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Toronto Notes 2019 Pediatric Otolaryngology Subglottic Stenosis
Congenital
• diameterofsubglottis<4mminneonate(duetothickeningofsofttissueofsubglotticspaceor maldevelopment of cricoid cartilage)
Acquired
• followingprolonged,repeated,ortraumaticintubation
■ most commonly due to endotracheal intubation; nasal intubation is less traumatic and preferred in
long-term intubation, as it puts less pressure on the subglottis (tube sits at different orientation) and
there is less movement
■ subglottic stenosis is related to duration of intubation and pressure of the endotracheal tube cuff
• canalsobeduetoforeignbody,infection(e.g.TB,diphtheria,syphilis),orchemicalirritation
Clinical Features
• biphasicstridor
• respiratorydistress
• recurrent/prolongedcroup
Diagnosis
• rigidlaryngoscopyandbronchoscopy
Treatment
• ifsoftstenosis:dividetissuewithknifeorlaser,dilatewithballoon±steroids • iffirmstenosis:laryngotracheoplasty
Laryngomalacia
• shortaryepiglotticfolds,omega-shapedepiglottis,pendulousmucosa
• causedbyindrawingofsupraglottisoninspiration,leadingtolaryngopharyngealrefluxofacid
Clinical Features
• high-pitchedinspiratorystridorat1-2wk
• stridorisconstantorintermittentandmorepronouncedsupineandfollowingURTI
• usuallymild,butcanbeassociatedwithcyanosisorfeedingdifficultieswhensevere,leadingtofailureto
thrive
Treatment
• observation±protonpumpinhibitor(tobreaktheacidrefluxcyclethatleadstoedemaandworse airway obstruction) is usually sufficient, as symptoms spontaneously subside by 12-18 mo in >90% of cases
• ifsevere,divisionofthearyepiglotticfolds(supraglottoplasty)providesrelief
Foreign Body
Ingested
• usuallystuckatcricopharyngeusmuscle
• coins,toys,batteries(emergency)
• presentswithdrooling,dysphagia,stridorifverylarge
Aspirated
• usuallystuckatrightmainbronchus
• peanuts,carrot,applecore,popcorn,balloons • presentation
■ stridor if lodged in trachea
■ unilateral “asthma” if bronchial, therefore often misdiagnosed as asthma
■ if totally occludes airway: cough, lobar pneumonia, atelectasis, mediastinal shift, pneumothorax,
death
Diagnosis and Treatment
• suddenonset,notnecessarilyfebrileorelevatedWBC
• anypatientwithsuspectedforeignbodyshouldbekeptNPOimmediately
• olderpatient:inspiratory-expiratorychestX-ray(ifpatientisstable)
• younger patient: right and left decubitus chest X-rays. Lack of lung deflation while resting on dependent
side suggests foreign body blocking bronchus • bronchoscopyoresophagoscopywithremoval
Otolaryngology OT45
Laryngomalacia is the most common cause of stridor in infants
Foreign body inhalation is the most common cause of accidental death in children
Batteries MUST be ruled out as a foreign body (vs. coins) as they are lethal and can erode throughtheesophagus. Batterieshaveahalo sign around the rim on AP x-ray and a step deformity on lateral x-ray