Symptoms and signs of concern The Neonatal Airway: Stridor Stertor, Stridor and Apneas Respiratory Distress Cyanosis Dysphonia (hoarse cry) Nasal flaring Tachypnea Anthony E Magit, MD, MPH Rady Children’s Hospital Retractions University of California, San Diego Feeding difficulties
Historical factors of The sounds say a lot importance
Stertor Traumatic labor Responsible for 20% of TVC palsy Nasal or pharyngeal source Intubation Ease, size of tube, duration, re-intubation, failure of Inspiratory stridor extubation Supraglottis, rarely high Aggravating/alleviating factors trachea Agitation, positioning, feeding, crying Biphasic stridor Reflux (overt vs “silent”) Glottis/subglottis Neurologic impairment Expiratory stridor Cardiac disease or surgery Intrathoracic obstruction Birthmarks Syndromes
Neonatal anatomic and physiologic Physical exam considerations
Nasal/pyriform aperture/choana Vocal cord length 6-8mm Masses, edema, septal deviation, stenosis, atresia Oral cavity/oropharyngeal Transverse length post glottis Masses, tongue size, mandibular position, tonsils, 4mm tone Subglottic diameter 5-7mm Neck Masses, vertebral anomalies, vessels Tracheal length 4cm Listen to qualify abnormal sounds 1mm of edema airway Stertor caliber Stridor Breath sounds, crackles, murmurs In the glottis by 35% In the subglottis by 44% Watch neonate feed if possible
1 Neonatal anatomic and physiologic considerations Neonatal Nasal Obstruction Neonates are obligate nasal breathers until 3-6 Obligate nasal breathers months of age (some variability) x 2-5 mos Epiglottis touches soft Stertor A low-pitched inspiratory sound produced by nasal or palate nasopharyngeal obstruction: snorting Tongue occupies all space in mouth Oral breathing a reflex that doesn’t develop until several weeks after birth Nasopharyngeal airway narrower due to Waldeyer’s ring
Management Strategies Neonatal Nasal Obstruction Observation Neonatal rhinitis Medical treatment to reduce inflammation Choanal atresia/stenosis
Supplemental O2 or CPAP Nasolacrimal duct cysts Bypass the obstruction Pyriform aperture stenosis Oral airway Oral intubation Nasopharyngeal mass Surgery Repair the defect Septal Deviation Tracheotomy
Physical Examination-Neonate Neonatal Nasal Obstruction: Rhinitis of Infancy What is it? Mirror for nasal airflow Constellation of conditions that generates nasal mucosal edema with airway obstruction Headless stethoscope Not uncommon but not well recognized and not well described in literature Catheter Presentation Traumatic Stertor Everyone does this Respiratory difficulty Flexible endoscope Feeding difficulty, failure to thrive
2 Rhinitis of Infancy Rhinitis of Infancy Etiology unclear Diagnosis GERD Milk allergy Boggy, swollen Meconium aspiration turbinates Iatrogenic Clear secretions Aggressive nasal suctioning Stertor improves Maternal medications / drug abuse (transiently) with Antihypertensives, narcotics, -blockers, antidepressants decongestants Infection Chlamydia, Strep, Staph, Viral, Syphilis
Rhinitis of Infancy Choanal Atresia
Treatment Bilateral Atresia Unilateral Atresia Reduce nasal suctioning Present immediately after birth No acute respiratory distress Respiratory distress with Chronic unilateral nasal Saline drops cyanosis discharge Oxymetazoline drops x 3 days Relieved by crying Presents later in life Decadron ophthalmic 0.1% bid x 5-7 days Feeding difficulty GERD precautions / treatment Culture of nasal secretions Occasionally need oral steroids If persists, CT scan
Choanal Atresia Choanal Atresia CT Scan Diagnosis Nasal auscultation Suction nose immediately prior to scan Mirror exam, cotton All with bony component test Lateral nasal wall and pterygoid Mucoid cast Passage of a 5-6 Fr catheter Flexible endoscopy CT scan-mandatory
3 Choanal Atresia Choanal Atresia-Surgical repair Medical emergency Transnasal Stimulate to cry Transpalatal Insert finger Establish an airway Tools: Microdebrider McGovern, cross-cut nipple Drill Oral airway Ureteral sounds Intubation 120 degree telescope Backbiters Work up for associated anomalies Stenting Cardiac 50% Mitomycin CHARGE Syndrome Ciprodex
Nasolacrimal Duct Cysts Anterior pyriform aperture stenosis Presentation Isolated anomaly versus midline defect Nasal obstruction Respiratory distress with stertor Microform of holoprosencephaly but some nasal air flow Pituitary axis abnormalities (different than choanal atresia) Epiphora Mega-incisor PE and CT-Cystic mass in inferior meatus Management Remove endoscopically Presentation: Ophthalmology consult for NLD obstruction Respiratory difficulty Bilateral nasal airflow Difficulty passing catheters or flexible endoscope Narrow nasal vestibule
Anterior pyriform aperture nasal Anterior pyriform aperture stenosis stenosis
Systemic evaluation CT scan Observation Surgical repair involving a sub-labial drill-out of the pyriform aperture
Visvanathan V, Wynne DM. Congenital nasal pyriform aperture stenosis: a report of 10 cases and literature review. Int J Pediatr Otorhinolaryngol 2012; 76: 28-30
