THE CHALLENGING AIRWAY: INFANTS AND CHILDREN
| AIRWAY OBSTRUCTION: ASSESSMENT AND MANAGEMENT —Lauren D. Holinger, MD, Professor of
Otolaryngology—Head and Neck Surgery, Northwestern University Feinberg School of Medicine; Head, Division of Pediatric
Otolaryngology, Children’s Memorial Hospital, Chicago, IL
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| Presentation: terminology—parents may have difficulty explaining situation (eg, terms such as “wheezing” and “congestion”
can vary in interpretation); stridor most common term used by physicians to describe noisy breathing
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| Basic approach to infant: respiratory effort reflects severity of obstruction; assessment process determines urgency,
extent of evaluation, and need for surgery—mild problems may require simple, short evaluation and parental reassurance;
severe problems may require overnight hospitalization of infant for observation and endoscopic examination on next
day; SPECS-R mnemonic lists manifestations of severe obstruction requiring endoscopic examination—subjective
parental assessment of obstruction severity (S); disease progression (P); eating (E) difficulties, aspiration, or failure to
thrive; cyanosis (C), apnea, or apparent life-threatening episodes; sleep (S) disturbance related to obstruction; radiographic
(R) images indicating need for bronchoscopy
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| Clues to localize obstruction: exacerbation of problem—during sleep indicative of obstruction occurring above larynx
(eg, adenotonsillar hypertrophy, congenital lesions in nasopharynx); while patient awake, especially with exertion,
indicative of lesions in larynx, trachea, or bronchi; stridor—inspiratory (present in 85% of cases; indicative of extrathoracic
obstruction located above clavicles; usually caused by laryngomalacia or bilateral vocal fold paralysis); expiratory
(mimics asthma; usually caused by intrathoracic problem; typical finding with tracheomalacia and bronchomalacia)
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| Points: physical examination includes assessment of disease severity; flexible laryngoscopy performed in office serves as
extension of physical examination; evaluate patient npo and during feeding
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| Imaging: use decreasing in favor of using flexible laryngoscopy in office to assess lesion; airway films and anteroposterior
(AP) and lateral chest radiographs remain most important options; consider barium esophagoscopy or video fluoroscopic
swallow studies if child presents with choking, coughing, or aspiration; points—rarely necessary to confirm
presence of reflux with pH study; when necessary, perform computed tomography (CT) after endoscopy; good AP and
lateral airway films provide excellent data; copper and aluminum filters prevent cervical spine from obstructing AP images;
superior surface of vocal fold located level with apex of piriform sinus; good images of lateral and upper
airway—achieved by placing and maintaining child in position with chin up and forward, and shoulders down and back;
visualize laryngeal structures and pharynx; lateral chest films—provide information on airway into neck
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| Establish relationship with parents during initial evaluation: discuss possibility that child with severe obstruction
may require postoperative intubation and tracheotomy
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| Before initiating endoscopic examination: set aside dedicated suite for procedure; develop plan of action with anesthesiologist
(premature infants <6 mo of age tend to have apneic events following general anesthesia and must be hospitalized
overnight for observation); have all necessary equipment available before starting procedure; instruments—
place appropriate instruments in sterile cabinet (glass doors facilitate retrieval); check all instruments before child enters
operating suite; have variety of flexible scopes on hand, ie, use largest, shortest, rigid scope that will reach pathology
without traumatizing airway; when dealing with airway obstruction, smaller-than-standard sized instruments often appropriate
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| Laryngoscopy: flexible—performed initially with child awake; visualizes vocal fold motion and laryngeal dynamics;
direct—performed under general anesthesia; requires laryngoscope (left-handed instrument) be placed in right side of
mouth; uses Miller blade to achieve panoramic view of larynx and hypopharynx; points—maintain check list of structure
status; consider edematous larynx or tracheobronchial tree indicative of underlying pathology, eg, chronic laryngitis from reflux,
