Flexible laryngoscopy in neonates, infants, and young children

Study on Nocturnal Infant Crying Evaluation (NICE) and Reflux Disease (RED)

BACKGROUND

Nocturnal infant crying is often empirically treated with acid suppressants. The aim of this study was to evaluate the prevalence and characteristics of gastroesophageal reflux (GER) in infants with unexplained persistent crying.

METHODS

We enrolled all infants (0-12 months) referred for suspected GER disease who underwent esophageal impedance-pH monitoring (MII-pH) for unexplained persistent crying not improved by parental reassurance, dietary modification or alginate. Gastrointestinal malformation/surgery, neurological impairment and infections were exclusion criteria. Demographic and anthropometric parameters, GER symptoms and questionnaires (I-GERQ-R) and MII-pH data were recorded and analyzed. Normal MII-pH was defined when acid exposure was <3%, symptom index was <50% and symptom association probability was <95%. Acid exposure >5% and >10% was also considered. Statistical analysis was performed using Chi-Square and univariate and multivariable regression analysis.

RESULTS

We included 50 infants (median age 3.5 months) who fulfilled the study criteria: 30 (60%) had normal MII-pH. I-GERQ-R score was abnormal in 33 (66%) infants, and 21/33 (64%) had normal MII-pH (p = 0.47). In the 26 (52%) infants with nocturnal crying, MII-pH was normal in 16 (54%) (p = 0.82). Associated regurgitation (>3 or >10 episodes/die) did not predict abnormal MII-pH (p = 0.74, p = 0.82, respectively). Univariate and multivariable regression analysis did not identify any clinical variable significantly associated with abnormal MII-pH.

CONCLUSIONS

Infants with persistent unexplained and nocturnal crying should not be empirically treated with acid inhibitors.

Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children

PURPOSE

Vocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI yet can be challenging to perform and/or risks possible clinical decompensation in some children and is an aerosolizing procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI.

METHODS

A prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement.

RESULTS

Between 2021 and 2023, 85 paired evaluations were performed with patients having a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI: 0.91-1.00, P < 0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI: 90-100%). Diagnostic accuracy was 98.8% (95% CI: 93-100%).

CONCLUSION

LUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL.

TYPE OF STUDY

Prospective, single-center, single blinded (rater), cohort study.

LEVEL OF EVIDENCE

Level II.

Endoscopic evaluation of neonates with signs of upper airway obstruction in the neonatal unit of a tertiary hospital

INTRODUCTION

The aim of the study is to evaluate major causes of upper airway obstruction in newborns receiving healthcare at our institution, their method of endoscopic assessment and the rate of complications related to these procedures.

MATERIALS AND METHODS

This is a case series study of patients from institutional neonatal intensive care unit (NICU) presenting signs of ventilatory dysfunction for whom an endoscopic airway assessment was warranted. Information of interest was collected from medical records according to a Clinical and Endoscopic Assessment Protocol created for the study. The protocol included clinical manifestations needing ENT evaluation, clinical signs of ventilatory dysfunction, comorbidities (pulmonary, cardiac, neurological, and gastrointestinal), examination method (airway endoscopy under general anesthesia or awake), exam complications, and final diagnosis.

RESULTS

One hundred sixty-nine newborn patients who underwent airway endoscopy (awake bedside flexible fiberoptic laryngoscopy (FFL) or direct laryngoscopy and bronchoscopy (DLB) in the surgical ward) were included. Thirty-nine patients (23.07%) underwent bedside FFL. For the remaining 130 who underwent DLB under general anesthesia, the median procedure time was 30 min (20-44). Only 9 (5.32%) patients presented complications: desaturation (4), laryngospasm without desaturation with spontaneous resolution (2), apnea with resolution after stimulation (1), seizures (1), nasal bleeding (1). The most frequent diagnoses found were glossoptosis, posterior laryngeal edema, and laryngomalacia.

