Pediatric Otolaryngology for Anesthetists followed by the ...€¦ · Pediatric Otolaryngology for Anesthetists followed by the delightful Airway Disorders in Infants and Children

Pediatric Otolaryngology for Anesthetistsfollowed by the delightful

Airway Disorders in Infants and Children

Andrew M. Shapiro, MDPrivate Practice, Pediatric Otolaryngology

Clinical Associate Professor of SurgeryPennsylvania State University College of Medicine

0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP

What does a pediatric otolaryngologist do?

Inflammatory, congenital and neoplastic disorders involving the head and neck

Simple surgeries in fairly healthy kids Big surgeries in fairly healthy kidsSimple surgeries in sick kidsBig surgeries in sick kids

Ear surgeryNasal and sinus surgeryAirway surgeryPharyngeal surgeryCraniofacial surgeryTumors and congenital anomalies of the head and neck


OrganizationEmphasize that there are distinct qualities required when caring for childrenUnderstand the anesthetic implications of otolaryngologic surgeryUnderstand special situations and patient circumstancesReview significant ENT airway conditions


Characteristics of pediatric anesthesia

Laryngospasm, bronchospasm, concurrent illnessesPhysiologic differences

Higher metabolic rate↑O2 requirementTemperature management

↓Chest wall complianceHigh closing volumes

Evolving psychological status must be appreciated from neonates to adolescentsDental


Characteristics of Pediatric Otolaryngology Patients

“Healthy” PedENT patients are often “sick” on the day of surgery

Congestion, runny nose, cough“a case cancelled is not a case done”

“Sick PedENT patients tend to have chronic lung disease from prematurity, aspiration, cystic fibrosis, or reactive airway disease


Points of convergenceThe surgeon and the anesthetist are a TEAM (and I’m not just saying that!)Maintain good surgical access while preserving the ability to sustain ventilation (or vice versa)


Otologic CasesMyringotomy and tube insertions

Most common procedure under GA Mask anesthetic

Older children may benefit from IV/LMAPremed? Narcotic?

Tympanoplasty/tympanomastoidectomyNo muscle relaxant during procedureNo nitrous oxideSecure tubes and IV’s; lots of “turning” during case


Nasal and Paranasal sinus surgeryExpect secretions and bloodExpect a generous helping of vasoconstrictors

Control blood pressureExpect a “touchy airway”


Anatomic ClassificationSupraglottic

NoseChoanal atresiaNOWCA

Craniofacial DysmorphologyPierre Robin SyndromeTreacher collinsApertsCrouzonsMoebius

MacroglossiaBeckwith WiedemannSyndromeDown’s Syndrome

TumorsHemangiomaNeuroblastoma

Laryngomalacia Glottic

Vocal cord paralysisTumors and cysts

• Laryngoceles• Papillomatosis• Cystic hygroma• Laryngoceles

AtresiaWebs

SubglotticStenosisWebsAtresiaTumors

HemangiomaCystic HygromaCysts

TracheaTracheomalaciaStenosisCystAtresia

ExtrinsicGoiterVascular RingHemangiomaCystic hygromaTeratomaMediastinal masses


IntroductionThe Pediatric Airway

AnatomyNasal/Pharyngeal

Obligate Nosebreathing

LaryngealSupraglottisGlottisSubglottis

• Cricoid

Upper trachea


The Nose and PharynxAnatomy

Nasal Cavities Pharynx

NasopharynxOropharynxHypopharynx




Obstruction at the Pharyngeal LevelStertor (vs. stridor)Often worst when asleepOften improved by positioning

Neck extension, sniffing position


Tonsils and adenoidsChronic tonsillitisTonsillar hyperplasia

OSA 2% incidence. 10%SDBPeaks 2-5 years oldSecond peak in adolescenceMedical treatment

Weight lossManagement of infection

CPAPSurgical therapy

T/A, UPPPHighly effective in “normal” children


T & A: techniques

Tonsillectomy“Cold”

GuillotineDissection and snareMicrodebrider

“Hot”CauteryBipolar cauteryLaserCoblation

AdenoidectomyCuretteCauteryMicrodebrider

Adjunctive measuresSteroidsLocal AnestheticsAnalgesicsAntibioticsAntiemetics


Higher risk tonsillectomy

Age < 3 yearsDocumented profound OSANeuromuscular disordersChromosomal anomaliesCraniofacial/airway disordersRecent upper respiratory infectionBleeding disorderActive infection or peritonsillar abscessSevere obesity


Upper airway obstruction in neurologically impaired children

Hypotonia reduces predictability of T&AReasonable approach if significant adenotonsillar hypertrophy is presentUPPP? Kershner et al int J ped oto 2002

tracheotomy vs. salivary diversion, laryngeal diversion, supraglottoplasty, midfacial and maxillary advancementsBiPAP/CPAP

