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A 17 month-old child with laryngeal papillomata is presented. The symptoms were stridor and gradually developing dyspnea. He underwent two surgical procedures within 4 months, using microsurgical techniques, and eventually recovered. The etiological factors of this rare entity are discussed. The relatively benign course in our patient is stressed, in view of the usual protracted course which is reflected in the literature.
A case of neurofibroma of the larynx occurring in generalized neurofibromatosis (von Recklinghausen's disease) is presented, and the previously reported pediatric cases are reviewed. Laryngeal involvement in neurofibromatosis is rare and the predominant signs and symptoms include dyspnea, stridor, loss or change of voice and dysphagia. Problems posed related to diagnosis, management and course of this infrequent laryngeal localization are discussed.
Neonatal goiter is a rare cause of a neck mass and stridor. Often, the diagnosis can be made on clinical grounds exclusively, but there may be times when a neck mass becomes a diagnostic dilemma. There are several different imaging modalities available to the clinician that are useful in the rapid diagnosis of neonatal goiter. Presently, however, there is no definite algorithm for the workup of a neonatal neck mass. The two cases presented here demonstrate the imaging findings of plain film radiography, sonography, scintigraphy, and CT in neonatal goiter.
OBJECTIVE: Percutaneous dilatational tracheostomy is increasingly practiced in intensive care units and has a low incidence of early complications. The late effects of this procedure are still poorly known and were the focus of this study. DESIGN: Prospective descriptive clinical study. SETTING: Interdisciplinary intensive care unit in a 300-bed teaching hospital. PATIENTS: A consecutive group of critically ill patients who underwent percutaneous tracheostomy between Nov. 90 and March 93, surviving at least 2 months after decannulation. MEASUREMENTS AND RESULTS: There were 17 patients fulfilling the inclusion criteria and 16 of them were seen and examined. The follow-up protocol required a formal standardized patient interview, a physical examination of the stoma site and a fiberoptic laryngotracheoscopy. Results of these sub-tests and overall outcome rating were standardized and expressed as good, moderate or poor. Subjective rating was good in all patients. All denied suffering from any side effects of their tracheostomy. Clinical examination revealed neither stridor nor hoarseness in any of the patients. Most of the scars were whitish and less than 1 cm in length, a few were sunken in, none had adhesions. In 15 patients the clinical result was good and in one, moderate (whitish, sunken-in scar, longer than 2 cm). Ten patients underwent tracheoscopy, while 6 did not. There were no signs of significant stenosis or tracheomalacia. In 8 patients with minor findings results were scored as good, while 2 were classified as moderate (combination of swelling and scar formation of a string-like membrane). The overall rating was good in 13 patients (81%) and moderate in 3 patients (19%). There were no poor outcomes. CONCLUSIONS: Late outcome of percutaneous dilatational tracheostomy in critically ill patients is mostly good. Pending further studies, the use of this technique in intensive care units appears justified.
From 1984 to 1989, 175 esophageal cancer patients, 10 patients admitted for severe caustic esophagitis, and 1 patient with pyothorax due to iatrogenic perforation of the esophagus underwent an esophageal resection or bypass operation. One hundred sixty-eight esophageal resections were performed on 167 patients; 13 were total, 106 subtotal and 49 distal. Nineteen digestive transplants were pulled up to the neck to bypass the esophagus or re-establish continuity after an esophagectomy made elsewhere. Digestive continuity was restored by a long gastric transplant in 120 patients, a colon segment in 17, a jejunal loop in 35, and a short gastric transplant after limited esophago-gastrectomy in 14 patients. Thirty day mortality was 0 in the whole group. Hospital mortality was 1.2% in the resection group and 10.5% in the bypass group (p = 0.048). Nonfatal postoperative complications consisted of respiratory distress in 33 patients, recurrent nerve palsy in 10, anastomotic fistula in 10 (cervical in 8 and intrathoracic in 2) and anastomotic stenosis in 18 patients. Respiratory complications were more frequent in patients with a cancer of the thoracic esophagus (29/111) than in those operated on for a cancer located in the esophago-gastric junction (4/50) (p less than 0.01). Anastomotic stenosis occurred more frequently in the neck (17/137) than in the chest (1/49) (p less than 0.05). Nine patients were reoperated on for a technical complication; intraabdominal hemorrhage (1), thoracic duct injury (2), acute cholecystitis (1), tight stricture of the esophageal anastomosis (2), jejuno-duodenal anastomotic fistula (2), or stridor related to recurrent nerve palsy (1).(ABSTRACT TRUNCATED AT 250 WORDS)
We describe a patient with recurrent respiratory papillomatosis (RRP) associated with human papilloma virus (HPV), who developed a fatal squamous cell carcinoma of the lung. At the age of 1 year he presented with hoarseness, dyspnoea and inspiratory stridor but the diagnosis of RRP was made only 1 year later. At the age of 4 years he was tracheostomized because of upper airway obstruction. In spite of multiple surgical excisions and topic treatment with 5-fluorouracil the papillomata extended to the lung parenchyma. At the age of 16 years he developed a squamous-cell carcinoma of the lung and died 4 months later. Transformation to pulmonary carcinoma is a rare complication in non-irradiated patients with lung papillomatosis. We found only 11 similar cases in the literature.
