1
|
Costa E, Pazinatto DB, Trevisan LP, Maunsell R. Post-extubation laryngitis in children: diagnosis, management and follow-up. Braz J Otorhinolaryngol 2024; 90:101440. [PMID: 38797032 DOI: 10.1016/j.bjorl.2024.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 04/14/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES To describe the occurrence of post-extubation laryngitis, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes. METHODS Retrospective study including children up to 13 years old at a tertiary hospital between March 2020 and March 2022 with diagnosis of post-extubation laryngitis confirmed by endoscopic examination. Exclusion criteria were prior history of intubation or anatomical airway abnormalities. Medical records were reviewed to characterize patients, underlying diagnosis, laryngeal lesions, treatment, and outcomes at 12-month follow-up. RESULTS The study included 38 endoscopically confirmed post-extubation laryngitis cases, corresponding to 86.4% of suspected cases. The mean age was 13.24 months, and 60.5% were male. Acute respiratory failure was the leading cause of intubation. Initial treatment was clinical, and initial diagnosis was defined by nasopharynoglaryngoscopy and/or Microlaryngoscopy and Bronchoscopy (MLB) findings. Initial diagnostic MLB was performed in 65.7% of the patients. Approximately half (53%) of the patients exhibited moderate or severe laryngeal lesions. When compared to mild cases, these patients experienced a higher rate of extubation failures (mean of 1.95 vs. 0.72, p = 0.0013), underwent more endoscopic procedures, and faced worse outcomes, such as the increased need for tracheostomy (p = 0.0001) and the development of laryngeal stenosis (p = 0.0450). Tracheostomy was performed in 14 (36.8%) children. Patients undergoing tracheostomy presented more extubation failures and longer intubation periods. Eight (21%) developed laryngeal stenosis, and 17 (58.6%) had complete resolution on follow-up. CONCLUSION Post-extubation laryngitis is a frequent diagnosis among patients with clinical symptoms or failed extubation. The severity of laryngeal lesions was linked to a less favorable prognosis observed at one-year follow-up. Otolaryngological evaluation, follow-up protocols, and increased access to therapeutic resources are essential to manage these children properly. LEVEL OF EVIDENCE Level 4.
Collapse
Affiliation(s)
- Elaine Costa
- Disciplina de Otorrinolaringologia Cabeça e Pescoço, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Brazil.
| | - Débora Bressan Pazinatto
- Disciplina de Otorrinolaringologia Cabeça e Pescoço, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Brazil
| | - Luciahelena Prata Trevisan
- Disciplina de Otorrinolaringologia Cabeça e Pescoço, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Brazil
| | - Rebecca Maunsell
- Disciplina de Otorrinolaringologia Cabeça e Pescoço, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Brazil
| |
Collapse
|
2
|
Amaya S, Murillo M, Gutiérrez Pérez ML, Cervera HS, Andrade MJ, Zuñiga MA, Barreto N, Daza MI, Carvajal LF, Alarcón CM, Aponte L, Olbrecht VA. The role of local inflammation in complications associated with intubation in pediatric patients: A narrative review. Paediatr Anaesth 2023; 33:427-434. [PMID: 36719267 DOI: 10.1111/pan.14643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023]
Abstract
Although the most important primary local inflammatory response factor to intubation is not yet clear, it is known that it may be directly attributed to the presence of trauma during intubation or the response of oral bacterial flora present in the trachea. It is known that prolonged intubation is associated with worse outcomes, but other underlying systemic issues, such as sepsis and trauma, are also associated with this result. Likewise, patients who require advanced airway management and excessive manipulation are more likely to experience complications. There are various inflammatory mediators that are generated during orotracheal intubation, many of which can be considered targets for therapies to help reduce inflammation caused by intubation. However, there is little evidence on the management of the inflammatory response induced by orotracheal intubation in pediatric patients. Therefore, the aim of this narrative review is to highlight the intubation associated complications that can arise from poorly controlled inflammation in intubated pediatric patients, review the proposed pathophysiology behind this, and discuss the current treatments that exist. Finally, taking into account the discussion on pathophysiology, we describe the current therapies being developed and future directions that can be taken in order to create more treatment options within this patient population.