Increased perioperative morbidityIndividualized treatment - no reasonable studies to clearly delineate best treatment options


Postoperative problems can be minimized by anesthetic techniques

ApneaLaryngospasmPostobstructive pulmonary edemaBleeding

Judicious narcoticsLocal anesthetic

Steroids/AntiemeticsPropofolTiming of extubationImmediate gentle positive pressure


Now, the real reason I’m here…


IntroductionThe Pediatric Airway

AnatomyNasal/Pharyngeal


LaryngealSupraglottisGlottisSubglottis

• Cricoid

Upper trachea


StridorDefinition

Distinguish from stertorCauses

LaryngomalaciaVocal cord paralysisSubglottis stenosis


Cross Sectional Airway Diameter

Adult1mm edema = 81% of normal area

Term Newborn1mm edema = 44% of normal area

20mm

5mm


Clinical presentationFailed extubation attempts in NICUStridorRecurrent croupProgressive respiratory failure with stridorFeeding difficultiesFailure to thrivePersistent coughTracheotomy


EvaluationHistory

Details of extubation attemptsPresence, absence, and characteristics of stridor

Onset/Progression Impact of position

Nature of cryFeeding abnormalitiesPrior airway interventionsCardiopulmonary statusTerm or prematureApgarBirth weight/weight gainOther medical problems

Physical examinationImagingEndoscopy


EvaluationHistory

Physical examinationComplete head and neck examination

Craniofacial disorders, retrognathia, nasal obstruction, laryngomalacia, vocal cord paralysis

Body HabitusDegree of dyspneaQuality of stridor

Changes with position, activityCry/VoiceAuscultation of chest

ImagingEndoscopy


EvaluationHistoryPhysical examination

ImagingHi KV AP and Lateral plain filmsAirway flouroscopy/Barium SwallowMRI in patients with suspected vascular/mediastinal pathologyEndoscopy


EvaluationHistoryPhysical examinationImaging

EndoscopyFlexible

Need for sedation and inability to control airway and ventilation Useful for proximal airway evaluation at bedside or as outpatientDistal airway evaluation in intubated patients

RigidSpontaneous ventilationMicrolaryngoscopy

• Webs, glottic scarring, interarytenoid adhesions, fixation or paralysisSubglottis

• Size, maturity, length, stomal siteRemainder of tracheobronchial treeSizing of airway


Airway Endoscopy-Stages1. Preparation and

Communication a) Equipmentb) Monitoring

2. Induction3. Diagnostic Laryngoscopy and

topical anesthetic4. Diagnostic Suspension

laryngoscopyControlled airway for microscopy or bronchoscopy

and Diagnostic Bronchoscopy5. Therapeutic intervention


Anesthesia for airway endoscopyClear communication essentialAvoid jet in young childrenTechniques

Apneic techniqueSpontaneous ventilation in young children

Topical anesthetic?In older children (5 -10 years) relaxant with controlled ventilation

NEVER ABOLISH SPONTANEOUS RESPIRATION UNLESS AN ALTERNATIVE AIRWAY IS ASSURED


Anesthesia for Laser EndoscopyAssure patient and staff protection

Have a fire “plan of action”Minimize FiO2Avoid adding fuel to the fire when possible

Endotracheal tubes/packsApneic ventilation

Relaxant extends working time, accuracy


Anatomic ClassificationSupraglottic

NoseChoanal atresiaNOWCA

Craniofacial DysmorphologyPierre Robin SyndromeTreacher collinsApertsCrouzonsMoebius

MacroglossiaBeckwith Wiedemann SyndromeDown’s Syndrome

TumorsHemangiomaNeuroblastoma

Laryngomalacia Glottic

Vocal cord paralysisTumors and cysts

• Laryngoceles• Papillomatosis• Cystic hygroma• Laryngoceles

AtresiaWebs

SubglotticStenosisWebsAtresiaTumors

HemangiomaCystic HygromaCysts

TracheaTracheomalaciaStenosisCystAtresia

ExtrinsicGoiterVascular RingHemangiomaCystic hygromaTeratomaMediastinal masses


Nasal DisordersChoanal Atresia

Obstruction in posterior nasal cavity90% bony, 10% membraneousBilateral in 40%; other congenital anomalies in 50%Failure to pass #6 catheterUnilateral- observeBilateral

Oral airway; gavage; repair; tracheostomy


Nasal DisordersPyriform Aperture StenosisHairy polypEncephalocele/Glioma


Craniofacial disordersPierre Robin Syndrome

Micrognathia, cleft palate, glossoptosisRespiratory distress worst with feedingNasopharyngeal airwayImprovement with mandibular growth

Distraction osteogenesis


Craniofacial DisordersTreacher Collins Sydrome

Autosomal DominantFindings

Antimongoloid slantlower lid colobomaauricular malformationMalar/mandibular hypoplasia


Craniofacial DisordersCrouzon’s Syndrome

Midfacial hypoplasiaGlossoptosis, posterior pharyngeal compromise


Break time!