CONCLUSION

This retrospective case series describes the prevalence of different pathologies that cause upper airway obstruction in neonates. Airway endoscopy seems an effective and safe diagnostic tool in neonatal airway obstruction. Glossoptosis was the most prevalent cause of obstruction in our center.

A Quantitative Analysis of Smartphone-Based Endoscopy and Video Tower Endoscopy

OBJECTIVES

Examine the differences between traditional tower-based endoscopy (TBE) and smartphone-based endoscopy (SBE) using objective measures of cost, setup time, and image quality.

METHODS

Cost analysis study and randomized single-blinded prospective trial was performed at a tertiary academic health center. Twenty-three healthcare providers, 2 PA-C, 9 residents, 2 fellows, 10 attendings varying in practice from 1 to 27 years were a part of the study. Actual cost analysis was used for purchase of the Karl Storz video tower system and the Save My Scope smartphone-based endoscopy system for cost analysis. For setup time, providers entered a room and were randomized to set up either an SBE or TBE system and timed from room entry to a visible on-screen image. A crossover was then performed so all providers performed both setups. For image discernment, standardized photos of a modified Snellen's test were sent via text message to providers who were blinded as to which photo represented which system. Practitioners were randomized as to which photo to receive first.

RESULTS

Cost savings was 95.8% ($39,917 USD) per system. Setup time for the smartphone system was 46.7 seconds less than video tower system on average (61.5 vs 23.5 seconds; P < .001, 95% CI: 30.3-63.1 seconds). Level of visual discernment was slightly better for SBE over TBE, with reviewers able to identify Snellen test letters at a size of 4.2 mm with SBE versus 5.9 mm with TBE (P < .001).

CONCLUSIONS

Smartphone-based endoscopy was found to be cheaper, quicker to set up, and to have marginally better image quality when transmitted via messaging than tower-based endoscopy, although the clinical significance of these visual differences are unknown. If appropriate for their needs, clinicians should consider smartphone-based endoscopy as a viable option for viewing and collaborating on endoscopic images from a fiberoptic endoscope.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Surgical treatment of severe laryngomalacia: Six month follow up

BACKGROUND

Laryngomalacia (LM) is the most common congenital anomaly of larynx that causes stridor in children. We evaluated the efficacy of epiglottic suture and laser epiglottopexy for treatment of infants with severe LM.

METHODS

Surgical intervention was performed in 19 patients with severe LM, after the diagnosis was established using flexible laryngotracheobronchoscopy. Five patients had isolated type 1 LM, and 14 patients had a combination of type 1 and 3 LM. Indication for surgical treatment was the presence of LM with at least one of the following: malnutrition (body mass index [BMI] Z score < -2 SD), dysphagia or symptoms of gastroesophageal reflux and mean oxygen saturation (SaO2 ) <92% with oxygen desaturation index (ODI) > 3.

RESULTS

Epiglottic suture was performed in 11 patients, and laser epiglottopexy in eight, at mean age 3.95 ± 2.4 months. Rate of operation was 2.2-fold greater for more severe anomaly (combination of type 1 and 3 LM) than for isolated type 1. At 6 month follow up symptoms had gradually improved, as well as nutritional status, with increase of mean BMI Z score from -3.7 to -0.9 (P < 0.01). Mean preoperative SaO2 was 89.4 ± 4.3% with mean ODI of 5.8. At 6 month follow up, mean SaO2 was 96.7 ± 1.1%, and mean ODI was 1.2 (P < 0.01).

CONCLUSIONS

Epiglottic suture and laser epiglottopexy are efficient surgical techniques that lead to significant improvement of symptoms, oxygenation and nutritional status in patients with LM.

