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PubMed2003

Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management.

OBJECTIVE: We sought to describe the clinical presentation of patients with retropharyngeal abscess (RPA), utility of imaging studies, and implications on management. METHODS: A retrospective chart review was performed at a tertiary-care, pediatric hospital with cases identified by a discharge diagnosis of RPA; posttraumatic RPA cases were excluded. Patients without confirmatory radiographic findings, fluoroscopy, or computed tomography (CT) were excluded. RESULTS: Sixty-four cases involving 64 patients were studied. The median age of the patients was 36 months; 48 (75%) of the 64 patients were younger than 5 years. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). In 29 children (45%), it was noted that there was limitation of neck extension, in 23 (36.5%) torticollis, and in 8 (12.5%) limitation of neck flexion. The physical examination revealed stridor with wheezing in only 1 patient (1.5%) and wheezing in 1 other (1.5%). Twenty-seven patients (42%) underwent surgery; 37 (58%) were treated with antibiotics only. Performance of a surgical procedure was significantly associated with CT scan findings. Ten (37%) of 27 patients with defined abscess on CT scan were treated with antibiotics alone. There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group. CONCLUSIONS: Children with RPA present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis. Most patients with retropharyngeal cellulitis and some with RPA can be treated successfully without surgery.

Adolescent↗
PubMed1987

Chronic airway obstruction in children: evaluation with cine-CT.

The radiographic diagnosis of airway lesions, especially laryngomalacia and tracheomalacia, often is imprecise. Endoscopy, which allows detailed examination of the upper airway, is an invasive procedure requiring sedation or anesthesia. A prospective study was undertaken to show the value of cine-CT (Imatron) scanning in diagnosing airway lesions in children. Eleven patients, aged 10 days to 4 years old, with a history of stridor were evaluated by both cine-CT and flexible fiberoptic endoscopy. Cine-CT studies of 12 children imaged for other reasons and without clinical evidence of airway disease served as controls to assess normal airway motion. Endoscopy identified 13 abnormalities, 11 of which were identified by cine-CT. Cine-CT has the capacity to image common causes of chronic stridor in children. It is rapid, noninvasive, and requires no sedation in most children. Although additional work is needed to clarify the role of cine-CT, this study suggests that cine-CT is a sensitive and specific imaging technique for evaluation of chronic stridor in infants and children.

Child, Preschool↗
PubMed1999

Psychogenic Respiratory Distress: A Case of Paradoxical Vocal Cord Dysfunction and Literature Review.

BACKGROUND: Pulmonary disease such as asthma is a psychosomatic disorder vulnerable to exacerbations precipitated by psychological factors. A case is described in which a patient thought to have treatment-refractory asthma was discovered to have a conversion reaction, specifically paradoxical vocal cord dysfunction (PVCD), characterized by abnormal vocal cord adduction during inspiration. DATA SOURCES: Reports of PVCD were located using a MEDLINE search and review of bibliographies. MEDLINE (English language only) was searched from 1966 through December 1998 using the terms functional asthma, functional upper airway obstruction, laryngeal diseases, Munchausen's stridor, paradoxical vocal cord dysfunction, psychogenic stridor, respiratory stridor, vocal cord dysfunction, and vocal cord paralysis. A total of 170 cases of PVCD were reviewed. STUDY FINDINGS: PVCD appears to be significantly more common among females. PVCD spans all age groups, including pediatric, adolescent, and adult patients. PVCD was most often misdiagnosed as asthma or upper airway disease. Because patients present with atypical and/or refractory symptoms, several diagnostic tests are employed to evaluate patients with PVCD; laryngoscopy is the most common. Direct visualization of abnormal vocal cord movement is the most definitive means of establishing the diagnosis of PVCD. A number of psychiatric disturbances are related to PVCD, including conversion and anxiety disorders. PVCD is associated with severe psychosocial stress and difficulties with modulation of intense emotional states. CONCLUSIONS: Psychogenic respiratory distress produced by PVCD can be easily misdiagnosed as severe or refractory asthma or other pulmonary disease states. Recognition of PVCD is important to avoid unnecessary medications and invasive treatments. Primary care physicians can detect cases of PVCD by attending to clinical symptoms, implementing appropriate laboratory investigations, and examining the psychological covariates of the disorder. Psychotherapy and speech therapy are effective in treating most cases of PVCD.

