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Review Article Upper Airway Obstruction in Children Pediatric Anesthesia 2009 19 (Suppl. 1): 88–99 doi:10.1111/j.1460-9592.2009.03005.x Review article Upper airway obstruction in children IAIN A. BRUCE MD, FRCS (ORL-HNS) AND MICHAEL P. ROTHERA FRCS Department of Paediatric ENT, Royal Manchester Children’s Hospital, Manchester, UK Introduction redundant arytenoid mucosa prolapsing into the glottis and a long curled epiglottis (Figure 2). Surgical Poiseuille’s law is central to the understanding and management of the condition is largely based on management of all airway obstructions in children, correction of these anatomical anomalies. The natural with the clinical impact of even a small reduction in history of the inspiratory stridor is to often worsen radius being compounded by the inverse relation- initially for 6–9 months, before gradually improving, ship of the resistance to the radius to the power 4. with most children being free of symptoms by Indeed deterioration from a ‘mild’ obstruction to life 18–24 months (1). In the absence of atypical symp- threatening airway compromise may be heralded by toms (e.g. cyanosis, altered cry, choking with feeds), slight decrease in airway diameter (Figure 1). Suc- which could suggest an alternative diagnosis or the cessful outcome in all cases of childhood airway presence of synchronous lesions elsewhere in the obstruction is dependant upon the efficient cooper- airway, the condition may be diagnosed by awake ation between suitably experienced otolaryngolo- flexible fibreoptic laryngoscopy (FFL) in the outpa- gists, anesthetists, and intensivists. tient department. Laryngomalacia can be classified The aim of this article is to discuss the presenta- into three types dependant on site of the abnormality tion, assessment, and management of the common (1). Type 1 is due to prolapse of redundant arytenoid causes of childhood airway obstruction as seen in a mucosa into the glottis. Type 2 is a result of short tertiary level unit. Traditionally, airway manage- aryepiglottic folds and Type 3 is characterized by ment often comprised tracheostomy insertion, but collapse of the epiglottis posteriorly over the glottis. It the development of endoscopic techniques has is our departmental policy to perform rigid endos- superseded this in an ever increasing proportion of copy in the following circumstances: (i) severe pro- cases. Treatment strategies and principles will be gressive symptoms; (ii) atypical symptoms; (iii) FFL highlighted and placed in context with results inconclusive; and (iv) clinical or fibreoptic suspicion reported in the literature. of a synchronous airway lesion (SAL). The possibility of an SAL has lead some authors to advocate rigid Laryngomalacia endoscopy in all cases of suspected laryngomalacia (2). However, although the rate of SALs in the Laryngomalacia is the commonest cause of congenital literature is significant (20–30%) (1, 3, 4) the impact stridor. The presenting symptom is usually inspira- upon outcome and time to symptom resolution has tory stridor commencing within the first 2 weeks of been shown to be negligible (3, 4). Laryngomalacia, life, exacerbated by feeding, agitation, and lying in the like vocal cord palsy (VCP), is a dynamic condition supine position. The airway obstruction results from and therefore, if formal airway assessment is collapse of supraglottic structures on inspiration. The indicated, it should be performed under general etiology is not fully understood, but the condition is anesthesia with the child breathing spontaneously. consistently associated with certain anatomical Supraglottic collapse is most obvious during the abnormalities, namely short aryepiglottic folds, ‘waking phase’ at the end of the procedure. The majority of children will not require surgical Correspondence to: Iain A. Bruce, Department of Paediatric ENT, Royal Manchester Children’s Hospital, Manchester, UK (email: intervention, with the remaining 5–10% requiring [email protected]). some form of surgical treatment (1, 4). Surgical Ó 2009 The Authors 88 Journal compilation Ó 2009 Blackwell Publishing Ltd UPPER AIRWAY OBSTRUCTION IN CHILDREN 89 Figure 3 Figure 1 ‘Cold steel’ aryepiglottoplasty in laryngomalacia. Illustration of the increase in airway resistance with decrease in airway diameter. being a causal factor. A neurological form of the condition exists and may be seen in children with neurological or neuromuscular conditions, such as cerebral palsy. In such cases, surgical intervention should be approached with caution and it may be most appropriate to manage severe airway collapse with a tracheostomy. Vocal cord palsy Vocal cord palsy is a relatively common cause of airway obstruction in children that may be idio- pathic, iatrogenic, as a result of a neurological