Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4518_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

30 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 45 / 505 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

https://t.me/medicina_free

A. F. Karas and J. W. Lee

Other Syndromes

• Beckwidth-Wiedemann syndrome

– AD, mostly sporadic – Macroglossia, organomegaly, omphalocele – Monitor for hypoglycemia in perioperative period

• Mobius syndrome

– Wide spectrum of anomalies secondary to central brainstem defects – Bilateral or unilateral CN VI and VII paralysis

• Prader-Willi syndrome

– Chromosome 15q11 – Hyperphagia and morbid obesity → OSA

• Angelman syndrome

– Chromosome 15q11 – Microcephaly, coarse facial features – Seizures, ataxia, severe developmental delay

• Kartagener’s syndrome

– Primary ciliary dyskinesia, decient outer dynein arm – Triad: chronic rhinosinusitis, bronchiectasis, situs inversus – Male infertility

• Kallman’s syndrome

– X-linked – Most common form of hypogonadotropic hypogonadism – Absence of olfactory bulb (anosmia)

Further Reading

Scott AR, Tibesar RJ, Sidman JD.Pierre Robin Sequence: evaluation, management, indications for

surgery, and pitfalls. Otolaryngol Clin N Am. 2012;45(3):695–710. Solomon BD.VACTERL/VATER association. Orphanet J Rare Dis. 2011;6:56. Rodman R, Pine H. The otolaryngologist’s approach to the patient with Down syndrome.

Otolaryngol Clin N Am. 2012;45:599–629. Swibel Rosenthal LH, Caballero N, Drake AF.Otolaryngologic manifestations of craniofacial syn-

dromes. Otolaryngol Clin N Am. 2012;45(3):557–77. Collins WO, Choi SS.Otolaryngologic manifestations of achondroplasia. Arch Otolaryngol Head

Neck Surg. 2007;133:237–44. Marom T, Roth Y, Goldfarb A, Cinamon U.Head and neck manifestations of 22q11.2 deletion

syndromes. Eur Arch Otorhinolaryngol. 2012;269(2):381–7.

Chapter 4

https://t.me/medicina_free

Pediatric Airway andEsophagology

AnatoliF.Karas andJanetWaiminLee

Pearls

• Recommend using formula (age+ 16)/4 for uncuffed endotracheal tube (ETT)

and ½ size smaller for cuffed ETT.

• Recommend using ½ size smaller ETT based on age formula for patients with

Down syndrome.

• Endotracheal tube cuff pressures >20mmHg will exceed the capillary lling

pressure and cause ischemic damage over time.

• More severe airway pathology is less likely to respond to endoscopic verses open

interventions.

• The history is essential to providing a complete and focused differential diagno-

sis to pediatric airway pathology.

• Voice dysfunction in children may become more of an issue as they are intro-

duced to more social environments; they may become withdrawn if they are not

able to be easily understood or communicate with others. The emotional/social

impact is not yet well elucidated but should not be ignored.

A. F. Karas Department of Otorhinolaryngology, Head & Neck Surgery, Rush University Medical Center, Chicago, IL, USA

Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA e-mail: anatoli_f_karas@rush.edu

J. W. Lee (*) Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, NC, USA e-mail: janet.w.lee@duke.edu

https://doi.org/10.1007/978-3-031-26048-3_4

https://t.me/medicina_free

A. F. Karas and J. W. Lee

Differences Between Pediatric andAdult Airways

• Pediatric larynx higher in the neck (C2, descends to C6 with age).

• Epiglottis curved/omega shaped, tip in contact with soft palate.

• Thyroid cartilage oblique, no dening angle.

• Infant vocal cords shorter, 4–4.5mm long at birth, adults 14–23mm.

– True vocal cord in infants—50% composed of vocal process compared to

25–33% in adults

• Infant subglottis is narrowest part of airway (glottis narrowest part in adults):

4.5–7mm in full-term infant.

– 1 mm circumferential mucosal edema in infant narrows subglottis by >60%.