Collapse
Affiliation(s)
- Sebastian Amaya
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marcelino Murillo
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Martha L Gutiérrez Pérez
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
- Otorhinolaryngology Interest Group, Universidad El Bosque, Bogotá, Colombia
| | - Hector S Cervera
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - María J Andrade
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - María A Zuñiga
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Natalia Barreto
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - María I Daza
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Luisa F Carvajal
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Catalina M Alarcón
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Laura Aponte
- Anesthesiology and Critical Care Interest Group, Universidad El Bosque, Bogotá, Colombia
- Colombian School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Vanessa A Olbrecht
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| |
Collapse
|
3
|
Menon R, Vasani SS, Widdicombe NJ, Lipman J. Laryngeal injury following endotracheal intubation: Have you considered reflux? Anaesth Intensive Care 2023; 51:14-19. [PMID: 36168788 DOI: 10.1177/0310057x221102472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Laryngotracheal injury is an increasingly common complication of intubation and mechanical ventilation, with an estimated 87% of intubated and ventilated patients developing a laryngotracheal injury often preventing their rehabilitation from acute illness. Laryngotracheal injuries encompass a diverse set of pathologies including inflammation and oedema in addition to vocal cord ulceration and paralysis, granuloma, stenosis, and scarring. The existing literature has identified several factors including intubation duration, endotracheal tube size, type and cuff pressures, and technical factors including the skill and experience of the endoscopist. Despite these associations, a key aspect in the sequelae of laryngotracheal injuries is due to reflux and is not clearly related to iatrogenic and mechanical factors.Laryngopharyngeal reflux is a type of reflux that contaminates the upper aerodigestive tract. The combination of patient positioning and continuous nasogastric tube feeding act to affect the upper aerodigestive tract with acidic and non-acidic refluxate that causes direct and indirect mucosal injury impeding healing.Despite laryngopharyngeal reflux being an established and recognised causative factor of upper aerodigestive tract inflammatory pathology and laryngotracheal injury, it is very understudied in critical care. Further, there is yet to be an agreed pathway to assess, manage and prevent laryngotracheal injury in intubated and ventilated patients. The incidence of laryngopharyngeal reflux in the intubated and mechanically ventilated patient in the intensive care unit is currently unknown. Prospective studies may allow us to understand further potential mechanisms of upper aerodigestive tract injury due to laryngopharyngeal reflux and herald the development of preventative and management strategies of laryngopharyngeal reflux-mediated upper aerodigestive tract injury in critically ill patients.
Collapse
Affiliation(s)
- Rahul Menon
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Sarju S Vasani
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Neil J Widdicombe
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
- The University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, Nimes, France
| |
Collapse
|
4
|
Shah VN, Suresh NV, Pasick LJ, Ghiam MK, Torres LA. Pediatric bilateral vocal cord granulomas presenting as airway foreign body following prolonged intubation due to COVID-19 related multisystem inflammatory syndrome. OTOLARYNGOLOGY CASE REPORTS 2021; 20:100311. [PMID: 34957360 PMCID: PMC8076726 DOI: 10.1016/j.xocr.2021.100311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background This report is a case of bilateral vocal cord granulomas (VCG) in a 9-year-old child presenting as an airway foreign body and stridor following prolonged intubation due to COVID-19 pneumonia complicated by multisystem inflammatory syndrome in children (MIS-C). Case presentation This case reports a 9-year-old male who presented to the emergency department with acute stridor concerning for airway obstruction. X-ray findings suggested an airway foreign body; however, on rigid bronchoscopy, ball-valving bilateral VCG obstructing 90% of the glottic airway were identified. After excision of the VCGs, the patient's symptoms resolved with no postoperative complications. Conclusion With suspected foreign body aspiration in a pediatric patient with a history of prolonged intubation, it is important to consider a broad differential diagnosis. VCGs are rare complications of prolonged intubation that could be in children with prior history of intubation following COVID-19 pneumonia.
