Larynx Peds Stridor

Front 1

stridor is of what origin? stertor?

Back 1

larynx trachea

nose, nasopharynx, oropharynx

Front 2

inspiratory stridor comes from? expiratory? biphasic?

Back 2

supraglottis, glottis

trachea

subglottis

Front 3

laryngomalacia accounts for what % of stridor in infants?

Back 3

60%

Front 4

what causes laryngomalacia

Back 4

omega epiglottis
tall, foreshoretened AE folds
redundant arytenoid mucosa, floppy

then edema from mucosal trauma exacerbates sx.
unproven cause, known association with higher rates of reflux

Front 5

what percentage of LM patients have synchronous airway lesions? what percentage require intervention

Back 5

12-45%

5%

Front 6

what is the course of LM?

Back 6

normal breathing at birth
develops stridor over days/weeks -2 months
peak at 6-9 months
resolves by 18 mo- 2 years

worse when supine, with feeding, or with exertion

cyanosis should prompt an airway eval for other lesions

Front 7

work up for LM

Back 7

NP scope for dx
Cannot r/o other airway lesions until DL/B performed

Sleep study in concerning cases for hypoxia and hypercapnea

Front 8

what are the indications for surgical intervention? ~10% of patients

Back 8

severe stridor
cyanosis/hypoxia
hypercapnea
apnea
pulmonary hypertension / cor pulmonale

Front 9

what might a supraglottoplasty entail? what are the risks of surgery?

Back 9

(1) division of the aryepiglottic folds, (2) excision of a wedge of the aryepiglottic fold with or without trimming the arytenoids or the lateral border of the epiglottis, and (3) suturing of the epiglottis to the base of the tongue

risks: airway fire if laser, post op swelling, bleeding, aspiration, supraglottic scarring (interarytenoid region)

Front 10

Contrast ductal vs saccular cyst in the infant?

Back 10

ductal - obstruction of duct, found anywhere in larynx, most commonly in supraglottis

saccular - congenital obstruction of space in the laryngeal ventricle, does not communicate with the laryngeal lumen

treat both with unroofing or excision.

Front 11

What percentage of cases with congenital laryngeal abnormalities are vocal cord paralyses?

Back 11

10% (contrast to LM as 60%)

M>F
bilateral > unilateral

Front 12

What is the most common cause of VC paralysis? most common neurologic cause in peds?

Back 12

idiopathic, congenital (usualy bilateral)

Neuro: Arnold chiari is most common neurologic abnormality (usually bialteral). Also encephalopathy and Guian Barre

also birth trauma, intubation, head injury

Front 13

work up in peds for VC paralysis?

Back 13

airway eval - palpate arytenoids and r/o other lesions, secure airway if distress

MRI brain to chest

Swallow eval

Front 14

which is more likely to recover: acquired or congenital VC paralysis? unilateral or bilateral?

Back 14

acquired
unilateral

Front 15

treatment for unilateral TVC paralysis in kids?

Back 15

speech therapy. rarely trach.

Front 16

treatment for bilateral TVC paralysis kids?

Back 16

trach for airway.

serial endoscopies with no permanent interventions for 1 year - in case of spontaneous recovery

Front 17

why do laryngeal webs occur? how do you treat them?

Back 17

failure of complete canalization of the trachea/larynx.

when severe is assoc with SG stenosis

tx with excision of thin webs. laryngofissure, excision, and stent for thick webs

Front 18

what is the laryngeal cleft classification?

Back 18

Classification of posterior laryngeal clefts. Type I: interarytenoid cleft; superior to the glottis. Type II: partial cricoid cleft; extends inferior to the glottis and partially through the posterior lamina of the cricoid. Type III: total cricoid cleft, with or without extension into the cervical tracheoesophageal wall. Type IV: laryngotracheoesophageal cleft extending beyond the thoracic inlet.

Front 19

how are clefts diagnosed and treated?

Back 19

dx: aspiration, video swallow, endoscopy

tx: open vs endoscopic closure if needed
vs thickened feeds until swallow improves (type I)

Front 20

what is the strongest indicator of a laryngeal foreign body?

Back 20

history

Front 21

what is the key formula that explains why small changes in the pediatric airway result in croupy cough?

Back 21

Poisioulle's law - airflow in a cylinder is directly proportional to the fourth power of the radius

Front 22

explain how to calculate and determine SGS using the cotton myer grading system?

Back 22

Grade is a %. Determined by largest possible ETT that can be passed / age appropriate tube size.

