Stridor Research Articles

外科的治療を要した喉頭軟弱症の２例

Laryngomalacia is one of the most common forms of laryngeal stenosis in newborns and infants. We reported two cases of laryngomalacia that were treated with surgical intervention for intractable dyspnea and dysphagia. A 4-year-old girl with complication due to cerebral palsy presented with progressive inspiratory stridor and saliva aspiration. Combined type laryngomalacia was diagnosed and she underwent a tracheotomy. A 2-year-old boy suffered from brain injury incurred from domestic violence at 4-months of age. He presented with inspiratory dyspnea followed by repeated aspiration bronchitis. Endoscopic examination revealed strongly flaccid arytenoid mucosa. The mucosal lesion was resected with a CO2 laser. A retrospective review of the charts of 13 cases of laryngomalacia in our hospital revealed that 9 cases (69%) were arytenoid type and 3 (23%) were combined type. Ten cases (77%) were complicated with central nervous system (CNS) disorders such as cerebral palsy. Besides dyspnea, swallowing disturbance was a major symptom in the cases. Generally symptoms will decrease with a physical growth; however, those cases with CNS disorders, gastroesophageal reflux, or additional laryngeal anomalies tended to have persistent symptoms. In such cases, surgical intervention might be indicated.

The application of thin rhinolarynx electronic videoendoscope in the infants with laryngopharyngeal disease

Objective To investigate the value of thin rhinolarynx electronic videoendoscope in the diagnosis of laryngopharyngeal disease of infants. Methods Pentax-1130 thin rhinolarynx electronic videoendoscope was used to examine 121 infants (included newborn) under 3 years with laryngeal stridor accompanied with inspiratory dyspnea or hoarse voice. Results Of 121 children,66 cases were laryngomalacia (54. 5%), 29 cases were laryngopharyngeal congenital cyst (24. 0% ), 7 cases were laryngeal papilloma (5. 8% ) ,6 cases were vocal cord paralysis(5. 0% ) ,5 cases were foreign body in glottis(4. 1% ) ,3 cases were retropharyngeal abscess(2. 5% ) ,retropharyngeal mass,fibroma of larynx,glottic laryngeal web,foreign body in hypopharynx and tracheal stenosis were each 1 case(0. 8% ). Conclusion Among 121 cases with laryngeal stridor accompanied with inspiratory dyspnea except laryngomalacia, nearly half of the cases were found structural disease by using rhinolarynx electronic videoendoscope. Thin rhinolarynx electronic videoendoscope plays predominant role in the diagnosis of laryngopharyngeal disease happened in the infant and newborn. It is easy to follow-up, without requirment of subscription and conscious-sedation. The image is clear and reliabale. The examination can be performed under general breathing, with less complication and could be applicable extensively. Key words: Rhinolarynx electronic videoendoscope; Infant; Infant; newborn; Laryngopharyngeal disease

Repeated Episodes of Respiratory Distress in an Obese Parturient After Cesarean Delivery

A 25-yr-old obese parturient with mild asthma underwent an uneventful spinal anesthetic for primary cesarean delivery. Within 4 h after delivery, the patient twice developed acute shortness of breath, inspiratory stridor, and hypoxemia that required intubation. A battery of blood tests revealed no evidence of an allergic reaction. She had a normal echocardiogram and chest computed tomography, but her neck computed tomography showed an enlarged left thyroid lobe asymmetrically compressing the endotracheal tube cuff. We hypothesized that, after delivery, decreased maternal vascular capacitance increased central venous pressure such that venous engorgement of an undiagnosed goiter may have caused symptomatic tracheal compression.

Surgical treatment of laryngomalacia

Laryngomalacia is the most common laryngeal anomaly affecting newborns. It is usually characterized by short aryepiglottic folds, a tightly curled epiglottis, redundant soft tissue overlying the accessory cartilages, and reduced laryngeal tone. It most often presents with high-pitched inspiratory stridor that worsens with feeding, supine positioning, and exertion. Most cases are mild and may be treated successfully with medical and conservative management. More severe cases are often treated with surgical management. This article reviews the indications for surgery and describes various surgical techniques for treatment of laryngomalacia.

