Upper Airway Obstruction In Children Research Articles

Pediatric sleep apnea: Early onset of the ‘syndrome’?

Obstructive sleep apnea is a common disorder in childhood, particularly in the last decade when an increased prevalence of obesity has been documented. The neurocognitive and behavioral problems associated with this disorder have been known for a long time. However, the increased knowledge of cardiovascular and metabolic complications in adults with sleep apnea has been followed by a better understanding of the systemic effects of upper airway obstruction in children. Obstructive sleep apnea (OSA) has been shown to induce autonomic imbalance in children and to affect blood pressure, cerebral blood flow and cardiac function in an early phase. OSA may also induce chronic systemic inflammation and may contribute to the development of metabolic syndrome in obese children. Very recent research indicates that in children primary snoring, the mildest form of the sleep-disordered breathing spectrum, may also be associated with morbidity. It is, therefore, likely that these respiratory sleep disorders do not simply influence children's' performance in private and social life, but may more seriously affect children's' health. The aim of this review is to outline early systemic complications of obstructive sleep apnea and primary snoring in infants and children.

Arytenoid Prolapse following Laryngotracheoplasty

Objective Dynamic arytenoid prolapse (AP) is a potential and often late source of upper airway obstruction in children following laryngotrachoplasty (LTP). Reasons for this occurrence remain unclear. We examined the incidence and clinical features of AP in patients following LTP to explore the etiology and optimal surgical approach to this problem. Methods Retrospective database and chart review of children diagnosed with AP after LTP at a pediatric tertiary care institution from 1981–2007. Results 120 patients with no history of AP were diagnosed with AP following LTP (incidence 7.3% = 120/1634). 63 patients had unilateral prolapse, while 57 had bilateral AP. Average time from LTP to presentation was 44 months. Common symptoms were dyspnea on exertion, tracheostomy-dependence, and sleep-disordered breathing. Posterior cricoid interventions and revision LTP were most frequently associated with postoperative AP. 64% (n=77) of patients required surgical intervention. Endoscopic arytenoid reduction (AR) was performed in 54 patients, while 13 underwent AR during revision LTP. 2 patients underwent AR with cordotomy. Tracheostomy was performed with AR in another 2 patients. 28 patients required a second procedure for persistent prolapse. 36%(n=42) of patients did not require surgery. Airway complaints were relieved, or tracheostomy decannulation was achieved, in all patients after AR in which AP was the source of obstruction (avg. f/u=34.4mos). Conclusions Dynamic AP is a notable cause of airway obstruction following LTP. Subtle airway complaints and decannulation failures are common clinical features. Both endoscopic and open AR procedures are successful in relieving AP. Potential etiology for AP after LTP is discussed.

Video fluoroscopy for evaluating adenoid hypertrophy in children

Adenoid hypertrophy is a common cause of upper airway obstruction in children. Traditionally, adenoid size has been evaluated using a conventional lateral skull film. Flexible endoscopy is now the gold standard for the evaluation of the upper airway. Children need to be cooperative in order to complete a videonasopharyngoscopy examination, which is not always possible. The purpose of this paper is to determine the sensitivity and specificity of lateral video fluoroscopy for assessing adenoid size compared to conventional lateral skull films with videonasopharyngoscopy as the gold standard. Twenty pediatric patients with adenoid hypertrophy demonstrated by videonasopharyngoscopy, and 20 control patients without adenoid hypertrophy were assessed with video fluoroscopy and lateral skull radiograph. Two independent examiners evaluated all studies. Specificity, sensitivity, and predictive values were obtained for findings on video fluoroscopy and lateral skull film. Video fluoroscopy showed 100% sensitivity, and 90% specificity for the diagnosis of adenoid hypertrophy. Lateral skull films showed 70% sensitivity, and 55% specificity. A Spearman correlation coefficient demonstrated a significant correlation (P<0.05) between findings on video fluoroscopy and videonasopharyngoscopy. In contrast, there was a no significant correlation (P>0.05) between lateral skull films and videonasopharyngoscopy. Video fluoroscopy appears to be a safe and reliable procedure for assessing adenoid hypertrophy in children.

