Vocal Cord Paralysis Difficult problem, difficult diagnosis Stridor at birth-worse with feeding, crying May have history of difficult or forceps delivery, but not always Post cardiac surgery Assessment includes CXR, CNS Often need repetitive flexible bedside laryngoscopy to assess vocal cord motion Often needs operative endoscopy
Vocal Cord Paralysis Bilateral: Airway issues, Aspiration issues Expectant (can take years to resolve) Close monitoring of O 2 sat, apnea, weight gain Tracheotomy Posterior laryngeal expansion Botox (for spastic paralysis) Cordotomy Arytenoidectomy Re-innervation procedures Unilateral: Voice Issues, Aspiration Issues Observation Vocal Cord Injection Multiple approaches Thyroplasty
Congenital Airway Abnormalities: Anterior Glottic Web Glottic webs Tend to be thick and extend to subglottis Laryngeal atresia variant 22 q deletion association Rare familial pattern Surgical Options Endoscopic vs. Open Keel placement
Congenital Airway Abnormalities: Laryngeal Clefts High index of suspicion needed Stridor & aspiration problems Assess with microlaryngoscopy 2 handed distraction technique Palpation of interarytenoid region
Congenital Airway Abnormalities: Laryngeal Cleft Laryngeal cleft: types 1 -4 1 -observation 2 -endoscopic repair 3 -Laryngofissure with buttress and multilayer closure 4 -Thoracotomy
Congenital Airway Abnormalities: Vascular Rings and Slings Innominate artery compression “Pulsatile” tracheomalacia “Dying spells” ? vascular ring – esophagram, MRI, CT Bronchoscopy – fishmouth appearance Repair - Aortopexy
Recurrent Respiratory Papillomatosis History Hoarseness May have history “asthma” recurrent croup Correct diagnosis generally made years after onset of symptoms Usually identified around age 3 Has been found in neonates Must ask about maternal vaginal condylomata If preadolescent, think about sexual abuse Office NPL or 1
Recurrent Respiratory Papillomatosis: Particular Challenges Frequent recurrence Spread of disease 6 -13% to distal airways 2 -7% to lungs Devastating impact Surgical extirpation rarely curative No predictive therapeutic intervention available Malignant transformation in 1 -4%
Recurrent Respiratory Papillomatosis: General Treatment Principles Communicate with anesthesia Interval debulking for airway and voice LASER, Forceps, Microdebrider, Conservative approach (“First do no harm”) Counsel parents Protect anterior commissure Avoid tracheostomy Aims: reduce tumor burden decrease spread of disease create a safe and patent airway preserve voice quality increase interval between surgical procedures
Severe RRP- Cidofovir View at initial endoscopy (s/p 4 procedures elsewhere) View at 1 st cidofovir injection (s/p 11 monthly procedures)
Cidofovir Impact
RRP and Cidofovir Often see dramatic initial response Disease that persists/recurs after cessation of cidofovir often is less extensive and easier to control with some individuals progressing to lasting remission Can achieve prolonged remission in many, but not a universal “cure all” Patient selection- Major benefit is control of “severe disease” (those patients requiring repetitive surgery or with airway risk) The current histological and blood chemistry information is reassuring No liver or kidney toxicity noted Malignant transformation may occur-especially in adults; use with caution and reason
Foreign Bodies. Airway History is key There may not be witnessed event If witnessed, have parents bring similar object Signs: Transient/ Unilateral wheeze Barky cough, Hoarseness, Intermittent dyspnea Clinical Stages Acute choking/ gagging episode Asymptomatic interval- FB becomes lodged/ reflexes become fatigued Complications- Erosion/ Obstruction/ Infection
Foreign Bodies. Airway
Foreign Bodies. Esophageal Can cause respiratory distress Carefully review Xray Repeat Xray immediately before OR Warn parents – foreign body may pass with anesthesia Look for more than one foreign body Esophageal edema can be considerable
Foreign Bodies. Esophageal
Gastroesophageal Reflux Disease Airway issues High index of suspicion “Silent” GERD vs. Classic symptoms Pediatric Airway Manifestations of Gastroesophageal Reflux Deborah M. Burton, M. D. Seth M. Pransky, M. D. Richard Katz, M. D. Donald B. Kearns, M. D. Allan B. Seid, M. D. Annals Otol Rhinol Laryngol Sept 1992
Gastroesophageal Reflux Disease Classic symptoms Emesis Dysphagia Burping Choking Gagging Rumination Irritability “colic” Arching Torticollis Sleep disturbance Magit/Pransky: AAO Stridor 2007
Multiple ENT Minfestations of Extra-esophageal Reflux -Rhinitis of infancy -Recurrent Otitis -Chronic Sinusitis -Stertor / Stridor -Hoarseness -Chronic cough (especially nocturnal) -Halitosis -Laryngospasm / Apnea -Severe Laryngomalacia -Recurrent Croup -Subglottic stenosis exacerbation -Recurrent Bronchitis -Asthma exacerbation
Gastroesophageal Reflux Disease Non-operative Assessment: Often not very conclusive or accurate Radiologic p. H probe: double lumen Newer pharyngeal probes Empiric treatment if clinical picture suggestive of GERD
Gastroesophageal Reflux Disease Operative Assessment DL&B Mucosal changes Biopsy Tracheal aspirate for LLM EGD with biopsy
Eosinophilic Esophagitis Symptoms similar to GERD No response to GERD Rx EGD with biopsy distal esophagus Eosinophilic infiltrate Allergy evaluation-esp foods Dietary manipulation Inhaled steroids (swallowed)
Gastroesophageal Reflux Extra-Esophageal Reflux Connect refractory or unexplained airway symptoms to acid reflux Prophylactic treatment before and after airway surgery
Tracheostomy Not a bad word! Avoid a trach, create a crisis!
Pediatric Stridor: Conclusions Assess urgency of intervention Thorough evaluation of the situation: age, history, clinical presentation Anticipate risks and benefit of examination Relationship with anesthesia critical-spontaneous ventilation Pediatric endoscopic equipment Consider all possibilities, co-morbidities and synchronous lesions
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