Laryngeal Disorders


LaryngomalaciaMost common cause of stridor in neonateEtiology: collapse of supraglottic structures into airway lumen, creating turbulent flow and obstructionIdiopathic--Anatomy vs. innervationGERD relationship (suck swallow dyscoordination)Coarse, non musical inspiratory stridor during first few weeks of life

Accentuated by supine position, feedingCry is normal

Evaluation: Flexible laryngoscopy, airway flouro, BSTreatment

Spontaneous resolution by 2 years in vast majority of patientsEpiglottoplastyTracheostomy


Vocal Cord Paralysis2nd most common cause of congenital stridorBilateral

EtiologyIdiopathic, CNS lesions, birth trauma

PresentationProgressive stridor, voice may be normalHigh risk for aspiration

UnilateralEtiology

Mediastinal anomalies, idiopathic(heart, TEF surgery), trauma

PresentationHoarse cry,feeding difficulties, aspiration

EvaluationEndoscopyImaging

MR or CT of Brain, Neck and MediastinumLaryngeal EMG

ManagementTracheotomy: spontaneous recovery in >50% within 2 yearsVocal cord lateralization: arytenoidectomyvs. transverse cordotomy


Congenital laryngeal websIncomplete recanalization of laryngotrachealanlageSx: Mild dysphonia to airway obstruction

1/3 have associated anomalies, most often subglottic stenosisChromosome 22q11.2 deletion (VCFS)

Rx: Observation-> surgery->tracheotomyLaryngeal Atresia

Acute airway obstructionTE fistula may allow some ventilationTracheostomy is lifesavingPolyhydramnios may provide a clue, allow for preoperative preparation


Laryngeal CystCongenital saccular cyst

25% of laryngeal cystsObstruction of sacculewith accumulation of mucus

Vallecular cystSubglottic cyst


Subglottic hemangioma1.5% of congenital airway anomalies

Female 2:1 Male. ½ with cutaneoushemangiomataUsually asymptomatic at birth, rapid growth after 2 months through 12 monthsSymptoms mimic recurrent croup

Treatment optionsObservation, tracheostomy, steroids (systemic and local), interferon, surgical excision


Recurrent Respiratory PapillomatosisHPV 6,11Entire respiratory tractInfancy through adultNo cureSurgical therapy, medical adjunctVaccine holds promise


Subglottic stenosisCongenital

RareIncomplete recanalizationMore mild

Elliptical cricoid

AcquiredMost common1-8% of intubated neonatesOther causes

TraumaBurns NeoplasmsInfectionCollagen vascular disorders


Pathogenesis of acquired subglottic stenosisintubation

Pressure injury

Mucosal edemaUlcerationPerichondrial injuryCartilage necrosis

Fibroblasts& Granulation tissue

Circumferential scarring


Subglottic Stenosis – the recipeCongenital subglottic stenosisGERDInfectionNasogastric tubeETT size and propertiesMovement of ETTReintubationsDuration?


StagingClassification from to

Grade I No obstruction

50%

Grade II 51% 70%

Grade III 71% 99%

Grade IV No lumen


Evaluation:GER/GERD, GLPR/GLPRD

GER is common in children with subglottic stenosis and usually asymptomatic

GER/GLPR likely exacerbates SGS and compromises repair No gold standard to differentiate GER and GERDDual pH probe:

50% of candidates have upper probe pH<4 more than 1% of the timeMajority had no symptoms


Evaluation: Swallowing Dysfunction Increased risk of aspiration postoperativelyRely on history

Videoflouroscopic examinationLimited in patients with food aversion or congenital aerodigestive anomalies

FEES


ManagementObservationTracheostomyEndoscopic techniquesCricoid splitAugmentation LaryngoplastyPartial cricotracheal resection


ObservationNon tracheotomized Grade I or mild grade II

Occasional symptoms – infrequent hospitalizationsNo retractionsNo feeding difficulties

Tracheotomized patients reactive larynxAge/weight/pulmonary status/neurologic disease/aspiration potential/craniofacial or systemic abnormalities


Endoscopic ManagementMild SGS

May be required following open repair techniquesTechniques

DilationCO2 laser

wedge resections


TracheotomyTemporizing measure

Allows for growth prior to definitiveprocedure

Time for improvement of BPDFacilitates dischargeGold Standard?

