Upper Airway Obstruction In Infants Research Articles

Nonsurgical improvement of severe upper airway obstruction in infants with Robin sequence and cleft palate using Stanford orthodontic airway plate treatment.

Severe respiratory distress of neonates with Robin sequence is traditionally managed by surgery. Stanford orthodontic airway plate treatment (SOAP) is a nonsurgical option. The study aimed to determine whether SOAP can improve polysomnography parameters of neonates with Robin sequence. Polysomnography of neonates with Robin sequence treated with SOAP at a single hospital were retrospectively analyzed. Patients without polysomnography at all 4 time points (pre, start of, mid, and posttreatment) were excluded. Data were analyzed using a linear mixed effects model. Sixteen patients were included. All patients had cleft palate. The median age (minimum, maximum) at the start of treatment was 1.1 months (0.3, 5.1) with the treatment duration of 4.5 months (3.5, 6.0). The mean obstructive apnea-hypopnea index (95% confidence interval) decreased from 39.3 events/h (32.9, 45.7) to 12.2 events/h (6.7, 17.7) (P < .001), obstructive apnea index decreased from 14.1 (11.2, 17.0) events/h to 1.0 (-1.5, 3.5) events/h (P < .001), and oxygen nadir increased from 79.9% (77.4, 82.5) to 88.2% (85.5, 90.8) (P < .001) between pre and start of treatment. Respiratory improvements were sustained during and after the treatment. All patients avoided mandibular distraction osteogenesis or tracheostomy following SOAP. As being a rare diagnosis, the number of participants was, as expected, low. However, the current study shows that SOAP can improve polysomnography parameters, demonstrating its potential utility before surgical interventions for neonates with Robin sequence and cleft palate experiencing severe respiratory distress. Choo H, Sidell DR, Kim J-W, Ahn H-W, Day HS, Sullivan SS. Nonsurgical improvement of severe upper airway obstruction in infants with Robin sequence and cleft palate using Stanford orthodontic airway plate treatment. J Clin Sleep Med. 2024;20(11):1807-1817.

Jaw Thrust: A Simple Predictor of Success in Mandibular Distraction Osteogenesis.

The hypoplastic mandible in the congenital condition Pierre Robin sequence (PRS) displaces the base of the tongue posteriorly, which results in upper airway obstruction (UAO) that can potentially be corrected with mandibular distraction osteogenesis (MDO). Jaw thrust (JT) is routinely performed during evaluation of the airway; similar to MDO, it projects the mandible and tongue anteriorly to open the airway. The authors demonstrate that JT can be used as a criterion to predict successful MDO outcomes in infants with PRS. The study was a single-center, retrospective chart review of infants diagnosed with PRS between 2016 and 2023. Data regarding their demographics, comorbid diagnoses, JT success, airway anomalies, laryngeal grade of view, apnea-hypopnea index, and perioperative course were statistically analyzed. Of the 16 patients included in the study, 11 had successful relief of their airway obstruction with JT and proceeded with MDO. The unsuccessful JT group had significantly greater proportions of females, birth prematurity, gastrostomies, tracheostomies, and longer hospital stays. In the successful JT group, both the mean laryngeal grade of view ( P =0.029) and mean apnea-hypopnea index ( P =0.025) improved significantly post-MDO. Post-MDO tracheostomy was also avoided in all but 1 patient who was not previously tracheostomized. There is no widely accepted algorithm to guide craniofacial surgeons on the optimal intervention for relieving UAO in infants with PRS. In our institutional experience, patients whose preoperative JT relieved UAO also successfully relieved UAO with MDO. In patients with PRS, JT may be a useful criterion for selecting appropriate candidates for MDO.

Caring for Infants with Robin Sequence Treated with the Tübingen Palatal Plate: A Review of Personal Practice.