Clinical Evaluation

• Location of stridor by its pattern

– Inspiratory: supraglottic – Biphasic: subglottic, glottic – Expiratory: xed intrathoracic trachea

• SPECSR mnemonic

– Subjective—parent’s impressions – Progression – Eating/feeding difculties – Cyanosis – Sleep disordered breathing – Radiography

• Pediatric airway abnormalities that may improve in prone position

– Laryngomalacia – Pierre Robin sequence – Vascular compression – Mediastinal mass

• Common gastroesophageal reux disease (GERD)-related (or exacerbated)

laryngeal disorders

– Recurrent croup – Chronic cough – Laryngospasm – Dysphonia – Subglottic stenosis

4 Pediatric Airway andEsophagology

https://t.me/medicina_free

– Aspiration – Laryngomalacia

• History

– Laryngomalacia most common cause of stridor in infants, may worsen gradu-

ally in the rst few weeks of life. – Viral prodrome, fever, coryza → infection. – Foreign body (FB) unlikely in non-ambulatory child (especially without older

siblings). – Less than 6months old, new-onset biphasic stridor, no FB history → subglot-

tic hemangioma. – If prior history of intubation, NICU, prematurity → subglottic stenosis, sub-

glottic cyst. – Evaluate for vallecular cyst on bedside laryngoscopy. – History of cardiothoracic procedure → recurrent laryngeal nerve (RLN) injury.

Radiographic Examination

• “Steeple sign”—subglottic narrowing on anterior-posterior (AP) neck X-ray, can include dilated hypopharynx → croup, can also be seen in subglottic hemangioma (usually asymmetric) and bacterial tracheitis

• Indistinct vocal cords → infectious process

• “Thumb sign”—thickening of epiglottis on lateral neck X-ray → epiglottitis/ supraglottitis

• “Candle-dripping sign”—linear soft tissue lling defect within the trachea, irregularity of the tracheal wall → exudative/bacterial tracheitis

Laryngomalacia

• Most common cause of inspiratory stridor, stridor worse with crying and lying supine

• Uncertain pathophysiology, thought to be affected by:

– Anatomic factors: shortened aryepiglottic folds, anterior cuneiform cartilage

prolapse – Immature neuromuscular control – GERD

• Medical therapy

– Reux control – Speech-language pathology (SLP) evaluation, feeding strategies, positioning

https://t.me/medicina_free

• Indications for surgical intervention

– Severe stridor with failure to thrive or weight loss – Obstructive sleep apnea – Severe chest deformity – Cyanotic episode – Pulmonary hypertension, cor pulmonale

• Surgical approaches

– Supraglottoplasty—division of aryepiglottic folds, removal of redundant

mucosa and cuneiform and corniculate cartilages as needed – Epiglottopexy – Tracheostomy for severe cases – Possible Nissen/g-tube adjunct for severe cases for recalcitrant reux

A. F. Karas and J. W. Lee

Laryngeal Cleft

• Can contribute to chronic cough, aspiration, chronic lung disease

• May be suspected on modied barium swallow

• Diagnosis requires microdirect laryngoscopy and palpation of the interarytenoid space—cannot be ruled out on exible laryngoscopy

• Classication

– Type 1: supraglottic interarytenoid cleft above the level of the vocal cords

Treatment: observation, diet modication, injection laryngoplasty, endoscopic repair

– Type 2: partial cricoid cleft, extends below the level of the vocal cords

Treatment: observation, diet modication, injection laryngoplasty, endoscopic/open repair

– Type 3: total cricoid cleft, without extension into the thoracic inlet

Treatment: diet modication, endoscopic/open repair

– Type 4: laryngotracheoesophageal cleft, almost universally fatal

Vocal Cord Paresis/Immobility

• Presentation

– Unilateral: weak cry, aspiration. – Bilateral: presentation depends on cord position.

