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PubMed1976

Upper airway obstruction--a report on sixteen patients.

In sixteen patients with upper airway obstruction, breathlessness was a symptom in all with maximum mid vital capacity flow rates in inspiration or expiration of 1-7 litres per second or less. With one exception, all these patients had stridor. The stridor was inspiratory in nine, expiratory in one and both inspiratory and expiratory in two. There was no diagnostic difficulty in the twelve patients with extrathoracic airway obstruction and in this group tests of inspiratory flow (forced inspired volume in one second, peak inspiratory flow or maximum mid inspiratory flow) were of most value in following the progression of the disease and the response to treatment. Flow volume loops were particularly useful where extrathoracic obstruction and diffuse intrapulmonary airway obstruction co-existed. The two patients with intrathoracic upper airway obstruction caused considerable difficulty with diagnosis and both were initially thought to have, and treated unsuccessfully for, asthma. In each patient flow volume loops showed a low flow expiratory plateau, diagnostic of severe intrathoracic airway obstruction but recorded in the absence of any clinical or radiographic features of emphysema. An obstructing lesion of the intrathoracic trachea was therefore suspected and this was confirmed by tracheal tomography. In one patient serial expiratory flow volume curves demonstrated the combination of intrathoracic upper and lower airway obstruction. Two patients had tracheal stenosis in the region of the suprasternal notch. Each showed a characteristic twin humped expiratory flow volume curve and in one patient the stenosis was demonstrated both physiologically and radiologically to move in and out of the thorax. The importance of a standard posture during serial measurements is emphasized. The ratio of forced expired volume in one second measured in millilitres, to the peak expiratory flow measured in litres per minute, was of limited value if differentiating upper from lower airway obstruction in these patients. It is concluded that upper airway obstruction is likely to become more common and that respiratory function tests, in particular the flow volume loop, play an essential part in the recognition and management of this problem.

Adolescent↗

PubMedDate not supplied

[Early diagnosis of a serious form of Pelizaeus-Merzbacher's disease confirmed by molecular analysis of the gene for proto-lipoproteins].

INTRODUCTION: Pelizaeus-Merzbacher's disease involves extensive demyelination of the Central Nervous System. This is due to a defect in the gene for proteolipoproteins, found on the X chromosome. It appears early as marked axial hypotonia, stridor, nystagmus and anomalous movements of the head, and later as variable pyramidal, extrapyramidal and cerebellar involvement. CLINICAL CASE: A three year old boy, with no unusual family history, was seen for psychomotor retardation. He had marked hypotonia, absence of evidence of social contact, inspiratory stridor, nystagmus and horizontal nodding movements of the head. MR at 4 months showed absence of supratentorial and infratentorial myelinization. Analysis of the gene for proteolipoproteins showed a specific mutation on the exon 5 C227Y. At eight and a half years there was persistence of the severe axial hypotonia with minimal visual function and social contact was maintained through hearing. CONCLUSIONS: It is possible to make an early diagnosis of Pelizaeus-Merzbacher's disease in the first weeks of life, on the typical clinical picture and MR findings of marked extensive hypomyelination, although assessment of myelination is difficult at this age. Early diagnosis is very important, since molecular analysis of the proteolipoproteins gene permits confirmation of the diagnosis, identification of heterozygotes and the establishment of prenatal diagnosis.

Age Factors↗

PubMed1999

Neonatal vallecular cyst: report of eleven cases.

BACKGROUND: Vallecular cyst is fairly uncommon in neonates and infants. Although benign in nature, it may cause severe airway obstruction and even death. This study retrospectively analyzed the clinical manifestations of vallecular cyst in neonates and discussed its management. METHODS: From June 1993 through January 1997, 11 cases of vallecular cyst were collected and reviewed retrospectively. There were 8 male infants and 3 female infants. Their clinical manifestations, age at the onset of symptoms, age at diagnosis, and surgical management were analyzed. Fibrolaryngoscopy was used for preoperative diagnosis and postoperative follow-up. RESULTS: The infants' initial presentations were inspiratory stridor, respiratory distress, noisy breathing, feeding difficulty, and failure to thrive. There was a high incidence of patients with coexisting signs of laryngomalacia (10/11). Ten patients received laryngomicrosurgery with CO2 laser for deroofing the cyst. Additional supraglottoplasty was performed at the same time in 4 patients with laryngomalacia type A + C and in one patient with severe laryngomalacia type C. Their symptoms all resolved soon after surgery. The phenomenon of laryngomalacia also disappeared. There has been no recurrence up to the present. CONCLUSION: Although fairly uncommon, vallecular cyst should be included in the differential diagnosis of congenital laryngeal stridor in neonates. The use of fibroendoscopy can promptly diagnose vallecular cyst and any synchronous airway lesions. Although most of the synchronous laryngomalacia (type C) in this study was secondary to vallecular cyst, we suggest that supraglottoplasty be taken into consideration during cyst deroofing when the signs and symptoms of laryngomalacia type A are also present.