Mortality rate varies with degree of obstruction above stomaImpairment of speech and language skillsNursing/childcare issues


History of airway reconstruction 193O’s

Chevalier Jackson recognizes that many children with laryngeal stenosis do not outgrow their obstruction –permanent tracheotomy was treatment of choice

1960’sMcDonald and Stocks: long term intubation for the management of prolonged ventilatory support in newbornsGreater survival potential of premature newbornsShift of subglottic stenosis from older children and adults to premature infants


History of airway reconstructionIncreased incidence of subglottic stenosis recognizedTreatment consisted of repeated dilations

Dogma was “never divide the larynx” to avoid growth disturbance1956 Rethi Expansion of larynx and trachea with long term stent1970’s Fearon and Cotton: Pedicled thyroid cartilage grafts1980’s Free cartilage grafts allow for posterior and anterior grafting1993 First series of successful cricotracheal resections reported


Cricoid SplitOverviewIndications

Acquired subglottic stenosis in neonate (>1500g) without significant coincidental airway or pulmonary disease<30%FiO2, <35mm Pressure, no vent support

Surgical techniqueOutcomeComplications



Augmentation LaryngotracheoplastyOverviewIndicationsSurgical technique

Single stage vs. 2 stageSource of donor cartilageAutologous materials

OutcomeComplications


Single Stage LTR Uses cartilage grafts for expansion and a short phase of stenting with ETTStoma is grafted and closedPostoperatively

0-14 days of intubation in ICU+/-Paralysis and sedationBronchoscopy and downsize prior to extubation



Results>90% success rates in most seriesSuccess is dependent upon degree of stenosis

<50% in severe grade III and IV stenosis


Partial Cricotracheal resectionOverviewIndicationsSurgical techniqueOutcome

Complications



Adjunctive measuresStenting

Useful for areas of stenosis beyond subglottis (posterior glottic stenosis)result in addition granulation tissue and scarring,

Mitomycin CAntineoplastic antibiotic inhibits fibroblast formation

Fibrin glueHolds mucosal flaps, produces an airtight seal


Postoperative carePICUIntubation for 0 – 14 days for single stage

Sedation – minimal paralysisBronchoscopy/downsizing/extubation


Complications of Airway ReconstructionIntraoperative

HypoxiaPneumothoraxPneumomediastinumVocal cord paralysis

Early PostoperativeSQ emphysemaSeromaHematomaSingle Stage

ETT obstructionUnplanned extubationNarcotic withdrawlPulmonary problemsNasal alar ulcerationFailed extubation

Intermediate postoperativeGranulationsRestenosisGraft displacementGraft resorptionChonditisSuprastomal/ posterior glottic stenosis

Late PostoperativeVoice problemsEpiglottic/arytenoid collapseWebTracheocutaneous fistula


Tracheal AnomaliesTracheomalacia

Abnormal flaccidity of trachea leading to collapse on expiration

Collapse of greater than 20% on endoscopy (spontaneous ventilation)Primary vs secondary

MRIRarely occurs with laryngomalacia

Rx: Mild- typically improves within 1-2 yearsReflux therapySevere – tracheostomy with PPVSurgical correction varying success

Stent placement (internal or external)Segmental resectionCartilage grafting


Tracheal DisordersTracheal Stenosis

Congenital vs. acquiredSymptoms depend upon severity and lengthComplete tracheal ringsBiphasic or expiratory stridor, wheezing, failure to thrive, bronchiolitis, cough recurrent croupVery gentle endoscopy!Rx:

conservative for mild cases; resolution with growthSevere cases: segmental resection vs. anterior split with perichondrial grafting vs slide tracheoplasty or homograft tracheal transplantation

Complications: granulation tissue at anastamotic site


Tracheal DisordersVascular Compression

3% of population with anomalies of great vessels

Rarely result in airway obstructionRings vs slingsDouble aortic arch most common ringInnominate artery most common slingRight aortic arch with aberrant left subclavianBarium swallow and MR are essential


ConclusionsDiagnosis of airway disorders in the neonate requires a comprehensive and systematic approachStridor is not a diagnosis, but a symptom: the characteristics will help localize the sourceTwenty five years ago – once a trach, always a trach

Now, almost all tracheotomy dependent children with airway obstruction can eventually be decannulated

Important to have a bag of tricks, as different approach works in different patientslist of options for restoration of the pediatric airway continues to expand

Documents

Pediatric Otolaryngology for Anesthetists followed by the ...€¦ · Pediatric Otolaryngology for Anesthetists followed by the delightful Airway Disorders in Infants and Children