Congenital and acquired developmental problems of the upper airway in newborns and infants

Infantile Subglottic Hemangioma: A Case ReportInfantile Subglottic Hemangioma: A Case Report

ABSTRACT

Subglottic hemangiomas are rare benign vascular tumors of infancy which involve the airway. It is a subtype of infantile hemangiomas and is a potentially life-threatening condition with a mortality rate of 50% if left untreated. Hence, early intervention in this condition is essential. Here we present a case of a 4-month-old infant, a male infant with a history of cough and noisy breathing requiring multiple hospital visits before eventually being diagnosed with subglottic hemangioma. Due to its similar presentation with other more common respiratory illnesses, the diagnosis can be missed. Oral propranolol is the first-line therapy, which was used successfully in our case.

Anatomical investigations on the upper airway in premature and newborn babies

Safe intubation of newborns remains a challenge. This investigates the upper airway anatomy of (pre-)term infants was investigated to improve airway management and the development of airway devices. Angles and diameters of both oral and nasal intubation pathways of 22 cadavers of premature and term stillborn infants were measured, relative to their gestational age (GA) and tested for statistical significance. The systematic influence of sex on the distribution of values was examined. Cast models of the oral and nasal intubation pathway were (produced using a silicone dental impression material) 3D-scanned. No significant correlation with GA was seen in the angles studied. However, four distances around the hard and soft palate did show statistically significant positive correlations with GA. Regarding differences between the sexes, only the angle between the entrance of the trachea and the esophagus was greater for male cadavers. The angles of the ventilation pathway of (pre-)term infants do not depend systematically on GA. Anatomically, laryngeal masks might therefore also be well-suited ventilators for preterm infants. Alterations in the size but not the shape of laryngeal masks for small preterm infants is recommended. The data obtained may thus be used as a basis for the development of airway devices and airway simulators for medical education and clinical training.

Pediatric flexible bronchoscopy in the intensive care unit: A multicenter study

INTRODUCTION

Flexible bronchoscopy (FB) is frequently used for assessment and treatment of patients with respiratory diseases. Our aim was to investigate the contribution of FB to diagnosis and therapy in children admitted to the intensive care units (ICU) and to evaluate the safety of FB in this vulnerable population.

METHODS

Children less than 18 years of age who underwent FB in the five neonatal and pediatric ICUs in Istanbul between July 1st, 2015 and July 1st, 2020 were included to the study. Demographic and clinical data including bronchoscopy indications, findings, complications, and the contribution of bronchoscopy to the management were retrospectively reviewed.

RESULTS

One hundred and ninety-six patients were included to the study. The median age was 5 months (range 0.3-205 months). The most common indication of FB was extubation failure (38.3%), followed by suspected airway disease. Bronchoscopic assessments revealed at least one abnormality in 90.8% patients. The most common findings were airway malacia and the presence of excessive airway secretions (47.4% and 35.7%, respectively). Positive contribution of FB was identified in 87.2% of the patients. FB had greater than 1 positive contribution in 138 patients and 80.6% of the patients received a new diagnosis. Medical therapy was modified after the procedure in 39.8% and surgical interventions were pursued in 40% of the patients. Therapeutic lavage was achieved in 18.9%. There were no major complications.

CONCLUSION

Flexible bronchoscopy is a valuable diagnostic and therapeutic tool in neonatal and pediatric ICUs and is not associated with major complications.

Congenital Laryngeal Stenosis and Concomitant Birth Defects in a Term Newborn: A Case Report

Congenital laryngeal stenosis is a rare and unusual anomaly that usually presents in the first minutes after delivery as severe life-threatening respiratory distress. It may exist as an isolated entity or in association with other congenital malformations, in particular cardiac anomalies. In this paper, we present the case of an infant with prenatal suspicion of tetralogy of Fallot. Immediately after delivery, the patient required intubation, which proved difficult. He was eventually diagnosed with laryngeal stenosis requiring laryngological treatment.

Analysis of Airway and Midface in Crouzon Syndromes

BACKGROUND

Crouzon syndrome is associated with severe respiratory impairment of the upper airway due in part to midfacial dysmorphology. We calculated the distinctive nasal diameter and pharyngeal airway volume in patients with Crouzon syndrome and compared them with age-matched control subjects.

METHODS

Children with computed tomography scans in the absence of surgical intervention were included. Computed tomography scans were digitized and manipulated using Surgicase CMF (Materialise). Craniometric data relating to the midface and airway were collected. For all linear measurements, mean percent increases or decreases were calculated relative to the size of control subjects, and volumetric assessment of the airway was tabulated. Statistical analysis was performed using t test.

RESULTS

Twenty-six computed tomography scans were included (control n = 17, Crouzon n = 9). All children were in early mixed dentition. Pharyngeal airway volume was decreased in patients with Crouzon syndrome relative to control subjects by 46% (P = 0.003). The distance from the posterior tongue to the posterior pharyngeal wall decreased 31% when comparing the Crouzon group versus the control (P = 0.04).

