BackTable / ENT / Podcast / Transcript #141

Podcast Transcript: Stridor in Newborns: Evaluation & Management

with Dr. Briac Thierry

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Briac Thierry, Pediatric ENT at Necker Hospital for Sick Children in Paris, France, review stridor in newborns, with a special emphasis on laryngomalacia. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Stridor Patient Presentation & Diagnostic Questioning

(2) The Physical Exam & Fibroscopy in Infant Stridor

(3) Alternate Tests for Stridor Detection

(4) Characterizing the Laryngomalacia

(5) Treatment for Babies with Moderate Laryngomalacia

(6) Direct Laryngoscopy Bronchoscopies: When & How to Employ

(7) Treatment Options for Mild Laryngomalacia

(8) Encountering Less Common Etiologies

(9) Tracheostomy: Conditions & Procedural Tips

(10) The Team Approach: Putting the Pieces Together

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Stridor in Newborns: Evaluation & Management with Dr. Briac Thierry on the BackTable ENT Podcast)

Ep 141 Stridor in Newborns: Evaluation & Management with Dr. Briac Thierry

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[Dr. Gopi Shah]
Hello, everyone, and welcome to the BackTable ENT Podcast where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah. I'm a pediatric ENT and I have a really awesome guest today. I have Dr. Briac Thierry. He's a pediatric otolaryngologist practicing at Necker Sick Children Hospital in Paris, France. Dr. Thierry is the leader of the airway program in his department. He's an active member of the International Pediatric Otolaryngology Group, the IPOG, authoring six consensus statements, including guidelines for pediatric tracheostomy decannulation to the management of suprastomal collapse in children. He is here today to talk to us about the evaluation and management of newborns with stridor. Welcome to BackTable, Briac, bienvenue à BackTable. How are you?

[Dr. Briac Thierry]
Bonjour, Gopi.

[Dr. Gopi Shah]
Bonjour.

[Dr. Briac Thierry]
Hi, everyone.

[Dr. Gopi Shah]
Briac, for our audience who may not know you, can you tell us a little bit about yourself and your practice?

[Dr. Briac Thierry]
Sure. I've done my practice the European way. It was all in med school in Paris. I've done my residency in Paris and I've done my training in Paris. I've been in the Hôpital Necker for a long time right now, which is known for having invented the stethoscope by René-Théophile-Hyacinthe Laennec. It was also the first hospital to perform a kidney allotransplantation, but it was a long time ago. Now, it's a pediatric referral center with plenty of NICU and PICU beds, about 150. I also insist on the fact that we are in a highly centralized state, so it means we have plenty of referrals from all over France. I work in a national referral center.

[Dr. Gopi Shah]
That's great. Before we get into our clinical topic, I just want to say hello to your colleague and partner, Charlotte Célérier. She's a friend, a colleague here, and she's wonderful and was one of the reasons I got to meet you, so shout out to Charlotte.

[Dr. Briac Thierry]
Exactly.

(1) Stridor Patient Presentation & Diagnostic Questioning

[Dr. Gopi Shah]
All right. Today we're going to talk about the newborn who presents with a stridor. How do they usually present to you? How much of the time do you see these patients in your clinic and how often is it a consult in the hospital for you?

[Dr. Briac Thierry]
I think most of the time it's in the clinic and they are referred to my consultation from the pediatrician. A few times, they are referred into the hospital and they are in NICU or PICU. This is not the most frequent time. We are going to talk definitely about stridor and laryngomalacia and the most frequent is laryngomalacia in the clinic.

[Dr. Gopi Shah]
Tell me a little bit about stridor. There's the big box of noisy breathing. How do you explain it to your trainees or to families?

[Dr. Briac Thierry]
I explain to them that the stridor is due to the vibration of the upper airway of the larynx, and the supraglottic structures because you have an obstruction in the upper airway. This obstruction leads to bradypnea and as it’s an obstruction in the cervical area of the airway, it leads to inspiratory bradypnea. You've got a sound which is inspiratory. When I try to talk about stridor to the resident, it's a high-pitched tone. I'm not an expert about this.

[Dr. Gopi Shah]
When patients and families present to your clinic or if you see them in consultation, what kinds of questions do you ask them?