Synchronous video laryngoscopy and sonography of the larynx in children

Unlike laryngoscopy, laryngeal sonography is easily applicable, well tolerated by young children and less exhausting for the examiner. The aim of this study was to determine if sonography can adequately visualize the laryngeal structures and vocal fold movements of children. Synchronic video laryngoscopy and sonography of the larynx were performed in 35 children (aged 2-8 years) without a laryngeal disease. 10 investigators at differing stages of otolaryngological training were tasked with identifying vocal fold movement and specific anatomical structures after seeing (1) the sonography-only video and (2) the sonography video with a laryngoscopy video overlay. The percentage of correct identification of the structures and the vocal cord movement with and without additional video-overlay was compared. A sonographical view of the larynx could be found and the following anatomical structures were identified: subcutaneous fat tissue, left and right sternohyoid and thyrohyoid muscles, thyroid cartilage, left and right vocal folds, left and right paraglottic spaces, left and right side arytenoid cartilages, and rima glottides. Concerning the evaluation of the videos amongst the investigators: they identified >80 % of vocal fold movement and the targeted anatomical structures except the arytenoid cartilages (only up to 63 %), having the sonography only. In combination with the laryngoscopy video-overlay, investigator detection rates significantly improved (>90 % of vocal fold movement, p < 0.001; >90 % in most anatomical structures, (p < 0,001). Laryngeal sonography is a helpful diagnostic tool to identify laryngeal structures and the movement of the vocal folds in children.

Per-oral flexible laryngoscopy in awake neonates and infants: the 'pacifier' technique

BACKGROUND

It is common for ENT specialists to be called to neonatal intensive care units to assess neonates with suspected laryngomalacia. At Addenbrooke's Hospital, Cambridge, UK, it is standard practice to initially try to assess the larynx whilst the patient is awake. This can cause the patient to cry and become irritable, and can induce worry in the parents. A literature search revealed that numerous procedures have been successfully performed on neonates and infants whilst they were being pacified.

OBJECTIVES

This paper describes various procedures where pacification has been used effectively. Furthermore, it reports a pacification technique developed for per-oral flexible laryngoscopy in awake neonates and infants.

Value of ultrasonography in diagnosis of pediatric vocal fold paralysis

OBJECTIVES

To investigate the appearance of the pediatric larynx on ultrasound images and the diagnostic potential of ultrasound in cases of pediatric vocal fold paralysis.

METHODS

First, we confirmed the ultrasonographic features of the laryngeal landmarks in 2 pediatric cadaveric larynxes. Secondly, 45 children were enrolled in a clinical study (13 patients with vocal fold paralysis and 32 normal children). Quantitative analysis of vocal fold mobility was carried out by measuring the maximum glottic angle (MGA) and vocal fold-arytenoid angle (VAA).

RESULTS

All the paralyzed vocal folds showed abnormal mobility, and were flaccid during breathing and phonation. The rima glottis appeared as a hyperechoic air-column band in ultrasound images during phonation. The mean value of the MGA was 61.47 ± 9.00 in the normal larynx and 42.25 ± 10.41 in the paralyzed larynx. In the affected side of the paralyzed larynx, the VAA in maximum abduction was smaller than that in the normal larynx or in the unaffected side. The median difference of the VAA between maximum abduction and maximum adduction was less than that in the normal larynx. The kappa value was 0.96.

CONCLUSION

MGA and VAA are quantitative indicators of vocal fold immobility. Ultrasound is a reliable method of diagnosis of pediatric VFP. To diagnose VFP from an ultrasound image, the criteria are: (1) abnormal mobility (this was the most important and direct evidence), (2) hyperechoic air-column band of the glottic rima during phonation, (3) flaccid vocal fold and (4) asymmetry of the glottal structures.

The safety of aerodigestive tract flexible endoscopy as an outpatient procedure in young children

BACKGROUND

Flexible endoscopy (FE) for the pediatric aerodigestive tract is an invasive and complicated procedure; therefore, it is usually performed under an inpatient setting. We investigated whether FE could be a safe procedure for outpatient young children (< 5 years old) and analyzed the findings.