The effect of recurrent tonsillitis and adenotonsillectomy on growth in childhood

Tonsil and adenoid hypertrophy may cause recurrent tonsillitis and upper airway obstruction in children. A reduced dietary intake and failure to gain weight is frequently reported by parents of children with a history of recurrent acute tonsillitis and adenotonsiller hypertrophy. The purpose of this prospective study was to evaluate whether surgical treatment of adenotonsillar hypertrophy affects the circulating concentrations of insulin-like growth factor-1 (IGF-1) and IGF-binding protein 3 (IGFBP-3) along with IGF-1 SDS and IGFBP-3 SDS's adjusted to age which are more important in evaluating growth in childhood. Thirty-eight prepubertal children 24 boys and 14 girls participated in this study. The mean age at surgery was 6.66+/-1.84 years (range 4-10 years). Weight, height, IGF-1 and IGFBP-3 levels and standard deviation scores were evaluated before and 12-18 months after adenotonsillectomy (T&A). The number of infections in a year reduced from 8.6+/-4.4 to 0.37+/-0.68 after operation. The mean weight standard deviation score (SDS) increased significantly after T&A (p<0.01). The mean IGFBP-3 level increased from 1912+/-511.5 to 2989+/-1125ng/ml (p<0.001) and IGFBP-3 SDS increased from -3.0+/-0.58 SDS to -1.96+/-1.27 SDS (p: 0.001). However, the mean serum IGF-1 level increased from 80.3+/-48.5 to 116.8+/-105.9ng/ml (p: 0.135), and IGF-1 SDS increased from -1.36+/-0.51 SDS to -1.31+/-1.14 SDS (p: 0.701), which were both not statistically significant. We have demonstrated postoperative weight gain and significant increase in IGFBP-3 concentrations and IGFBP-3 SDS, accompanying significant decrease in the number of tonsillitis episodes after adenotonsillectomy.

Humidified air inhalation for treating croup: a systematic review and meta-analysis

Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment. To assess the efficacy of humidified air in the treatment of croup. Systematic review and meta-analysis. We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We included randomized controlled trials with or without blinding. All studies treating children with a clinical diagnosis of croup with warm or cool humidified air delivered by steam or humidified tent whether inpatients, attenders at the Emergency Department or in the community were eligible. Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardized mean difference of -0.14 (95% confidence interval = -0.75 to 0.47). No outcomes were significantly different between the groups. The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. There is insufficient evidence to exclude either a small beneficial or a harmful effect.

Increased Cerebral Blood Flow Velocity in Children With Sickle Cell Disease: Adenotonsillectomy or Transfusion Regimens?: In Reply

We appreciate the possible implications for children with sickle cell anemia (SCA) in the response by Bader-Meunier et al to our article on increased cerebral blood flow velocity in children with SCA with mild sleep-disordered breathing.1 Although there seems to be a link between sleep-disordered breathing and changes to the cerebral vasculature, the mechanism has not been elucidated. Candidates include the mechanical effects of snoring,2 associated hypoxemia,3 and infection/inflammation.4 Tonsillectomy is sometimes performed for recurrent tonsillitis or relief of upper airway obstruction in children with SCA,5 although mean overnight oxyhemoglobin saturation may not improve,5 and there are few systematically collected data that have addressed a relationship with SCA complications such as transcranial Doppler (TCD) abnormality.TCD testing has been undertaken at least once in 384 children with homozygous SCA in the London cohort, and adenotonsillectomy has been performed on clinical grounds. In 183 (47.7%) patients, TCD data are available on 2 occasions (mean age at follow-up: 11.2 years [SD: 4.5 years]). Of these, 40 (21.9%) had undergone adenotonsillectomy between the 2 TCD measurements (mean age at surgery: 7.7 years [SD: 3.9 years]), 28 had adenotonsillectomy before the first TCD (not included in this analysis), and 115 had not undergone adenotonsillectomy. We applied hierarchical regression analysis retrospectively to examine the effect of 3 predictor variables on middle cerebral artery velocity (MCAV): age at follow-up TCD (step 1); MCAV at baseline (preoperative in surgical cases: step 2); and surgical status (removal of tonsils or not; 0, 1: step 3). Age at follow-up TCD significantly predicted follow-up MCAV (F1,153 = 28.14 [P < .001]; R2 = .16). When baseline MCAV was added (step 2), the explanatory power of the model significantly increased (F2,152 = 57.87 [P < .001]; ΔR2 = .28 [P < .001]). However, at step 3, surgical status did not add to the power of the model (F3,151 = 38.45 [P < .001]; ΔR2 = .00 [P = .656]). As can be seen from the summary in Table 1, older age was predictive of lower MCAV at follow-up, whereas higher baseline MCAV was predictive of higher follow-up MCAV. Surgical status did not affect final MCAV levels. Of 18 children with MCAV of ≥200 cm/second, 15 had a repeat TCD measurement, of whom 2 had had adenotonsillectomy between the measurements; MCAV decreased from 262 to 250 cm/second in one patient and from 212 to 205 cm/second in the other; both still fell into a range that, according to Stroke Prevention in Sickle Cell Anemia (STOP) criteria, would make transfusion required. Of 17 children with MCAV of ≥170 but <200 cm/second (conditional), all had repeat TCD measurements, of whom 2 had had adenotonsillectomy between the measurements; MCAV decreased from 179 to 170 cm/second in one and from 194 to 14 cm/second in the other.Although these data suggest that adenotonsillectomy has limited influence on MCAV in children with SCA, surgery may be performed for different reasons, including obstructive sleep-disordered breathing, chronic or intermittent oxyhemoglobin desaturation, or, alternatively, chronic infection. In addition, adenotonsillectomy for patients with SCA is often undertaken some time after the onset of symptoms because of operative risk factors. Postoperative MCAV, therefore, may be differentially affected by the original etiology and the duration and severity of exposure to infection, inflammation, and hypoxemia as well as the treatment per se. Perioperative carotid dissection4 is also a risk; this was a possible cause of the very low postoperative velocity in 1 of our conditional patients. Once initiated, cerebrovascular disease in SCA is rarely completely reversible,6 but it is possible that in the cases reported by Bader-Meunier et al, a detrimental effect of hypoxemia and chronic infection on the endothelium was reversed before secondary vascular changes commenced.Polysomnography would be informative for future study of young children with SCA to clarify the associations between adenotonsillar hypertrophy, objectively rated obstructive sleep-disordered breathing, and increased MCAV. This would be comparable with the design of our original study in children without SCA.

