Stridor In Infants Research Articles

Etiology of Stridor in Infants

We undertook to identify data that facilitate determination of an accurate diagnosis of the cause of stridor in infants and to develop a framework to conceptualize the problem. We reviewed medical records of patients less than 1 year of age with the presenting symptom of stridor who were initially evaluated in the outpatient setting of a tertiary children's hospital. Infants with obvious congenital syndromes, cerebral palsy, or hypotonia were excluded. All infants underwent history-taking, physical examination, and when symptoms were mild, office flexible laryngoscopy. With moderate or severe stridor, a more complete endoscopic evaluation was undertaken in the operating room. Of 202 patients, 119 (59%) were boys and 83 (41%) were girls. Their ages ranged from 3 days to 11 months; 175 (87%) were 6 months of age or younger. Congenital anomalies were diagnosed as the cause of stridor in 170 (84%). Congenital laryngeal anomalies caused stridor in 157 (78%); congenital tracheal abnormalities were the cause in 13 (6%). The most common congenital laryngeal anomaly was laryngomalacia (94%). Forty-two (21%) of the 202 patients had at least 1 other anomaly that contributed to airway compromise. Half of all patients had laryngopharyngeal reflux, the most common associated condition. Of patients referred with a presumptive diagnosis by non-otolaryngologists, 28 of 94 (30%) were referred with erroneous presumptive diagnoses for which they were being treated, the most common of which was tracheomalacia. A standard, rational approach to the evaluation of stridor in infants facilitates management. A framework for evaluation is presented.

A variant of laryngomalacia in the neurologically normal older child

Laryngomalacia is the most common cause of stridor in infancy. It is generally considered to be a fairly benign condition necessitating surgical intervention in relatively few cases. It resolves by the age of 4 years in the majority of children. We present three cases in which laryngomalacia persisted and actually worsened in later childhood and postulate a possible mechanism for this.

Subglottic cysts in children: A 10-year review

Subglottic cysts are associated with prematurity and periods of early neonatal intubation and are a rare cause of infant stridor. In this study we analyse our experience of this rare but important problem. We discuss the aetiology, diagnosis and management of subglottic cysts. We carried out a retrospective review of all cases of subglottic cysts presenting to the otorhinolaryngology department at the Leeds teaching hospitals trust during the period between 1995 and 2005. In total seven patients were identified. A retrospective review of the case notes of all patients proven to have subglottic cysts at direct laryngoscopy and bronchoscopy was undertaken. Seven patients were identified, four males and three females. Five were born premature (24-31 weeks). All were intubated with average intubation period of 20.6 days. Six of our patients' underwent endoscopic marsupialisation using cup forceps and one with a contact diode laser. Two patients had recurrence of the cyst and had a repeat of endoscopic marsupialisation. This study highlights the associated risk of neonatal intubation with the risk of formation of subglottic cysts, and the need for early diagnosis and appropriate treatment to avoid unnecessary morbidity.

Congenital Laryngeal Saccular Cyst: Report of a Case in an Infant

Respiratory obstruction and stridor in infants and children are not uncommon. A rare cause of these life-threatening symptoms is congenital saccular cyst. An accurate diagnosis of saccular cyst can be made by eliciting a good history, by endoscopic visualization of the lesion, and by computed tomography. Endoscopic excision is the preferred treatment for infants, whereas an external approach is reserved for older children. It can be difficult for anesthetists to intubate infants when the anatomy of the larynx is distorted, but the choice of tracheotomy for an infant has many drawbacks as well. We discuss the clinical presentation and management of a 3-month-old boy who was brought to us with a congenital laryngeal saccular cyst.