[Dr. Briac Thierry]
I try to separate the very simple cases from the difficult ones. Does the child have respiratory signs? Does he have a permanent stridor? Does he have apnea? Does he experience the spell? You have to get an idea about the severity of the illness. You have to ask questions about the feeding. How does bottle feeding go? How long does it take to take a bottle? How many milliliters?

Also, you have to ask about growth and weight. It's very important to have a recent weight. Also, you need to have some information about the voice because it's not the same if the child has a voice or if he never has had one. Also, does he make aspiration when he's feeding?

[Dr. Gopi Shah]
Do you ever ask about symptoms relating to sleep at all? Sleep in this age group is, I don't know, hard to assess sometimes too, but do you find that these kids have noisy breathing or stridor in their sleep? What have you found in your practice when it comes to sleep?

[Dr. Briac Thierry]
Usually, the most frequent etiology of stridors that we will find is laryngomalacia. During sleep, in the mild and in the moderate cases, you don't hear any noise at night. It could be that they make some noise, but it's random. Anyway, you will need to know how they sleep during the night because it's also a severity sign.

[Dr. Gopi Shah]
We say laryngomalacia is the most common. What other etiologies or other differential do you usually have when it comes to the noisy breathing in the newborn?

[Dr. Briac Thierry]
Plenty.

[Dr. Gopi Shah]
It's like a box, right? Box of chocolates. There's lots to choose from.

[Dr. Briac Thierry]
Yes, it's plenty. You will find plenty of diseases that can cause some noise. Well, I'm thinking about bilateral vocal fold paralysis, congenital laryngeal stenosis, tracheal stenosis, but also vallecular cysts and subglottic cysts. You can make some noises if you have some papillomas. You have plenty of etiology of obstruction. Any obstruction of the larynx and the upper airway can cause a noise at night. It's quite difficult for the pediatrician or for the family to differentiate the stridor from another noise that appears in an inspiratory phase of the respiration, so there are plenty of diseases.

[Dr. Gopi Shah]
Are you able to differentiate stridor due to mild laryngomalacia from other etiologies? When you see the baby, are there physical signs or the sound?

[Dr. Briac Thierry]
Just about the sound, the stridor, the laryngomalacia is quite typical, but it can be difficult to differentiate this sound from, for example, bilateral vocal fold paralysis. It's also a high-pitched sound. I would say, yes, probably, but in fact, I really don't know. You have some other signs and your physical examination is going to be quite important also. Definitely, you would perform a fibroscopy and this one is going to make the diagnosis.

[Dr. Gopi Shah]
Before we go to the physical exam and the scope, tell me some of the risk factors. We usually get a good perinatal history, and always ask about intubation in the newborn. What else do you think about?

[Dr. Briac Thierry]
You have to be very careful about medical history, as you said, prematurity, dysmorphia, genetic syndrome, craniofacial dysmorphia, and also history of intubation before, like in cardiothoracic surgery. These are the conditions that you need to look for during the physical examination and during your consultation because it's going to be important for the history of the child and the diagnosis.

[Dr. Gopi Shah]
Tell me about spitting up or GERD reflux. Do you feel like that can be the sole reason? We know with the laryngomalacia and GERD, the relationship it's what came first, right?

[Dr. Briac Thierry]
I think that you have to isolate laryngomalacia from the others at first. If we are speaking about laryngomalacia, which is a congenital anomaly of the larynx, then we can speak of the role of reflux. For the others, I really don't know. For this one, it has been published that maybe reflux has a role in this. I don't know, but it has been said that you should use some medication about this and I do. I'm not sure about this. Also, we have to take this information with caution because we know now that reflux therapy can cause some illness afterwards, when they are teenagers or adults. We don't prescribe as much antireflux medication as we did before.

(2) The Physical Exam & Fibroscopy in Infant Stridor

[Dr. Gopi Shah]
No, that's a good way to look at it. Tell me about the physical exam. What are you looking at? Then go ahead and tell me some tricks and tips for the flexible laryngoscopy, because I don't think I appreciated that sometimes it's really hard to get a good view on an infant or neonate until I did my fellowship. In residency, we weren't scoping a ton, and then all of a sudden in fellowship, it's like, "Okay, go see the baby." I'm like, "Gosh, I don't know if I got a good view. I don't know if I can tell if the cords are moving." Tell me what your tricks are, but tell me first about the exam. Sorry, jump ahead.