CONCLUSIONS

Three-dimensional analysis revealed notably decreased pharyngeal and nasal airway volumes in patients with Crouzon syndrome, but nasal bone tissue and soft tissue measurements showed very little change between patients and control subjects.

Airway Malformations and Bronchiectasis: A Pediatric Study

Congenital airway malformations are most often identified in early childhood. The development of bronchiectasis in association with malformations of the lower airway has been described, particularly among adult patients. The coexistence in a pediatric population of these conditions is not well described. This study was conducted to identify whether younger patients with airway malformations commonly develop bronchiectasis. International Classification of Diseases, Ninth revision (ICD-9 codes) were defined for airway anomalies and bronchiectasis. The electronic medical records system of a children's hospital was then searched for the number of patients with upper airway anomalies with or without bronchiectasis. The airway database was then cross referenced with the ICD codes for bronchiectasis to identify patients with both conditions. There were 844 patients with airway anomalies and 117 with bronchiectasis in the electronic system during the time period of August 1, 2009 to September 30, 2014. There was only 3 patients identified with both bronchiectasis and airway anomalies. The coexistence of bronchiectasis is low among the pediatric population with upper airway anomalies studied. This would suggest that the children with airway anomalies have been treated with strategies that are effective in the prevention of recurrent lower respiratory tract infection. Further study may be done to define the effectiveness of various strategies in preventing aspiration and lower respiratory tract infection. In addition, this methodologic technique utilizing database integrative platforms is useful in the identification of patients for further study and to identify the coexistence of pediatric conditions.

Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy

IMPORTANCE

Post-intubation subglottic stenosis (SGS) in children can be life threatening. Definitive treatment varies and lacks a universally accepted approach.

OBJECTIVE

We performed a prospective study to assess the safety and feasibility of holmium laser combined with cryotherapy delivered via flexible bronchoscopy for the treatment of post-intubation SGS in children.

METHODS

This study involved all patients with post-intubation SGS seen at the Interventional Pulmonology Department of Beijing Children's Hospital between July 2014 and December 2016. Holmium laser treatment and cryotherapy was then performed under flexible bronchoscopy, whose parents refused to accept the alternative standard treatment of tracheotomy and balloon dilation under direct laryngoscopy.

RESULTS

Sixteen patients with post-intubation SGS were included in this study. Ages ranged from 2 months to 12.25 years old. According to the Cotton-Myer grading system, three cases were Grade II, 12 cases were Grade III, and one case was Grade IV. According to the McCaffrey system, eight cases were Stage 1, two cases were Stage 2, and six cases were Stage 3. The average number of procedures was 4.88. Fifteen of the 16 patients achieved clinical cure. One patient achieved clinical improvement. The average treatment course duration was 55.31 days. No severe complications were seen. Post-treatment clinical symptoms, endoscopic findings and quality of life showed marked improvement.

INTERPRETATION

Our study supports the conclusion that holmium laser treatment combined with cryotherapy via flexible bronchoscopy appears to be a safe and feasible treatment for post-intubation SGS in children.

Upper airway obstruction in neonates: Does sleep exacerbate symptoms?

Objective

Describe the factors that exacerbate upper airway obstructions (UAOs) in neonates.

Study Design

Retrospective chart review.

Setting

Pediatric tertiary care hospital.

Subjects and Methods

All neonates hospitalized between 1/1/2010 and 12/31/2014 diagnosed with either: 1) laryngomalacia, 2) Pierre Robin sequence, or 3) vocal cord paralysis were included in this study. Patient charts were reviewed to determine factors that exacerbated symptoms of airway obstruction. The independent variable was patient diagnosis, and the outcome measure was exacerbating factors.

Results

In patients with laryngomalacia (n = 31), 41.9% worsened with agitation, 38.7% worsened with feeding, 16.1% worsened with positioning, 0.0% worsened during sleep, and 25.8% had no aggravating factors. In Pierre-Robin patients (n = 31), 48.4% worsened with agitation, 16.1% worsened with feeding, 61.3% worsened with positional changes, 0.0% worsened during sleep, and 12.9% had no aggravating factors. In vocal cord paralysis patients (n = 25), 72.0% worsened with agitation, 8.0% worsened with feeding, 20.0% worsened with positional changes, 4.0% worsened during sleep, and 24.0% had no aggravating factors.

Conclusion

Airway obstruction was not reliably exacerbated during sleep for any of the diagnoses studied in this review. Our findings show that agitation exacerbates airway obstruction in most patients with vocal cord paralysis, and positioning exacerbates airway obstruction in the majority of patients with PRS. Aggravating factors in laryngomalacia are variable. These findings question the utility of polysomnography as a diagnostic tool for hospitalized neonates with these conditions.

Level of Evidence

4.