Collapse
Affiliation(s)
- Viraj N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neeraj V Suresh
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Luke J Pasick
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael K Ghiam
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Leonardo A Torres
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
5
|
Garefis K, Garefi M, Tarazis K, Chatziavramidis A, Pervana S, Konstantinidis I. Postintubation hypopharyngeal granuloma causing stridor in an infant. EAR, NOSE & THROAT JOURNAL 2021:1455613211062441. [PMID: 34875907 DOI: 10.1177/01455613211062441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Konstantinos Garefis
- 2nd Academic ORL, Head and Neck Surgery Department, 37794Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Maria Garefi
- Department of Pediatric, 117031General Hospital of Veroia, Veroia, Greece
| | - Konstantinos Tarazis
- 1st Department of ORL, Head and Neck Surgery, National and Kapodistrian University of Athens, Hippokrateio Hospital, Athens, Greece
| | - Angelos Chatziavramidis
- 2 Academic ORL, Head and Neck Surgery Department, 37794Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Stavroula Pervana
- Department of Pathology, 37794Papageorgiou Hospital, Thessaloniki, Greece
| | - Iordanis Konstantinidis
- 2 Academic ORL, Head and Neck Surgery Department, 37794Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| |
Collapse
|
6
|
Aldriweesh B, Khan A, Aljasser A, Bukhari M, Alrabiah A, AlAmmar A. Correlation of airway ultrasonography and laryngoscopy findings in adults with subglottic stenosis: a pilot study. Eur Arch Otorhinolaryngol 2021; 279:1989-1994. [PMID: 34842971 DOI: 10.1007/s00405-021-07195-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Ultrasonography of the airway has potential as an alternative, non-invasive, method to monitor patients with subglottic stenosis in an outpatient setting. This prospective, interventional, double-blinded study aimed to correlate ultrasound-based and laryngoscopy-based subglottic stenosis assessment in adults. METHODS The study was conducted between July 2020 and March 2021 at a tertiary referral center. Consecutive adult patients with subglottic stenosis were evaluated using airway ultrasonography 1 day prior to scheduled laryngoscopy. The radiologist was blinded to the preoperative endoscopic findings, and the primary surgeon was blinded to the ultrasonographic measurements. The intraoperative subglottic diameter was defined as the outer diameter of an endotracheal tube passing through the subglottis without producing an air leak. RESULTS Sixteen patients (11 females; age range, 17-66 years; mean = 44.06, SD = 12.79) were included. The ultrasonographic subglottic diameter ranged from 5.20 mm to 8.00 mm (mean = 6.24 mm, SD = 0.90). In 15 of 16 patients, the diameter difference between the ultrasonographic and intraoperative measurements ranged from -0.80 mm to 0.30 mm (mean = -0.20 mm, SD = 0.35). However, patient 6 had a difference of - 2.10 mm between the two measurements, which was attributed to thick laryngotracheal secretions interfering with the ultrasonographic air shadow. Data analysis of all 16 patients showed a statistically significant correlation between the readings obtained by the two techniques (r = 0.84, P = 0.000051). CONCLUSION This study found a significant correlation between ultrasonography-based and laryngoscopy-based subglottic stenosis assessment in adult patients. It provides a basis for an alternative and potentially reliable method to monitor patients with subglottic stenosis.
Collapse
Affiliation(s)
- Bshair Aldriweesh
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia. .,Department of Otolaryngology-Head and Neck Surgery, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia.