chronic bronchitis; maintain proper patient positioning during airway endoscopy—3 axes must be aligned to position
rigid instrument; in adult, place support under occiput and move head forward into “barking dog” position; in infant,
because head larger relative to body, place support under shoulders; place 7- to 12-yr-old patient in neutral position; additional
technical aspects—microscopic laryngoscopy with operating microscope (grabbing larynx externally and lifting forward
provides good view of hypopharynx, postcricoid space, and cervical esophagus); telescopes, in some cases, provide
better detail than can be achieved with operating microscope; sizing larynx objectively with endotracheal tube (important development
in diagnostic endoscopy of pediatric airway; objective measurements enable detection of stenosis that would otherwise
be overlooked); bronchoscopy with telescope alone—performed when airway substantially compromised; avoids
exacerbation of edema, postoperative croup, and respiratory distress; can reach trachea and each main bronchus; in baby
breathing spontaneously—spray larynx with 1% to 4% lidocaine (Xylocaine); insufflate sevoflurane through catheter
placed through nostril and into pharynx; key point—develop and maintain consistent system for performing procedure;
postoperative care—depending on degree of respiratory distress, administer helium-oxygen mixture (Heliox), steroids, and
racemic epinephrine; if airway compromised, administer intravenous (IV) dexamethasone (Decadron)
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| Infant larynx: differs from adult larynx; epiglottis—normally has ω shape; develops more tubular shape with laryngomalacia;
during infant tracheotomy—thyroid notch located posterior to hyoid bone and cannot be used as landmark;
sternal notch considered viable landmark, ie, in infants, lower end of vertical incision ≈1 cm above notch
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| Common conditions causing stridor and respiratory distress: posteroglottic stenosis; laryngomalacia—most
common problem; epiglottis develops exaggerated ω shape; edema throughout; 80% of infants also have laryngopharyngeal
reflux and associated laryngeal edema; although problem congenital, onset of symptoms usually occurs at 1 to 3 wk of
age (delayed onset may be related to role of reflux in producing edema); during inspiration, posterior supraglottic laryngeal
structures collapse forward to produce low-pitched inspiratory sound; symptoms usually stabilize by 6 mo of age and begin
to improve slowly; few infants require surgery to relieve obstruction and improve airway; subglottic stenosis—
extrathoracic lesion; fixed; produces biphasic stridor, although inspiratory component prominent; infants can present with
recurrent croup and pneumonia; suspect underlying congenital problem in any child that develops problem during first 6 to
12 mo of life (cold or mild edema can push asymptomatic infant over threshold and produce symptoms of airway obstruction);
management depends on severity of problem, site of airway narrowing, and nature of histopathology
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| Congenital subglottic hemangioma: differs from capillary and venous malformations seen in larynx; tends to be soft on
palpation and asymmetric; does not necessarily have pink color or appearance of hemangioma (ie, normal-appearing respiratory
epithelium may cover lesion); may be associated with cutaneous lesion (ask parents if baby has birthmark);
management—eclectic endoscopic approach; patients can receive oral steroids or endoscopic procedure; avoid open procedures;
caveat—subglottic hemangioma self-limited problem; physician can place tracheotomy and wait for hemangioma to
resolve; laser or open surgery can lead to chronic laryngeal stenosis
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| OBSTRUCTIVE SLEEP APNEA (OSA): POLYSOMNOGRAPHIC AND BEHAVIORAL ISSUES PRE- AND POST-
ADENOTONSILLECTOMY— Ron B. Mitchell, MD, Associate Professor of Otolaryngology and Pediatrics, Virginia
Commonwealth University School of Medicine, Richmond
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| Pediatric sleep apnea (SA): children tend to experience hypopneas and not obstructive episodes; associated with behavioral
problems and decreased quality of life (QOL); tonsillectomy performed most often to treat mild OSA; usually clinical
diagnosis, ie, pre- and postoperative polysomnography (PSG) rarely obtained by otolaryngologists; apnea-hypopnea
index (AHI) evaluated in most pediatric patients; PSG data show surgical management of OSA improves sleep parameters