[Dr. Briac Thierry]
It's really quite simple. We're going to perform a very simple examination of the child. We are going to look for signs of congenital anomaly as we talked about previously, like syndromic sign of microdeletion, cardiothoracic anomaly, et cetera. We are going to look for a severity sign of breathing like retraction. We are going to look in the larynx for a laryngeal anomaly, and after, we are going to perform the fibroscopy. The fibroscopy, it could be challenging, so, yes, I've got plenty of tips for this. The child has to fast for at least three hours so you don't have any vomiting issues during the examination. You have to be helped by a nurse. I think it's very important because you need to hold the child and they perform a much better job than the parents do at this time because they're afraid and because the baby's going to cry. You need a nurse and you will perform the fibroscopy by the mouth. I think it's definitely the most easy and by the mouth, you can put a bigger tube, a bigger scope than in the nose, so you can put a four-millimeter scope without any problem in the mouth. It's quite difficult to put this in the nose of a neonate. You don't need any anesthesia for this because it's not painful. You don't need any gas.

Then, I'm ready to perform the scope. I make myself quite comfortable, so I raise the table and also if I have any suspicion of a bilateral vocal fold immobility, and I know that the scope is going to last for four, five minutes, I place the fibroscope and the camera on my right shoulder so I will be comfortable and I wouldn't hurt my arm during the scope. Well, this is just a tip, but you can make the scope much longer if you perform it this way. Then, you need to see the vocal folds and you need to see the larynx because this is what you want to perform. I put with my left hand, I put my little finger in the mouth so that the child has some suction on my finger and I can hold the tip of my scope with my thumb and my index finger and then I will just look at the larynx and if it's difficult, with my little finger also, I can put some extension, some neck extension, and then I will, in the end, see the larynx and what I want to see is the mobility of the vocal fold.

[Dr. Gopi Shah]
That's a very different way than I do it. That's very interesting. I love it. My usual go-to is transnasal with a skinny scope, but now I understand why they don't eat for three hours because you're going to go transoral, but with a larger scope, you're going to see more. That's pretty cool. Then you don't have to worry about nosebleeds or if the baby has choanal atresia, pyriform stenosis, whatever, it's okay because you're going through the mouth. Then, does the pinky help pull the tongue out a little bit too or when the little finger is in the mouth, does that help move the tongue out a little bit? Everything's so tiny. Maybe the tongue doesn't really get in the way.

[Dr. Briac Thierry]
I think if the child is having some suction on your little finger, it can help because the tongue is not getting out, but it helps.

[Dr. Gopi Shah]
Ah, okay. That's really cool. Do you normally record all these?

[Dr. Briac Thierry]
Yes.

[Dr. Gopi Shah]
I find it helpful because I usually record as well, and if it's in the hospital, we use an adapter for the iPhone so we can record it. Then, I like it because you can slow it down. Once you're looking at it, you can slowly watch the cords and see if they close, open, what one side is doing versus the other. Do you do that?

[Dr. Briac Thierry]
Well, not really. I've got another tip for this.

[Dr. Gopi Shah]
Oh, okay. Tell me.

[Dr. Briac Thierry]
If you have any suspicion of immobility of the vocal folds, you can record it. Well, you will record it, but you just need to stay longer. Instead of doing this in one minute, you can perform this for four, five, or six minutes. It's so long. Okay? The parents, they don't like it. The kid doesn't either, but at some point, you will see that the child at first is crying because it doesn't like it and it's difficult to understand if the vocal folds are not moving because of the crying or just because they're not moving. If you put the examination much longer, at some point--

[Dr. Gopi Shah]
They have to relax.

[Dr. Briac Thierry]
Yes, the child relaxes, it does, he is not crying anymore. Then, you will see the vocal folds much better and you will see if you've got a movement or not. You have to accept the fact that it's going to last forever.

[Dr. Gopi Shah]
That's a great point because you're right, usually we're like, okay, let's try to do it as fast, in one to two minutes, that seems long but you're right, the baby's so tense sometimes where they're crying. I'm like, is it that something the cords are out or is it, because there's so much tension, there's straining and then, you're right, you have to give it enough time to exhale, relax and then see what's actually going on.