Human Papilloma Virus in Hyperplastic Tonsillar and Adenoid Tissues in Children

Human papillomavirus (HPV) in childhood causes skin and anogenital warts as well as the recurrent respiratory papillomatosis, a life-threatening cause of upper airway obstruction in children. To date, the information on HPV infection in tonsillar and adenoid hyperplasia in children is limited. The purpose of this study was to investigate the presence of HPV DNA in children with benign tonsillar and/or adenoid hyperplasia. One hundred six samples of paraffin-embedded adenoid and/or tonsillar tissues from 102 children, 57 girls and 45 boys (age range, 2-14 years), were tested for the presence of HPV DNA using polymerase chain reaction (PCR) with general primers GP5+/GP6+. HPV typing was performed by PCR with specific primers for HPV-16, -18, -33 and -11. HPV DNA was detected in 9 (8.5%) of the 106 collected specimens. The frequencies of HPV typing were 6 of 9 (66.7%) for HPV-16, 2 of 9 (22.2%) for HPV-11, zero of 9 (0%) for HPV-33 and HPV-18, whereas one HPV-positive sample remained untyped. No multiple HPV infection was detected. HPV was detected in 6 (9.4%) children with tonsillar hyperplasia and in 3 (7.1%) with adenoid hyperplasia. The mean age of children with HPV-positive specimens was lower than that of HPV-negative children (P = 0.006). No statistical correlation in the prevalence of HPV infection was observed according to children's sex, origin or residence (urban or rural). Although the significance of the presence of HPV DNA in tonsillar and adenoid hyperplasias remains obscure, the PCR detection of high-risk HPV DNA should be evaluated cautiously.

Awake upper airway obstruction in children with spastic quadriplegic cerebral palsy

Some children with severe cerebral palsy develop symptoms of upper airway obstruction (UAO) while awake. The aetiology, natural history and treatment of this complication have not previously been systematically described. This study documents a case series of children with severe cerebral palsy admitted to hospital because of severe awake UAO and reviews the relevant literature. The case records of children admitted to hospital with UAO while awake over an 8-month period were reviewed. Details of antecedent illness, comorbidities, acute management and follow up were collated. One case is presented in detail. Eight children were admitted with UAO. Seven children required intensive care admission. One child died, and two underwent tracheostomy. Nasendoscopy showed pharyngeal collapse without anatomical obstruction in the majority. One child was discovered to have a brainstem malignancy. Upper airway obstruction is a potentially severe and life-threatening complication of cerebral palsy. In this series, a majority of children had obstruction related to pharyngeal hypotonia and collapse. This can lead to prolonged hospitalization and intensive care admission. It may raise difficult management issues.

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.

Laryngeal inflammatory pseudotumour: An unusual cause of airway obstruction

We report a rare case of a laryngeal pseudotumour in a child presenting with stridor, which was treated by endoscopic laryngeal resection, without the need for a tracheostomy. A short review of the literature is also presented. Although rare, laryngeal pseudotumour should be considered as part of the differential diagnosis of stridor and upper airway obstruction in children.

