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BackTable / ENT / Article
Complex Airway Disorders in Infants with Stridor: Diagnosis & Surgical Strategies
Olivia Reid • Jan 7, 2024 • 31 hits
Otolaryngologists Dr. Gopi Shah and Dr. Briac Thierry discuss the intricacies of complex airway disorders in infants with persistent stridor, including diagnosis, surgical approaches, and tracheostomy considerations.
Various challenging conditions are highlighted spanning from vallecular cysts to bilateral vocal fold immobility. Dr. Thierry emphasizes the need for preparedness in addressing vallecular cysts' sudden obstructive nature during sedation and the weight-based threshold for considering tracheostomy in infants. This outlines the importance of cautious attempts and staged interventions for these complex conditions, reframing tracheostomy as a valid treatment option rather than a last resort. Given the multifaceted skills required for infant airway surgery, effective communication and collaboration among various medical teams is vital to ensure optimal patient care and successful surgical outcomes.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• The use of direct laryngoscopy bronchoscopy should be considered if conservative measures fail and weight loss persists, as the procedure allows for more in-depth airway examination, checking for subglottic and tracheal anomalies, clefts, and proper sizing of the airway.
• Additional etiologies of persistent stridor, apart from laryngomalacia, include vallecular and subglottic cysts, tracheal rings, and bilateral vocal cord paralysis.
• The objective threshold for considering tracheostomy primarily revolves around weight with the guideline being below 2.5 kilos in the US and around 3.0 kilos in Europe.
Table of Contents
(1) Direct Laryngoscopy Bronchoscopy: Optimizing Diagnosis & Treatment for Persistent Stridor
(2) Surgical Pearls in Infant Airway Pathologies
(3) Critical Considerations for Tracheostomy in Pediatric Airway Disorders
Direct Laryngoscopy Bronchoscopy: Optimizing Diagnosis & Treatment for Persistent Stridor
When conservative measures like proton pump inhibitors (PPIs) and thickening agents fail to yield improvement in infants presenting with persistent stridor, the use of a direct laryngoscopy bronchoscopy (DLB) can be employed to confirm isolated laryngomalacia and assess for potential secondary airway lesions. This is vital in cases in which the patient’s weight loss or worsening symptoms persist past the window in which the initial line of defense would be deemed effective.
The DLB protocol involves meticulous airway examination, including checks for subglottic and tracheal anomalies, clefts, and appropriate sizing of the airway using uncuffed endotracheal tubes under positive pressure. It has been found that the use of Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) during a DLB both enhances ventilation and minimizes desaturation risks, according to Dr. Theirry. Once the region affected by laryngomalacia is identified, a tailored treatment approach is recommended, with a gravitation towards cold scissors and bipolar techniques over lasers due to precision and reduced risk of tissue damage.
[Dr. Gopi Shah]
Now let's say the baby comes back to you. Let's say you tried a PPI. Let's say we saw the baby at two weeks, you did the PPIs and thickener, they come back to you, now they're about four to six weeks in age and the family's like, "It's the same or worse and the weight hasn't caught up. Now we're losing weight." At this point, are you thinking about a DLB?
[Dr. Briac Thierry]
Yes. In fact, if you have a repercussion on the weight, then you change, and it's not moderate, it could be severe or it could be a failure of the treatment of the moderate laryngomalacia. Then you need to perform some DLB because you want two things. You want to confirm that it's an isolated laryngomalacia, so you don't have any other findings in the airway, you don't have any subglottic stenosis, you don't have any tracheal stenosis, anything like this. Also, you will perform the treatment during the DLB.
[Dr. Gopi Shah]
Yes. The secondary lesions with laryngomalacia, isn't it like 20%? It's pretty high. There's a large group of kids where all it is is isolated, but there's still a chunk of kids where there's a high association with secondary lesions.
[Dr. Briac Thierry]
Yes. It's very important to perform the DLB for this point because you want to check the airway and you want to treat the laryngomalacia, but also you can treat other lesions at the same time.
[Dr. Gopi Shah]
Tell me about your setup for a DLB and how you like to do your direct laryngoscopy bronchoscopies.
[Dr. Briac Thierry]
As I said, you need to have a plan at first when you're performing a DLB. You have a diagnosis first and then you will have the treatment. Well, a few tips to perform the endoscopy and I think it can make the difference. Recently, we changed our checklist. We have a special checklist for endoscopy, and it helps the nurse and the anesthesiologist because we are talking about different scenarios during the DLB, and it helps when it happens. I use THRIVE. Well, this tool has been a game-changer for the last four years. It's completely different now that we have THRIVE than before.
[Dr. Gopi Shah]
What is THRIVE? What does that stand for?
[Dr. Briac Thierry]
It stands for Transnasal Humidified Rapid Insufflation Ventilatory Exchange. It's a very difficult name just to say you are going to put some air impression in the nose and you have like two--
[Dr. Gopi Shah]
Nasal cannulas, yes.
[Dr. Briac Thierry]
Probes. Yes. In the nose. You will throw some air into the nose of the child. It's a wonderful tool.