Airway obstruction in a dog after Dieffenbachia ingestion

To describe a case of Dieffenbachia ingestion in a dog presented for dysphagia and airway obstruction successfully treated with a temporary tracheostomy and supportive care beyond that reported in the veterinary literature. An 8-year-old male neutered Labrador Retriever, weighing 30 kg, was presented with the complaint of choking and gagging. Abdominal radiographs showed that he had a distended stomach full of foreign material and a gastrotomy was performed. After receiving preanesthetic medication, the dog developed inspiratory stridor and during anesthetic induction, marked oropharyngeal swelling complicated tracheal intubation. During surgery a large amount of dog bedding and Dieffenbachia plant material was removed. Because of the severity of the oropharyngeal swelling, the dog required a temporary tracheostomy and treatment for an acute allergic reaction related to the Dieffenbachia ingestion. The patient was discharged after 6 days in the hospital and had no significant complications. To our knowledge, this is the first reported case of successful treatment of an airway obstruction related to the toxicity of Dieffenbachia ingestion.

Low-dose levodopa is effective for laryngeal dystonia in xeroderma pigmentosum group A

Xeroderma pigmentosum (XP), a genetic disorder in DNA nucleotide excision repair, is characterized by skin hypersensitivity to sunlight and progressive neurological impairment. Laryngeal dystonia and vocal cord paralysis are complications that can arise in older XP group A (XPA) patients. We report three patients with XPA being administered low-dose levodopa (0.3–1.5 mg/kg/day) for laryngeal dystonia. Patients were aged from 13 to 18 years, exhibited paroxysmal choking and inspiratory stridor, and were diagnosed with laryngeal dystonia. Two XPA patients responded to low-dose levodopa, and paroxysmal choking and involuntary movements resolved, although one of the two patients showed incomplete resolution due to suspected vocal cord paralysis. The other patient was unable to tolerate the medication because of a transient decrease of muscle tone in the extremities. We previously reported a decreased immunostaining of dopaminergic (DA) terminals in the basal ganglia of XPA patients, which may be involved in laryngeal dystonia. Low-dose levodopa has been reported to alleviate DA receptor supersensitivity in tic patients, while laryngeal dystonia occurs in patients with tardive dyskinesia caused by DA receptor supersensitivity. Thus, low-dose levodopa may improve laryngeal dystonia by alleviating DA receptor supersensitivity in XPA patients. We recommend that low-dose levodopa be used for treatment of paroxysmal respiratory disturbances and/or involuntary movements in XPA patients.

Esophageal Obstruction due to Foreign Body Ingestion Presenting as Ataxia

Purpose: Introduction: Patients with foreign body ingestion (FBI) can present with varied symptoms including dysphagia, odynophagia, choking, coughing, gagging, drooling, wheezing, decrease in appetite and refusal to eat. Patients with developmental disabilities (DD) and mental retardation (MR) are particularly challenging, not only because of the higher risk of FBI, but also due to the delay in diagnosis as the classical symptoms may be lacking and their inability to communicate may mask FBI. Here we describe a case of 46-year old woman with MR who had FBI and presented subacutely with ataxia. Case Report: A 46 y/o Caucasian woman with MR secondary to childhood encephalitis and seizure disorder was brought to the emergency room by her mother for increased agitation and ataxia for one week. She was afebrile and hemodynamically stable with no evidence of inspiratory stridor or respiratory compromise. Her chest X-ray and computed tomographic scan of the head showed no acute abnormality. Electroencephalogram showed no seizure activity. Esophagoscopy was performed as the patient had history of swallowing foreign objects and had notably hoarse voice, kept trying to gag herself and repeatedly rubbing her chest, suggestive of some chest discomfort. She was found to have a 16 oz soda bottle cap in the mid-esophagus as the etiology for her symptoms which was successfully removed using rigid esophagoscope and a curved Coda balloon catheter after the initial failure to remove it with the flexible scope. Patient was started on proton pump inhibitors and her ataxia and agitation improved. She was discharged the next day of procedure. Discussion: This is the first case report of esophageal obstruction due to FBI presenting as ataxia. This case illustrates the difficulty in diagnosing FBI in non-verbal patients with MR who have impaired cognitive skills. A very high index of suspicion is needed in these patients as FBI in these patients can have varied presentations. They not only have a higher predisposition to FBI but the usual protective mechanism like gagging episodes occur more frequently and hence a sudden episode may not provoke additional anxiety in the caregiver. FBI should be considered early in the differential diagnosis of sudden behavioral change and altered mental status. Patients with suspected FBI should have prompt esophagoscopy, as it can not only confirm the diagnosis but also can help in removal of the foreign body. Conclusion: This case illustrates that patients with MR may not have a classical presentation associated with FBI. They can even present as ataxia and a high index of suspicion is needed to make a prompt diagnosis to avoid potentially lethal complications.

Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways

Exercise induced asthma may symptomatically be difficult to differentiate from exercise related obstruction in the upper airways, sometimes leading to diagnostic confusion and inappropriate treatment. Larynx accounts for a significant fraction of total airway resistance, but its role as a limiting factor for airflow during exercise has been hampered by lack of diagnostic tools. We aimed to study laryngeal function in exercising humans by transnasal laryngoscopy. Continuous video recording of the larynx was performed in parallel with continuous film recording of the upper part of the body and recording of breath sounds in subjects running to respiratory distress or exhaustion on a treadmill. A successful examination was obtained in 20 asymptomatic volunteers and 151 (91%) of 166 young patients with a history of inspiratory distress or stridor during exercise. At rest, six patients had abnormal laryngeal findings. During exercise, a moderate or severe adduction of laryngeal structures was observed in parallel with increasing inspiratory distress in 113 (75%) patients. In 109 of these, adduction started within supraglottic structures, followed by adduction of the vocal cords in 88. In four patients, laryngeal adduction started in the vocal cords, involving supraglottic structures secondarily in three. Larynx can safely be studied throughout a maximum intensity exercise treadmill test. A characteristic laryngeal response pattern to exercise was visualised in a large proportion of patients with suspected upper airway obstruction. Laryngoscopy during ongoing symptoms is recommended for proper assessment of these patients.

Efficacy of jaw thrust device in the upper airway obstruction

Objective To evaluate the efficacy of jaw thrust device in the upper airway obstruction. Methods Thirty-five ASA Ⅰ or Ⅱ patients aged 18-64 yr with body mass index < 30 kg/m2 undergoing elective surgery under general anesthesia were included in this study. The anesthesia face mask was placed and held tightly by 4 straps of JTD and connected to the anesthesia machine. Anesthesia was induced with midazolam, propefol, fentanyl and atracurium. When muscle relaxation was achieved, tracheal intubation was not performed. The airway obstruction was assessed by airway peak pressure and stridor score (breathing sounds detected by auscultation over the trachea). And then tracheal intubation was performed, and the patients were mechanically ventilated. Results There was no significant difference in airway pressure and stridor scores between JTD and jaw thrust maneuver. Conclusion JTD can effectively lift the jaw and improve the upper airway obstruction. Key words: Airway obstruction; Anesthesia, general

Symptomatic Congenital Vallecular Cyst in a Neonate

A term infant was born by precipitous vaginal delivery to a multiparous woman. From birth, the infant presented with respiratory distress and an inspiratory stridor requiring commencement of continuous positive airway pressure. The stridor, respiratory distress, and cyanosis were more prominent when the infant was agitated. The clinical examination result was normal except for edema of the face and bruising. A direct laryngoscopy was performed and showed the presence of a vallecular cyst (Figure, A).

P096 Congenital stridor and bilateral vocal cord palsy as a presenting feature of DOK7 congenital myasthenic syndrome

P096 Congenital stridor and bilateral vocal cord palsy as a presenting feature of DOK7 congenital myasthenic syndrome

Stridor in a newborn caused by infantile myofibromatosis—A case review

Infantile myofibromatosis is a common fibrous tumor of infancy, however still considered a rarity. A newborn boy was examined due to inspiratory stridor and subcostal retractions since birth. Several subcutaneous nodules were present on the trunk and legs. Transnasal fiberoptic laryngoscopy and trachea-laryngoscopy showed discrete edema of the anterior part of the vocal cords but no other apparent abnormality. MRI raised suspicion of a laryngeal tumor. Through an external laryngofissure a lesion extending from the right hemilarynx was exposed and excised in fractions. Pathological examination showed infantile myofibromatosis. Stridor in newborns is frequently caused by congenital laryngeal anomalies, i.e. laryngomalacia but a neoplastic process should be considered as a differential diagnosis.