(3) Alternate Tests for Stridor Detection

[Dr. Briac Thierry]
Yes. Well, there is also something that we could use, but we don't really because well, not yet, is the ultrasonography.

[Dr. Gopi Shah]
Tell me, have y'all started using that in your practice, ultrasound?

[Dr. Briac Thierry]
Yes, I do, a little bit. I think it's useful, but we should perform this in all the children, and for now, well, it is not possible now, but we will. You can see the movement of the vocal folds and since you are not putting the scope in the mouth, the child is not crying. He is relaxed at the beginning of the examination. You don't have to wait forever. I think this should be the way of performing the examination, especially for the mobility of the vocal folds. Well, definitely with the scope, you will also see the epiglottis, you will see the itinerary, you will see the larynx, you will see anything that I cannot see with the ultrasonography because I'm not used to it at this point. I think it should be an exam--

[Dr. Gopi Shah]
A tool.

[Dr. Briac Thierry]
Yes, a tool that we should use more often.

[Dr. Gopi Shah]
Yes. That's cool. Is there ever any role of other imaging, like do you ever get X-rays, airway films, airway fluoroscopy, anything like that, in your practice?

[Dr. Briac Thierry]
Well it has been in the IPOG about laryngomalacia. Well, we don't use it, we don't need an X-ray because the patient has a strider, then you will perform the fiberoscopy and you will see. If you have any suspicion, I think the X-ray is not the first exam that we should do. I'm sorry not to agree with the IPOG.

[Dr. Gopi Shah]
No, I agree and I don't really have a role for airway fluoroscopy or neck X-rays for this particular reason either. I did use the IPOG, the IPOG guidelines for laryngomalacia actually to help me study for our complex pediatric OTO boards that just started about three years ago. They're very helpful, just as a side note, for any of our listeners or audience. I think it's very helpful either way, because the algorithms, the flow sheet chart for just managing these babies come to your clinic, whether you're uber academic peds or a general otolaryngologist in the community, you're going to see these babies. It's nice to have some directions because you might see these all the time or this might be once in every couple of months depending on your practice.

[Dr. Briac Thierry]
It's very helpful anyway, but about X-ray, I'm not sure.

(4) Characterizing the Laryngomalacia

[Dr. Gopi Shah]
Yes. Okay, so let's say this is the baby that's in your clinic, at what point do you consider observation? When do you start considering trying reflux management or when are you like, "Hey, we need to do something in the OR for this baby?"

[Dr. Briac Thierry]
There is something that we should emphasize a little bit before this, that this patient has a stridor and then you have to consider that it's just a laryngomalacia and not something else. This is very important because usually, well in the, I don't know, 75% of the cases, it would be indeed laryngomalacia. Then you've got this patient, you perform the fibroscopy, you want to see a sign of obstruction, which is corresponding to laryngomalacia, so you want to see the collapses of the supraglottis structure and you want to see also the mobility of the vocal folds. Then, and only then, you will say it's laryngomalacia and I will take care of it like laryngomalacia. Until you have all these points, you are not sure and you don't know. Well, then if it's laryngomalacia and you don't have any repercussions of the laryngomalacia, you will call it.

I think the IPOG at this point is very useful because it helps you characterize the laryngomalacia. You will have the mild, the moderate and the severe depending on the repercussions of the laryngomalacia. On the first one, you don't have anything. The patient has a stridor and it's just isolated. The baby doesn't have any repercussions on the feeding and it doesn't have any repercussions on the breathing. Okay. You can see for this kind of stridor, I don't see them after. I just tell them, "Okay, the child needs to have a follow-up by the pediatrician. I'm not the person you want to see anymore." Then you have the moderate. If you have any respiratory signs or feeding repercussions, then you will first do the medical treatment.

[Dr. Gopi Shah]
For the babies that are mild, if I'm seeing them under three months of age, I used to see them in follow-up because I thought laryngomalacia could get a little worse between three to six months or the other reason is because I would worry maybe I need to check their weight in a couple of weeks or if something changes, so I always did. Am I being too cautious?

[Dr. Briac Thierry]
I think that you may not be the specialist that they want to see. You just need to check the weight and the growth. Maybe this is not your work.