4 Pediatric Airway andEsophagology

https://t.me/medicina_free

If immobile and aDducted → signs of airway obstruction, stridor If immobile and aBducted → aspiration, weak/no cry, but no stridor or airway obstruction

• Differential diagnosis of vocal cord palsy, unilateral or bilateral

– Idiopathic – History of cardiac surgery (esp. PDA ligation with left cord paresis) – Birth trauma, other trauma – Neurologic disease

Arnold-Chiari malformation Hydrocephalus Cerebral palsy Hypoxic encephalopathy

– Malignant disease: familial, brainstem lesions – Drug related: vinca alkaloids (neurotoxic)

• Diagnostic workup

– MRI brain – Modied barium swallow – SLP evaluation – Operative airway evaluation to rule out anatomic restriction of movement

(arytenoid xation, posterior glottic stenosis, etc.)

– Consider laryngeal EMG

• Treatment

– Unilateral—rarely any airway/respiratory issues, primarily voice and

swallowing

Observation Speech therapy Injection laryngoplasty Recurrent laryngeal nerve-ansa cervicalis anastomosis

– Bilateral—almost all present with some component of respiratory problems

Observation—spontaneous recovery possible, 5–7days of age Lateral cordotomy, partial arytenoidectomy Lateralization suture Cricoid split—endoscopic, open, possible late failures secondary to synkinesis Tracheostomy

https://t.me/medicina_free

A. F. Karas and J. W. Lee

Recurrent Respiratory Papillomatosis

• Etiology: HPV 6, 11; develops at the junction of squamous and respiratory epithelium

– Vertical maternal transmission, presents with dysphonia, stridor, respiratory

distress, ball-valving glottic lesion

– Pulmonary dissemination nearly uniformly fatal

• Types

– Juvenile onset (<12years old)—more common, more aggressive – Adult onset

• Derkay staging/severity system

– Score of 1–3 (0 = absent, 1 = surface lesion, 2 = raised lesion, and

3=bulky lesion)

– Assign score to each site in aerodigestive tract

Larynx

• Epiglottis (lingual and laryngeal surface), aryepiglottic folds (Right/ Left), false vocal folds (R/L), true vocal cords (R/L), arytenoids (R/L), anterior commissure, posterior commissure, subglottis

Trachea

• Upper 1/3, middle 1/3, lower 1/3, bronchi (R/L), tracheostomy stoma

Other

• Nose, palate, pharynx, esophagus, lungs, other

– Six questions regarding patient’s clinical course: interval of surgery, total

number of surgeries, urgency of this surgery, quality of voice, degree of stridor at the time of this surgery, and degree of respiratory distress

• Treatment

– Surgical debulking: laser, microdebrider, cold knife; may need staged

approach to avoid glottic webbing – Tracheostomy, avoid unless absolutely necessary – Adjuvant therapies: interferon, cidofovir, Avastin

Indications >4 surgeries/year, distal pulmonary spread, rapid regrowth of disease with airway compromise

Laryngeal Webs

• Congenital—isolated or associated with 22q11 deletion syndrome

• Acquired—iatrogenic (postsurgical, prolonged intubation), caustic injection, trauma

4 Pediatric Airway andEsophagology

https://t.me/medicina_free

• Cohen grading system

– Type 1: thin, membranous, <35% of glottis – Type 2: 35–50% of glottis – Type 3: 50–75% of glottis, often extends to anterior cricoid cartilage – Type 4: up to 99% of glottis

• CHAOS (congenital high airway obstruction syndrome), complete laryngeal stenosis

Subglottic Stenosis

• Congenital

• Acquired—trauma/intubation, infection, chronic inammatory disease, neoplastic disease

• Cotton-Myer Grading system

– I: <50% – II: 51–70% – III: 71–99% – IV: no detectable lumen, complete obliteration

• Surgical treatment

– Grade I/II: endoscopic laser, dilation, cold knife – Grade III/IV: endoscopic management may be trialed for Grade III, but suc-

cess is less likely than for less severe cases. May require tracheostomy, laryngotracheal reconstruction (cricoid split with anterior ± posterior cricoid augmentation), cricotracheal resection

– Single stage (no postoperative tracheostomy present) versus double stage

(persistent postoperative tracheostomy with staged decannulation)