Submucosal Hemangioma of the Trachea in an Infant: Diagnosis and Follow-Up with 3D-CT/Bronchoscopy

Introduction:

Case Presentation:

Conclusions:

Congenital laryngomucocele: a rare cause of airway obstruction in a newborn

Congenital laryngoceles are defined as cystic dilatation of laryngeal saccules and are an extremely rare cause of newborn respiratory distress. A laryngomucocele occurs when the neck of the laryngocele gets obstructed and fills with the mucoid secretions of the saccule. It may cause stridor, respiratory distress, and severe airway obstruction in the narrow airway of a newborn and necessitates urgent surgical intervention. There is only 1 case of congenital laryngomucocele reported in an autopsy examination in the English literature, and here we report the first living congenital laryngomucocele case and discuss the clinical approach.

Stent implantation into the tracheo-bronchial system in rabbits: histopathologic sequelae in bare metal vs. drug-eluting stents

Background

Stent implantation into the tracheo-bronchial system may be life-saving in selected pediatric patients with otherwise intractable stenosis of the upper airways. Following implantation, significant tissue proliferation may occur, requiring re-interventions. We sought to evaluate the effect of immunosuppressive coating of the stents on the extent of tissue proliferation in an animal model.

Methods

Bare metal and sirolimus-coated stents (Bx Sonic and Cypher Select, Johnson & Johnson, Cordis) were implanted into non-stenotic lower airways of New Zealand white rabbits (weight 3.1 to 4.8 kg). Three stents with sirolimus coating and six bare metal stents could be analyzed by means of histology and immunohistochemistry 12 months after implantation.

Results

On a macroscopic evaluation, all stents were partially covered with a considerable amount of whitish tissue. Histologically, these proliferations contained fiber-rich connective tissue and some fibromuscular cells without significant differences between both stent types. The superficial tissue layer was formed by typical respiratory epithelium and polygonal cells. Abundant lymphocyte infiltrations and moderate granulocyte infiltrations were found in both groups correspondingly, whereas foreign-body reaction was more pronounced around sirolimus-eluting stents.

Conclusions

After stent implantation in the tracheo-bronchial system of rabbits, we found tissue reactions comparable to those seen after stent implantation into the vascular system. There was no difference between coated and uncoated stents with regard to quality and quantity of tissue proliferation. We found, however, a significantly different inflammatory reaction with a more pronounced foreign-body reaction in sirolimus-coated stents. In our small series, drug-eluting stents did not exhibit any benefit over bare metal stents in an experimental setting.

Prognosis and Risk Factors for Congenital Airway Anomalies in Children with Congenital Heart Disease: A Nationwide Population-Based Study in Taiwan

BACKGROUND

The mortality risk associated with congenital airway anomalies (CAA) in children with congenital heart disease (CHD) is unclear. This study aimed to investigate the factors associated with CAA, and the associated mortality risk, among children with CHD.

METHODS

This nationwide, population-based study evaluated 39,652 children with CHD aged 0-5 years between 2000 and 2011, using the Taiwan National Health Insurance Research Database (NHIRD). We performed descriptive, logistic regression, Kaplan-Meier, and Cox regression analyses of the data.

RESULTS

Among the children with CHD, 1,591 (4.0%) had concomitant CAA. Children with CHD had an increased likelihood of CAA if they were boys (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.33-1.64), infants (OR, 5.42; 95%CI, 4.06-7.24), or had a congenital musculoskeletal anomaly (OR, 3.19; 95%CI, 2.67-3.81), and were typically identified 0-3 years after CHD diagnosis (OR, 1.33; 95%CI 1.17-1.51). The mortality risk was increased in children with CHD and CAA (crude hazard ratio [HR], 2.05; 95%CI, 1.77-2.37), even after adjusting for confounders (adjusted HR, 1.76; 95%CI, 1.51-2.04). Mortality risk also changed by age and sex (adjusted HR and 95%CI are quoted): neonates, infants, and toddlers and preschool children, 1.67 (1.40-2.00), 1.93 (1.47-2.55), and 4.77 (1.39-16.44), respectively; and boys and girls, 1.62 (1.32-1.98) and 2.01 (1.61-2.50), respectively.

CONCLUSION

The mortality risk is significantly increased among children with CHD and comorbid CAA. Clinicians should actively seek CAA during the follow-up of children with CHD.

Nasal region dimensions in children: a CT study and clinical implications

Atresias of nasal cavity, especially in young children, pose an essential problem in children's otolaryngology. Only a few morphometric studies of nasal cavity concerning healthy neonates and young infants without nasal stenosis are available. Multislice computed tomography is a perfect tool enabling a precise evaluation of anatomic structures. The aim of this study was a complex morphometric evaluation of clinically important bone and mucosal structures of nasal cavity and examination of their dependence on age and sex in children up to 3 years of age. 180 children, age range 0–3 years, were divided into 5 age groups, and measurements of 18 distances between skeletal structures and between mucosal structures of nasal cavity were performed on their CT scans. A correlation between the widths of selected bone structures was examined. There were no statistically significant differences in analyzed morphometric parameters between adjacent age groups. The differences were statistically significant only between extreme age groups. There was a correlation between evaluated structures and age. Our results are a valuable supplement of nasal cavity morphometric data of young children. They may be useful in setting reference values of evaluated parameters in children and in diagnosis and planning of surgical treatment in children's otolaryngology.