Journal Article↗
PubMed2006

Comparison of armoured laryngeal mask airway with endotracheal tube for adenotonsillectomy.

OBJECTIVE: To assess the reliability of armoured laryngeal mask airway for adenotonsillectomy and to compare the haemodynamic changes during anaesthesia with those of endotracheal tube. DESIGN: A prospective comparative study. PLACE AND DURATION OF STUDY: Services Hospital Lahore/ Services Institute of Medical Sciences from April to September 2003. PATIENTS AND METHODS: A total of 100 patients undergoing adenotonsillectomy between ages 10-35 years and ASA I status were enrolled for the study. Two groups with 50 patients in each group were formed. Group I patients underwent surgery with armoured laryngeal mask airway while group II underwent surgery with endotracheal intubation. Baseline heart rate, systolic blood pressure and diastolic blood pressure were noted pre-operatively, one minute after insertion and every five minutes after induction in both the groups. A change in all these haemodynamic parameters from the baseline was noted. The effect of Boyle Davis Gag and adequacy of surgical access were also noted. Occurrence of cough, laryngospasm and stridor were noted at the time of recovery in both the groups. RESULTS: Baseline variables in both groups were identical. Surgical access was adequate in 48/50 patients in group I while it was adequate in 49/50 patients in group II. The frequencies of cough, laryngeal spasm and stridor were lower in group I. In group I, there was insignificant change from baseline in heart rate, systolic and diastolic blood pressure at one, five and ten minutes after induction. In group II, significant change from baseline was observed in heart rate (p < 0.01), systolic blood pressure (p < 0.05) and diastolic blood pressure (p < 0.05). CONCLUSIONS: Armoured laryngeal mask is reliable for performing adenotonsillectomies. It provides adequate surgical access for adenotonsillectomy. It is also associated with lower occurrence of cough, bronchospasm and stridor at recovery. Use of armoured laryngeal mask is associated with fewer haemodynamic changes compared with those of endotracheal tube.

Adenoidectomy↗
PubMedDate not supplied

Diagnosis of anomalous innominate artery syndrome by spiral CT with 3D reconstruction of the airway: report of one case.

Stridor in infants is a symptom that indicates partial obstruction of the large airways. Vascular rings are an unusual cause of tracheal compression which can induce stridor in infants and children. We report a 4-month-old boy with recurrent wheezing and stridor for 2 months. Spiral computed tomography (CT) and three-dimensional (3D) reconstruction aided in the diagnosis of external compression on the trachea by an innominate artery. Successful relief of the airway's obstruction was achieved by aortopexy. Three months after surgery, he was symptom free without any medication.

Aorta, Thoracic↗
PubMed1975

[Double aortic arch in infancy and childhood].

The diagnosis of double aortic arch was suspected by oesophagography and subsequently proven by angiography in six children. The patients' age ranged from 14 days to 13 years. The diagnostic value of angiography in establishing the existence of two aortic arches is emphasized, which can easily be performed by right heart catheterization. In five patients the aorta descended to the right of the spine; the left arch was hypoplastic and became stenotic or atretic distal to the subclavian artery. In only one case the aorta descended on the left side. In this case both arches had approximately the same size. Four patients were symptomatic immediately after birth and presented with severe inspiratory stridor. The clinical course was so dramatic that surgery was inevitable at the age of four weeks, at 4, 6 and 7 months respectively. The youngest patient died postoperatively. In the other infants the stridor disappeared only months after surgery. One girl had a stridorous respiration occasionally during infancy, later on she complained of dysphagia. She was operated on at the age of 13 years. The double aortic arch was an incidental finding in a girl of 8 years; surgery was not performed.

Adolescent↗
PubMed2003

[A case report of the laryngeal edema and peripheral cyanosis after extubation of the tracheal tube].