Paradoxical vocal fold motion dysfunction in asthma patients

Paradoxical vocal fold motion dysfunction (PVFMD) is a disorder of the larynx characterized by adduction of the vocal cords during the respiratory cycle leading to symptoms of extrathoracic airway obstruction. PVFMD mimics asthma and patients with PVFMD (PVFMD+) are often diagnosed incorrectly as refractory asthma and receive unnecessary treatment. This study determined the prevalence of PVFMD in asthma patients and described the relationship between asthma and PVFMD. A descriptive study of 94 asthmatic patients and 40 control subjects, all of whom were examined via laryngoscopy and had pulmonary function tests were performed. The prevalence of PVFMD was 19% (n = 18) in the asthmatic group and 5% (n = 2) in the control group (P < 0.001). No relationship was found between presence of PVFMD, asthma attacks and asthma severity (P > 0.05). Laryngopharyngeal reflux and allergy were significantly more prevalent in the PVFMD+ group than in the group without PVFMD (PVFMD-) (P < 0.05). The most common symptoms in the PVFMD+ patients were difficulty in breathing (88%), inspiratory stridor (66%) and a choking sensation (50%) and the most common symptoms in PVFMD- asthmatic patients were cough (63%), dyspnoea (55%) and wheezing (51%). Asthma seems to facilitate the formation of the paradoxical dysfunction in the larynx as the prevalence of PVFMD in asthma patients is significantly higher than in patients with out asthma.

Fiberoptic videolaryngoscopy during bicycle ergometry: A diagnostic tool for exercise‐induced vocal cord dysfunction

Exercise-induced vocal cord dysfunction is difficult to diagnose because the paradoxical vocal cord adduction should be observed during exercise. Our goal was to develop and validate a new diagnostic method for exercise-induced vocal cord dysfunction by combining continuous fiberoptic laryngoscopy with a bicycle ergometry test. Thirty consecutive patients referred to a laryngologist because of suspicion of exercise-induced vocal cord dysfunction and 15 healthy controls underwent the exercise test until dyspnea or exhaustion rated as 18-19/20 on the Borg scale. Laryngeal findings, electrocardiography, blood pressure, heart rate, and respiratory rate were monitored, and forced expiratory flow in the first second was measured before and after the exercise. The medical history was assessed by use of a structured questionnaire. Among the 30 patients, 27 (90%) performed the test successfully, as did all controls. Diagnostic signs of inspiratory stridor, supraglottic collapse, and vocal cord adduction appeared in five (19%) patients but in none of the controls. Of the 30 patients referred, the laryngologist considered 25 to be suspect. Of them, 9 (36%) showed signs diagnostic or highly suspect for exercise-induced vocal cord dysfunction. Of the 15 patients whose dyspnea could be induced during the test, nine (60%) were suspected of having exercise-induced vocal cord dysfunction. Fiberoptic videolaryngoscopy during bicycle ergometry was a well-tolerated and relatively easily established diagnostic tool that could induce dyspnea in more than one half the patients examined. If the symptom of dyspnea appeared, the most frequent diagnosis was exercise- induced vocal cord dysfunction.

Paediatric airway management

This issue of SAJCC includes an article on post-extubation stridor in children by Daan den Hollander and David Muckart from Durban.

Congenital subglottic cyst in a term neonate

A full-term infant born via vaginal delivery developed inspiratory stridor shortly after birth. Routine resuscitation was performed at delivery without the need for intubation. He received supplemental oxygen for 1...

Nasal Osteoma in a Dairy Cow: a Combined Clinical, Imaging and Histopathological Approach to Diagnosis

An 8-year-old Brown Swiss dairy cow was presented with unilateral epistaxis and mild inspiratory stridor. At that time endoscopic examination revealed a smooth-surfaced mass within the left nasal cavity. Biopsy samples were collected and a diagnosis of fibrosarcoma was made. Eighteen months later the animal developed severe respiratory distress that led to difficulties in feeding and consequently to emaciation and a dramatic drop in milk production. The cow was humanely destroyed and submitted for post-mortem examination. The head was subject to further investigation by radiography, computed tomography and magnetic resonance imaging. These techniques revealed a non-infiltrative, well-circumscribed mass of both radiodense and heterogeneously intense structures. Histopathological examination revealed a mass consisting of well-differentiated and interlacing bone trabeculae lined by osteoblasts and multinucleated osteoclasts. In contrast to the initial diagnosis, the later diagnostic approaches supported the diagnosis of osteoma.