| | - Adeena Khan
- Department of Radiology, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Manal Bukhari
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Alrabiah
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed AlAmmar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
7
|
Exuberant Intratracheal Granuloma. Case Rep Otolaryngol 2021; 2021:6697478. [PMID: 33688444 PMCID: PMC7920715 DOI: 10.1155/2021/6697478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 01/30/2021] [Accepted: 02/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Upper airway granulomas are commonly encountered benign masses and are a result of pronounced tissue reactivity to localized respiratory mucosal trauma. The mechanism of injury to respiratory epithelium is most commonly iatrogenic and associated with intubation or indwelling tracheostomy. Case Report. A 40-year-old obese female with a history of multiple intubations, poorly controlled diabetes mellitus type II, and history of tracheal stenosis presented with sudden onset respiratory distress requiring intubation at an outside hospital. Direct laryngoscopy revealed a rapidly forming transglottic tissue mass, measuring 5.0 × 2.2 × 0.8 cm. The following case represents an unusual exception to our experience with granulomas given its rapidity of onset and migration of tissue around the endotracheal tube. Discussion. Laryngeal erythema and granulation formation are expected postintubation findings in most patients; however, the large size of granuloma tissue and rapid onset of symptoms in this case make it remarkable. Our patient had multiple risk factors for postintubation stenosis: female sex, poorly controlled diabetes, hypertension, obesity, and multiple prior intubations for periods lasting longer than forty-eight hours. Conclusion Our case highlights a rare laryngeal finding of a large granulation tissue mass causing sudden onset airway obstruction.
Collapse
|
8
|
Burke B, Tierney W, Georgopoulos R, Latifi SQ, Agarwal HS. Acute Tracheal Necrosis After Intubation in a Childhood Onset Systemic Lupus Erythematosus. Chest 2021; 159:e65-e67. [PMID: 33563456 DOI: 10.1016/j.chest.2020.08.2076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022] Open
Abstract
Upper airway involvement in systemic lupus erythematosus (SLE) disease process is uncommon. A 15-year-old girl, a known patient with class IVA lupus nephritis, presented in acute renal failure due to flare-up of SLE. She underwent an uneventful elective intubation procedure for placement of a hemodialysis catheter. After 36 hours of extubation, she developed biphasic stridor and severe shortness of breath that was unresponsive to multiple medications. Prompt airway evaluation by laryngoscopy and confirmation of acute tracheal necrosis by histopathology along with reintubation and high-dose steroid therapy resulted in good outcome and recovery.
Collapse
Affiliation(s)
- Brendan Burke
- Department of Pediatric Critical Care, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - William Tierney
- Department of Otolaryngology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Rachel Georgopoulos
- Department of Otolaryngology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Samir Q Latifi
- Department of Pediatric Critical Care, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Hemant S Agarwal
- Department of Pediatric Critical Care, Cleveland Clinic Children's Hospital, Cleveland, OH.
| |
Collapse
|
9
|
Lambercy K, Pincet L, Sandu K. Intubation Related Laryngeal Injuries in Pediatric Population. Front Pediatr 2021; 9:594832. [PMID: 33643969 PMCID: PMC7902727 DOI: 10.3389/fped.2021.594832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Laryngeal intubation related lesions (LIRL) in pediatric patients cause extreme morbidity in both elective and emergency settings. It has a wide range of presentations from minor laryngeal edema to a life-threatening airway obstruction. We report here our units' experience with LIRL in neonates, infants, and small children. Material and Methods: This is a retrospective monocentric cohort study between January 2013 and April 2019. Results: Thirty-nine patients with intubation lesions were included in the study. We looked at the lesions type, characteristics, management, and outcome. Half the patients were premature and having comorbidities. Main LIRL were subglottic stenosis (31%), ulcers (26%), granulations (18%), retention cysts (18%), posterior glottic stenosis (13%), and vocal cords edema (5%). Unfavorable lesions causing airway stenosis were associated with an intubation duration of over 1 week and were an important factor in causing airway stenosis (p < 0.05). The endoscopic treatment performed for these lesions was lesion and anatomical site-specific. Tracheostomy was needed in five patients, and was avoided in another two. Seven patients (18%) received open surgery prior to their decannulation. Conclusions: LIRL management is challenging and stressful in the pediatric population and optimal treatment could avoid extreme morbidity in them. Intubation duration and associated comorbidities are important factors in deciding the severity of these lesions. Protocols to prevent the formation of these lesions are critical.