Cervical neuroblastoma, a disease primarily of infants, has a favorable prognosis. Eleven patients are reported. Clinical presentations (other than mass) included stridor and swallowing problems. Masses when felt were commonly mistaken for infectious adenitis. Imaging studies (US, CT, MRI) showed solid masses with vascular displacement and narrowing; intraspinal extension was absent though extension into the adjacent sites of mediastinum and skull occurred. Horner syndrome was seen in five patients with accompanying heterochromia iridis in one. Five tumors had calcification. A high index of suspicion will lead to biopsy and less delay in diagnosis once a mass is felt or imaged.
Lipoblastomas are rare benign tumors arised from the fetal-embryonal fat that occur almost exclusively in children. About 70% of them arise in the limbs but several other sites have been reported. To date there are only 4 cases of mediastinal lipoblastoma in children, described in the international literature. The radiologic examination, including the chest X-ray, sonography and CT scan, can be used to detect the mass and its relationship to surrounding structures, and to define the typical features of the fat-like tissue. A case of a mediastinal lipoblastoma in a 14-months-old infant is reported, with a respiratory stridor and occasional dyspnoea, appearing only in the supine position. The radiologic findings, treatment and follow-up are also described.
A special new lateral view of the chest, called the "Freddy Frog" view, was used in 50 children between the ages of 5 and 7 years. This resulted in optimal demonstration of the superior mediastinal and superior bony structures without superficial overlying soft tissues and can replace the separate lateral views of the neck and chest in cases of stridor.
A peanut is a commonly inhaled foreign body during childhood. Some cases are difficult to diagnose especially in cases without a clear history of inhalation. We describe a 16-month-old boy presenting with stridor and fever. The chest x-ray suggested inhalation of a foreign body but there was no history of this. A high spot on a T1-weighted chest MRI was due to a peanut which was seen to have moved from the right main bronchus to the left inferior bronchus, between the two MRI studies. MRI can provide information on position and size of the peanut, the conditions of the surrounding tissues and may be also useful in treatment. We consider MRI to be a valuable new method for the diagnosis of peanut inhalation.
We report two cases of diffuse neonatal haemangiomatosis. The multiple cutaneous lesions were associated with massive hepatic involvement and congestive heart failure in one, while in the other laryngeal haemangiomas caused stridor and inspiratory distress. A significant regression in vascular lesions was achieved with high dose corticosteroid therapy.
Congenital alacrima is an autosomal dominant disorder showing markedly deficient lacrimation and punctate corneal epithelial erosions. The G (Opitz-Frias) syndrome is also an autosomal dominant disorder characterised by hypertelorism, hypospadias, stridor, and dysphagia. Here we report a 5-year-old boy with the G syndrome presenting congenital alacrima.
Lymphangiomas and lymphangiomyomas are benign abnormal collections of lymphatic vessels which form a cystic mass. The mediastinum is an uncommon location for these hamartomas in children, but may be life-threatening. We report herein the case of a 23-month-old boy who presented with stridor and a history of recurrent respiratory tract infections. Soon after his admission he suddenly developed respiratory failure and was found to have a multiloculated, cystic mediastinal mass which was initially thought to be a lymphangioma. The mass was extensively infiltrative, and histological examination showed prominent smooth muscle proliferation in the walls of the cysts, confirming a diagnosis of lymphangiomyoma. The terminology and relevant literature on the topic are reviewed following the presentation of this case.