Stridor – an unusual presentation of myxoedema

Life-threatening upper airway obstruction can result from various causes. We describe a case report of undiagnosed hypothyroidism presenting with life threatening upper airway obstruction, altered sensorium and cardiac involvement. A 56-year-old male, initially admitted to the psychiatric ward with a 2-day history of paranoid delusions, hallucinations and insomnia, developed acute stridor, oxygen desaturation and agitation, and was referred to the anaesthetist for emergency airway management. On initial examination, oxygen saturation was 70% on air and he showed signs of a partially obstructed airway with inspiratory stridor. During transfer to the emergency theatre he became unresponsive and arrested. Resuscitation was commenced and spontaneous circulation and respiration returned on an attempt at intubation. In the emergency theatre, laryngoscopy following inhalational induction with sevoflurane in oxygen showed significant pharyngeal oedema, but a normal looking grade 2 view of glottis and the patient’s trachea was intubated with a size 7 tracheal tube. Fibreoptic bronchoscopy following intubation did not show any obvious tracheobronchial obstruction. Chest X-ray showed an enlarged cardiac shadow (Fig. 1). CT scan of the chest and echocardiogram confirmed a large pericardial effusion, but no external compression of the tracheo-bronchial tree. A subsequent ENT examination confirmed generalised oropharyngeal oedema of soft palate and floor of the mouth. Thyroid function tests showed low free T3 and T4 and elevated TSH. The patient was started on intravenous liothyronine 10 μg, followed by regular levothyroxine and steroids. Chest X-ray showing pericardial effusion. Hypothyroidism can be associated with variety of psychotic and affective disorders [1]. Untreated, it can lead to accumulation of mucopolysacchrides in various tissues, and such deposits in supra glottic structures will lead to soft tissue swelling and upper airway obstruction [2]. This will require immediate airway management and these patients can be treated successfully in the intensive care unit with intravenous and oral levothyroxine [3]. However, in order to avoid such airway emergencies, a high index of suspicion is essential for the early diagnosis of hypothyroidism, especially when encountered with acute mental state changes in obese patients.

Vallecular cyst as a cause of congenital stridor: report of five patients

Vallecular cysts are an unusual cause of congenital stridor. To describe the imaging findings in five patients, with emphasis on the usefulness of sonographic studies. Between 1990 and 2007, five patients with a cystic lesion situated in the anterior neck, at the vallecular space, were seen in our institution. Clinical records and imaging findings were retrospectively reviewed. All patients presented with persistent inspiratory stridor that was present from the first week of life. Neck US was performed as part of the investigations in four and showed a vallecular cyst. The diagnosis was confirmed with flexible bronchoscopy in four infants and CT in one; all were resected. Pathology showed a multilayered epithelial border with normal thickness and differentiation; there were no signs of malignancy. Although vallecular cysts are very rare, they should be considered in the differential diagnosis of congenital stridor. When the commonest causes have been ruled out, neck US may be diagnostic. The diagnosis can be confirmed with flexible bronchoscopy or further imaging such as CT or MRI.

Endoscopic surgical treatment of posterior glottic stenosis

A six-year-old girl developed posterior glottic stenosis following surgery for lateral curvature. She was post-operatively intubated for 17 days and had inspiratory stridor after extubation. Laryngoscopy revealed an adhesion at the posterior commissure which severely limited abduction of the bilateral vocal folds and arytenoids. Initially, tracheal fenestration was performed and the scar tissue of the posterior commissure was vaporised using a CO2 laser under endolaryngeal microsurgery. However, despite this procedure the stenosis reformed and an interarytenoid adhesion developed.Endolaryngeal microsurgery was performed again three months later. Using endoscopic microscissors, the posterior commissure and interarytenoid scar tissue were submucosally separated and the bilateral corniculate cartilages of the superior arytenoids were debulked using CO2 laser. A posteriorly based mucosal flap obtained from the postcricoid region was extended to approximate to the mucosa of the posterior commissure. The mucosal flap was sutured to the inferior subglottic mucosa by two 4-0 polyglactin absorbable sutures. Three months later, the patient's respiratory and phonatory function was satisfactory.Based on the successful results of the present case, the authors highly recommend the use of a posterior mucosal flap for the treatment of posterior glottic stenosis. This procedure does not require the use of either a laryngofissure or a laryngeal stent.