A 65-year-old male in malnutrition due to advanced colon cancer underwent resection of transverse colon tumor and the invaded abdominal muscles with necrosis and abscess. After epidural catheter insertion between Th 10-11 for 9 cm cephalad, anesthesia was induced with thiopental 200 mg and fentanyl 50 micrograms. Tracheal intubation was done with vecuronium 5 mg, and anesthesia was maintained with sevoflurane with nitrous oxide in oxygen and epidural block. During surgery, systolic blood pressure often went up to 130 to 140 mmHg and down to 50 to 60 mmHg. Dopamine 3-5 micrograms.kg-1.min-1 was administered but occasional ephedrine bolus injection was still necessary. The intestine, including the intact part, was edematous. After the surgery, when systolic blood pressure was stable at about 130 mmHg and his consciousness was clear with regular spontaneous respiration, the tracheal tube was removed. However, soon after the extubation, expiratory stridor and cyanosis of the bilateral hands and feet were observed. Hydrocortisone 200 mg and nicardipine 0.5 mg were administered and room temperature was raised. About 30 minutes later, stridor and cyanosis subsided. In the ward after surgery, only hoarseness was observed. The stridor might have been due to the laryngeal edema, which could be attributed to stimulation by tracheal tube in the patient with malnutrition. The hemodynamic instability during surgery and cyanosis after extubation might have come from changes of the vascular resistance by sepsis.

Aged↗
PubMed1992

[A case of aspirin-induced asthma due to ketoprofen adhesive agent].

A 40-year-old woman who had been diagnosed as having aspirin-induced asthma was admitted with stridor. She had a history of surgery for sinusitis and nasal polyps, and severe asthmatic attack requiring mechanical ventilation after administration of puranoprofen (Niflan). On the second day of hospitalization, she used a ketoprofen adhesive agent (Miltax, 30 mg) for a stiff shoulder. Stridor developed five hours later, progressing to a severe asthmatic attack with loss of consciousness, requiring mechanical ventilation. The serum level of ketoprofen was very high (81.7 ng/ml); therefore, provocation challenge test was performed to confirm the possible relationship between the ketoprofen adhesive agent and asthmatic attack. After closed patching of the agent (15 mg) on her lower leg, stridor developed, and FEV1.0 and PFR decreased, in association with an increase of the serum level of ketoprofen to a maximum of 38.0 ng/ml. These results show that the topical application of a ketoprofen adhesive agent induced the asthmatic attack by transdermal absorption in this patient.

Adult↗
PubMed2003

[10-year experience in flexible bronchoscopy in pediatric patients].

BACKGROUND: Approximately a decade ago, pediatric Flexible Bronchoscopy (FB) was introduced in Chile, after being used for several years in adults. AIM: To describe our clinical experience in FB in a ten years period. PATIENTS AND METHODS: Records of procedures done between January 1993 and September 2002 at the Pediatric Service of the Catholic University Hospital, were retrospectively reviewed. We evaluated the clinical indications for the procedures in relation to patient's age and the correlation between indications and FB findings. RESULTS: A total of 700 procedures were performed during the period, 59% in men and 53% in patients younger than 1 year. Seventy seven percent of procedures were done in an examination room, using a nasal approach. The main indication was visualization of the airway (49%). The most common clinical diagnosis, in descending order were: atelectasis, stridor and etiologic study of pneumonia by bronchoalveolar lavage (BAL). In children younger than 6 months the most common clinical diagnosis was stridor, followed by atelectasis. The main diagnosis in the whole sample, reached by FB was atelectasis secondary to mucous plug. In children younger than 6 months, the main diagnosis was laryngomalacia. A positive microbial culture was obtained in 43% of patients in whom BAL was done. Complications were uncommon (5%) and mostly mild. In 2.3% of cases, these were severe, such as bronchospasm and need for mechanical ventilation. Severe complications were observed in patients younger than 3 months with severe stridor or in children with cancer, who required FB and BAL. CONCLUSIONS: Flexible bronchoscopy is a safe and useful procedure in pediatric patients.