METHODS

Outpatient FE records were retrospectively reviewed between 1996 and 2003. Patients aged less than 5 years were enrolled and allocated to 3 age groups: group A (<or=3 months), group B (4-12 months), and group C (1-5 years). Patients with or without previously known major airway anomalies were also grouped for analysis.

RESULTS

A total of 728 children (479 boys, 249 girls) who underwent 834 FE procedures were collected. Of those without previously known airway anomalies, stridor was the most common symptom in group A (60.2%), and snoring in group B (34.1%) and group C (74.2%). Laryngomalacia was the most common FE finding in group A (60.2%) and group B (34.1%), and nasal adenoid hypertrophy in group C (69.6%). After FE, there were 57 admissions (6.8%), and higher in those aged less than 1 year or in those with major airway anomalies. Seven (0.7%) were complication-associated admissions.

CONCLUSION

From this study, we conclude that FE is a safe, effective and tolerable outpatient procedure in the majority of young children, and serious complications were uncommon.

Synchronous airway lesions and associated anomalies in children with laryngomalacia evaluated with rigid endoscopy

OBJECTIVE

To evaluate the prevalence of synchronous airway lesions (SALs) and associated anomalies in children with laryngomalacia requiring rigid endoscopic evaluation, the clinical significance of such lesions, and safety and outcome of selective rigid endoscopy.

SETTING

National Children's Hospital.

DESIGN AND METHOD

Retrospective analysis. The records of all children diagnosed with laryngomalacia who underwent rigid endoscopy were identified from the surgical database over a 4-year period.

OUTCOME MEASURES

Age at presentation, signs and symptoms at time of presentation, presence of associated neurological and/or congenital anomalies (ANCAs), presence of synchronous airway lesions, need for surgical intervention, complications and time to resolution of symptoms were assessed.

RESULTS

There were 26 children in the study. The mean age at presentation ranged from 0 to 10 months of age. One child (3.8%) required surgical intervention for severe isolated laryngomalacia. Seven children (26.9%) had at least one SAL identified. Of these, six (85.7%) were previously diagnosed on flexible fibreoptic laryngoscopy (FFL). Two of the seven children with SALs required surgical management of the SAL. Prematurity and ANCAs prolonged hospital stays in these children. However, the presence of SALs did not affect the length of hospital stay or the time to resolution of symptoms. Symptom resolved in all children by 3 years of age, whether or not SALs or ANCAs are present. There was no adverse outcome in the study group.

CONCLUSION

Despite having indications for rigid endoscopy, many children with laryngomalacia do not have SALs, which even when present, are rarely clinically significant. SALs and ANCAs do not impact the time to symptom resolution. The current indications for rigid endoscopy in the evaluation of laryngomalacia are appropriate and safe.

Endoscopic findings in children with stridor

Congenital and acquired airway diseases are responsible for upper respiratory distress and stridor in children. In neonatal intensive care units, we have seen increased survival in premature babies, but also a high incidence of airway complications related to intubation, which present as stridor.

Aim

To review endoscopic findings in children with stridor.

Study design

a cross-sectional cohort study.

Methods

A retrospective analysis was done of 55 cases of children with stridor who underwent endoscopic exams, between January 1997 and December 2003.

Results

69% were aged below one year. The main indications for endoscopy were post-extubation stridor (63.63%) and evaluation of neonatal stridor (21.82%). Many associated diseases were seen, including lung diseases (60%), neurological condition (45.4%), and GERD (40%). The main endoscopic findings and indications for tracheotomy were subglottic stenosis (27.27%) and airway inflammatory process (21.82%) occurring in children under five years old. Congenital disorders were more frequent in children under age one year.

Conclusion

Neonatal stridor has many causes; those related to tracheal intubation are more frequent in hospitals that treat more complex diseases. Pediatricians and otorhinolaryngologists should know the main causes of stridor and perform detailed clinical evaluations to determine case severity. The endoscopic examination, must be meticulous.