Cysts↗

PubMed2000

Wegener's granulomatosis: an unusual cause of upper airway obstruction.

A 10-year-old child with a 2-month history of tracheitis presented with acute stridor, for which he required tracheostomy. Granulation tissue was found in the subglottic region and he was treated with antibiotics and corticosteroids. A week after successful decannulation of his tracheostomy, his stridor recurred and, on endoscopy under general anaesthesia, circumferential granulomas extending into both main bronchi were found. A diagnosis of Wegener's granulomatosis was made and confirmed on histology.

Airway Obstruction↗

PubMedDate not supplied

Subglottic hemangioma associated with cutaneous and cerebellar hemangiomas detected by MRI: report of one case.

Subglottic hemangioma (SGH) is a benign neoplasm that may cause severe and life-threatening respiratory obstruction in infants. However, patients usually present with inspiratory stridor in the first few months of life and may be mistakenly diagnosed as recurrent or persistent croup. Definitive diagnosis is made by image studies, endoscopic examination and biopsy or all. We report a 2-month-old female infant of SGH with initial clinical manifestations of dyspnea and inspiratory stridor co-existing with cutaneous and cerebellar hemangiomas. Clinicians must be alert the possibility of SGH when associated with cutaneous hemangioma. This patient has received oral steroid treatment for more than two months with improvement of the airway obstruction. Although purplish patch lesions over left side of face, eyelid, cheek, and peri-oral regions regressed, the size of the SGH on the followed MRI was slightly enlarged. The diagnosis and various treatments of SGH are discussed and reviewed in this paper.

Adrenal Cortex Hormones↗

PubMed2000

[Feeding function, blink reflex and MRI in the severely handicapped].

Blink reflexes were studied in 41 patients with severe handicaps, and were correlated with feeding problems and other lower brainstem symptoms such as drooling, an absent gag reflex and stridor. Ventrodorsal diameters of the pons and medulla oblongata on sagittal MRI were also studied in 29 of the cases. The patients were divided into three groups: tube feeding (25 cases), oral feeding (13 cases) and mixed feeding (3 cases). In the tube feeding group, all but three cases showed a prolonged or absent R1 component, and all cases showed prolonged or absent R2 and R2' components. These abnormalities were significantly more frequent in the tube than in the oral feeding group. The patients with drooling, stridor or an absent gag reflex more frequently showed prolonged or absent components than the patients without these symptoms. The brainstem size on MRI was not different between the tube and oral feeding group. These results suggest that the blink reflex, particularly its late components, is a useful indicator for evaluating feeding function and other lower brainstem functions.

Adolescent↗

PubMed2001

[Undiagnosed double aortic arch causing respiratory disturbances after 15-years].

The double aortic arch is a very rare vascular anomaly belonging to a group so called vascular rings. The pressure of abnormal "doubled" aorta on the trachea and esophagus is a cause of sometimes sever symptoms of the respiratory tract such as dyspnea, stridor or cyanosis and recurrent respiratory infections. The authors present a case of a 15 year old boy who had stridor, cough and recurrent respiratory infections. Due to the symptoms the boy was treated for bronchial asthma. Correct diagnosis of double aortic arch was made after the X-ray examination of the chest with barium in the esophagus, followed by bronchoscopy, angiographic and NMR examinations. Surgery treatment was successful.

Adolescent↗

PubMed2001

Paradoxical vocal cord adduction mimicking as acute asthma in a pediatric patient.

We report an adolescent girl with paradoxical vocal cord adduction who presented with acute onset of hyperventilation, wheezing and stridor that did not respond to bronchodilator and anti-inflammation therapy. The paradoxical vocal cord motion was confirmed by flexible fiberoptic bronchoscopic examination. We found the stridor was induced by hyperventilation, and was caused by paradoxical vocal cord movement. The abnormal cord motion may be psychogenic and could be misdiagnosed as asthma. It is important to investigate the underlying background and social history and to avoid unnecessary use of beta-agonists, steroids, and even endotracheal intubation or tracheostomy.

Acute Disease↗

PubMed2000

Tracheobronchial foreign bodies in children.