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| Sleep apnea and QOL (PSG study of 80 children evaluating SA before and after adenotonsillectomy [T
and A]): assessment of sleep parameters—included monitoring minimum O2 saturation (SaO2 ), respiratory distress index
(RDI), AHI, and respiratory arousal index (RAI); showed T and A improved every clinical parameter measured; assessment
of postoperative data showed—in all subjects, postoperative AHI lower than preoperative AHI; all children
identified with AHI <10 normalized postoperatively; 73% of children with AHI >10 normalized postoperatively; all children
with abnormal postoperative PSG had symptoms detectable by parents; point—follow children postoperatively; to
facilitate identification of postoperative problems, parents should be questioned about symptoms
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| QOL data show: SA—leads to lower QOL scores; rivals effect of juvenile arthritis and chronic asthma on children and
their caregivers; T and A—improvement seen in every item and domain and in total QOL score; QOL values at 3 and 18
mo postsurgery improved dramatically over preoperative values
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| Direct neurocognitive assessment of behavior: measurable by number of instruments; disadvantages—labor-intensive;
expensive; time-consuming; difficult to perform in young children; limited to small study population; advantages—
objectivity; lack of reliance on caregiver proxy; widely used and validated; assessment shows—children with SA experience
reduction in memory, immediate recall, mental flexibility, and intelligence; even children with primary snoring and no
evidence of SA demonstrate some evidence of neurocognitive deficits; certain functions improve after T and A, including
executive functions, attention, mental processing, and intelligence
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| Behavioral instruments (questionnaires) completed by caregiver: alternative means of assessing behavior;
disadvantages—intrinsic subjectivity may affect results; increased difficulty in measuring change; advantages—low
cost; ability to collect large amounts of data; data show—SA leads to poor behavior and school performance; treatment of
sleep problems improves both behavior and academic performance; Behavior Assessment System for Children (BASC)
data—show postoperative improvements in behavior less dramatic than postoperative improvements in QOL; improvements
in behavior and QOL statistically and clinically significant
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| Additional observations of interest: good but not excellent correlation exists between behavior and QOL in patients
with SA; comparison of children with OSA to children with mild sleep-disordered breathing (SDB) showed—SDB
associated with decreased QOL and with behavior problems; behavioral improvements occur independently of severity
of SA as measured by PSG
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| Conclusions: T and A improves behavior, QOL, and sleep in children with OSA; future studies must—quantify OSA;
use PSG before and after surgery; standardize selection criteria
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| SLEEP-DISORDERED BREATHING: CORRELATION BETWEEN BEHAVIOR AND SLEEP IN PATIENTS FOLLOWING
T AND A —Julie L. Wei, MD, Assistant Professor, University of Kansas School of Medicine, Kansas City
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| Introduction: PSG—considered gold standard for diagnosing OSA; children clinically diagnosed with SDB may not always
meet PSG-defined criteria; survey of otolaryngology practice patterns showed <5% of school-aged children receive
PSG prior to surgery; QOL instruments—used as alternatives to or in combination with PSG to assess improvement in
sleep and behavior after T and A; consistently find significant improvement in QOL after surgery
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| Prospective observational study evaluating QOL instruments used to assess sleep and behavior after T
and A: instruments evaluated—pediatric sleep questionnaire (PSQ); Connors Parent Rating Scale-Revised (CPRS-R)
used to assess behavior; generates T-score (mean score 50; score ≥60 indicates behavioral problem; point—QOL instruments
differ in nature from PSG and may represent different aspects of SDB spectrum; study data show—association between
T and A and improvements in sleep and behavior as measured by PSQ and CPRS-R; degree of reduction in T score
after T and A varies directly with baseline T score on CPRS-R; treatment of children with clinically diagnosed SDB, even
when unconfirmed by PSG, can improve behavior and sleep; when PSG not feasible, PSQ can be used as—screening
