobility Drawback:Drawback: Poor for assessing subglottic structures

13 Radiologic Evaluation Plain films have limited utilityPlain films have limited utility oPA/ Lateral Neck Airway FluoroscopyAirway Fluoroscopy oEvaluate the dynamics of respiration Inspiratory/ Expiratory CT ScanInspiratory/ Expiratory CT Scan

14 Rigid Laryngoscopy and Bronchoscopy Indications:Indications: oTo establish diagnosis or evaluate for synchronous lesions (after flexible exam) oSevere or progressive stridor oCyanosis or apnea concerns oRadiologic abnormalities oParental or physician anxiety oForeign body evaluation

15 Rigid Laryngosocpy

16 Rigid Bronchoscopy

17 Congenital Disorders of the Larynx Laryngomalacia60%Laryngomalacia60% Congenital subglottic stenosis16%Congenital subglottic stenosis16% Vocal cord paralysis13%Vocal cord paralysis13% All Others:7%All Others:7% oCongenital laryngeal web oLaryngocele and Saccular cyst oLaryngeal/ Laryngotrachealesophogeal Cleft oVascular lesions Holinger, LD. Etiology of Stridor in the Newborn, Infant, and Child. Annals of ORL, 1980; 89:

18 Laryngomalacia Most common cause of stridor in infantsMost common cause of stridor in infants PresentationPresentation oStaccato/ Coarse inspiratory stridor oWorse with exertion, feeding, crying oNoisy breathing generally begins at about 2-4 weeks of age Office EvaluationOffice Evaluation oCharacter of stridor oPositional changes oFlexible nasopharyngoscopy

19 Laryngomalacia Endoscopic appearanceEndoscopic appearance oOmega epiglottis oForeshortenend aryepiglottic folds oCuneiform and corniculate prolapse

20 Laryngomalacia Classification Kay DJ, Goldsmith AJ. Laryngomalacia: A Classification System and Surgical Treatment Strategy. Ear Nose Throat J May;85(5):328-31, 336. Type IType IIType III Type IVType V

21 Laryngomalacia Vast majority are mildVast majority are mild Parental reassurance & educationParental reassurance & education oTransient worsening, gradual improvement oWeight gain issues oGERD issues- Consider GERD treatment if there is evidence on endoscopy

22 Severe Laryngomalacia Respiratory difficultyRespiratory difficulty oApnea/ Cyanosis/ ALTE Feeding difficultyFeeding difficulty Failure to thriveFailure to thrive Uncontrolled GERDUncontrolled GERD Sleep apneaSleep apnea CNS abnormalitiesCNS abnormalities

23 Severe Laryngomalacia Surgical Treatment Supraglottoplasty- Aryepiglottic fold division +/- Excision of corniculate cartilages

24 Severe Laryngomalacia Epiglottic Procedures Epiglottic Procedures: oEpiglottoplasty- Excision of a V-shaped wedge of tissue from the epiglottis oEpiglottopexy- Epiglottis is pexied to the base of tongue with stitch/ laser Whymark AD, Clement WA, Kubba H, Geddes N. Laser Epiglottopexy for Laryngomalacia. Archives of Otolaryngology Head and Neck Surgery, 2006; 132:

25 Vocal Cord Paralysis Bilateral: Airway issues, Aspiration issuesBilateral: Airway issues, Aspiration issues o Expectant (can take years to resolve) o Close monitoring of O 2 sat, apnea, weight gain o Tracheotomy o Posterior laryngeal expansion o Botox (for spastic paralysis) o Cordotomy o Arytenoidectomy o Re-innervation procedures Unilateral: Voice Issues, Aspiration IssuesUnilateral: Voice Issues, Aspiration Issues o Observation o Vocal Cord Injection o Thyroplasty

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