Posterior Glottic Stenosis

• Can present as airway obstruction, dysphonia

• On exible laryngoscopy, may look like bilateral vocal cord paresis

• Bogdasarian classication

– I: interarytenoid adhesion

Treatment: observation, endoscopic lysis

– II: posterior commissure stenosis

Treatment: observation, endoscopic/open repair

– III: posterior commissure stenosis with unilateral cricoarytenoid xation

Treatment: endoscopic/open repair, tracheostomy

https://t.me/medicina_free

– IV: posterior commissure stenosis with bilateral cricoarytenoid xation

Treatment: tracheostomy, open repair

A. F. Karas and J. W. Lee

Tracheal Obstruction

• Tracheal stenosis

– Acquired/inammatory – Congenital—complete tracheal rings – Surgical management: observation, endoscopic excision, tracheoplasty, seg-

mental resection, slide tracheoplasty

• Tracheobronchomalacia

– Immature tracheal cartilage with dynamic collapse – May require surgical decompression if due to extrinsic vascular compression

Innominate artery (anterior) Double aortic arch

• Predominantly airway symptoms (stridor, respiratory distress, cough)

• Surgical repair necessary

Right aortic arch

• Airway symptoms as well as dysphagia

Anomalous right subclavian artery (dysphagia lusoria)

• Vascular compression POSTERIOR to the trachea and esophagus

• Associated with non-recurrent right laryngeal nerve

Pulmonary artery sling/dilation

• Left pulmonary artery arises from right pulmonary artery

• Vascular compression BETWEEN trachea and esophagus on barium swallow

• Association with complete tracheal rings

– May require tracheostomy to bypass malacic segment or to allow use of posi-

tive pressure if severe

Airway Foreign Bodies

• Third most common cause of accidental death in children younger than age 1, typically seen in children ages 1–3years

• May be food or non-food objects

4 Pediatric Airway andEsophagology

https://t.me/medicina_free

• Diagnosis

– History of choking episode, witnessed ingestion/aspiration, coughing – Physical exam: abnormal chest auscultation (diminished breath sounds,

wheezing, rhonchi), respiratory distress

– Radiography: most objects are radiolucent on X-ray. Lateral decubitus or

inspiratory/expiratory lms may reveal air trapping. If FB present for some time, may have atelectasis/inltrate

• Treatment

– Flexible laryngoscopy can be considered. However, a negative exam does not

rule out FB.Care should be taken as procedure can exacerbate symptoms.

– Microdirect laryngoscopy and bronchoscopy, urgency dictated by clinical

picture.

– May need ECMO (extracorporeal membrane oxygenation) available in cases

of severe obstruction or known large foreign body.

– If endoscopic management with rigid instrumentation fails, may need exible

bronchoscopy for more peripheral or upper lobe foreign bodies or open management in cases of severe impaction.

– Consider postoperative antibiotics and/or steroids depending on intraopera-

tive ndings, especially in cases of organic material (e.g., oils from nuts may cause continued inammation).

Tracheoesophageal Fistula

• Types

– Esophageal atresia with distal TEF (85%) – Isolated esophageal atresia (10%) – H-Type TEF (4%) – Esophageal atresia with proximal TEF (0.5–1.0%) – Esophageal atresia with proximal and distal TEF (0.5%)

• Generally present with immediate feeding problems and aspiration with inability to pass feeding tube

– H-type may present later with recurrent pneumonia – Diagnosed with uoroscopy, endoscopy – Surgical correction required, risk of postoperative stricture

Caustic Ingestion

• Acidic ingestion leads to coagulative necrosis (supercial)

• Alkaline ingestion leads to liquefactive necrosis (deep)

<<< < Предыдущая 1 2 3 45 / 505 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202634 Мб0Книга_4506_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202634 Мб0Книга_4507_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4512_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4517_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4518_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4520_Библиотеки_им_академика_М_И_Перельмана.djvu
#
31.08.202630 Мб0Книга_4522_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4523_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4524_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4525_Библиотеки_им_академика_М_И_Перельмана.pdf