tool; adjunct to clinical history and physical examination for determining surgical candidacy; observation—long-term follow-up
key to determining whether improvements in sleep and behavior maintained over time
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| TONSILLECTOMY: COMPARISON OF TECHNIQUE AND COMPLICATIONS —Richard Schmidt, MD, Staff Otolaryngologist,
Alfred I. DuPont Hospital for Children, Wilmington, DE
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| Intracapsular tonsillectomy (IT): compared to similar patients treated with traditional tonsillectomy (TT), IT
reduced—severity of postoperative pain by protecting pharyngeal constrictor muscles from inflammation (thought to be
main cause of pain); incidence of readmission for dehydration; incidence of delayed bleeding by not exposing larger primary
tonsillar vessels; anecdotal data from Alfred I DuPont Hospital suggest patients undergoing IT do better than
those treated with standard electrocautery approach—parents reported children could eat solid food on evening of
surgery; lower incidence of delayed hemorrhaging
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| Retrospective chart review for evaluation of Alfred I DuPont experience: data show—incidence of postoperative
bleeding 3.4% with TT and 1.1% with IT; 2.1% of patients undergoing TT and 0.5% of patients undergoing IT returned
to surgery to achieve control of bleeding; 5.5% of patients treated with TT required return visit or readmission for
pain, compared to 3.3% of patients treated with IT; 0.65% of children undergoing IT required revision surgery;
conclusion—IT associated with lower risk for secondary hemorrhage and less pain requiring hospital-based management
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Educational Objectives
| The goal of this program is to educate the listener about techniques for managing airway disease in infants and children. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Diagnose disorders producing pediatric airway obstruction.
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| 2. Manage common causes of pediatric airway obstruction.
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| 3. Assess post-adenotonsillectomy polysomnographic and behavioral outcomes in patients with obstructive sleep apnea.
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| 4. Determine the impact of adenotonsillectomy on behavior and sleep in children with sleep-disordered breathing.
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| 5. Compare complication rates associated with traditional tonsillectomy and intracapsular tonsillectomy performed
with a microdebrider.
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Discussed on This Program
Dexamethasone [Decadron, others]
Heliox (helium-oxygen mixture)
Lidocaine HCl [Xylocaine, others]
Methylphenidate HCl [Ritalin, others]
Racepinephrine (racemic epinephrine) [microNefrin, Nephron, S-2]
Sevoflurane [Ultane]
Suggested Reading
Galland BC et al: Changes in behavior and attentional capacity after adenotonsillectomy. Pediatr Res 59:711, 2006;
Holinger LD: Etiology of stridor in the neonate, infant, and child. Ann Otol Rhinol Laryngol 89:397, 1980; Holinger
LD: treatment of severe subglottic stenosis without tracheotomy: a preliminary report. Ann Otol Rhinol Laryngol 91:407,
1982; Lister MT et al: Microdebrider tonsillotomy vs electrosurgical tonsillectomy: a randomized, double-blind, paired
control study of postoperative pain. Arch Otolaryngol Head Neck Surg 132:599, 2006; Mitchell RB, Kelly J: Child behavior
after adenotonsillectomy for obstructive sleep apnea syndrome. Laryngoscope 115:2051, 2005; Mitchell RB et
al: Long–term changes in quality of life after surgery for pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck
Surg 130:409, 2004; Tran KD: Child behavior and quality of life in pediatric obstructive sleep apnea. Arch Otolaryngol
Head Neck Surg 131: 52, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Holinger gave his scientific presentation at the Annual Clinical Conference of the Kansas City Society of Ophthalmology
and Otolaryngology, held January 6-7, 2006, in Kansas City, MO; Dr. Mitchell gave his scientific presentation at
Surgery, Sleep, and Breathing II: An International Symposium, presented June 5-7, 2006, in Chicago, IL, by the Medical
College of Wisconsin; Drs. Schmidt and Wei gave their scientific presentations at the annual Combined Otologic Spring
Meetings (COSM) Conference of the American Society of Pediatric Otolaryngology (ASPO) held May 20-22, 2006, in
Chicago, IL. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of
this program.
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