The Tübingen Palatal Plate (TPP) is a minimally invasive yet highly effective functional orthodontic treatment for upper airway obstruction in infants with Robin Sequence (RS). It consists of a palatal plate to cover the cleft and a velar extension that shifts the root of the tongue forward. We review our practical experience with this approach. First, upon admission, our local orthodontists perform an (3-D) intraoral scan of the maxilla. Based on the scan data, the TPP is manufactured in a semi-digital workflow. The length and angulation of its extension is checked via awake laryngoscopy and the effectiveness confirmed by a sleep study. Plates are kept in place by adhesive cream. When inserting the TPP, the tip of the tongue must be visible. Next, metal fixation bows should be secured to the forehead using tape and elastic bands. Plates are removed daily for cleaning, and the oral mucosa is then checked for pressure marks. Feeding training (initially only via finger feeding) may even start before plate insertion. Breathing often normalizes immediately once the plate is inserted. For isolated RS, we have never had to perform a tracheostomy. This has largely been possible through our highly dedicated and competent team, particularly the nursing staff, and the early involvement of parents.

Patient-specific distractors for customized mandibular distraction osteogenesis to relieve upper airway obstruction in infants with Pierre Robin sequence

The purpose of this article is to report the author’s technique for using patient-specific distractors for customized distraction osteogenesis of the mandible in patients with Pierre Robin sequence and upper airway obstruction. The advantages of virtual planning and patient-specific plates in other aspects of craniomaxillofacial surgery, such as orthognathic and reconstructive surgery, have been reported previously. Similar to patient-specific plates, the theorized advantages of patient-specific distractors in infants with Robin sequence and upper airway obstruction include increased accuracy, decreased operating time, and less morbidity to vital anatomic structures such as the inferior alveolar nerve and developing tooth buds. This technique is novel in using patient-specific distractors in the craniomaxillofacial skeleton.

The Clinical Features and Risk Factors of Subglottic Cysts in Children: A Clinical Experience Using the Spontaneous Respiration Technique.

Subglottic cysts (SGCs) are a rare cause of respiratory distress resulting from upper airway obstruction in infants and young children. Risk factors other than prematurity with a history of endotracheal intubation have not yet been well elucidated. Therefore, we aimed to describe the clinical features and analyze the risk factors of SGCs. We conducted a retrospective review of medical records of pediatric patients who underwent marsupialization for SGCs between January 2017 and March 2022. These records were then compared with those of controls with a history of neonatal intubation, with a case-to-control ratio of 1:3. Eleven patients (eight boys and three girls) diagnosed with SGCs and 33 control patients (26 boys and seven girls) were included. All patients had a history of premature birth and neonatal intubation. Symptoms of SGCs appeared at a mean age of 8.2 months (range, 1-14 months) after extubation. The mean duration of intubation was 21.5 days (range, 2-90 days), and the intubation period was longer in patients with SGCs than in controls (21.5±24.8 days vs. 5.3±7.1 days; P<0.001). Furthermore, gestational age (28.3±4.2 weeks vs. 33.8±4.4 weeks; P=0.001) and birth weight (1,134.1±515.1 g vs. 2,178.2±910.1 g; P=0.001) were significantly lower in patients with SGCs than in controls. Multivariable analysis identified the intubation period as an independent risk factor. This study showed that gestational age, birth weight, and the intubation period were significantly associated with the development of SGCs. Pediatric patients presenting with progressive dyspnea who have the corresponding risk factors should undergo early laryngoscopy for the differential diagnosis of SGC.

The Role of Dysphagia Assessment in the Identification of Upper Airway Obstruction in Infants.

The Role of Dysphagia Assessment in the Identification of Upper Airway Obstruction in Infants.

Perioperative airway complications in infants and children with Crouzon and Pfeiffer syndromes: A single-center experience.

Crouzon and Pfeiffer syndromes are rare genetic disorders characterized by craniosynostosis, exorbitism, and maxillary hypoplasia. Patients with these syndromes frequently require general anesthesia for various diagnostic and surgical procedures and may present a challenge to anesthetists with regard to airway management. The primary aim of this study was to determine the incidence, timing, and management of perioperative upper airway obstruction in infants and children with Crouzon and Pfeiffer syndromes. The secondary aim was to determine the degree of difficulty in performing endotracheal intubation. A retrospective review of 812 anesthetic encounters in 67 patients was conducted. The following were recorded: timing and management of episodes of perioperative upper airway obstruction, from induction of anesthesia to discharge from recovery, degree of difficulty with laryngoscopy using the Cormack-Lehane grading system and number of intubation attempts required, patient demographics, respiratory comorbidity, surgical procedure, and anesthetic airway management techniques. Upper airway obstruction at induction of anesthesia was very common, with an incidence of 31% (167/542 anesthetic encounters affecting 54 patients). In a quarter of these incidents, bag-valve-mask ventilation was challenging, but a laryngeal mask airway was almost always effective. Upper airway obstruction on emergence from anesthesia was less common, with an incidence of 2.7% (14/515 anesthetic encounters affecting 10 patients). Contributing factors included patient comorbidity (obstructive sleep apnea, nasal stenosis) and the nature of surgery (craniofacial or airway procedures). Intubation was rarely difficult in this cohort, with 85% of laryngoscopies rated Cormack-Lehane grade 1 or 2 (n=373), and 89% of intubations successful on the first attempt (n=306). Upper airway obstruction at induction of anesthesia is common in patients with Crouzon and Pfeiffer syndrome. These patients are likely to present some difficulties with perioperative airway management, especially bag-valve-mask ventilation, but rarely endotracheal intubation.