Airway malformations such as laryngeal atresia, tracheal agenesis and subglottic stenosis are rare and present at birth with significant respiratory distress with or without stridor. There may be an initial improvement on bag and mask ventilation. Repeated attempts at intubation are met with failure. The related embryology and clinical aspect of airway malformations have been discussed. The prognosis in tracheal agenesis is universally fatal but cases with laryngeal atresia and subglottic stenosis may be saved with prompt tracheostomy and later surgical reconstruction.
Tracheostomy for management of severe laryngomalacia is associated with significant morbidity and mortality. Two cases are reported wherein the laryngeal abnormality was corrected by ary-epiglottic fold incision and CO2 laser supraglottoplasty. Stridor and respiratory obstruction were relieved and a long term tracheostomy avoided. Endoscopic correction of laryngomalacia offers significant benefits over conventional treatment with tracheostomy in terms of decreased morbidity and improved quality of life.
OBJECTIVE: To compare the efficacy of sequential injectable crystalline penicillin (C.pen) and gentamicin combination followed by oral amoxicillin with sequential IV and oral amoxicillin-clavulanate (amox-clav) in treatment of severe or very severe hypoxemic pneumonia. METHODS: Children aged 2-59 months with WHO-defined severe or very severe pneumonia with hypoxemia (SpO2 < 90%) were included in the study. Patients with fever > 10 days, bacterial meningitis, prior antibiotic therapy > 24 hours, stridor, heart disease and allergy to any of the study drugs were excluded. They were randomly allocated to two groups--Group A and Group B. Group A received C. pen and gentamicin intravenously (IV), followed by oral amoxicillin and group B got amox-clav IV, followed by oral amox-clav. Minimum duration of IV therapy was 3 days and total 7 days. Respiratory rate, oxygen saturation and chest wall indrawing were monitored 6 hourly. RESULTS: 71 patients were included. There were two (5.2%) blood cultures positive in group A and three (9%) in group B. Organisms isolated were S. pneumoniae (n=3) and H. influenzae-b (n=2). There was only one treatment failure in each of the groups. One was due to penicillin resistant H. influenzae -b and the other was due to worsening of pneumonia. The mean time taken for normalization of tachypnea, hypoxia, chest wall indrawing and inability to feed was similar (P-N.S). Mean duration of IV therapy in group A was 76+/-25 hrs and group B was 75+/-24 hrs (p>0.1). CONCLUSION: In children of 2-59 months, sequential injectable C. pen and gentamicin combination, followed by oral amoxicillin or sequential IV and oral amox-clav were equally effective for the treatment of severe or very severe hypoxemic community acquired pneumonia.
BACKGROUND: The timing of aggressive airway intervention in adult epiglottitis is controversial. AIMS: To correlate Friedman's staging of epiglottitis on admission with the airway interventions undertaken. METHODS: A retrospective study of 23 adult patients, mean age 51 years (range 29-81 years), who had been admitted with acute supraglottitis between March 1988 and December 2000 was undertaken. RESULTS: Three patients (13%) had airway interventions; two with tracheostomy and one with tracheal intubation. All were Friedman stage III and had rapid symptom progression during the 24 hours prior to admission. Three other stage III patients with symptom progression longer than 24 hours and all the remaining patients (stage II or less) were managed with observation and intravenous therapy. CONCLUSIONS: Friedman originally advocated airway intervention in any patient stage II or worse, but this intubation threshold should probably be lowered to those patients with rapid-onset stage Ill (moderate respiratory distress, stridor, respiratory rate > 30 per minute, pCO2 > 45mmHg) disease.
Respiratory distress accompanied by stridor is an uncommon complication of 131I radioiodine therapy for differentiated thyroid cancer that occurs within 48 hours of treatment. This report presents three cases with papillary thyroid carcinoma in which 131I therapy caused this acute complication. One of them had no apparent risk for this complication such as the existence of remnant thyroid tissue or laryngeal problems before the treatment. These cases remind physicians that 131I therapy is not a simple, riskless procedure.