Presentation on theme: "Treatment of Pediatric Airway Disorders: Beyond Tracheostomy"— Presentation transcript:
1 Treatment of Pediatric Airway Disorders: Beyond Tracheostomy Meredith N. Merz, M.D.Nationwide Children’s HospitalDepartment of Pediatric OtolaryngologyApril 6, 2011
2 Objectives1. 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: 1. Acts as an airway from pharynx into trachea and lungs2. Instrument of phonation3. Protects the lower airwaysClosure of glottis during swallowingEpiglottis folds posteriorly over glottisCough
4 Infant Larynx Larynx is more rostral Epiglottis apposes the soft palateHyoid bone is impacted on thyroid cartilageVocal cords are oriented transverselyEpiglottis is short and curled in on itselfArytenoids are anteriorly oriented and involve half the length of the vocal folds
5 Infant LarynxBosma JF. Anatomy of the Infant Head. Baltimore, Johns Hopkins University Press, 1986, pp
6 Stridor Harsh sound caused by turbulent airflow Implies partial airway obstructionLocation of lesion determines character of stridorSupraglotticExtrathoracicIntrathoracic
7 Physics Review… Poiseuille’s Law Q = [πd4 (P1-P2)] / 128ν Flow within a system is related to the radius of the tube to the fourth powerResistance is related to the inverse of the radius to the fourth powerBernouilli’s Law:W = PAvAs velocity increases through a constant area the pressure on the wall of the lumen decreasesA region of anatomic narrowing is predisposed to collapse further with increased turbulent airflow
9 Localizing Stridor Supraglottic obstruction Extrathoracic obstruction With inspiration the loosely supported supraglottic structures collapse. Increased turbulence causes increased constrictionStridor is inspiratory and high pitchedExtrathoracic obstructionAirway is affected equally by inspiration and expirationStridor is biphasic, often accompanied by increased work of breathingIntrathoracic obstructionRelative positive pressures of expiratory forces narrow the airway lumen, resulting in increased constrictionStridor is expiratory and “musical”; Wheeze
10 Airway Evaluation- History Age at onsetOnset: acute, chronic, progressivePrior respiratory problemsBirth historyPrior intubationGERD symptomsWheezing episodesFeeding problems:FTT, weight gainChoking episodesAggravating factors
11 Airway Evaluation- Initial Examination InspectionGeneral appearance and position, color, retractions, level of consciousnessAuscultationMouth/Nose, Neck and ChestRepositioningProne/Supine, lateral, jaw thrustIs there acute distress?Nasal flaringTachypneaCyanosisRetractionsTripod position
12 Flexible Nasopharyngoscopy Gold Standard for office evaluationAssess nares/ choanaeAssess adenoid and lingual tonsilAssess laryngeal structuresAssess TVC mobilityDrawback:Poor for assessing subglottic structures
13 Radiologic Evaluation Plain films have limited utilityPA/ Lateral NeckAirway FluoroscopyEvaluate the dynamics of respirationInspiratory/ Expiratory CT Scan
14 Rigid Laryngoscopy and Bronchoscopy Indications:To establish diagnosis or evaluate for synchronous lesions (after flexible exam)Severe or progressive stridorCyanosis or apnea concernsRadiologic abnormalitiesParental or physician anxietyForeign body evaluation
17 Congenital Disorders of the Larynx Laryngomalacia 60%Congenital subglottic stenosis 16%Vocal cord paralysis 13%All Others: 7%Congenital laryngeal webLaryngocele and Saccular cystLaryngeal/ Laryngotrachealesophogeal CleftVascular lesionsHolinger, LD. Etiology of Stridor in the Newborn, Infant, and Child. Annals of ORL, 1980; 89:
18 Laryngomalacia Most common cause of stridor in infants Presentation Staccato/ Coarse inspiratory stridorWorse with exertion, feeding, cryingNoisy breathing generally begins at about 2-4 weeks of ageOffice EvaluationCharacter of stridorPositional changesFlexible nasopharyngoscopy
20 Laryngomalacia Classification Type IType IIType IIIType I- Inward collapse of the AE foldsType II- Long tubular epiglottis which curls on itselfType III- Anterior and medial collapes of the corniculate and cuneiform cartilagesType IV- Posterior inspiratory collapse against the posterior pharyngeal wall or vocal foldsType V- Short aryepiglottic foldsType IVType VKay DJ, Goldsmith AJ. Laryngomalacia: A Classification System and Surgical Treatment Strategy. Ear Nose Throat J May;85(5):328-31, 336.
21 Laryngomalacia Vast majority are mild Parental reassurance & education Transient worsening, gradual improvementWeight gain issuesGERD issues- Consider GERD treatment if there is evidence on endoscopy
22 Severe Laryngomalacia Respiratory difficultyApnea/ Cyanosis/ ALTEFeeding difficultyFailure to thriveUncontrolled GERDSleep apneaCNS abnormalities
23 Severe Laryngomalacia Surgical Treatment Supraglottoplasty- Aryepiglottic fold division +/- Excision of corniculate cartilages
24 Severe Laryngomalacia Epiglottic Procedures Epiglottoplasty- Excision of a V-shaped wedge of tissue from the epiglottisEpiglottopexy- Epiglottis is pexied to the base of tongue with stitch/ laserWhymark 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 issues Expectant (can take years to resolve)Close monitoring of O2 sat, apnea, weight gainTracheotomyPosterior laryngeal expansionBotox (for spastic paralysis)CordotomyArytenoidectomyRe-innervation proceduresUnilateral: Voice Issues, Aspiration IssuesObservationVocal Cord InjectionThyroplasty
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