Grade 1 0-50%
Grade 2 50-70%
Grade 3 71-99%
Grade 4 - no lumen

Front 23

congenital SGS is the ____ most common abnormality of the pediatric airway

Back 23

3rd.

But acquired SGS accounts for 90% of SGS

Front 24

how does acquired SGS occurr? how can we prevent it?

Back 24

pressure, necrosis, perichondritis, cicatricial scarring

smaller uncuffed tubes, extubate when able, nasotracheal intubation to avoid movement/friction

Front 25

SGS: diagnosis, treatment

Back 25

dx: XR helps, endoscopy is gold standard and allows for grading

tx:
monitoring (grade 1-2, allows for growth of child

trach secures airway in symptomatic patient
dilation

airway recon
LTR - anterior cric split - splits cric and first 2 tracheal rings with graft placement
CTR - instead of widening the airway, we resect the stenotic segment - risk of RLN injury and dehiscence of anastamosis

thermal damage from lasers can incite more scarring resulting in recurrent and worsened scarring

Front 26

6 month old female with stridor and a cutaneous red lesion on the scalp: what's the dx?

Back 26

subglottic hemangioma

presents by 6 months of age.
F > M 2:1
50% of SG hemangiomas have a cutaenous counterpart, usually in the head and neck

Front 27

what is the histology of a hemangioma?

Back 27

most commonly capillary, but cavernous forms exist

is a vascular hamartoma (overgrowth/neoplasm of a particular tissue in it's tissue of origin)

Front 28

what are the phases of growth of a hemangioma?

Back 28

12 months of proliferation, then years of involution

Front 29

diagnosis?

Back 29

x -ray may reveal asymetrically narrowed subglottis

needs DL/B for dx: unilateral, sessile, compressible, vascular lesion. Only biopsy if diagnosis is uncertain. Be prepared for bleeding.

Need MRI for evaluation of neck and SG hemangiomas to r/o contiguous lesion

Front 30

treatment.
trach: discuss Risks and benefits
steroids
laser

Back 30

Trach: stabilizes airway until involution occurs. can affect speech and language development. Skilled home care needed incases of total upper a/w obstruction

steroids: systemic vs injection. can cause some swelling injection. get long term weight gain, growth retardation, hypertension, and cushingoid effects

laser: can use Co2 and KTP. Might need repeat tx, risk of heat induced scarring

excision: may avoid trach. may be used with other modalities.

propanolol: not discussed

Front 31

whats the most common neoplasm of the larynx in children? how does it present?

Back 31

RRP.

b/n 2-5 years, hoarseness, gradual onset of stridor

increased risk if first born child of teenage mom

needs multiple debridements at child onset is more aggressive than adult onset

Front 32

where do you see malignant transformation with RRP?

Back 32

distal bronchial tree.

is rare, but ALWAYS sent path

prognosis is poor

Front 33

Which type of HPV is more aggressive?

Back 33

11> 6

Front 34

goals of surgery

Back 34

maintain an adequate airway while avoiding tracheotomy

preserving the voice

controlling the papilloma

Keys: leave small amt of papilloma to avoid scarring (particularly important with CO2 laser), masks needed with laser due to viral particles in air, avoid trach due to risk of distal spread,

Front 35

describe the presentation of Supraglottitis (epiglottitis)?

Back 35

2-6 yo
possibly unvaccinated
stridor - late finding with impending obstruction
tripoding
drooling
muffled voice
rapid onset
febrile
severe dysphagia
no cough

ddx: foreign body, RPA,

Front 36

treatment of epiglottitis?

Back 36

Avoid stimulating the child
NP scope is ok if dx is unclear and there's no airway distress
Xray can be used r/o other etiologies

OR for intubation vs trach
inhalational anesthesia for intubation (No IV)
then culture blood and airway
Ceftriaxone abx
usually can exubate in 48-72 hrs.

Front 37

describe the presentation of laryngotracheobronchitis (croup)?

Back 37

child between 6 months and 3 years

slow onset, barky cough, stridor, temperature
swallowing fine.

biphasic stridor indicates worsened prognosis.

likely lasts 3-5 days, infectious with parainfluenza for 2 weeks.

dx: clinical, but Xrays help

treat: humidification, racemic epi, steroids (decreases hospital stay and need for intubation), heliox, ...intubation in 1.5% of cases

Front 38

whats the most common bug in bacterial tracheitis?

Back 38

post viral staph aureus superinfection

x-ray and endoscopy show diffusely ulcerated tracheal mucosa with copious purulent secretions partially obstructing the lumen of the trachea.

most patients need to be intubated.

the, culture and direct abx.