Assessment and causes of stridor

The role of respiratory function tests in infants with stridor: diagnosis at glance and follow-up

BACKGROUND

Recently, the development of advanced, noninvasive methods has allowed the study of respiratory function even in uncooperative infants. To date, there is still little data on the application of this technique in infants with suspected airway obstruction.

THE AIMS OF OUR STUDY WERE

- To evaluate the role of respiratory function testing (PFR) in the diagnosis and follow-up of infants with stridor - To evaluate the differences between patients with inspiratory stridor and expiratory stridor. - To evaluate the concordance between PFR and endoscopy.

METHODS

We enrolled infants aged < 1 year with a diagnosis of inspiratory and/or expiratory chronic stridor and a group of healthy controls. For each patient we performed PFR at diagnosis (T0) and for cases at follow-up, at 3 months (T1), 6 months (T2), 12 months (T3). At T0, all patients were classified according to a clinical score, and at follow-up, stature-ponderal growth was assessed. When clinically indicated, patients underwent bronchoscopy.

RESULTS

We enrolled 48 cases (42 diagnosed with inspiratory stridor and 6 expiratory stridor) and 26 healthy controls. At T0, patients with stridor had increased inspiratory time (p < 0.0001) and expiratory time (p < 0.001) than healthy controls and abnormal curve morphology depending on the type of stridor. At T0, patients with expiratory stridor had a reduced Peak expiratory flow (p < 0.023) and a longer expiratory time (p < 0.004) than patients with inspiratory stridor. We showed an excellent concordance between PFR and endoscopic examination (k = 0.885, p < 0.0001). At follow-up, we showed a progressive increase of the respiratory parameters in line with the growth.

CONCLUSIONS

PFR could help improve the management of these patients through rapid and noninvasive diagnosis, careful monitoring, and early detection of those most at risk.

Non-brachycephalic dogs with stertor have higher nasopharyngeal collapsibility compared with dogs without stertor and foramen lacerum level is ideal for evaluating nasopharyngeal collapse on dynamic CT

Stertor, a clinical sign associated with obstructive airway syndrome, is often observed in non-brachycephalic dogs. This prospective, case-control study aimed to compare soft palate dimensions, nasopharyngeal cross-sectional area (CSA), and nasopharyngeal collapsibility at various locations in non-brachycephalic dogs with and without stertor. A total of 50 dogs were recruited and stratified into control (n = 34) and stertor (n = 13) groups. Static and dynamic computed tomography was conducted without tracheal intubation, and the following variables were calculated: normalized soft palate length and thickness, normalized maximum and minimum nasopharyngeal CSAs (rCSAmax and rCSAmin), and nasopharyngeal collapsibility at the level of the cranial end of the soft palate, pterygoid hamulus, foramen lacerum, bony labyrinth, and caudal end of the soft palate. The stertor group demonstrated significantly lower rCSAmax and rCSAmin, as well as higher nasopharyngeal collapsibility compared with the control group, while no significant differences were noted in the soft palate dimension. Evaluating nasopharyngeal collapse at the foramen lacerum level was recommended due to the clear presence of identifiable bony landmarks and lower overlap in the nasopharyngeal collapsibility between dogs with and without stertor. Physical dimensions of the soft palate may not be the primary contributing factor to nasopharyngeal collapse and clinical signs in non-brachycephalic dogs.

Diagnostic Dilemma: A Patient With Pulmonary Fibrosis Who Presented for Severe Tracheal Stenosis After COVID-19 Pneumonia

A 44-year-old man with pulmonary fibrosis presented to our pulmonary hypertension clinic with biphasic stridor and dyspnea. He was sent to the emergency department, where he was found to have 90% subglottic tracheal stenosis and was successfully treated with balloon dilation. Seven months prior to the presentation, he required intubation for coronavirus disease 2019 (COVID-19) pneumonia complicated by hemorrhagic stroke. He was discharged after percutaneous dilatational tracheostomy, which was decannulated after three months. Our patient possessed several risk factors for tracheal stenosis, including endotracheal intubation, tracheostomy, and airway infection. Furthermore, our case is of great importance given the developing literature on COVID-19 pneumonia and its subsequent complications. Additionally, his history of interstitial lung disease may have confounded his presentation. Therefore, it is important to understand stridor, as it is an important exam finding that clinically distinguishes upper and lower airway disease. Our patient's biphasic stridor is consistent with the diagnosis of severe tracheal stenosis.

Assessment, diagnosis and treatment of children who present with stridor

The presence of stridor in children signifies a partial obstruction in the upper airways, the cause of which may range from mild to life-threatening depending on aetiology. The most common causes of stridor in this population are laryngotracheobronchitis (viral croup) and foreign body aspiration. This article gives an overview of the signs, symptoms and potential causes of stridor and the signs and symptoms of, and diagnostic criteria for, viral croup. The author also discusses evidence-based assessment criteria and treatments and criteria for admission or discharge. A case study is used for illustration.