OBJECTIVE: The objective of this study is to prove that rigid bronchoscopy is a relatively safe procedure in experts' hands and should be carried out in children whenever symptoms like persistent cough, chest infection or stridor persist despite proper antibiotic therapy. METHODS: A review of 534 bronchoscopies in children was carried out between August 1988 and May 1995. Three hundred and fifteen were male and 219 were female children. The most common age was between 1 and 2 years while the mean age being 1 year 10 months. RESULTS: Out of 534 bronchoscopies, 332 were positive for foreign bodies in the tracheosbronchial tree and 202 were negative. The most common site of lodgment of foreign body was the right bronchus. The clinical presentation was variable. An increase in the number of cases was observed. A variety of foreign bodies were encountered, the majority being peanuts. CONCLUSION: In our opinion rigid bronchoscopy is a relatively safe procedure and should be carried out in children whenever symptoms like persistent cough, chest infection or stridor persist despite proper antibiotic therapy.

Bronchi↗

PubMed2002

[Upper airway obstruction in thyroid diseases].

INTRODUCTION: Respiratory symptoms (stridor) in thyroid diseases are rather common, but often overlooked, especially in older people in whom they may be misinterpreted as asthma or chronic bronchitis. MATERIAL AND METHODS: To assess the value of lung function tests for differential diagnosis we used these tests in 33 patients with upper airway obstruction caused by an enlargement of the thyroid gland. The clinical examination consisted of an evaluation of the respiration, examination of the movement of the vocal chords, thyroid parameters, Tc scintigraphy, ultrasound examination, and X-ray examination of the thorax and trachea up to the level of the glottis, supplemented by a CT scan if needed. Lung function tests were carried out in all patients before and after the operation as conventional spirometry with registration of the flow-volume curve and application of peak expiratory flow (PEF), maximal expiratory and inspiratory flow at 50% of the vital capacity (MEF 50 and MIF 50) and MEF 50/MIF 50. RESULTS: The surgical treatment consisted in hemithyroidectomy in 10 patients and total thyroidectomy in 23 patients. In all cases, considerable clinical improvement in respiration was achieved and the X-ray examination showed a normalisation of the lumen of the trachea. In 24 of 33 patients (73%), the flow-volume curve showed preoperatively a configuration compatible with a variable upper airway obstruction (i.e. MIF 50 < MEF 50). An increase postoperatively was found in the PEF of 21 patients (64%) and MEF 50/MIF 50 < 1 in 19 patients (58%). DISCUSSION: It is important to distinguish between respiratory symptoms (stridor) caused by obstruction of the upper air way and dyspnoea in cardiopulmonary diseases. Lung function tests with registration of the flow-volume curve and measurement of MEF, MIF, and PEF are a useful supplement, as values indicating upper airway obstruction will be present in about 60% of the cases. Lung function tests pre- and postoperatively will serve as a good control on the effect of the operation on the thyroid gland.

Adult↗

PubMed2002

The use of the air leak test and corticosteroids in intubated children: a survey of pediatric critical care fellowship directors.

INTRODUCTION: Uncertainties exist regarding the value of the air leak test or use of steroids for preventing post-extubation stridor and extubation failure in children. OBJECTIVE: Determine the practice preferences of pediatric critical care physicians regarding the air leak test and administration of glucocorticosteroids to prevent airway edema. METHODS: A 14-question survey regarding the value of the air leak test, use of glucocorticosteroids, and management of airway edema in intubated children was sent to all North American pediatric critical care fellowship directors affiliated with medical school teaching hospitals. RESULTS: The response rate was 85% (58/68). Seventy-six percent (44/58) routinely check for air leak prior to extubation. The physicians who check for air leak were more likely to delay extubation in order to administer glucocorticosteroids (60% [26/43] vs 15% [2/13], p = 0.01). An air leak of >or= 30 cm H(2)O was more likely (than >or= 20 cm H(2)O) to result in delaying extubation (95% [35/37] vs 51% [19/37], p <0.001). Of the respondents who use steroids for airway edema prophylaxis, 73% (24/33) give steroids based on the air leak test. CONCLUSIONS: The majority of surveyed pediatric critical care fellowship program directors rely on the air leak test and use corticosteroids to prevent post-extubation stridor and extubation failure. At an air leak of >or= 30 cm H(2)O most of the surveyed physicians would delay extubation and initiate glucocorticosteroids.

Algorithms↗

PubMed2002

A huge epiglottic cyst causing airway obstruction in an adult.