Aryepiglottoplasty for laryngomalacia: the Alder Hey experience

Laryngomalacia is the most common cause of stridor in infants. Severely affected children are at risk of feeding difficulties, apnoeic episodes and cor pulmonale secondary to upper airway obstruction. The aim of this study was to assess the outcome of aryepiglottoplasty. This is a simple surgical procedure that relieves the obstruction by dividing the aryepiglottic folds. Thirty children had an aryepiglottoplasty at the Royal Liverpool Children's Hospital between January 1995 and June 2001. The case notes of all 30 children were reviewed for age, sex, age at operation, indications, operative technique, complications and long-term outcomes. Complete resolution of stridor was obtained in 83 per cent of patients, with an improvement in a further 7 per cent. Post-operative complications included lower respiratory tract infections (13 per cent) and vomiting (7 per cent). In conclusion, simple endoscopic aryepiglottoplasty remains an effective way of treating upper airway obstruction in children. Its high resolution and low complication rate make it a safe, first choice procedure for treatment of moderate to severe laryngomalacia.

An unusual case of laryngomalacia presenting as asthma refractory to therapy

Laryngomalacia is the most common cause of stridor in infants, but few reports exist of clinically relevant laryngomalacia in adults. To present and discuss an unusual late presentation of laryngomalacia and its significance in the evaluation and management of asthma. An 18-year-old woman presented to an academic medical center with symptoms of "wheezing" on inspiration and exertion, with relatively normal spirometric findings. She was clinically diagnosed as having asthma at the age of 13 years, but her symptoms were poorly controlled by maximal medical therapy. Further evaluation with rhinolaryngoscopy demonstrated laryngomalacia characterized by redundant soft tissue overlying the right arytenoid cartilage and aryepiglottic fold. The patient demonstrated positive bronchoprovocation, with a 33% decrease in forced expiratory volume in 1 second after the administration of histamine, 1 mg/mL. However, with the otolaryngology evaluation, it was determined that her laryngeal findings were clinically significant. She subsequently underwent operative laryngoscopy with carbon dioxide laser excision of the laryngeal abnormality, resulting in improvement in her symptoms and a marked decrease in her need for asthma medication. We report an unusual case of laryngomalacia presenting as asthma that was successfully treated with laser surgical excision. This case emphasizes the necessity of differentiating classic wheezing from stridor and upper airway obstruction.

Outcome of vocal cord paralysis in infants.

Although laryngomalacia is the leading cause of stridor in infancy, vocal cord paralysis, despite its low incidence, is still the second most common cause. However, the etiology of infant vocal cord paralysis is different from that of adults, and the management protocol is controversial. Therefore, we conducted this study to better characterize the cause and outcome of vocal cord paralysis in infants. From January 1997 to December 2003, we treated thirteen infants younger than one year for vocal cord paralysis. Seven infants were idiopathic (idiopathic group), two might be caused by prior surgery (iatrogenic group), two might be caused by central neuropathy (neurological group), and two were born after difficult delivery (obstetrical group). In the idiopathic group, six infants spontaneously recovered and one infant had right-side recovery, but the left side was still paralytic. All infants in the iatrogenic and obstetrical groups spontaneously recovered. However, no infant in the neurological group recovered. Spontaneous recovery occurred in 76.9% of affected infants. More than half (70%) of these spontaneous recoveries occurred within 6 months. In our experience, direct flexible laryngoscopy is mandatory for all infants younger than one year of age presenting with stridor. Except for extreme infants (e. g. bilateral vocal cord paralysis with severe respiratory distress and central neuropathy) who require a temporary tracheotomy to relieve the airway obstruction, we recommend waiting for at least 6 months before proceeding to invasive surgical interventions.

Microaspiration in infants with laryngomalacia.

Laryngomalacia is the most common congenital laryngeal anomaly and the most frequent cause of stridor in infants. Infants with laryngomalacia may have associated respiratory symptoms other than stridor. In this study, we evaluated whether infants with laryngomalacia have episodes of microaspiration by calculating the amount of lipids present in the alveolar macrophages. We reviewed bronchoalveolar lavage (BAL) findings obtained in 14 infants with laryngomalacia and in 11 control children. BAL was performed during flexible fiberoptic bronchoscopy (FFB) to diagnose persistent stridor. The presence of microaspiration was determined by evaluating the amount of lipid per single macrophage, assigning each cell a score from 0 to 4 according to the amount of lipid in the cytoplasm. The lipid-laden macrophage index was similar in patients and controls (31.5, range 12-177 vs. 45, range 35-106). In 5 of the 14 (36%) patients the index exceeded 100, and more than 25% of the cells were graded 3 and 4, indicating the presence of microaspiration. The lipid-laden macrophage index correlated significantly with the number and percentage of BAL neutrophils (Pearson correlation test, r = 0.83, P < .001 and r = 0.925, P < .001) as a marker of lung inflammation. Infants with laryngomalacia may have episodes of microaspiration. BAL performed during FFB to evaluate stridor may add helpful therapeutic information without increasing the risks of the procedure.