Pediatric Laryngotracheal Obstruction: Current Perspectives on Stridor

OBJECTIVES/HYPOTHESIS

To assess how medical advances have impacted the diagnosis, management, and outcomes of pediatric laryngotracheal obstruction, and to describe the advantages of audio-video documentation of stridorous children.

STUDY DESIGN AND METHODS

Retrospective.

METHODS AND MATERIALS

268 patients were referred for suspected laryngotracheal obstruction during the 30 months between September 1, 1995 and March 1, 1998: 173 had 206 flexible fiberoptic laryngoscopies, and 160 had 273 direct laryngoscopies. One hundred and forty-one children were identified with laryngotracheal obstruction, yielding 40 different diagnoses that could be classified into 9 major categories. Thirty-six children (25.5%) had multiple sites of upper airway obstruction.

RESULTS

138 children had follow-up >1 month. Twelve children died (8.7%), leaving 126 survivors (mean follow-up=21.1 months). Outcomes were classified as resolved (44.2%), improved (37.0%), stable (9.4%), failed (0.7%), or death (8.7%). Better outcomes were seen in more readily treated diagnostic categories, such as tracheobronchial foreign body, chronic laryngitis, and suprastomal granulation tissue; laryngeal stenosis, tracheomalacia, and recurrent respiratory papillomatosis, had less favorable outcomes (P<.001). The former group also showed superior outcome compared to laryngomalacia (P<.001) and vocal cord mobility disorders (P=.004). Ninety-four patients (68.1%) had comorbidities complicating their management. Comorbid conditions were universal among deceased patients and least common in the resolved outcomes category (56.7%), supporting the premise that patients with poor outcomes are more likely to have comorbidities than patients with resolution of laryngotracheal symptoms (P=.034).

CONCLUSIONS

Audio-video recording of pediatric laryngotracheal obstruction offers numerous advantages. Children classified into an array of diagnostic categories usually have favorable outcomes, but opportunities for continued advances exist, particularly regarding management of comorbidity and chronic obstruction.

[Contribution of flexible bronchoscopy to the diagnosis of upper airway alterations]

INTRODUCTION

Flexible bronchoscopy (FB) is becoming an increasingly common diagnostic and therapeutic technique and is currently an essential procedure in pediatric pulmonology departments. Because the procedure is easy to perform under sedation and topical anesthesia, avoiding surgery with general anesthesia, which is required for rigid bronchoscopy, it has allowed the use of airway endoscopy in infants and children to be increased and has reduced patient risks.

OBJECTIVE

To analyze the contribution of FB to the diagnosis of upper airway alterations and to characterize the frequency and type of upper airway anomalies.

PATIENTS AND METHODS

We retrospectively reviewed the FB performed in our center between January 1993 and March 2003 in children aged less than 14 years old.

RESULTS

A total of 456 FB were performed in 378 children. One hundred eleven FB (24.5 % of all endoscopies) were required for suspected upper airway anomalies and 55.8 % corresponded to stridor. Upper airway inspection revealed abnormality in 30.7 % (140 FB). There were no severe complications.

CONCLUSION

FB is useful in the diagnosis of upper airway abnormalities. The main indication for FB is stridor and the most common abnormal finding of the upper airway is laryngomalacia.

Outpatient fibre-optic laryngoscopy for stridor in children and infants

Many neonates are referred for a diagnosis with stridor. The gold standard investigation has traditionally been a rigid or direct microlaryngoscopy. This impacts on existing theatre schedules, demands a high level of skills from the paediatric anaesthetist along with the risk of exposing a neonate to a general anaesthetic. A bed in paediatric intensive care is often required and must be reserved. As laryngomalacia is the most common diagnosis and less serious than the investigations for infants with stridor themselves, clinicians have been looking to use the flexible fibre-optic laryngoscope to view the upper airway in awake neonatal patients. We present our experience in 66 neonatal patients initially managed by awake per-oral flexible fibre-optic laryngoscopy for stridor. We conclude that the technique is safe, straightforward and allows a diagnosis to be achieved in a significant number of cases. We recommend it as a first line investigation, reserving microlaryngoscopy for the group of patients in whom a diagnosis cannot be made in the outpatient clinic.