Bronchoalveolar Lavage↗
PubMedDate not supplied

[Sleep disorders in multiple system atrophy].

Sleep disorders are so common in multiple system atrophy that they should be considered an integral part of the disease. Sleep fragmentation occurs in more than half of the patients, with sleep onset and sleep maintenance insomnia. Periodic leg movements of sleep are also common, although they are generally asymptomatic. REM sleep behavior disorder, a parasomnia in which the patient presents vigorous movements associated with intense dreaming dreaming during REM sleep, is detected polysomnographically in almost all the patients with variable severity. Nocturnal stridor is produced by obstruction on the glottis level. The cause of stridor is unknown but two alternative explanations have been proposed: paralysis of the muscles opening the vocal chords and excessive contraction of the muscles that close them. A combination of both, however, is the most likely explanation. Nocturnal stridor is associated with decreased survival and its treatment is based on continuous positive air pressure (CPAP) when it occurs only during sleep or tracheostomy when it worsens and becomes also diurnal.

Humans↗
PubMed2005

[Glucocorticosteroids in the treatment of subglottic laryngitis in children].

Subglottic laryngitis is one of the acute children's diseases, directly caused by a violently growing edema of the subglottic area. Its symptoms generally appear very suddenly, when children seem to be in perfect health, at night, several hours after falling asleep. Their symptoms included barking cough, clear voice, stridor, inspiratory dyspnoea with participation of auxiliary respiratory muscles, excitation and anxiety of a child, changes in skin coloration. The movement of the wings of the nostrils is intensified. In especially severe cases, agitation, cyanosis, pallor of skin, obnubilation, apnea, loss of consciousness and circulatory failure may also occur. Subglottic laryngitis is a disease, which can threaten the life of a small child. The aim of this study was to observe efficacy of the treatment of the subglottic laryngitis with glucocorticoids, especially budesonide in nebulization. The research covered 169 children: 58 girls (34.31%) and 111 boys (65.69%) aged 9. months do 5. years (mean 3 years 6 months) hospitalized in the Children's Hospital in Warsaw with the following symptoms: dry barking cough, stridor, inspiratory dyspnoea with the participation of auxiliary respiratory muscles, agitation and change of colour of skin. The examination of each patient included subjective, objective (pediatric and laryngological). Disease severity was assessed by a clinical croup score based on stridor, cough retractions, dyspnoea and cyanosis and the overall clinical assessment was scored on a visual scale. The results indicate that nebulised budesonide can be used as a safe and effective alternative treatment in children with moderate to severe subglottic laryngitis.

Administration, Inhalation↗
PubMed2006

[Surgical treatment of laryngomalacia in children].

INTRODUCTION: Laryngomalacia is the most common congenital malformation of the larynx which causes stridor in newborns and infants. The stridor is inspiratory and it is first noted at birth but sometimes may not develop until 2 weeks of age. It increases in severity during crying, nursing, agitation, excitement and is made worse with head flexion or supination. Other symptoms such as supraclavicular, intraclavicular, intercostal and abdominal retractions may be associated. Boys are affected over twice as often as girls. Diagnosis of laryngomalacia is made by rigid or flexible laryngoscopy. Although this disorder is usually self-limited, in some cases the symptoms are so severe that operative intervention cannot be avoided. MATERIAL AND METHODS: Between 2002 and 2005, 13 infants were operated for severe form of laryngomalacia in the Pediatric ENT Dept in Poznań. In all patients the rigid or flexible laryngoscopy was performed to confirm the diagnosis. Then aryepiglottoplasty or epiglottoplasty were performed in all cases. It involved excision of the redundant mucosa over the arytenoid cartilages, the offending parts of he aryepiglottic folds, and trimming the lateral edges of the epiglottis, using microlaryngeal scissors and forceps. RESULTS: In all children symptoms such as: laryngeal stridor, feeding difficulties and dyspnea improved or completely resolved. In one case post-operative ventilation for several hours was required. All patients except one demonstrated significant airway improvement in the immediate postoperative period. CONCLUSIONS: Direct laryngoscopy must be performed prior to the aryepiglottoplasty to decide what amount of tissue to resect. Endoscopic aryepiglottoplasty with use of microlaryngeal instruments is an effective and safe method of the treatment of severe form of laryngomalacia. It is better to perform this procedure in general anesthesia without intubation.