Laryngeal myxedema: An unusual etiology of infant stridor

Objectives: We report the clinical findings of a child with laryngeal myxedema and stridor due to untreated congenital hypothyroidism. A review of the literature regarding the incidence, radiologic findings, and clinical characteristics of this rare, but life-threatening disease are presented. Methods: Case presentation of a 7-month-old infant from Micronesia who presented to our service with stridor and severe hypoxemia. The clinical features of untreated congenital hypothyroidism will be presented along with a review of the literature. Results: A 7-month-old male was admitted to the pediatric service for stridor and hypoxemia. Examination of the infant revealed biphasic stridor in all positions, reduced oxygen saturation on room air, retractions, and grunting. On nasopharyngoscopic exam, the patient had diffuse edema of the larynx and supraglottis that obscured the normal anatomy. He also had diffuse hypotonia and generalized weakness. Thyroid function tests were obtained, and the patient was found to have severe hypothyroidism. He was started on levothyroxine therapy, and subsequently had a decrease in his laryngeal edema and improvement in his oxygenation. Conclusion: Although most stridor in infants is due to laryngomalacia, vocal cord paralysis, or congenital subglottic stenosis, less common etiologies are still encountered and must be kept within a broad differential diagnosis in order to achieve appropriate patient care.

Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta-analysis.

OBJECTIVE: To determine whether corticosteroids are effective in preventing or treating postextubation stridor and in reducing the need for subsequent reintubation of the trachea in critically ill infants and children. DESIGN: Meta-analysis of published randomized controlled trials. DATA SOURCES: References of each trial from a MEDLINE search were reviewed, and experts in the field were contacted. STUDY SELECTION: Any randomized controlled trial comparing the administration of corticosteroids with placebo on the prevalence of reintubation or postextubation stridor in infants or children receiving mechanical ventilation via an endotracheal tube in an intensive care unit. DATA EXTRACTION: Data extraction and methodologic quality assessment were assessed independently by two reviewers. DATA SYNTHESIS: Six controlled clinical trials met the criteria for inclusion; three trials pertain to neonates and three to children. Five trials examined the use of steroids for the prevention of reintubation (four of these evaluated postextubation stridor specifically); one trial examined the use of steroids to treat existing postextubation stridor in children. There was a nonsignificant trend toward a decreased rate of reintubation in all subjects when prophylactic steroids were used (n = 376, relative risk [RR] = 0.34, 95% confidence interval [CI] = 0.05-2.33). Prophylactic use of steroids reduced postextubation stridor in the pooled studies (n = 325, RR = 0.50, 95% CI = 0.28-0.88). In young children, there were significant reductions of postextubation stridor with preventive treatment (n = 216, RR = 0.53, 95% CI = 0.28-0.97), and a trend toward less stridor was observed in neonates (n = 109, RR = 0.42, 95% CI = 0.07-2.32). There was a nonsignificant trend toward a reduced reintubation rate when steroids were used to treat existing upper airway obstruction requiring reintubation (RR = 0.55, 95% CI = 0.17-1.78). Side effects were seldom reported and could not be evaluated. CONCLUSIONS: Prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation.