Use of Nasopharyngoscopy in the Evaluation of Children With Noisy Breathing

STUDY OBJECTIVE

To evaluate the practice of using nasopharyngoscopy without routine fiberoptic bronchoscopy for children presenting to a pediatric pulmonary practice with nonspecific noisy breathing.

DESIGN

Retrospective chart review. Records of patients who underwent nasopharyngoscopy between January 1, 1990, and December 31, 1999, were reviewed. Follow-up was obtained by office records and direct contact with the patient's family and/or primary care physician.

SETTING

Academic, tertiary care facility.

RESULTS

Eighty-one children who underwent upper airway endoscopy to evaluate noisy breathing consistent with extrathoracic lesions were identified. One child had two evaluations separated by years for differing complaints, making a total of 82 procedures. Stridor was the chief complaint in three fourths of the children. Half of the children with stridor were found to have laryngomalacia. Long-term follow-up was available for 75 of 81 children, with median follow-up of 6 years (range, 1 to 13 years). No medical problems related to missed airway lesions developed in any infants initially evaluated using nasopharyngoscopy.

CONCLUSIONS

Nasopharyngoscopy without lower airway endoscopy can be used safely for the initial evaluation of noisy breathing in infants and children provided excellent follow-up is available.

Investigations in paediatric obstructive sleep apnoea: do we need them?

Ninety percent of normal children with obstructive sleep apnoea (OSA) improve, or are cured, with adenotonsillectomy. However, 10% of apparently normal children show no improvement following this operation and it has a very poor outcome in Down's syndrome, where only about one in six children improve. Adenotonsillectomy is also rarely curative in children with cerebral palsy or craniofacial syndromes. In these children investigations of the site and severity of their obstruction is necessary. Taking a detailed history and asking the parents to fill in a questionnaire for data collection will identify most children with OSA. Pulse oxymetry has some limitations but is a good screening tool. It does not provide enough information for the management of children with complex upper airway obstruction who are likely to have on going problems with OSA throughout their childhood despite intervention. For these children formal sleep studies are needed. Full polysomnography is the gold standard investigation to ascertain the severity of OSA. To ascertain the site of upper airway obstruction during sleep, sleep nasendoscopy has been found to be an excellent tool. This is performed under a light general anaesthetic in main theatres and is demonstrated using video footage in the presentation. This is a new classification to document the site of airway obstruction in paediatric OSA. A micro-layryngobronchoscopy is also required in any child who has daytime noisy breathing, a previous history of cardiac malformation or Down's syndrome, in whom a more distal site of airway obstruction may be present.

Laser partial epiglottidectomy as a treatment for obstructive sleep apnea and laryngomalacia

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

The role of fibreoptic laryngoscopy in infants with stridor

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

Diagnostic laryngeal endoscopy

Diagnostic laryngeal endoscopy is a crucial part of the evaluation of patients with dysphonia. Multiple methods are available, and often several are required to provide a comprehensive physiologic and anatomic evaluation. The pros and cons of each method are discussed and the development of a standardized examination protocol is reviewed.

Neonatal upper airway assessment by awake flexible laryngoscopy

Awake flexible laryngoscopy (AFL) provides simple and quick assessment of both the structure and function of the upper airway. To determine its value in neonates, a prospective study was carried out over 2 years of 110 neonates (80 term, 30 premature) under 6 weeks of age (corrected for prematurity) presenting with symptoms suggestive of upper airway disease who underwent AFL performed by the author. A diagnosis was made in 79 cases, while no cause was found for the symptoms in 31. The commonest diagnoses were vocal cord paralysis (29; bilateral 16, unilateral 13), nasal stenosis (9), laryngomalacia (9), glossoptosis (7), subglottic stenosis (6), and choanal atresia (5; bilateral 2, unilateral 3). The AFL was repeated in 31 neonates and the condition was found to be stable in 16, improved in 8, resolved in 2, and progressed in 1, and an additional diagnosis was made in 4. Endoscopy under general anesthesia with or without corrective surgery was performed in 15 neonates (7 also having repeat AFL). The diagnosis was confirmed in 14 and an additional tracheal abnormality was found in 1. The AFL was complicated by cyanosis in 2 neonates and epistaxis in 1, but all complications resolved with minimal intervention. These data suggest that the neonatal upper airway can be relatively safely and reliably assessed by AFL performed by an experienced clinician.

