New Approaches to Managing Airway Disease in Children
Anna K. Meyer, MD, FAAP Assistant Professor Division of Pediatric Otolaryngology University of California, San Francisco
February 2013
• No disclosures
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1 Overview
• Laryngotracheal Stenosis • Laryngomalacia • Airway Hemangioma • Obstructive Sleep Apnea • Vocal Cord Paralysis • EXIT Procedure*
*time-permitting
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Laryngotracheal Stenosis
• NICU management: Prevention – Small ETT – Uncuffed ETT – Reduced Intubation • Limitation of meconium ETT suction • Reduced oxygen delivery • CPAP* • Surfactant – Reducing infection
Jatana, et al., 2010
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• Balloon dilation • Advantage over rigid or bougie dilation – Maximize radial direction – Less shearing vertical damage to airway
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Choanal Atresia
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3 Laryngotracheal Stenosis
• Endoscopic posterior graft • Gerber, et al., 2013: 89% success
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Laryngomalacia
• All that wheezes is not asthma…..
……all noisy breathing is not laryngomalacia.
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4 Stridor: Evaluation
• SPECSR – Severity – Progression/Phase – Eating – Cyanosis/apneas – Sleeping – Radiologic review
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Etiologies of Stridor
• Supralaryngeal • Laryngeal – Pyriform aperture stenosis – Laryngomalacia – Choanal atresia – Vocal cord paralysis – Lacrimal duct cyst – Saccular cysts – Webs – Nasopharyngeal mass – Respiratory papillomas – Facial skeletal abnormalities – Subglottic hemangiomas – Base of tongue mass – Subglottic stenosis – Laryngeal cleft – Adenotonsillar hypertrophy – Foreign body – macroglossia
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5 Etiologies of Stridor
Tracheobronchial – Tracheomalacia, bronchomalacia – Vascular anomalies – Stenosis – Foreign body – TEF – Bronchiolitis, bronchitis
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Evaluation
Flexible laryngoscopy High kilovoltage, magnified airway films Airway fluoroscopy Swallow studies Rigid endoscopy – which patients?
Classic Laryngomalacia Inconsistent with Laryngomalacia Inspiratory-only Stridor Expiratory or biphasic stridor No work of breathing Work of breathing Normal weight gain Poor weight gain No OSA Abnormal AP films Normal AP films Supraglottoplasty
Re-evaluation in one month Rigid endoscopy Mancuso, et al., 1996 12
6 Medical Management
• Reassuring parents of favorable prognosis – Condition is usually self-limiting • Position adjustments – More prominent when supine or agitated • Reflux precautions/medications • Frequent evaluation by pediatrician to assess: – Growth – Feeding – Breathing
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Surgical Indications
• Failure to thrive • Obstructive sleep apnea • Awake persistent apneas/cyanosis • Pulmonary hypertension/Cor pulmonale • Severe reflux • Recurrent aspiration • Disease not spontaneously resolve
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7 Treatment
• Approaches • Laser • Microdebrider • Cold steel • Unilateral vs. bilateral
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Airway Hemangioma
• Beta Blockers
9 weeks old Léauté-Labrèze C et al Post-4 weeks of systemic June 12, 2008
corticosteroids 16
8 10 weeks old post-7 days propranolol
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6 months age steroids discontinued at 2 mos
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9 9 mos age propranolol discontinued
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Airway Hemangioma
At admission 6 days post-propranolol
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10 Airway Hemangioma
• 5-10% non-responders • Traditional approaches: laser, steroids, etc. • Submucous resection
Vijayasekaran, et al., 2006; O- Lee & Messner, 2008 21
Obstructive Sleep Apnea
• Failure of tonsillectomy – SDB often is multifactorial – Effective in 60-70% of children with significant tonsillar hypertrophy – Only effective in 10 – 25% of complex children • Obesity • Retrognathia • Craniofacial syndromes • Neuromuscular disorders
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11 Common Causes of Residual OSA in Children
• Adenoid pad regrowth • Lingual tonsillar hypertrophy • Tongue base collapse • Occult laryngomalacia • Inferior turbinate hypertrophy
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Sleep Endoscopy
Durr, Meyer, Rosbe, 2012; Koltai, 2012 24
12 Treatments
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Tongue Base
• Tongue reduction • Suture suspension • Anterior mandibular osteotomy/genioglo ssus advancement • Mandibular distraction
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13 Vocal cord paralysis
• Acute paralysis – Tracheotomy – Vocal cord suture lateralization – Injection vocal cord augmentation • Long-term/permanent paralysis – Endoscopic posterior graft – Arytenoidectomy – Cordotomy – Thyroplasty – Reinnervation
Chen & Inglis, 2011
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Reversible lateralization
• Lichtenberger, 1983 • Endo-extralaryngeal carrier instrument
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14 Suture Lateralization
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Pediatric Lateralization
Matthur, et al., 2004 30
15 EXIT Procedure
• EX utero Intrapartum Treatment • Defined by interdisciplinary approach
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Cervical Masses
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Congenital High Airway Obstruction Syndrome (CHAOS)
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19 Summary
• More endoscopic approaches • More technology • Earlier interventions • More complex evaluations
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