Neonatal Airway Abnormalities

Neonatal airway abnormalities are commonly encountered by the neonatologist, general pediatrician, maternal fetal medicine specialist, and otolaryngologist. This review article discusses common and rare anomalies that may be encountered, along with discussion of embryology, workup, and treatment. This article aims to provide a broad overview of neonatal airway anomalies to arm those caring for these children with a broad differential diagnosis and basic knowledge of how to manage basic and complex presentations.

The Evolution of Pharmacological Activities Bouea macrophylla Griffith In Vivo and In Vitro Study: A Review

Bouea macrophylla Griffith (B. macrophylla) is one of the many herbal plants found in Asia, and its fruit is plum mango. This plant is rich in secondary metabolites, including flavonoids, tannins, polyphenolic compounds, and many others. Due to its bioactive components, plum mango has powerful antioxidants that have therapeutic benefits for many common ailments, including cardiovascular disease, diabetes, and cancer. This review describes the evolution of plum mango’s phytochemical properties and pharmacological activities including in vitro and in vivo studies. The pharmacological activities of B. macrophylla Griffith reviewed in this article are antioxidant, anticancer, antihyperglycemic, antimicrobial, and antiphotoaging. Each of these pharmacological activities described and studied the possible cellular and molecular mechanisms of action. Interestingly, plum mango seeds show good pharmacological activity where the seed is the part of the plant that is a waste product. This can be an advantage because of its economic value as a herbal medicine. Overall, the findings described in this review aim to allow this plant to be explored and utilized more widely, especially as a new drug discovery.

Pediatric flexible bronchoscopy: A single-center report

INTRODUCTION

Pediatric flexible laryngotracheal bronchoscopy (FB) is an integral part of diagnostics and treatment at tertiary pediatric respiratory centers.

AIM

FBs performed between 2013 and 2018 at our Pediatric Allergy and Respiratory Medicine Unit of the Department of Women's and Children's Health at Padua University were examined in terms of the indications, findings, and adverse events.

MATERIALS AND METHODS

The electronic medical records of pediatric patients who underwent FB at least once between 1 January 2013 and 31 December 2018 were considered. Patients' clinical data, indications for FB, anatomical findings, information derived from bronchoalveolar lavage (BAL) and bronchial brushing, and possible adverse events were analyzed.

RESULTS

There were 447 pediatric FBs performed in 428 patients (aged from 1 month to 18 years) for diagnostic purposes (92.4%), to clear secretions (3.6%), or to monitor a known condition (4.0%). The main indications were recurrent lower respiratory tract infections (LRTI, 32.2%) and chronic wet cough (9.4%). Lower airway malacia was the most common abnormal finding in these two groups (36.1% and 28.6%, respectively). BAL bacterial culture was positive in 55 children (39.6%) with recurrent LRTI and in 25 (59.5%) with chronic wet cough, being Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis the microorganisms most commonly isolated. FB proved a safe procedure and was well tolerated.

CONCLUSIONS

Pediatric FB is an essential tool at our tertiary pediatric respiratory center. It helps establish the anatomical conditions underlying several chronic respiratory conditions and any correlated microbiological findings, with a significant impact on further patient management.

A seven-month-old with chronic intermittent biphasic stridor

Paediatric stridor can indicate serious pathology and requires prompt evaluation and management. Causes range from laryngomalacia to aerodigestive tract foreign bodies. We report on a chronic presentation of paediatric stridor, discuss the workup, management and lessons learned. A seven-month-old boy presented with chronic intermittent biphasic stridor for the previous five months. Diagnostic microlaryngoscopy and bronchoscopy revealed significant localised tracheomalacia. Urgent chest computed tomography was performed to investigate further. Radiological findings revealed an oesophageal foreign body prompting immediate rigid oesophagoscopy and removal of an embedded pistachio shell. The patient had an uneventful recovery. Foreign bodies in the airway and oesophagus are quite common in children, causing symptoms from the aerodigestive tract. It is uncommon for oesophageal foreign bodies to present with stridor in the absence of digestive tract symptoms. The otolaryngologist should consider this as a diagnosis, particularly in young children with an atypical presentation and symptoms.