Role of ultrasound in the assessment of vocal cord function in infants and children

The determination of the cause of stridor in the infant and child is an important directive for the otolaryngologist. The limitations of current clinical diagnostic techniques have provided the impetus for pursuing newer, more practical techniques to diagnose vocal cord paralysis in children. The purpose of this paper is to describe a new technique to image the larynx and determine its role in discerning vocal cord paralysis in children. This study began with an animal study (lamb model) demonstrating that computerized ultrasound can accurately delineate laryngeal anatomy and function. The human protocol included 27 patients (age 1 day to 14 years): 15 with normal larynges and 12 with vocal cord paralysis. Recorded ultrasound studies of these subjects were compiled in a randomly ordered videotape and presented twice and viewed in a blinded manner by four expert raters. Statistical analysis of their readings revealed that ultrasound is a highly accurate technique to document vocal cord paralysis, with a high degree of interrater and intrarater reliability. Beyond the accuracy and consistency of computerized ultrasound, there are many other aspects of this technique that make it clinically attractive. Laryngeal ultrasound is noninvasive, painless, and widely accepted. It is relatively safe, with no radiation exposure and no need for sedation or anesthesia. It is well tolerated by patients and their families. The results are easily displayed and recorded and available for hard copy storage. This investigation should not be interpreted as an endorsement for laryngeal ultrasound as a replacement for endoscopy in children. This work does indicate, however, that ultrasound is a technique that can accurately address the special issue of vocal cord mobility in infants and children. At present, this is the primary use for laryngeal ultrasound, although with additional investigation and sophistication it is likely that ultrasound of the larynx may become useful for other purposes.

Stridor in neonates

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

Sleep fluoroscopy for localization of upper airway obstruction in children

The management of children with upper airway obstruction (UAO) in whom previous airway surgeries or concomitant craniofacial or neuromuscular abnormalities exist is complicated by potential obstruction at multiple sites. Sleep fluoroscopy (SF) provides a dynamic representation of relative degrees of obstruction at multiple levels of the pediatric airway. Fifty-five SF studies were performed on 50 infants and children to localize obstructive sites. Correlation was assessed with findings on direct laryngoscopy and bronchoscopy under spontaneous ventilation. In 24 (44%), endoscopic and SF findings correlated exactly. The SF studies identified a site of UAO in 11 patients with normal findings on endoscopic examination and multiple sites of UAO in 16 others. Two thirds of these occurred at the hypopharynx and tongue base. The SF studies failed to detect 5 airway abnormalities in 4 patients. The sensitivity of SF for endoscopically verified laryngotracheal lesions was lowest for glottic (67%) and subglottic (70%) locations and higher for tracheal (92%) and supraglottic (100%) sites. Sleep fluoroscopy altered the course of treatment in 26 (52%) children. It appears to be a valuable adjunct to endoscopy in the identification and management of pediatric UAO when hypopharyngeal collapse or multiple levels of obstruction are suspected.