Reappraising prone positioning for infants with Robin sequence: a cautionary tale

(Pierre-)Robin sequence (RS) is characterised by mandibular retrognathia, glossoptosis and upper airway obstruction (UAO). To alleviate the latter, placing such infants prone was already suggested as a first-line treatment by...

Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review.

Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as a step toward evidence-based clinical decision-making for RS. A literature search was performed in the PubMed and Embase databases (1990-2020) following PRISMA guidelines. Articles reporting on RS and UAO treatment were included if the following objective measures were studied: oximetry, polysomnography, and blood gas. Quality was appraised by the methodological index for nonrandomized studies (range: 0-24). A total of 91 articles met the inclusion criteria. The mean methodological index for nonrandomized studies score was 7.1 (range: 3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings, in more than half. Of 71 studies that evaluated UAO interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive apnea-hypopnea index (27%), and oxygen desaturation index (16%). Only 42 studies reported indications for UAO intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified. This systematic review demonstrates a lack of standardization, interpretation, and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS. Logjes RJH, MacLean JE, de Cort NW, et al. Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review. J Clin Sleep Med. 2021;17(8):1717-1729.

31: Impact of Cuffed Endotracheal Tube Size on Post-Extubation Upper Airway Obstruction in Infants

31: Impact of Cuffed Endotracheal Tube Size on Post-Extubation Upper Airway Obstruction in Infants

Etiological profile of upper airway obstruction in infants

BackgroundRespiratory distress is recognized as any sign of breathing difficulty in infants. Some congenital anomalies present immediately with airway distress, while others are asymptomatic or discovered later in infancy or childhood. Our objectives are to detect different laryngeal causes of respiratory distress in infants and to measure the relative risk of some variables like age, sex, family history, and other congenital anomalies for developing laryngeal causes of respiratory distress. This observational cross-sectional study was carried out during the period from June 2017 to December 2018 at Children’s University Hospital. The study included 80 infants who presented with respiratory distress and admitted to the hospital. All patients subjected to a detailed history from their parents and full general and ENT examinations. X-ray, MSCT neck or direct laryngoscope were carried out in selected cases.ResultsAs regard age, 58% of cases were between 1–6 months, 28% of cases between 6 months and 1 year, and 14% between 1–2 years. Laryngeal causes of respiratory distress among infants were distributed as follow: 70% laryngomalacia, 18% subglottic stenosis, 8% laryngeal web, and 4% of cases were caused by vocal fold paralysis (VFP). The laryngeal causes of respiratory distress did not reveal any statistically significant difference among different age groups or between both genders (P = 0.257, 0.286; respectively). Also, there was no statistically significant difference between infants with positive family history and those without as regard the laryngeal causes of respiratory distress (P = .378).ConclusionThe majority of respiratory distress cases (58%) were between 1–6 months. Bivariant analysis of variables age, sex, family history, and other congenital anomalies showed that they were not potent risk factors for developing laryngomalacia, subglottic stenosis, laryngeal web, and vocal fold paralysis. Laryngomalacia represented the commonest cause of respiratory distress (70%) followed by subglottic stenosis (18%), then laryngeal web (8%), and finally the vocal fold paralysis represented the least percentage (4%). Apart from laryngomalacia, the percentages of other causes seem to vary according to sample size and geographic area of study. So, being familiar with the common causes of respiratory distress in a given region is very essential in order not to miss a potentially life-threatening diagnosis.