Collapse
Affiliation(s)
- Karma Lambercy
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Laurence Pincet
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Kishore Sandu
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| |
Collapse
|
10
|
Waler A, Sanchez K, Cervantes SS, Chen C. Management of pediatric laryngeal webs secondary to severe croup and traumatic intubation. Int J Pediatr Otorhinolaryngol 2020; 139:110409. [PMID: 33068948 DOI: 10.1016/j.ijporl.2020.110409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022]
Abstract
Laryngotracheobronchitis is a common, typically self-limiting viral infection. However, severe laryngotracheobronchitis can require urgent intubation to prevent imminent airway obstruction. The concurrent inflammation and urgency make laryngeal trauma more likely. We report two cases of children who underwent emergent intubation for acute respiratory distress due to viral laryngotracheobronchitis and subsequently developed anterior laryngeal webs. Both underwent laryngoplasty with keel placement, with resolution of their laryngeal webs. These cases describe pediatric laryngeal web formation as a rare complication of traumatic intubation and a novel technique for endoscopic keel placement.
Collapse
Affiliation(s)
- Alex Waler
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Kyle Sanchez
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Sergio Santino Cervantes
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA; Department of Pediatric Otolaryngology, Nemours Children's Hospital, Orlando, FL, USA.
| | - Cynthia Chen
- University of Central Florida College of Medicine, University of Central Florida, Orlando, FL, USA; Department of Pediatric Otolaryngology, Nemours Children's Hospital, Orlando, FL, USA.
| |
Collapse
|
11
|
Liu Y, Wu W, Huang Q. Endoscopic management of pediatric extubation failure in the intensive care unit. Int J Pediatr Otorhinolaryngol 2020; 139:110465. [PMID: 33120102 DOI: 10.1016/j.ijporl.2020.110465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study investigated the endoscopic findings associated with pediatric extubation failure (EF) and evaluated the prognosis of endoscopic procedures. METHODS We retrospectively reviewed the data of children with EF in the intensive care unit from January 1, 2013 to December 31, 2019. Fifty-one children receiving endoscopic examination were enrolled in this study. EF was defined as the need for reintubation within 72 h of the first attempted extubation. RESULTS Thirty-three children (65%) were successfully extubated after endoscopic procedures, and 18 children (35%) failed in extubation. There was a higher percentage of children transferred from other hospitals with intubation in the failure group (56% vs 12%, p = 0.002). Subglottic stenosis (SGS) (35%) and laryngeal and tracheal granulation (33%) were two of the most common findings. Fourteen patients (82%) with granulation were successfully extubated. Two children in the failure group were diagnosed with mitochondrial myopathies (chrM:3243) and congenital myasthenic syndrome (CHAT). The success rate in cases of SGS reached 83% (15/18). Five patients diagnosed with laryngomalacia and another 3 patients with tracheomalacia failed extubation after supraglottoplasty and needed a temporary tracheostomy. CONCLUSION Granulation and subglottic stenosis were the leading causes of extubation failure. Patients transferred with intubation might have a poor prognosis after endoscopic procedures. Neuromuscular and metabolic disorders could be a hidden reason for extubation failure.
Collapse
Affiliation(s)
- Yupeng Liu
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Wenjin Wu
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Qi Huang
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
| |
Collapse
|
12
|
Espahbodi M, Kallenbach SL, Thorgerson AA, Huang CC, Shay SG, McCormick ME, Chun RH. The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations. Int J Pediatr Otorhinolaryngol 2020; 138:110268. [PMID: 32805493 DOI: 10.1016/j.ijporl.2020.110268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/15/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations. OBJECTIVE To determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings. METHODS A retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013-June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed. RESULTS Of the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB. CONCLUSIONS Infants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.
Collapse
Affiliation(s)
- Mana Espahbodi
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA
| | | | - Abigail A Thorgerson
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Chiang-Ching Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Sophie G Shay
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael E McCormick
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert H Chun
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA.