Assessment of the Infant Airway with Videorecorded Flexible Laryngoscopy and the Objective Analysis of Vocal Fold Abduction

Accurate diagnosis of upper airway abnormalities by flexible laryngoscopy in infants is hampered by rapid laryngeal motion and lack of patient cooperation. This study evaluates the added role of videorecorded flexible laryngoscopy and the objective measurement of vocal fold abduction in improving the diagnosis of upper airway abnormalities in infants. Seventy-eight infants had videorecorded flexible laryngoscopy performed as part of their evaluation of a suspected airway disorder. These recordings were reviewed by three otolaryngologists for confirmation of the clinical diagnosis. From the video image, the maximum angle of vocal fold abduction was measured with image analysis software. Of 78 patients 40 had supraglottic or glottic abnormalities, 9 had nasal or nasopharyngeal obstruction, 9 had subglottic abnormalities (diagnosed subsequent to videolaryngoscopy), and 15 patients had normal findings on examination. Of those with laryngeal abnormalities, laryngomalacia was the most common diagnosis (23 of 78). Vocal fold paralysis was present in 4 patients. A separate group (9 of 78) of patients was identified as having symmetric bilateral limitation of vocal fold abduction. Laryngeal dyskinesia was diagnosed in these 9 patients. The mean values of maximal vocal fold abduction were as follows: (1) normals, 59.5 degrees; (2) laryngomalacia, 57.0 degrees; (3) paralysis, 26.6 degrees; and (4) incomplete abduction with laryngeal dyskinesia, 27.6 degrees. Videolaryngoscopy is a valuable tool for documentation, parent education, and analysis of infant laryngeal abnormalities. Repeat viewing of the video examination and frame-by-frame analysis improve the diagnostic accuracy. Using this approach, we have calculated the anterior glottic abduction angle in the normal and abnormal Infant larynx. In addition, we have identified a group of infants with incomplete abduction of the vocal folds that appears to be different from that found in vocal cord paralysis.

Direct Laryngoscopy in Children: Rigid and Flexible Fiberoptic

Examination of the child's larynx is mandatory in the management of pediatric airway problems. The techniques used to perform this examination have evolved over time and now present the airway specialist with choices that can be tailored to each specific situation. Traditionally, rigid direct laryngoscopy (RDL) has been used to evaluate the pediatric larynx. More recently, flexible fiberoptic laryngoscopy (FFL) has been used to visualize the child's airway. RDL and FFL each play a role in the evaluation of the pediatric larynx. Expertise with both techniques is mandatory for the otolaryngologist managing respiratory disorders in children. FFL has become our technique of choice to evaluate the pediatric larynx especially when airway dynamics are of concern. RDL remains the preferred technique when laryngeal/tracheal surgery is planned or establishment and protection of the airway with intubation or bronchoscopy is required.

Aetiology of stridor in Malaysian children

Eighty-five children who presented with stridor were reviewed in order to determine the aetiology of stridor in these cases. Congenital causes accounted for 57.6% of cases. Laryngomalacia was the commonest congenital abnormality (77.5%). Other common causes of stridor were a foreign body in the airway (acquired) and laryngotracheobronchitis (33.3%) (infective). Tracheostomized children are a problem in developing countries, requiring prolonged hospitalization. We overcome this problem by teaching parents how to maintain the tracheostomy tube at home.

Flexible laryngoscopy in neonates and infants: insertion through a median opening in the face mask

The most common reasons for laryngoscopy in newborns and infants are inspiratory stridor and/or dyspnea. With the help of flexible endoscopes, especially with instruments of diminished diameter, laryngoscopy can be carried out even in premature newborns. We report on a technique of flexible laryngoscopy without the need for restraint and with improved safety. A modified face mask is used for endoscopy. An additional hole is made into the mask with a 4.5 mm drill. It is located in the midline just above the nostrils, about 2.5 cm above the ventilation opening. The flexible endoscope is passed into the nose and pharynx with ease. It does not interfere with the anesthetist's ventilation by the mask. In inhalation anesthesia with halothane, 100% oxygen is supplied. The larynx remains in its physiological position. The head is not retroflexed, and the tongue is not supported by an endoscope as in direct laryngoscopy. No muscle relaxation is used, and muscular activity of the larynx can be observed during spontaneous and assisted ventilation.