Airway Obstruction↗
PubMedDate not supplied

[Double aortic arch: report of one case].

A case of double aortic arch is reported. The male patient, 11-month-old, had breathed with a constant stridor since his birth and had frequent attacks of respiratory tract infection and dyspnea. The child was admitted because of restlessness, fever, stridor and cough. Dyspnea with cyanosis appeared later, and required intubation and mechanical ventilation. After then, three attempts to extubate the infant were made, but failed. A double aortic arch was suspected by bronchogram, esophagogram, and confirmed by cardiac catheterization. Through a left thoracotomy, the smaller left arch and the ligmentem arteriosum were divided to relieve the obstruction of trachea from the compression of the vascular ring. Postoperative convalescence was normal. Symptoms of double aortic arch vary with the degree of obstruction of the trachea and esophagus, ranging from mild to life-threatening respiratory obstruction and apnea. Inspiratory stridor, dyspnea, and wheezing, which are accentuated with feeding, crying, or respiratory infections, are characteristic clinical findings. The diagnosis is established by aid of an esophagography. Left thoracotomy, with division of the smaller aortic arch, is the only satisfactory treatment.

Aorta, Thoracic↗
PubMed1989

Vocal cord paralysis.

The information presented in this article demonstrates that unilateral or bilateral vocal cord paresis or paralysis in infants and children is difficult to diagnose and difficult to manage. In an attempt to provide the otolaryngologist with a concise set of relevant guidelines, the following rules for management are presented here. 1. Suspect bilateral abductor vocal cord paralysis (BAVP) when a neonate or infant presents with high-pitched inspiratory stridor and evidence of airway compromise. Factors that should increase the suspicion of BAVP include associated Arnold-Chiari malformation; congenital anatomic abnormality involving the mediastinum (for example, tracheoesophageal fistula, vascular ring, other vascular anomalies); dysmorphic syndromes, especially those involving brainstem dysfunction; and manifest findings indicative of neuromuscular disorder. The neonate or infant with Arnold-Chiari malformation and inspiratory stridor has bilateral abductor vocal cord paralysis until proven otherwise. 2. Suspect unilateral vocal cord paresis or paralysis in an infant or child with hoarse voice, low-pitched cry, or breathy cry or voice. The infant who develops mild stridor and hoarse cry following surgical repair of a patent ductus arteriosus or tracheoesophageal fistula has a unilateral vocal cord paralysis until proven otherwise. 3. Direct laryngoscopy with the flexible fiberoptic nasopharyngolaryngoscope and photodocumentation using a videocassette recorder offers the best method for diagnosis of vocal cord paresis or paralysis. Additional diagnostic studies that may be helpful include radiographic studies, CT scan, MRI scan, electromyography of the larynx, and, in older children, stroboscopy. 4. In using a flexible direct laryngoscope be careful not to interpret all motions of the vocal cords or arytenoids as evidence to preclude the diagnosis of vocal cord paralysis or paresis and be careful not to mistake the anterior intraluminal portion of a normal cricoid for an "anterior glottic web." 5. Tracheotomy is often required in order to assure adequate airway during infancy for children with BAVP. However, with the advent of sophisticated cardiorespiratory monitoring equipment and methods for monitoring blood oxygen and carbon dioxide levels, tracheotomy can be delayed until attempts have been made to improve the adequacy of the airway with neurosurgical intervention or other procedures.(ABSTRACT TRUNCATED AT 400 WORDS)

Child↗
PubMed1989

[Surgical repair of vascular ring with aberrant brachiocephalic artery].