4 Nasopharyngeal Mass Encephalocele Neoplasm (Synovial cell carcinoma) Intra-or extranasal Nasofrontal angle Adenoidal hypertrophy Medial in nasal cavity Rare in neonate Don’t biopsy! Encephalocele Bluish, compressible Enlarge with crying Meningitis, CSF leak
Septal Deviation Result of pressure due to intrauterine position Occasionally due to birth trauma Visible with otoscope CT for other anomalies Closed reduction for significant deformity-at bedside Most milder forms self correct by one month
Maternal medication history Stridor Harsh sound caused by turbulent airflow Implies partial airway obstruction
Laryngeal stridor-inspiratory, biphasic
5 Physical Examination Physical Examination Let parent hold child Let parent hold chilMirror for nasal airflow irror for nasal airflow“Headless” stethoscope “Headless” stethoscope Positional changes Mandibular thrust
Where to perform the procedures? Awake flexible laryngoscopy Flexible laryngoscopy Direct laryngoscopy can be done at the and bronchoscopy Assess dynamic status of larynx (*) bedside need to be performed Less controlled than under GA but safe Topical or no anesthetic in OR with experienced endoscopist required General anesthesia No need for NPO status Routine preoperative Lesions below the glottis not well unless not protecting NPO orders visualized airway Exception: ECMO pts Can be present up to 5% of time May also be done in OR can be done in unit Thus more of a screening procedure
Awake flexible laryngoscopy technique Rigid laryngotracheobronchoscopy
Afrin and/or ponticaine to nare for decongestion Investigation of choice for all complex airway as needed lesions Local is often not used as it can induce apneas Highly technical and requires an experienced Endoscope is advanced through the nares and/or team familiar with procedure and neonates mouth (surgeon, anesthesiologist, scrub tech) Suction may be needed to clear secretions Spontaneous ventilation allows dynamic Want to see TVC motion, rule out laryngomalacia, assessment of airway look for masses or other anatomic anomalies, and assess subglottis if possible Topicalization decreases risk of spasm Intubation is avoided if possible
6 Indications for operative endoscopy Laryngoscopy
To establish diagnosis Parson’s ventilating laryngoscope used to assess for TVC motion, masses, cysts, webs, and Severe or progressive stridor posterior laryngeal clefts Allows for improved visualization, ability to ventilate Cyanosis or apnea concerns patient Radiologic abnormalities Rigid telescope helps to magnify findings and allows for photodocumentation Parental or physician anxiety Arytenoid motion checked passively if TVC paralysis is present
Tracheobronchoscopy
Telescope can be advanced through TVC to assess subglottis, trachea, and mainstem bronchi Significant subglottic stenosis would preclude use of bronchoscope Common pathologies Ventilating bronchoscope can be utilized to evaluate to the level of the bronchi Assess for tracheomalacia, vascular rings, complete tracheal rings, stenosis, masses
Laryngomalacia Laryngomalacia
#1 cause of neonatal stridor Endoscopic appearance Inward collapse into laryngeal inlet during inspiration: A-E folds cuneiform cartilage Epiglottis Short A-E folds Omega shaped epiglottis
7 Laryngomalacia Laryngomalacia
Intermittent inspiratory Treat GERD, Vast majority are mild stridor observation in most Do these really need operative endoscopy? Worse with feeds, cases, rarely crying, supine supraglottoplasty Parental reassurance & education Better prone Transient worsening, gradual improvement Indications for OR Weight gain issues 15% associated with Respiratory difficulty GERD issues secondary airway Feeding difficulty lesions Failure to thrive
Discoordinate Severe Laryngomalacia pharyngo-laryngomalacia
Absence of classical laryngomalacia Respiratory difficulty findings Feeding difficulty Prolapse of pharyngeal tissues Failure to thrive Neurologic abnormalities
GERD Often older infants
CNS abnormalities Treatment with trial BiPAP, consider tracheostomy A-E fold division may make airway obstruction worse
Vocal cord paralysis Vocal cord paralysis
#2 most common congenital laryngeal anomaly In the NICU population, cardiac surgery is an Unilateral usually from birth trauma enormous risk factor Often goes unnoticed Weak cry, mild stridor, aspiration Paresis means partial paralysis Bilateral usually from CNS abnormality Indicates nerve is likely intact Generally an airway emergency with better prognosis Normal cry, high pitched insp stridor May need to wait years for Other causes: C-A joint fixation, posterior glottic return of function web/stenosis, infiltrative lesions Swallow study critical to ensure no aspiration
8 Posterior laryngeal cleft Dx with DL and Posterior cricoid esophagram lamina doesn’t fuse Tx with endoscopic vs Associated with T-E open repair Uncommon Pathologies fistulas, laryngomalacia, congenital cardiac dz, CLP, Trisomy 21 Inspiratory stridor, pneumonia, aspiration
