Difficult problem, difficult diagnosis Stridor at birth-worse with feeding, crying May have history of difficult or forceps delivery,

but not always Post cardiac surgery Assessment includes CXR, CNS Often need repetitive flexible bedside laryngoscopy

to assess vocal cord motion Often needs operative endoscopy

Vocal Cord Paralysis

Bilateral: Airway issues, Aspiration issues Expectant (can take years to

resolve) Close monitoring of O2 sat,

apnea, weight gain Tracheotomy Posterior laryngeal

expansion Botox (for spastic paralysis) Cordotomy Arytenoidectomy Re-innervation procedures

Unilateral: Voice Issues, Aspiration Issues Observation Vocal Cord Injection

Multiple approaches Thyroplasty

Vocal Cord Paralysis

Glottic websTend to be thick and extend to subglottisLaryngeal atresia variant22 q deletion association

Rare familial pattern

Surgical OptionsEndoscopic vs. OpenKeel placement

Congenital Airway Abnormalities: Anterior Glottic Web

Laryngeal CleftsHigh index of suspicion

neededStridor & aspiration

problemsAssess with

microlaryngoscopy 2 handed distraction

technique Palpation of

interarytenoid region

Congenital Airway Abnormalities: Laryngeal Cleft

Laryngeal cleft: types 1-41-observation2-endoscopic repair3-Laryngofissure with buttress and multilayer

closure4-Thoracotomy

Congenital Airway Abnormalities: Laryngeal Cleft

Innominate artery compression “Pulsatile” tracheomalacia “Dying spells” ? vascular ring –

esophagram, MRI, CT Bronchoscopy – fishmouth

appearanceRepair - Aortopexy

Congenital Airway Abnormalities: Vascular Rings and Slings

HistoryHoarseness

May have history “asthma” or recurrent croup

Correct diagnosis generally made 1 years after onset of symptoms

Usually identified around age 3 Has been found in neonates

Must ask about maternal vaginal condylomata If preadolescent, think about sexual abuseOffice NPL

Recurrent Respiratory Papillomatosis

Frequent recurrence Spread of disease

6-13% to distal airways2-7% to lungs

Devastating impact Surgical extirpation rarely

curative No predictive therapeutic

intervention available Malignant transformation in 1-

4%

Recurrent Respiratory Papillomatosis:Particular Challenges

Communicate with anesthesia Interval debulking for airway and voice

LASER, Forceps, Microdebrider,Conservative approach (“First do no harm”) Counsel parents Protect anterior commissureAvoid tracheostomyAims:

reduce tumor burden decrease spread of disease create a safe and patent airway preserve voice quality increase interval between surgical procedures

Recurrent Respiratory Papillomatosis: General Treatment Principles

Severe RRP- Cidofovir

View at initial endoscopy (s/p 4 procedures elsewhere)

View at 1st cidofovir injection (s/p 11 monthly procedures)

Cidofovir Impact

RRP and Cidofovir Often see dramatic initial response Disease that persists/recurs after cessation of cidofovir often is less

extensive and easier to control with some individuals progressing to lasting remission

Can achieve prolonged remission in many, but not a universal “cure all” Patient selection- Major benefit is control of “severe disease” (those

patients requiring repetitive surgery or with airway risk) The current histological and blood chemistry information is

reassuring No liver or kidney toxicity noted Malignant transformation may occur-especially in adults; use with

caution and reason

Foreign Bodies-Foreign Bodies-AirwayAirway

History is keyThere may not be witnessed event If witnessed, have parents bring similar object

Signs:Transient/ Unilateral wheezeBarky cough, Hoarseness, Intermittent dyspnea

Clinical StagesAcute choking/ gagging episodeAsymptomatic interval- FB becomes lodged/ reflexes

become fatiguedComplications- Erosion/ Obstruction/ Infection

Foreign Bodies-Foreign Bodies-AirwayAirway

Esophageal Can cause respiratory distress Carefully review Xray Repeat Xray immediately before OR

Warn parents – foreign body may pass with anesthesia

Look for more than one foreign body Esophageal edema can be considerable

Foreign Bodies-Foreign Bodies-EsophagealEsophageal

Foreign Bodies-Foreign Bodies-EsophagealEsophageal

Gastroesophageal Reflux Disease

Airway issues High index of suspicion “Silent” GERD vs. Classic symptoms

Pediatric Airway Manifestations of Gastroesophageal RefluxDeborah M. Burton, M.D.

Seth M. Pransky, M.D.Richard Katz, M.D.

Donald B. Kearns, M.D.Allan B. Seid, M.D.

Annals Otol Rhinol Laryngol Sept 1992

Classic symptomsEmesisDysphagiaBurpingChokingGaggingRumination

Irritability“colic”ArchingTorticollisSleep disturbance

Magit/Pransky: AAO Stridor 2007

Gastroesophageal Reflux Disease

Rhinitis of infancy Recurrent Otitis Chronic Sinusitis Stertor / Stridor Hoarseness Chronic cough

(especially nocturnal) Halitosis

Laryngospasm / Apnea Severe Laryngomalacia Recurrent Croup Subglottic stenosis

exacerbation Recurrent Bronchitis Asthma exacerbation

Multiple ENT Minfestations of Extra-esophageal Reflux

Gastroesophageal Reflux Disease

Non-operative Assessment:Often not very conclusive or accurate

Radiologic pH probe: double lumen

Newer pharyngeal probesEmpiric treatment if clinical picture suggestive of GERD

Operative AssessmentDL&BMucosal changes

Biopsy Tracheal aspirate for LLM

EGD with biopsy

Gastroesophageal Reflux Disease

Eosinophilic Esophagitis

Symptoms similar to GERD No response to GERD Rx EGD with biopsy distal esophagus

Eosinophilic infiltrate Allergy evaluation-esp foods Dietary manipulation Inhaled steroids (swallowed)

Gastroesophageal RefluxExtra-Esophageal Reflux

Connect refractory or unexplained airway symptoms to acid reflux

Prophylactic treatment before and after airway surgery

Not a bad word! Avoid a trach, create a crisis!

Tracheostomy

Assess urgency of intervention Thorough evaluation of the situation: age, history,

clinical presentation Anticipate risks and benefit of examination Relationship with anesthesia critical-spontaneous

ventilation Pediatric endoscopic equipment Consider all possibilities, co-morbidities and

synchronous lesions

Pediatric Stridor: Conclusions