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Pediatric posterior glottic stenosis (PGS) is a challenging clinical entity with multiple treatment options. This review describes the evaluation of patients with PGS and discusses existing surgical techniques. RECENT FINDINGS PGS secondary to a distinct scar band between the vocal folds can often be effectively managed with endoscopic division and surveillance. More advanced glottic scarring that also involves the interarytenoid mucosa, cricoarytenoid joints, or subglottis merits a more thorough investigation and repair. A postcricoid mucosal advancement flap can be employed in select adolescent or adult PGS, but long-term cricoarytenoid joint mobility is difficult to restore once it has been fixed. Younger pediatric patients have smaller airways and frequent concurrent subglottic stenosis which is better addressed with cartilage grafting. SUMMARY Surgical success in pediatric PGS depends on careful preoperative airway assessment and the accurate characterization of airway stenosis. A surgical technique should be chosen based on the severity and extent of stenosis.
Collapse
|
14
|
Spontaneous formation and resolution of a supraglottic mass in an infant. OTOLARYNGOLOGY CASE REPORTS 2020. [DOI: 10.1016/j.xocr.2020.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
15
|
Veder LL, Joosten KFM, Schlink K, Timmerman MK, Hoeve LJ, van der Schroeff MP, Pullens B. Post-extubation stridor after prolonged intubation in the pediatric intensive care unit (PICU): a prospective observational cohort study. Eur Arch Otorhinolaryngol 2020; 277:1725-1731. [PMID: 32130509 PMCID: PMC7198633 DOI: 10.1007/s00405-020-05877-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/19/2020] [Indexed: 11/27/2022]
Abstract
Purpose Prolonged endotracheal intubation may lead to laryngeal damage, with stridor being the most relevant clinical symptom. Our objective was to determine the incidence of post-extubation stridor and their clinical consequences in children within a tertiary referral center and to identify contributing factors. Methods 150 children, aged 0–16 years, intubated for more than 24 h were prospectively enrolled until discharge of the hospital. Potential relevant factors, thought to mediate the risk of laryngeal damage, were recorded and analyzed. Results The median duration of intubation was 4 days, ranging from 1 to 31 days. Stridor following extubation occurred in 28 patients (18.7%); 3 of them required reintubation due to respiratory distress and in 1 child stridor persisted for which a surgical intervention was necessary. In multivariate analyses, we found the following independent predictors of stridor: intubation on the scene, the use of cuffed tubes and lower age. Conclusion Despite a high incidence for post-extubation stridor, only few children need reintubation or surgical intervention as a result of post-extubation lesions. Intubation on the scene, the use of cuffed tubes and young age are associated with a significant increased risk of post-extubation stridor. Awareness of these factors gives the possibility to anticipate on the situation and to minimize laryngeal injury and its possible future consequences.
Collapse
Affiliation(s)
- L L Veder
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP-1421a, Rotterdam, The Netherlands.
| | - K F M Joosten
- Department of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K Schlink
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M K Timmerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - L J Hoeve
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M P van der Schroeff
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - B Pullens
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
16
|
Song JG, Cho WH, Ji SM, Park JH, Kim SK. Laryngeal granulomas in patients after two-jaw surgery - Four cases report. Anesth Pain Med (Seoul) 2019; 14:489-493. [PMID: 33329782 PMCID: PMC7713798 DOI: 10.17085/apm.2019.14.4.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/12/2019] [Indexed: 11/17/2022] Open
Abstract
Background Endotracheal intubation can cause focal ischemia, damage or edema to the laryngeal mucosa, and may be followed by serious complications such as vocal cord paralysis, ulcers, and granulation tissue formation. Laryngeal granuloma is rare but also a significant late complication of endotracheal intubation, and anesthesiologists should be concerned about it. Case We experienced four cases of laryngeal granuloma that developed after two-jaw surgery January 2017–December 2018 in our hospital and would like to report these cases with brief review of literature. Conclusions There are frequent movements on the head and neck in maxillofacial surgery and the nasotracheal intubation should be prolonged after bimaxillary osteotomy surgery because of post-operative airway problems. This may be why two-jaw surgery may have higher occurrence of laryngeal granuloma than others.