The role of fibreoptic laryngoscopy in infants with stridor

Stridor in infants may be potentially serious and would require further investigations in all cases. Laryngomalacia is the most common cause of congenital stridor. This is a self-limiting condition with a good prognosis but other causes of stridor should be excluded to enable the surgeon to plan further intervention if needed. Traditionally microlaryngoscopy and bronchoscopy under a general anaesthetic is performed to evaluate the airway. We have investigated the use of the flexible fibreoptic laryngoscope under local anaesthetics in infants with inspiratory stridor. The procedure was performed in the day surgery unit on a non-fasting, non-sedated child. A retrospective analysis of procedures performed between January 1998 and August 1999 was carried out. Of the 43 patients studied, laryngomalacia was diagnosed in 35, vocal cord palsies in six and two infants had a normal larynx. There were no complications during the procedure and only one child required further intervention. The results showed that the combination of fibreoptic laryngoscopy under local anaesthetic with follow-up is a safe, effective and cost effective method of assessing stridor in this group of patients.

Stridor and Upper Airway Obstruction in Children

Stridor is a high-pitched, crowing noise typically heard on inspiration and generally indicative of upper airway obstruction. Because it may indicate critical reduction in air and,thus, oxygen delivery, it must be assessed promptly and addressed with utmost urgency when airway compromise is imminent.The evaluation includes a brief history (duration and acuity;presence of fever; birth, neonatal, and airway instrumentation history;possibility of foreign body) and physical examination best undertaken with the child in the parent’s lap and with the chest visible. It is important to determine the character of the respiratory pattern (eg, sounds of breathing, distress, retractions,flaring, hoarseness) and to observe for anxiety, cyanosis, posturing,swallowing, or drooling.The pattern of stridor helps to localize the lesion. Inspiratory stridor is at or above the vocal cords and is due to the collapse of the soft tissues with negative pressure during inspiration. Analogous to wheezing,expiratory stridor occurs because of decreased airway caliber with expiration and emanates from the intrathoracic trachea and bronchi. Biphasic stridor, which occurs on inspiration and expiration, indicates unchanging airway caliber due to a fixed lesion, generally related to edema at and near the cricoid cartilage that encircles the trachea.Because neonatal breathing is predominantly nasal, nasal obstruction is evident soon after birth. Choanal atresia is bilateral in about one third of infants and presents with severe respiratory distress. Unilateral choanal atresia may not be identified for years. Diagnosis is made by failure to pass a catheter through the nares. Fifty percent of cases are associated with other anomalies(eg, CHARGE syndrome). Birth-related septal deviation also may present in infancy, but it resolves with modest manipulation.Stridor in infants most commonly is due to inspiratory collapse of the laryngeal cartilage with laryngomalacia, which appears in the first month of life and often resolves by 1 to 2 years of age. It may be associated with tracheomalacia, a partial collapse of tracheal cartilage with respiration. Vocal cord paralysis, the second most common cause of stridor in infants, is usually due to central nervous system lesions(eg, Arnold-Chiari malformation,raised intracranial pressure, other brainstem insults) or traction on the recurrent laryngeal nerve (often a birth complication). Other neonatal lesions include a small cricoid cartilage, acquired subglottic stenosis such as a complication of intubation,subglottic and laryngeal cysts or webs, tracheal rings, and subglottic hemangiomas.Croup and its variants are the infectious causes of stridor. Croup(laryngotracheobronchitis) most commonly is caused by parainfluenza virus (types 1 and 3), influenza A virus, respiratory syncytial virus,and adenovirus in children younger than age 3. Croup results from subglottic inflammatory edema. Because the vocal cords are spared, the voice often is normal and the stridor is biphasic. There is a barking cough,but no drooling or difficulty swallowing is apparent. There is accumulating evidence that steroids administered by various routes,including inhalation, can decrease hospitalization rates, shorten the disease course, and reduce the incidence of intubation for airway support. An infrequent but not rare variant is recurrent or spasmodic croup. Still not well understood, this entity may represent some combination of allergic or structural abnormality.Epiglottitis or supraglottitis presents as acute, rapidly progressive cellulitis of the epiglottis and hypopharynx, with inflammatory swelling and a risk of complete airway obstruction in children 2 to 6 years of age. The child drools, leans forward, hyperextends the neck, and has a sore throat and fever. Aggressive, prompt management of the airway is essential. Care must be taken to avoid increasing the child’s anxiety, procedures should be minimized, and the oral examination should be avoided. The differential diagnosis of croup and epiglottitis is crucial. The polysaccharide conjugated Haemophilus influenzae type b vaccine has all but eradicated this life-threatening disorder in the United StatesBacterial tracheitis, a superinfectious complication of airway alteration consequent to recent viral infection, most commonly is due to Staphylococcus aureus, but it also may be caused by Moraxella catarrhalis, Streptococcus pneumoniae, and nontypeable H influenzae.Other upper airway obstructive infections that may not present with stridor include tonsillitis (especially infectious mononucleosis),retropharyngeal abscess, and peritonsillar abscess.The presence of a foreign body always must be considered at the presentation of stridor and upper airway obstruction and must be reconsidered when symptoms do not resolve according to expectations. Some objects are not radio-opaque and, thus, present a challenge to radiologists. One consequence of the epidemic of human papillomavirus infection among sexually active youth and adults is that their offspring may acquire this virus during birth, leading in the first few years of life to recurrent respiratory papilloma in the larynx or elsewhere in the upper airway. Other considerations in the etiology of stridor include gastroesophageal reflux,corrosive ingestion, angioedema, and candidiasis. Like other common clinical syndromes, with stridor it is important to understand the horses while keeping the zebras in mind.