Relationship Between Upper Airway Obstruction and Gastroesophageal Reflux in a Dog Model

The association between gastroesophageal reflux (GER) and upper airway obstruction in children is recognized but not well understood. Our objective was to determine if the creation of a model of upper airway obstruction in dogs would cause GER and to determine if the GER is related to intrathoracic pressure changes. Five dogs underwent evaluation with esophageal manometry and pH probe at baseline and 1 week after creation of an upper airway obstruction. Airway obstruction was created by placement of a fenestrated cuffed tracheostomy tube, which was then capped and the cuff was inflated, requiring the animals to breathe via the fenestrations. The negative inspiratory pressure (Pes) (± SD) increased from 11.8 ± 4.8 cm H2O at baseline to 17.6 ± 4.9 cm H2O 1 week after creation of an airway obstruction (p =. 029). None of the dogs had GER at baseline with a reflux index (RI) value of 0.0; however, 1 week after creation of airway obstruction, three out of five dogs had GER, with a mean RI value of 21.2 ± 21.2. There was a significant (p =. 023) correlation (r =. 928) of the changes in Pes and RI values following airway obstruction.Upper airway obstruction (UAO) does cause GER in this canine model. Severity of GER is significantly correlated with Pes changes.

Viral croup: a current perspective.

Viral croup is the most common cause of upper airway obstruction in children 6 months to 6 years of age. Parainfluenza virus accounts for the majority of cases. The disease is characterized by varying degrees of inspiratory stridor, barking cough, and hoarseness because of laryngeal and/or tracheal obstruction. The diagnosis is mainly a clinical one and diagnostic studies usually are not necessary. The management has altered dramatically in the past decade. Good evidence exists to support the routine use of corticosteroid in all children with croup. Intervention at an earlier phase of the illness will reduce the severity of the symptoms and the rates of return to a health care practitioner for additional medical attention, visits to the emergency department, and admission to the hospital. Most children respond to a single, oral dose of dexamethasone. For those who do not tolerate the oral preparation, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives. Nebulized epinephrine should be reserved for patients with moderate to severe croup. Simultaneous administration of corticosteroid and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure.

Viral croup: a current perspective

Viral croup is the most common cause of upper airway obstruction in children 6 months to 6 years of age. Parainfluenza virus accounts for the majority of cases. The disease is characterized by varying degrees of inspiratory stridor, barking cough, and hoarseness because of laryngeal and/or tracheal obstruction. The diagnosis is mainly a clinical one and diagnostic studies usually are not necessary. The management has altered dramatically in the past decade. Good evidence exists to support the routine use of corticosteroid in all children with croup. Intervention at an earlier phase of the illness will reduce the severity of the symptoms and the rates of return to a health care practitioner for additional medical attention, visits to the emergency department, and admission to the hospital. Most children respond to a single, oral dose of dexamethasone. For those who do not tolerate the oral preparation, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives. Nebulized epinephrine should be reserved for patients with moderate to severe croup. Simultaneous administration of corticosteroid and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure.

Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome.

Although usually successful, not all obstructive sleep apnea is cured by removal of the tonsils and adenoids (T&A). This is particularly true in children with Down syndrome and craniofacial anomalies. This is because of the multiple levels of obstruction in their airways, with obstruction present not only at the level of the tonsils and adenoids but also from base of tongue obstruction, soft palate collapse, and hypopharyngeal collapse. The cine magnetic resonance image (MRI) is useful in evaluating the upper airway in those patients who have not achieved a normal polysomnogram after T&A surgery. Prospective case series. Fifteen children with Down syndrome who had previously undergone a T&A but continued to have abnormal postoperative polysomnograms underwent a cine MRI with fast gradient cine MRI images. The cine MRI identified different areas and levels of obstruction that ultimately affected the children's treatment courses. Recurrent adenoid tissue, glossoptosis, soft palate collapse, hypopharyngeal collapse, and enlarged lingual tonsils were identified. The results as well as several illustrative cases are presented. Cine MRI evaluates upper airway obstruction in children who may have multiple sources of obstruction causing their obstructive sleep apnea. This is particularly helpful in children with Down syndrome and craniofacial anomalies. This technology is useful in all children with complex upper airway obstruction.

Upper airway obstruction.

Upper airway obstruction in children is a life-threatening but treatable condition that is relatively rare. This article considers the more common acute causes:

Treatment of tracheostomy-dependent children with severe micrognathia

Purpose: Severe mandibular retrognathia is a common cause of upper airway obstruction in children with syndromic and nonsyndromic craniofacial anomalies. Mandibular distraction osteogenesis (DO) has been used to avoid tracheostomy in these patients. The purpose of this study was to evaluate the use of mandibular DO to facilitate decannulation of patients who previously underwent tracheostomy for life-threatening airway obstruction.