Experimental modelling of imposed upper airway obstruction in infants and children.

The interpretation of injuries to children and infants poses a number of difficulties to any medical practitioner involved in their care or tasked with the investigation their death. This includes differentiating accidental from non-accidental trauma and the consideration of medical factors making a child more prone to injury. Non-fatal but life-threatening upper airway obstruction is unfortunately a well-recognized pattern of abuse which may precede a fatal episode. In this experimental study, we aimed to model theoretical digit marks to the head using infant and young child resuscitation dummies, exposed to various methods of deliberate upper airway obstruction. This work has demonstrated that digit marks can be left anywhere on the head and face. However, the distribution of these marks varies dramatically based on how the airway was obstructed. Moreover, digit marks also appeared to be linked together in fairly reproducible patterns. Given the findings in this study, the identification of one or more fingertip type bruises anywhere on an infant or child's face or scalp, should raise the index of suspicion that the individual may have been subject to deliberate upper airway obstruction. This should prompt healthcare professionals to examine the child for markers of mechanical asphyxia, in order to accurately interpret any inadequately explained bruising to the head and face.

Angiofibrolipoma of the soft palate: A very rare cause of upper air way obstruction in an infant.

Introduction: Infants and children are very prone to air way obstruction due to smaller and immature air ways. There are multiple causes of upper airway obstruction in infants like infections, congenital lesions and rarely tumours of the upper airway. However, angiofibrolipoma, a rare variant of lipoma causing intermittent respiratory distress in an infant has not been reported until now. Objective: To report a very rare case of angiofibrolipoma arising from the soft palate in an infant. Case report: Two and half months old female child reported to the department of otolaryngology with a history of intermittent airway obstruction since one month of age. After evaluation she was found to have a fleshy polypoidal mass above the laryngeal inlet arising from soft palate causing airway compromise. She underwent surgical excison with bipolar cautery under general anaesthesia. Conclusion: Few cases of angiofibrolipoma has been reported in adults but none has been reported in children. This is to report a case of angiofibrolipoma in child causing airway obstruction.

Common Pediatric Airway Disorders.

Pediatric airway disorders may be congenital (anatomical) or acquired (infectious) and may involve the upper, lower, or entire airway, with obstruction being a common feature. The pathophysiology of upper airway obstruction in infants, children, and adolescents is distinctly different due to the anatomic differences that evolve with growth. Accordingly, clinical presentation and consequences of airway obstruction vary by age. This article reviews the common upper airway disorders by age with a review of classic presentation, recommended diagnostic steps, and management considerations for the general pediatrician. [Pediatr Ann. 2019;48(4):e162-e168.].

The 10 Commandments of Management for Acute Upper Airway Obstruction in Infants and Children

The 10 Commandments of Management for Acute Upper Airway Obstruction in Infants and Children

Long-Term Results of Mandibular Distraction Osteogenesis with a Resorbable Device in Infants with Robin Sequence: Effects on Developing Molars and Mandibular Growth.

Mandibular distraction osteogenesis with a unidirectional resorbable device is an effective treatment option for severe upper airway obstruction in infants with Robin sequence. Long-term effects, especially with regard to tooth development and mandibular outgrowth, are not known. Robin sequence infants with a follow-up of greater than or equal to 5 years were included. Baseline characteristics were extracted from medical records. Panoramic and lateral cephalometric radiographs were analyzed and patients were recalled for physical examination. Ten infants underwent mandibular distraction osteogenesis at a mean age of 3.7 months (median, 19 months; range, 11 days to 27 months). Mean length of follow-up was 6.8 years (range, 5.0 to 7.9 years). Ten Robin sequence infants without mandibular distraction osteogenesis (mean length of follow-up, 7.4 years; range, 6.7 to 8.9 years) were the controls. Shape anomalies, positional changes, and root malformations of molars were seen significantly more often than in the control group (p = 0.007, p = 0.009, and p = 0.043, respectively). Mandibular length was shorter (p = 0.030), but mandibular ramus height was comparable (p = 0.838) with that of the non-mandibular distraction osteogenesis group. Compared with healthy controls, all Robin sequence infants had a significantly shorter mandible. Mandibular distraction osteogenesis with a resorbable system reveals overall good short- and long-term results, but the effects on developing molars and mandibular outgrowth likely necessitate secondary procedures. This factor should be considered when deciding on treatment options and counseling of parents. Therapeutic, III.