[Dr. Gopi Shah]
Ah, okay. I tend to use an ET tube on the side either attached to the suspension laryngoscope, the Parsons, or sometimes I'll just hold it. Tell me, is that basically what it is but this way it's a nasal cannula, so it's not an extra thing to hold in your hand?
[Dr. Briac Thierry]
You don't have anything to hold in your hand because it's on the face of the child. Before we use exactly what you've described, and THRIVE, it's much better. You don't have any desaturation anymore. You have apnoeic ventilation. Well, you're supposed to perform the endoscopy under spontaneous ventilation, but if at some point the child doesn't have any ventilation, you can last the apnoeic ventilation for pretty long like one minute, one minute and a half, without any problem, without any desaturation. It's definitely wonderful. Well, I recommend it.
[Dr. Gopi Shah]
It's something I need to change. Okay.
[Dr. Briac Thierry]
Well, this is an important tip. Also, I used to prepare the local anesthesia of the glottic area before according to the weight of the child. I used to have some uncuffed, intubation probe prepared so that if I have some problem, I already have the disposal.
[Dr. Gopi Shah]
The ET tube, the endotracheal tube?
[Dr. Briac Thierry]
The ET tube, yes, and try to communicate with the anesthesia team quite a lot to make them understand. There is something very useful also, is that I have plenty of screens in the OR so they can see what I see, and this is very useful. Then well after, it's just an endoscopy, so I'm doing it. I try to perform this very systematically, so I will check the larynx, I will check the subglottic area, I will check the trachea, I will check the trachea for tracheoesophageal fistula, I will check the larynx for cleft. Then when everything is checked, I will perform the treatment.
[Dr. Gopi Shah]
When you check for the cleft, are you just using a laryngeal right angle, like the little laryngeal hockey stick or the hook or how do you check it usually?
[Dr. Briac Thierry]
I don't have this device, but I use forceps. I put some pressure into one of the vocal folds to spread the anterior arytenoid region and to see if there is a notch, if there is a depression, which is the definition of the cleft. I don't have this, but anyway, you can perform it with pretty much whatever you have.
[Dr. Gopi Shah]
Then any tips or tricks for sizing the airway? I know we have the uncuffed endotracheal tubes and we have the camera in and it's attached and anesthesia gives them some positive pressure, we check for bubbles. Is that the same way that you do it?
[Dr. Briac Thierry]
Exactly. You are supposed to have pressure while doing this, checking for the bubble, which is 20 centimeters of water. Well, like everyone, I don't have any tips for this.
[Dr. Gopi Shah]
Let's say that it is laryngomalacia. Let's say that the rest of the airway looks okay, do you do your supraglottoplasty? Do you like powered instruments? Do you like lasers? Do you like cold technique? What is your technique? What do you like to do?
[Dr. Briac Thierry]
We used to have plenty of lasers in the airway and we don't anymore. Now, there is something which is important before. When you perform the fibroscopy in the consultation, you will have the type of the laryngomalacia. There is a clinical classification that has been proposed. Well, it was a few years ago. You can identify the region of the larynx which are the most impacted by laryngomalacia. It can be the mucosa of the arytenoid, which is going into the airway, it can be the epiglottis faults which are short, or it could be the epiglottitis, which is falling into the airway. I think the first thing is to have the classification and to identify which region of the larynx is ill so that you can perform the good treatment.
Then, well, if I need to take out some regiment because I have the arytenoids, I definitely will use cold scissors. I don't use lasers anymore because I think it can burn because it's quite a powerful tool, the laser. Well, I think scissors is a good one. You just take the mucosa away, you can cut the epiglottic folds quite easily with scissors. If I want to perform an epiglottoplasty, I will use a bipolar, which is much more simple to use than the laser.
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Surgical Pearls in Infant Airway Pathologies
While the most common reasoning behind an infant’s stridor is laryngomalacia, there are various other challenging airway lesions that can be present in infants. One example is vallecular cysts, which require a great deal of pre-preparedness in the operating room due to the sudden obstructive nature of these cysts during sedation. This necessitates both anticipation and coordination with anesthesiologists when encountering vallecular cysts for prompt intervention and treatment. Subglottic cysts may also be present in infants and are associated with prematurity, treated via intubation or gentle removal. Furthermore, tracheal rings, often linked with cardiovascular anomalies, require careful evaluation during a DLB, as passing instruments through the rings leads to mucosal inflammation. In the case of bilateral vocal cord paralysis, Dr. Thierry explains the diagnostic challenges and potential for only a partial recovery based on mobility recovery and patient age.
[Dr. Gopi Shah]
There's so much we can talk about in terms of other reasons. I'm going to just go through some other reasons and I just want you to give me some pearls because I feel like there's so much. Each one of these things could be its own episode, but any tips for managing a molecular cyst? Any tips for that?
[Dr. Briac Thierry]
It's probably the most difficult DLB that you can have because the child, when you look at the child in the consultation, he's making some noise, feeding is difficult, but he looks okay. As soon as he is sedated, he will just kick out. He will stop breathing.
[Dr. Gopi Shah]
He's going to obstruct?