Laryngeal Constriction Phenomena in Infant Vocalizations

Purpose Instances of laryngeal constriction have been noted as a feature of infant vocal development. The purpose of this study was to directly evaluate the developmental occurrence of laryngeal constriction phenomena in infant crying, cooing, and babbling vocalizations. Method The cry and noncry vocalizations of 20 healthy term-born infants between the ages of 1 and 7 months were examined for instances of laryngeal constriction. Approximately 20,000 vocalization samples were acoustically evaluated, applying a combined visual (frequency spectra and melody curves) and auditory analysis; the occurrence of instances of different constriction phenomena was analyzed. Results Laryngeal constrictions were found during the production of cry and noncry vocalizations. The developmental pattern of constrictions for both vocalizations was charac-terized by an increase in constrictions followed by a decrease. During the age period of 3-5 months, when cry and noncry vocalizations were co-occurring, laryngeal constrictions were observed in 14%-22% of both types of vocalizations. An equal percentage of constrictions was found for both vocalizations at 5 months of age. Conclusions The findings confirm that the production of laryngeal constriction is a regularly occurring phenomenon in healthy, normally developing infants' spontaneous crying, cooing, and marginal babbling. The occurrence of constriction in both cry and noncry vocalizations suggests that an infant is exploiting physiological constraints of the sound-generating system for articulatory development during vocal exploration. These results lend support to the notion that the laryngeal articulator is the principal articulator that infants 1st start to control as they test and practice their phonetic production skills from birth through the 1st several months of life.

An Unusual Case of Noisy Breathing in an Infant

ABSTRACT

Laryngomalacia is a common cause of chronic noisy breathing that can present as stridor in infants and neonates. Mild cases of laryngomalacia are usually followed clinically and managed conservatively. However, the evaluation and diagnosis could be challenging in some patients. We present a case of a 3-week-old male infant with persistent and worsening noisy breathing, snoring, and poor weight gain, prompting further evaluation. The patient had an initial diagnosis of laryngomalacia and obstructive sleep apnea with complete resolution of loud breathing with continuous positive airway pressure. A repeated evaluation of the upper airway for further investigation led to the diagnosis of a neck mass compressing the airway. We review the clinical presentation, management, and follow-up of this patient, as well as the literature of possible etiologies. In the case of our patient, timely diagnosis and treatment had significant prognostic implications.

An unusual cause of stridor: congenital laryngeal web

Respiratory distress and stridor are some of the common presenting symptoms for children in Pediatric Emergency Department. Most of these children are diagnosed as having common illnesses such as laryngitis, croup or laryngomalacia. However, Pediatric Emergency physicians must keep in mind other rare respiratory diseases other than laryngitis or croup in the differential diagnosis of stridor. Stridor may occur due to congenital and acquired diseases. Laryngeal web is one of the rare congenital causes of stridor, which usually presents in the first weeks of life; however, it is very rarely diagnosed in the later period. Herein, we report a one-year-old boy who was evaluated for croup and was diagnosed as having laryngeal web.

Association of breathing sound spectra with glottal dimensions in exercise-induced vocal cord dysfunction

The objective of this study was to evaluate associations between the breathing sound spectra and glottal dimensions in exercise-induced vocal cord dysfunction (EIVCD) during a bicycle ergometry test. Nineteen subjects (mean age 21.8 years and range 13-39 years) with suspected EIVCD were studied. Vocal folds were continuously imaged with videolaryngoscopy and breathing sounds were recorded during the bicycle exercise test. Twelve subjects showed paradoxical movement of the vocal folds during inspiration by the end of the exercise. In seven subjects, no abnormal reactions in vocal folds were found; they served as control subjects. The glottal quotient (interarytenoid distance divided by the anteroposterior glottal distance) was calculated. From the same time period, the tracheal-vocal tract resonance peaks of the breathing sound spectra were analyzed, and stridor sounds were detected and measured. Subjects with EIVCD showed significantly higher resonance peaks during the inspiratory phase compared to the expiratory phase (p < 0.014). The glottal quotient decreased significantly in the EIVCD group (p < 0.001), but not in the control group. 8 out of 12 EIVCD patients (67%) showed stridor sounds, while none of the controls did. There was a significant inverse correlation between the frequencies of the breathing sound resonance peaks and the glottal quotient. The findings indicate that the typical EIVCD reaction of a paradoxical approximation of the vocal folds during inspiration, measured here as a decrease in the glottal quotient, is significantly associated with an increase in inspiratory resonance peaks. The findings are applicable in the documentation of EIVCD findings using videolaryngoscopy, in addition to giving clinicians tools for EIVCD recognition. However, the study is limited by the small number of subjects.

Rare chronic stridor: case report and literature review

Se presenta el caso de una paciente prescolar con estridor crónico de 4 meses de evolución, tratada varias veces mediante micronebulizaciones (MNB) con beta 2, adrenérgicos, O2 y corticoides con mejoría parcial, sin estudios complementarios ni antecedentes claros de atoramiento con cuerpo extraño (CE). Además, se realizó una radiografía de cuello (Rx) que reveló la presencia de imagen en punta de lápiz traqueal y una broncoscopia que comprobó la existencia de un cuerpo extraño puntiagudo (espina de pescado) en la vía aérea superior.Este caso se reportó por su inusual presentación, pues es un CE en la vía aérea superior que se manifestó con estridor crónico, sin mayores complicaciones.