The vascular ring causes tracheal and esophageal compression and some cases need the surgical intervention. We report a rare case of vascular ring with aberrant brachiocephalic artery. A nine-month-old boy had suffered from progressing stridor and was admitted to our hospital due to the stridor. The digital subtraction angiography revealed the aberrant brachiocephalic artery which compressed the trachea from anterior aspect. The compression of the trachea was released by tacking forward the aberrant brachiocephalic artery to the sternum with the aid of two stitches. The postoperative course was uneventful. The stridor almost disappeared at one year after the operation.

Aorta, Thoracic↗
PubMed1985

[Stress-inducible functional laryngospasm: differential diagnostic considerations for bronchial asthma].

Since 1974 about 30 cases of functional upper airway obstruction are known in literature. We report the findings in a 19 year old woman, who was free from any symptoms during rest. During exercise (swimming, jogging) she showed a loud inspiratory stridor, cyanosis, and dyspnoea. We found this stridor was induced by exercise or hyperventilation only (thread mill, CO2 rebreathing), and was caused by paradoxical vocal cord movement (fibreoptic laryngoscopy in local anaesthesia during CO2 rebreathing). All lung function parameters improved after inhalation of ipratropium bromide. We believe that it is important to investigate these patients during stridor attacks and without general anaesthesia. Otherwise it will be impossible, to get a correct diagnosis.

Adult↗
PubMed1996

Laryngeal and pharyngeal dysfunction in horses homozygous for hyperkalemic periodic paralysis.

OBJECTIVE: Evaluate histories, clinical signs, and laboratory data of 69 horses homozygous by DNA testing for hyperkalemic periodic paralysis (HPP). DESIGN: Cohort study. SAMPLE POPULATION: 69 of 189 horses testing homozygous for HPP between October 1992 and November 1994. PROCEDURE: Questionnaires addressing signalment, training regimes, medical history, and current status of affected horses were sent to owners, trainers, or attending veterinarians. Data from completed questionnaires were tabulated and evaluated, using descriptive statistics. RESULTS: Sixty-nine (37%) of 189 questionnaires were completed and returned. Clinical episodes of muscle weakness or paralysis varied in severity and frequency from mild muscle fasciculations to recumbency and death. Sixty-three of 68 HPP-affected horses were reported to have had stridor associated with exercise, excitement, stress, or episodes of muscle paralysis. Common endoscopic findings in affected horses included pharyngeal collapse, pharyngeal edema, laryngopalatal dislocation, and laryngeal paralysis. Twelve of 27 horses receiving acetazolamide had decreases in stridor while receiving medication. CLINICAL IMPLICATIONS: Most horses testing homozygous for HPP had clinical signs associated with pharyngeal and laryngeal dysfunction. Hyperkalemic periodic paralysis should be included on a differential list for horses examined for signs of laryngeal or pharyngeal dysfunction or stridor. Treatment with acetazolamide may help to control respiratory tract signs associated with this disease.

Animals↗
PubMed1996

[Vocal cord abductor paralysis in multiple system atrophy--paradoxical movement of vocal cords during sleep].

Bilateral vocal cord abductor paralysis (VCAP) is frequently associated with multiple system atrophy (MSA) and the early clinical manifestation of VCAP is nocturnal inspiratory stridor simulating heavy snoring observed in patients with obstructive sleep apnea syndrome. We examined six MSA patients with nocturnal stridor and four disease controls including sleep apnea syndrome. Vocal cord movements were analyzed by laryngofiberscopy during both wakefulness and sleep induced by intravenous administration of diazepam. The results were as follows: First, the stenotic portion in the upper airway tract was the larynx (the vocal cords) in MSA patients with stridor, while the soft palate or the pharynx in the disease controls. Second, in the MSA patients, while awake-laryngofiberscopy showed abduction restriction suggestive of VCAP in only one of the six patients, sleep-laryngofiberscopy showed obvious paradoxical movement of the vocal cord in all the rests, where the vocal cords abducted in expiration and adducted in inspiration. In addition, there were two patterns in the inspiratory vocal cord position during sleep: one pattern where vocal glottis was still opening at the posterior one-third area and the other pattern where vocal glottis was almost completely closed through total length of the cords. Tracheostomy should be considered in the latter stage of VCAP.

Aged↗