Surgical management of laryngomalacia

Laryngomalacia is the most common cause of stridor in infants and occasionally also manifests in older patients. Although a self-limited condition a small group of patients with laryngomalacia require surgical intervention for relief of their airway obstruction. A careful preoperative evaluation is necessary to determine the type of laryngomalacia present so that the appropriate type of supraglottoplasty is performed. The overall success of supraglottoplasty is excellent and prevents the necessity of tracheotomy for patients requiring surgical intervention.

DIAGNOSIS OF ANOMALOUS INNOMINATE ARTERY SYNDROME BY SPIRAL CT WITH 3D RECONSTRUCTION OF THE AIRWAY : REPORT OF ONE CASE

Stridor in infants is a symptom that indicates partial obstruction of the large airways. Vascular rings are an unusual cause of tracheal compression which can induce stridor in infants and children. We report a 4-month-old boy with recurrent wheezing and stridor for 2 months. Spiral computed tomography (CT) and three-dimensional (3D) reconstruction aided in the diagnosis of external compression on the trachea by an innominate artery. Successful relief of the airway’s obstruction was achieved by aortopexy. Three months after surgery, he was symptom free without any medication.

Two Cases of Retropharyngeal Abscess with Fever and Stridor in Infants

Two Cases of Retropharyngeal Abscess with Fever and Stridor in Infants

Recessive epidermolysis bullosa simplex associated with plectin mutations: infantile respiratory complications in two unrelated cases

Plectin is a 500 kDa protein involved in cytoskeleton-plasma membrane attachment with a wide tissue distribution including cutaneous and airway epithelia, muscle and neuronal tissue. Recently, mutations in the gene encoding plectin (PLEC1) have been implicated in the pathogenesis of an autosomal recessive variant of epidermolysis bullosa simplex in which cutaneous blistering starting in the neonatal period is associated with muscular dystrophy in later life. In this study, we report two unrelated patients, both of consanguineous parentage, who presented with cutaneous blistering and a hoarse cry from birth. Both experienced inspiratory stridor and respiratory distress, necessitating emergency tracheostomy in one case. Immunoreactivity to monoclonal antibodies against plectin was absent or markedly reduced in skin biopsies from both patients. Electron microscopy revealed a low intraepidermal plane of cleavage and hypoplastic hemidesmosomes with a reduced association with keratin intermediate filaments. Direct sequencing of PLEC1 in each case demonstrated two novel homozygous frameshift deletion mutations, 5069del19 and 5905del2, which both create downstream premature termination codons. Although currently neither patient has symptoms of muscle disease, the identification of mutations in PLEC1 may be predictive for the future development of muscular dystrophy. Recessive epidermolysis bullosa simplex resulting from abnormalities in plectin should be considered in the differential diagnosis blistering, hoarseness and stridor in infancy.