[Dr. Briac Thierry]
Yes, completely. There is nothing you can do about this. It's all about anticipation. You need to have all the operating room ready for this before he enters the room. You will need to have some scissors, some needle, some suction, some lasers, whatever you want, but it has to be ready. You definitely need to speak with the anesthesiologist team so that they understand what is going to happen because the child, he's looking great and then he will have a cardiac arrest. You don't want to go this way. It's all about anticipation. Even with anticipation, it can be difficult because at some point, it can be difficult to intubate this kind of child. For the DLB, I try to have the child sedated and then I will open the cyst, have suction, and then I will intubate with an ET tube and then I will perform the rest of the treatment. The beginning of this is opening the cyst, suction it, and intubate.
[Dr. Gopi Shah]
It reminds me of not a newborn necessarily, but the three or four-year-old that's presenting for the first time with papillomas, a big, bulky. It's the same situation where as soon as they, that's it.
[Dr. Briac Thierry]
There is something different with papilloma is that you can see the larynx, so it's much easier to have the intubation. With the vallecular cysts, you don't see the vocal folds anymore because you've got this epiglottis and the cyst on the way and you can't see anything. I think it's more tricky.
[Dr. Gopi Shah]
Yes, that makes sense. Tell me about subglottic cysts. Any tips for subglottic cysts?
[Dr. Briac Thierry]
I think in this case, you always have some history of prematurity because I think it's only in this case when you will see a subglottic cyst. I don't think it's very challenging because you have plenty of ways to remove them. One of them is intubation. If you are in any danger in the operating room, just put a tube in and you will cure the disease. It's easy. If you have time, you just need to peel off the top of the blister and it will be okay. I think it's easy.
[Dr. Gopi Shah]
Tell me about tracheal rings, thoughts on that? I know. Again, that's a whole another two podcasts, I know, but--
[Dr. Briac Thierry]
Yes. Do you have two hours?
[Dr. Gopi Shah]
I want your two minutes of wisdom on tracheal rings.
[Dr. Briac Thierry]
You will have signs, you will have cardiovascular anomalies in most of the cases, about 70%. It would be cardiac anomalies or vascular anomalies such as pulmonary arterial sling. If you perform a DLB and you see tracheal rings, don't go through. If you go through, you will have some inflammation of the mucosa and you will have the global situation worsening very fast. Then just schedule the slide tracheoplasty.
[Dr. Gopi Shah]
That's a good tip. If you see it, you don't necessarily need to go through. I like that. Okay.
[Dr. Briac Thierry]
You don't have to go through. The team of London is probably the only one we're going through because they have a very, very thin scope and they are used to it and they don't touch the mucosa.
[Dr. Gopi Shah]
Your two-minute pearl on bilateral vocal cord paralysis. Two minute pearls.
[Dr. Briac Thierry]
You do the fibroscopic assessment. You will see that you don't have any movement. You will check that you don't have any movement for several days. The diagnosis is not given at the first time. It will be in a week or two weeks.
Critical Considerations for Tracheostomy in Pediatric Airway Disorders
Dr. Briac Thierry discusses the nuanced approach to tracheostomy in pediatric airway cases, outlining specific thresholds and scenarios where this intervention becomes necessary. Tracheostomy is not the initial option for laryngomalacia unless there are significant comorbidities involved. The primary objective threshold for considering tracheostomy revolves around weight, below 2.5 kilos in the US and around 3.0 kilos in Europe, despite the difficulties associated with the procedure in smaller infants. For conditions like bilateral vocal fold immobility or subglottic stenosis, tracheostomy is contemplated after multiple unsuccessful endoscopic attempts, emphasizing a balanced approach that recognizes tracheostomy as a valid treatment rather than a failure in the most complex of cases.
[Dr. Gopi Shah]
Tell me about the threshold for tracheostomy, whether it's the initial baby with laryngomalacia or the subglottic stenosis baby in the NICU, when does that come into play?
[Dr. Briac Thierry]
I have never performed a tracheostomy for laryngomalacia first.
[Dr. Gopi Shah]
No. That's probably a good thing.
[Dr. Briac Thierry]
I know it's in the IPOG, but I definitely do not agree with this. Well, unless you have plenty of comorbidities. Well, this is--
[Dr. Gopi Shah]
The Cor pulmonale, the buzzwords that are so rare, fortunately.
[Dr. Briac Thierry]
For tracheostomy, there is one threshold which is completely objective. It's the weight. In the US, it's before 2.5 kilos, and in Europe, it would be more like three. Before these weights, you don't want to perform a tracheostomy because you know it's going to be difficult. Then tracheostomy, for example, for bilateral vocal fold immobility or for subglottic stenosis, would be after failure of different endoscopic attempts. For subglottic stenosis, it would be after three. For cricoid splits, I used to perform dilatation one time after the first one and maybe a second one. If it doesn't work anymore, I will perform a tracheostomy. I think you don't have to perform too many endoscopic attempts. Tracheostomy is not a failure. It's also a good treatment, and you can perform it. You have the right to.
Podcast Contributors
Dr. Briac Thierry
Dr. Briac Thierry is an ENT surgeon with APHP in Paris, France.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 7). Ep. 141 – Stridor in Newborns: Evaluation & Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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