An epiglottic cyst causing airway obstruction is rare in an adult. Early definitive diagnosis and management obviate an unnecessary tracheostomy. We report a case of a 64-year-old woman who arrived at our hospital with progressive stridor and foreign body sensation when swallowing for 6 weeks. A hot potato voice and biphasic stridor were remarkable upon physical examination. Indirect mirror and fibroscopic examination revealed a huge epiglottic cyst. The neck lateral X-ray and computed tomography scan demonstrated a huge cystic mass over the epiglottis. A 2.5 x 3.0 cm cystic mass was removed with endoscopic CO2 laser after needle decompression. The patient was discharged on the third day after surgery without complications. An epiglottic cyst in an adult seldom causes upper airway obstruction and is easily ignored by clinicians. We emphasize that complete airway evaluation including routine check-up of the larynx is mandatory for patients with intractable obstructive airway disease. Endoscopic laser surgery is effective in the surgical removal of an epiglottic cyst.

Airway Obstruction↗

PubMed2002

Upper airway obstruction resulting from an antiemetic.

Stridor and stertor can both be the cause of medical and surgical emergencies. The management of these conditions is largely dependent upon the underlying aetiology. This case report describes dystonia following prochlorperazine resulting in stridor and stertor.

Adult↗

PubMed1992

[Lung sound analysis of upper airway obstruction].

The frequency spectrum of stridor was studied by the computer program in the patients with upper airway obstruction. The results showed that the peak frequency of respiratory sound increased significantly, the frequency spectrum got wider and removed to the high frequency area above 200Hz, the E ratio was smaller than 1. These changes were more apparent during inspiration than those during expiration. It is concluded that the stridorous sound could be determined exactly and quantitatively, and differentiated from wheezing by the spectral analysis.

Airway Obstruction↗

PubMed1992

Upper airway obstruction as the sole manifestation of rheumatoid arthritis.

A 51-year-old woman with a history of rheumatoid arthritis (RA) suddenly developed laryngeal stridor. Rheumatoid factor was positive and the erythrocyte sedimentation rate was elevated, but she had no evidence of acute peripheral arthritis at this time. A flexible laryngoscopy revealed cricoarytenoid arthritis which was the sole clinical manifestation of active RA. Involvement of the cricoarytenoid joints must be considered in patients with RA with laryngeal stridor even in the absence of active peripheral arthritis.

Airway Obstruction↗

PubMed1992

[Surgical treatment of double aortic arch: report of a case associated with frequent respiratory infections].

A seven-month-old baby with double aortic arch was reported. He was admitted to our hospital with complaint of frequent respiratory infections shortly after birth. On examination, bronchofiberscopy revealed compression of the trachea and left main bronchus from behind and angiography showed complete vascular ring, namely double aortic arch with no other cardiac anomaly. Soon after the operation, stridor disappeared at rest, but mild stridor persisted on exertion. Three months later, he was re-admitted to our hospital because of pneumonia. Therefore, close observation is required for the patients with double aortic arch, even if the operation is effective.

Aorta, Thoracic↗

PubMed2003

Local experience in paediatric flexible bronchoscopy.

All children who underwent flexible bronchoscopy in the respiratory unit at Paediatric Institute, Hospital Kuala Lumpur from June 1997 to June 2002 were reviewed. A hundred and ten children underwent the procedure under sedation or general anaesthesia. The median age of these children was eight months. (Q1 3, Q3 30) The commonest indication for performing flexible bronchoscopy was for chronic stridor (50 cases) followed by persistent or recurrent changes such as lung infiltrates, atelectasis and consolidation on the chest radiographs (22). Laryngomalacia was found to be the commonest cause of stridor in 29 children. Two patients were diagnosed with pulmonary tuberculosis. With regard to safety, three procedures were abandoned due to recurrent desaturation below 85%. One of these patients had severe laryngospasm that required ventilation for 48 hours but recovered fully. Two neonates developed pneumonia requiring antibiotics following bronchoscopy. No patients developed pneumothorax or bleeding following the procedure. Bronchoscopy is a safe procedure when performed by well-trained personnel. Since it is an invasive procedure the benefits must outweigh the risks before it is performed.

Bronchoscopy↗

PubMed2004

Laryngomalacia: an atypical case and review of the literature.

Laryngomalacia is the most common cause of stridor in newborns and infants. Patients usually present with an inspiratory stridor only, although some exhibit other anomalies. To rule out other possible pathologies, bronchoscopy is advisable. However, the authors of some recent studies have advocated the use of fiberoptic laryngoscopy as a more cost-effective and less-invasive alternative. No surgical intervention is required to treat laryngomalacia in most cases. The disease usually resolves spontaneously by the time a patient reaches the age of 24 months. In this article, we describe a case of laryngomalacia that was atypical in that the patient was 10 years old. We also review the literature in an effort to increase awareness of this condition.

Airway Obstruction↗