Collapse
Affiliation(s)
- Jae Gyok Song
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Won Ho Cho
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Sung Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jeong Heon Park
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Seok Kon Kim
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| |
Collapse
|
17
|
Subparalyzing Doses of Rocuronium Reduce Muscular Endurance without Detectable Effect on Single Twitch Height in Awake Subjects. Anesthesiol Res Pract 2019; 2019:2897406. [PMID: 31191651 PMCID: PMC6525858 DOI: 10.1155/2019/2897406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/28/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To test the hypothesis that a low-dose rocuronium acts mainly by means of reducing muscular endurance rather than by reducing momentary force. METHODS In a randomized placebo-controlled double-blinded study, eight healthy volunteers were studied in two sets of experiments. In the first set, the subjects made a sustained maximum effort with the dominant hand for 80 seconds while squeezing an electronic handgrip dynamometer at three minutes after intravenous administration of placebo, 0.04 or 0.08 mg/kg rocuronium. Handgrip force at initiation of testing (maximum handgrip force) and after 60 seconds was evaluated. In the second set, the ulnar nerve of the subjects was electrically stimulated every tenth second for at least 10 and a maximum of 30 minutes following the administration of placebo and 0.08 mg/kg rocuronium. Single twitch height of the adductor pollicis muscle was recorded. RESULTS There was no significant difference in the effect on maximum handgrip force at time 0 between the three different doses of rocuronium. As compared with placebo, handgrip force after 0.08 mg/kg rocuronium was reduced to approximately a third at 60 seconds (214 N (120-278) vs. 69 (30-166); p=0.008), whereas only a slight reduction was seen after 0.04 mg/kg (187 (124-256); p=0.016). Based on these results, the sustained handgrip force after 0.2 mg/kg at 60 seconds was calculated to be 1.27% (95% CI [0.40, 4.03]) of the maximum force of placebo. No effect on single twitch height after 0.08 mg/kg rocuronium at four minutes after drug administration could be detected. CONCLUSIONS Subparalyzing doses of rocuronium show a distinct effect on muscular endurance as opposed to momentary force. The findings support the hypothesis that low doses of rocuronium act mainly by reducing muscular endurance, thereby facilitating, for example, tracheal intubation.
Collapse
|
18
|
Hron TA, Kavanagh KR, Murray N. Diagnosis and Treatment of Benign Pediatric Lesions. Otolaryngol Clin North Am 2019; 52:657-668. [PMID: 31088693 DOI: 10.1016/j.otc.2019.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Dysphonia is common in pediatrics and affects individuals from infancy through their teenage years. Pediatric dysphonia has a variable impact on children, ranging from no impact to a severe social barrier. Although most etiologies are benign, potentially life-threatening causes must be ruled out by direct examination of the larynx. The most common benign lesions of the larynx in pediatrics are vocal nodules, vocal fold polyps, cysts, granulomas, ectasias, sulcus vocalis, and vascular lesions, including hemangioma and postcricoid cushion. Treatment of benign vocal lesions should be tailored to the individual patient and the perceived impact.
Collapse
Affiliation(s)
- Tiffiny A Hron
- Harvard Medical School, Tufts University School of Medicine, Massachusetts General Hospital, Center for Laryngeal Surgery & Voice Rehabilitation, One Bowdoin Sq, 11th Floor, Boston, MA 02114, USA
| | - Katherine R Kavanagh
- Pediatric Otolaryngology, Connecticut Children's Medical Center, 282 Washington, 2L, Hartford, CT 06106, USA; Department of Otolaryngology-Head and Neck Surgery, University of Connecticut Medical School, Farmington, CT, USA
| | - Nicole Murray
- Pediatric Otolaryngology, Connecticut Children's Medical Center, 282 Washington, 2L, Hartford, CT 06106, USA; Department of Otolaryngology-Head and Neck Surgery, University of Connecticut Medical School, Farmington, CT, USA.
| |
Collapse
|