Continuous Positive Airway Pressure for Upper Airway Obstruction in Infants with Pierre Robin Sequence.

The aim of the study was to evaluate noninvasive continuous positive airway pressure as first-line treatment for upper airway obstruction in neonates with Pierre Robin sequence. Forty-four neonates were enrolled and classified in 4 groups: ventilator-dependent patients (severe upper airway obstruction group), patients with clinical upper airway obstruction, an abnormal (moderate upper airway obstruction group) or normal polygraphy (mild upper airway obstruction group), and those with no clinical upper airway obstruction (no upper airway obstruction group). Five neonates in the severe upper airway obstruction group (n = 9) were successfully managed by noninvasive continuous positive airway pressure and 4 required a tracheotomy. The moderate upper airway obstruction group (n = 4) was successfully managed by noninvasive continuous positive airway pressure and the other patients by prone positioning. Continuous positive airway pressure represents an effective treatment of upper airway obstruction in Pierre Robin sequence and may be recommended in selected patients. Therapeutic, IV.

Higher Rates of Adenotonsillectomy or Adenoidectomy for Upper Airway Obstruction in Infants with Severe Laryngomalacia

Objectives: Synchronous airway anomalies below the supraglottis are thought to compound the symptoms of laryngomalacia (LM). Upper aerodigestive obstructive lesions may also be present but have not been discussed. This study examines other sources of upper airway obstruction in infants with severe LM requiring supraglottoplasty (SGP). Methods: Data were compiled on infants who received SGP between 2004 and 2011. Those with neurological conditions, syndromes, or major comorbidities were excluded. The incidence, type, and timing of procedures to relieve upper airway obstruction above the larynx were examined in each infant within 4 years after SGP. Results: One hundred fifty-six infants were included. Forty-two (26.9%) had other sources of upper airway obstruction necessitating a surgical procedure beyond SGP. Thirty-two patients required an adenoidectomy alone, either during or within 30 months of SGP. Nine patients required adenotonsillectomy. One patient required tonsillectomy alone. Among the patients who underwent adenoidectomy, tonsillectomy was required later in 6 patients. Age at the time of SGP significantly affected the incidence of additional procedures. Infants receiving SGP at an age greater than 6 months were more likely to require management of adenotonsillar hypertrophy (82.1%) than their younger counterparts (14.8%) ( P &lt; 0.05). Conclusions: Accessory upper airway obstruction due to adenoidal or adenotonsillar hypertrophy, both synchronous and non-synchronous (occurring after) is more common in patients with severe laryngomalacia. Infants older than 6 months receiving SGP are more likely to require additional procedures to relieve upper airway symptoms. Management of accessory sources of upper airway obstruction should be explored in infants with laryngomalacia.

Stridor in Asian Infants: Assessment and Treatment

Stridor is the main symptom of upper airway obstruction in infants. It can be congenital or acquired, acute or chronic. Pathologies can be located from the nose down to the trachea. Common causes include laryngomalacia, vocal cord palsy, subglottic stenosis, tracheal anomaly, laryngeal cleft, vascular and lymphatic malformation, laryngeal papillomas, craniofacial abnormalities and even head and neck tumours. In this paper, we will discuss our approach to infants with stridor including assessment with flexible and rigid endoscopy and treatments to various conditions in a tertiary centre. Causes of stridor in infants undergoing rigid laryngotracheobronchoscopy in Queen Mary Hospital, University of Hong Kong Medical Centre between 2005 and 2011 will be retrospectively reviewed. Treatments according to various conditions will be discussed. Successful management of these neonates requires accurate diagnosis, early intervention, and multidisciplinary care by ENT surgeons, paediatricians, and paediatric anaesthetists.

An Unusual Presentation of Vallecular Cyst with near Fatal Respiratory Distress and Management Using Conventional Laparoscopic Instruments

Vallecular cyst is a rare cause of upper airway obstruction in infants and children and presentation like acute stridor with near fatal respiratory distress is extremely rare. It is one of the rare causes of difficult intubation, during which cyst aspiration can improve the access. Vallecular cyst is commonly managed using microlaryngoscope and specialized instruments. We hereby report a method of endoscopic management of these cysts using conventional laparoscopic instruments.