STRIDOR IN NEONATES

Stridor in neonates and infants is a symptom that indicates partial obstruction of the large diameter airways. Its presence should prompt a thorough examination and workup. Steps in evaluating stridor include a careful history and physical examination and rapid assessment of the severity of the clinical situation. Infants with respiratory distress and severe stridor should be safely and urgently transported to a tertiary care center, and colleagues from the departments of otolaryngology and anesthesia-critical care should be alerted. An essential component of the physical examination is auscultation. The phase of respiration in which the stridor is heard best provides important clues to help localize its cause. Radiographs, including plain films, dynamic fluoroscopic airway films, contrast esophagography, CT, and MR imaging are useful in specific clinical situations, based on the likely differential diagnosis. The anatomic causes for stridor in infants and neonates are vast. Successful management depends on expert consultation, proper equipment, and a staff that is experienced in the management of pediatric airway problems. The trend over the past decade has been to significantly decrease morbidity and mortality and also to decrease the number of tracheotomies necessary to stabilize pediatric airways. The best treatment outcomes result when there is good cooperation and communication among pediatricians, otolaryngologists, pulmonologists, and anesthesiologists.

Pediatric exercise-induced laryngomalacia.

Laryngomalacia is a well-recognized cause of airway obstruction and inspiratory stridor in infants. As children grow and become more active, laryngomalacia may manifest in different, unexpected ways. Otherwise healthy athletes may generate enough inspiratory force to draw the aryepiglottic folds into the endolarynx, causing a subtotal glottic obstruction. This problem may be overlooked or attributed to asthma, lack of fitness, or functional abnormalities. The purpose of this report is to review the prevalence, diagnosis, and treatment of exercise-induced laryngomalacia (EIL) in children and young adults. To study the incidence and diagnosis of this disorder, we examined 10 healthy volunteers. Fiberoptic laryngoscopy was used to videotape each subject's larynx during active exercise on a stationary bicycle. All volunteers demonstrated altered laryngeal dynamics with exercise, and 1 of the 10 volunteers developed laryngomalacia. Anatomically, it appears that the aryepiglottic fold serves as the critical point of obstruction. When symptomatic, laryngomalacia may be treated with supraglottoplasty. We have had experience with 2 EIL patients in the last 12 months who have undergone carbon dioxide laser microlaryngoscopy. Both patients benefited significantly from surgery. We conclude that EIL is underdiagnosed but responds well to treatment.

Radiographic evaluation of a subglottic cyst in an infant

The complete evaluation of stridor in infants requires a careful history and physical examination, and appropriate radiographic studies. Examination of the upper airway is appropriate in symptomatic patients. Premature infants are especially at risk for subglottic mucosal injury if intubation is required. Compromise of the subglottic space by various lesions may result in biphasic stridor due to a fixed obstruction, and other symptoms may include recurrent croup, cyanosis, apnea, feeding difficulty, and failure to thrive. Although not diagnostic, soft tissue radiographs of the neck may aid in suggesting a diagnosis before endoscopy.

Laser laryngoplasty for laryngomalacia

Laryngomalacia is the most common cause of stridor in infants. In severe cases, it results in obstructive sleep apnea, cor pulmonale, gastroesophageal reflux, failure to thrive, and pectus excavatum. Our experience with 24 children who underwent laser excision of redundant supraglottic tissue from May 1987 to July 1991 is reviewed. The technique emphasizes preoperative planning with flexible fiberoptic laryngoscopy, apneic anesthetic for the procedure, conservative resection of tissue and the need for complete airway evaluation. In our series, 71% of patients experienced complete resolution of symptoms. Nine of 10 postoperative sleep studies indicated improvement. In 4 patients, collapse developed later in other areas of the supraglottis, resulting in recurrence of stridor several months after the initial procedure, and requiring revision laryngoplasty. In several patients with other significant sites of upper airway obstruction (e.g., tonsils and adenoids, and a tongue base cyst), laryngomalacia became more significant following alleviation of the primary source of airway obstruction. Twelve patients (50%) required additional airway procedures either before or following initial laryngoplasty. Patient selection, sleep study data, and complications are reviewed.