Diagnosis and therapy for airway obstruction in children with Down syndrome.

To document the causes of upper airway obstruction in a population of children with Down syndrome and to highlight the role of associated comorbidities. Review of 23 cases involving children with Down syndrome who were referred for upper airway obstruction over a 2(1/2)-year period to the Pediatric Otolaryngology Service of the University of New Mexico, Albuquerque. Data on the following variables were obtained: reason for referral, demographics, diagnosis, surgical procedures, complications, and comorbidities. The children ranged in age from 1 day to 10.2 years (mean age, 1.8 years; median age, 6 months). Thirteen children were male and 10 were female. None of the children had subglottic stenosis. Laryngomalacia was the primary diagnosis in 10 children (43%), 8 of whom were younger than 1 month. Obstructive sleep apnea was the primary diagnosis in 11 children (48%), 8 of whom were older than 2 years. All children with obstructive sleep apnea and 4 children with laryngomalacia had a secondary ear, nose, and throat disorder. Gastroesophageal reflux was a comorbidity in 14 children (61%). The causes, severity, and presentation of upper airway obstruction in children with Down syndrome are related to the age of the child and to associated comorbidities. The treatment of comorbidities and secondary ear, nose, and throat disorders is an integral component of the surgical management of upper airway obstruction in such cases.

Crescimento pôndero-estatural de crianças após adenoamigdalectomia

A hiperplasia adenoamigdaliana é a principal causa de obstrução das vias aéreas superiores em crianças, sendo muitas vezes associada à apnéia do sono. Esta, por sua vez, resulta em uma série de comprometimentos: baixo rendimento escolar, cor pulmonale, distúrbios de comportamento não específicos, hiperatividade, sonolência diurna, distração e atrasos de desenvolvimento, sendo o déficit pôndero-estatural o mais grave. A adenoamigdalectomia é o tratamento de escolha. O objetivo deste trabalho é mensurar o crescimento e desenvolvimento das crianças antes e depois da adenoamigdalectomia através da comparação dos percentis pré e pós operatórios. FORMA DE ESTUDO: Clínico prospectivo randomizado. MATERIAL E MÉTODO: Cinquenta e cinco crianças de 2 a 12 anos, com história de obstrução das vias aéreas superiores por hiperplasia adenoamigdaliana foram submetidas a exame antropométrico (peso e altura), antes e 6 meses após a adenoamigdalectomia. Os dados foram transformados em percentil para peso e altura, de acordo com a idade e comparados através de análise estatística. RESULTADOS: No pré-operatório, encontramos a seguinte distribuição para o percentil altura: 78,2%, abaixo de p75 e para peso 70,9% abaixo de p50. No pós-operatório observou-se melhor distribuição das crianças: para altura 34,6% abaixo de p75, 32,8% entre p75-95 e 32,6% para p95 e acima e para peso: 35,5% abaixo de p50, 36,4% para p50-95 e 29,1% acima de p95. CONCLUSÃO: Observou-se uma melhora considerável do desenvolvimento pôndero-estatural das crianças após a adenoamigdalectomia.

Food allergy masquerading as foreign body obstruction

Allergic reactions to peanut and tree nuts can present as upper airway obstruction. To increase awareness that food allergy should be considered in the differential diagnosis of upper airway obstruction in children. We report an allergic reaction to cashew that was initially misdiagnosed as foreign body aspiration. When the presenting signs and symptoms of food allergy are limited to upper airway obstruction, they can be confused with foreign body aspiration. As peanuts and tree nuts are common causes of both food allergy and foreign body aspiration in children, both of these diagnoses should be considered in the differential diagnosis of airway obstruction.

The management of acute upper airway obstruction in children

The child with upper airway obstruction is one of the most challenging emergencies in paediatric practice. Rapid assessment of the child and an understanding of the epidemiology of the condition will allow the underlying pathology and its treatment to be defined. This article reviews the most common causes of upper airway obstruction and analyses the optimal management. Viral croup is the most frequent cause of paediatric upper airway obstruction. Prompt management with nebulized adrenaline and corticosteroids avoids the need for tracheal intubation in all but a fraction of cases. Sub-glottic stenosis and bacterial tracheitis are less common problems but their management is more complex. Laryngomalacia, foreign body aspiration, mediastinal tumours and lymphadenopathy are uncommon and management is directed towards the underlying lesion. Epiglottitis has become much less prevalent since the introduction of mass immunization, but should be considered in the unvaccinated child.