abnormality or birth trauma (8,9). Unilateral VCP presents with stridor, breathy cry (or voice) and feeding difficulties from birth or following surgical Figure 2 procedures in the thorax. The symptoms are often Supraglottic collapse in laryngomalacia. relatively mild and resolution of symptoms can usually be expected as compensation from the options include division of the aryepiglottic folds to contra-lateral vocal cord ensues over a period of ‘open’ the constricted supraglottis (Figure 3), resec- months. FFL in the awake child is often all that is tion of the redundant mucosa and suspension of the required to diagnose the problem in the absence of prolapsing epiglottis to uncover the laryngeal intro- other symptoms. Radiological assessment is also itus (5,6). Rates of complete resolution of stridor of important in both unilateral and bilateral VCP in over 80% have been reported following aryepiglot- order to diagnose associated central nervous system toplasty (6,7). A degree of gastro-esophageal reflux (e.g. Arnold-Chiari malformation) (10,11) and car- disease (GERD) is often associated with laryngoma- diovascular abnormalities (12). Supportive treatment lacia and all children should therefore receive anti- alone is often sufficient in unilateral VCP, with reflux medication (3). The exact relationship is not feeding via a nasogastric tube until the child devel- fully understood (1), with GERD possibly reflecting ops a ‘safe’ swallow and possibly chest physiother- changes in airway and intrathoracic pressures in apy until an adequate cough is obtained. Bilateral response to the airway obstruction, as opposed to VCP presents a far greater clinical challenge and can Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19 (Suppl. 1), 88–99 90 I.A. BRUCE AND M.P. ROTHERA cause potentially life-threatening airway obstruction. Dysphonia is not usually found in bilateral VCP (8,11). Tracheostomy insertion may be required in the emergency situation to safeguard the airway. Tracheostomy may be necessary in approximately half of cases of bilateral VCP (8). Magnetic resonance imaging of the brain in cases of bilateral VCP is mandatory in order to exclude an Arnold-Chiari malformation with hydrocephalus (10). Diagnosis is once more by rigid airway endoscopy, under general anesthesia with spontaneous ventilation, and cord mobility is best assessed during the waking phase. Care should be taken to also assess passive vocal cord movements in order to diagnose cord immo- bility due to crico-arytenoid fixation (9), complicat- ing prolonged intubation or intubation injury to the larynx. Vocal cord mobility may return to some degree in patients with VCP. Spontaneous recovery rates of up to 70% are reported (8) and therefore an Figure 4 interval of at least a year should be given before an Airway enlargement by laser arytenoidectomy in bilateral vocal cord palsy. E, epiglottis; VF, vocal fold; VP, vocal process of airway widening procedure is undertaken, with CO2 arytenoid cartilage; MP, muscular process of arytenoids cartilage; laser being the treatment modality of choice (9,11). AEF, aryepiglottic fold. Ultimately the aim of surgical treatment is to provide an adequate airway, facilitating tracheos- Virus types 6 and 11. Proliferations involving the tomy decannulation where present, while safeguard- larynx may present with childhood hoarseness and ing the best possible voice quality (9). Laser symptoms of progressive airway obstruction (Fig- arytenoidectomy has been shown to meet both of ure 5). Involvement of the tracheobronchial tree will these criteria in a study of six children from the also lead to airway obstruction and usually presents Great Ormond Street Hospital, in London (9). The a more significant management problem. The recur- improvement in airway was sufficient to facilitate rent nature of this condition often necessitates decannulation in the four children with tracheosto- multiple surgical procedures. mies preoperatively (9). A CO2 laser is used to widen The current management philosophy is toward a the airway by resecting the vocal process and part of more conservative approach, aimed at ameliorating the body of arytenoid cartilage on one side, paying airway symptoms while limiting subsequent scar- attention not to damage the membranous anterior ring of the larynx. Younger age at diagnosis has been 2 ⁄ 3 of the vocal cord (Figure 4). Improvement in shown to be a negative prognostic factor for remis- vocal cord function in idiopathic bilateral VCP can sion (14). Surgical debulking is the treatment of occur up to approximately 10 years of age and choice and several modalities have been used, therefore in such cases an endoscopic airway wid- including ‘cold steel’, microdebrider, CO2 laser and ening procedure should be delayed
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