Laryngeal Cleft Laryngeal Clefts High index of suspicion needed Types 1-4 Stridor & aspiration problems Assess with microlaryngoscopy 1-observation 2 handed distraction technique 2-endoscopic repair Palpation of interarytenoid region 3-Laryngofissure with buttress and multilayer closure 4-Thoracotomy
Tracheomalacia Tracheomalacia
Tracheal walls are soft and collapse during May be found in conjunction with compressive respiration, causing wheezing, stridor, or both lesions, such as mediastinal masses, vascular May or may not improve with age slings, and vascular rings. Also occurs in some children with chronic If extrathoracic, primarily inspiratory collapse and inflammation of the proximal airways airway sounds Chronic lung disease of infancy, GERD, or other forms of chronic aspiration. If intrathoracic, predominately expiratory collapse and airway sounds (more common) Frequently found after repair of a T-E fistula Diagnose with bronchoscopy Anterior wall collapses posteriorly Rule out vascular ring/sling Assess for tracheal stenosis, foreign bodies
9 Vascular rings Congenital subglottic stenosis #3 most common congenital laryngeal anomaly Biphasic stridor, barking cough, dyspnea with feeding Diameter of <4mm at the cricoid in a full-term infant, Double aortic arch (most common causing stridor) <3mm in a premature infant Right aortic arch Anomalous innominate artery May present as recurrent croup, or if more severe Anomalous L common carotid can cause biphasic stridor Pulmonary artery sling Retroesophageal R subclavian A (most common Rigid endoscopy to establish dx compressing aerodigestive tract) Most improve with age, some require trach and CT, MRI, barium swallow +/- angio laryngotracheal reconstruction Tx with pexy or reimplant of vessel if symptomatic
Congenital Airway Acquired Subglottic stenosis Abnormalities Intubation trauma Glottic webs remains a significant risk factor for acquired Tend to be thick and extend to subglottis stenosis Laryngeal atresia variant 22 q deletion association Reflux management is Rare familial pattern critical Surgical Options Endoscopic vs. Open Keel placement
Subglottic hemangioma Subglottic hemangioma Benign congenital vascular tumor Endoscopic dx without bx: Cellular hyperplasia of endothelial cells, mast cells, lesion is a compressible fibroblasts, and macrophages asymmetric submucosal mass Grow rapidly over the 1st year of life, generally resolve in posterolateral subglottis, with by age 5 bluish or reddish discoloration Typical symptomatology of insp or biphasic stridor +/- Many tx options inc trach barky cough +/- dysphonia (avoid), steroids, laser, endoscopic vs open excision, INF-2a Propranolol
10 Post Intubation Injuries Post Intubation Injuries Anterior commissure web Weak, hoarse cry History Mild-moderate respiratory distress Rx: endoscopic division Intubation--even transient Short term post-op intubation NICU Graduate Mitomycin C Stridor with URI History of recurrent croup or asthma Poor response to standard therapy
Post Intubation Injuries Post Intubation Injuries Posterior glottic injury: progressive changes Interarytenoid web Granulation Difficult problem Ulceration Mistaken for vocal cord paralysis Furrow Assess with MSL using 2 handed distraction technique Posterior Repair: endoscopic division alone Interarytenoid scar rarely successful Mitomycin C Mucosal flap interposition Posterior cricoid expansion
Post Intubation Injuries Post Intubation Injuries Subglottic Cysts Often multiple Subglottic Stenosis Removal Assess entire airway Forceps
Size & grade stenosis Laser (CO2 / KTP) Laryngotracheal reconstruction Microdebrider Treat for GERD
11 Concerns in Airway Surgery Management Approach Surgical Debate Postoperative edema, infection Open vs Endoscopic Long term treatment with steroids Pediatric laryngology All techniques with advantages and disadvantages Extended hospitalizations, intensive care Facility with all techniques Development of newer instruments/techniques Complications: subglottic stenosis, glottic webs Don’t abandon traditional “cold steel” instruments Voice abnormalities Goals Safe and effective means of achieving resolution Reduce pitfalls of current techniques Minimal number of interventions
Synchronous lesions Tracheotomy Not uncommon Not a bad word! Laryngomalacia Avoid a trach, create a crisis! GERD issue Genetic / Syndromic
Pediatric Stridor: Conclusions Conclusion Assess urgency of intervention Small airways can make for big problems Thorough evaluation of the situation: age, history, History and exam often can make diagnosis clinical presentation Anticipate risks and benefit of examination Bedside and/or operative laryngoscopy/bronchoscopy give critical information Relationship with anesthesia critical-spontaneous Flexible nasopharyngoscope, Parsons laryngoscope and ventilation ventilating bronchoscope crucial tools Pediatric endoscopic equipment Many entities do not require ultimate surgical Consider all possibilities, co-morbidities and intervention synchronous lesions
12 Thank you for your attention
Any questions?
13