[Dr. Gopi Shah]
You're right because, well, at that next visit, I'm not re-scoping. You know what I mean? If they look good, sound good, it's a counseling session. It's just "Oh," and a pat on the back, "Good job, parents."

[Dr. Briac Thierry]
Exactly.

[Dr. Gopi Shah]
Yes. That's interesting. Yes, you're right. What's it for? That's interesting. Yes.

[Dr. Briac Thierry]
Exactly. I don't see them after. If something happens, well, of course, they will--

[Dr. Gopi Shah]
They're going to call you.

[Dr. Briac Thierry]
Exactly. I don't do a systematic consultation after the first one if I don't see any gravity sign.

(5) Treatment for Babies with Moderate Laryngomalacia

[Dr. Gopi Shah]
Yes, that's cool. Okay. We'll first define, tell me a little bit about moderate, what puts them in that category versus mild or severe?

[Dr. Briac Thierry]
They'll have feeding difficulties. I think this is the first and maybe they will have some-- The stridor, it can be permanent. Well, they don't have apnea during the day. They will have the stridor. I think the most important is the feeding difficulties, but they grow. They don't have gross repercussions because of the feeding difficulties. It's just that bottle feeding takes more than 30 minutes. I think 30 minutes is a threshold that you can have in mind. It's quite simple. I will perform feeding strategies, acid suppression, and anti-reflux management and that's all.

I will see them in consultation two or three weeks after to see if it's still okay. There is something that we didn't talk about, is the physiology of the breathing of the neonates. In the end of the first months, they increase the volume of air that they need. They can have a decompensation of the laryngomalacia or any obstruction, to speak the truth, at this point. I may have a more intense follow-up if I see them in the first week. I will see them after this physiology increase of a respiration need.

[Dr. Gopi Shah]
That makes sense. I'm glad you made that point. In terms of the moderate laryngomalacia babies, do you prescribe a H2 blocker or a PPI? Do you have a preference?

[Dr. Briac Thierry]
Yes, I have a preference. I use a PPI and just the slightest dose needed, so one milligram per kilo. Also, I keep in mind that I don't want to keep this treatment for years. This is very important because it has been proven that if you take this kind of medication for years, then you will have an increased risk of inflammatory disease in adulthood. It's important to keep this quite short. Maybe weeks, maybe months, but I always have a consultation to stop the PPI.

[Dr. Gopi Shah]
Four to six weeks or how long do you keep them on it for, you think?

[Dr. Briac Thierry]
Well, it depends. Yes, probably, I don't know, maybe three months. We don't have any proof of this, so it's difficult to be reasonable, but well, there is something which is important. You don't want to keep this forever.

[Dr. Gopi Shah]
When you say it's time to stop the PPI, do you taper it, do you wean it down or can they just stop it?

[Dr. Briac Thierry]
No, I just stop it.

[Dr. Gopi Shah]
Okay. Then you'd mentioned some feeding strategies. Is that thickener? What are some of the feeding?

[Dr. Briac Thierry]
Yes, thickener.

[Dr. Gopi Shah]
Do you tell them this or does the speech and language pathologist, like the feeding, is there an evaluation? Tell me about that.

[Dr. Briac Thierry]
No, no, no. I'm performing the prescription myself, so I just prescribe them to put some thickener in the bottle and if they are breastfeeding, they can extract the milk then put some thicker into the milk.

[Dr. Gopi Shah]
For these kids, what's your threshold for getting a swallow study?

[Dr. Briac Thierry]
Yes, if they have aspirations.

(6) Direct Laryngoscopy Bronchoscopies: When & How to Employ

[Dr. Gopi Shah]
All right. 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.

[Dr. Gopi Shah]
Yes, that makes sense. Do you usually keep these babies intubated, extubated? Does it depend on how old they are? What's your post-op course?

[Dr. Briac Thierry]
Well, it depends on how the anesthesia is going. You need to perform, at first, the examination of the entire airway. If it's possible, I insist that they have spontaneous ventilation, well, in most of the cases, it's possible. If you have any problem, it's very easy to put in a tube and to perform a supraglottoplasty in this case because you are not going under the vocal fold and in the trachea. I used to perform it under general, under spontaneous ventilation. I used to wake up the child in the OR without any tube, and well, without a need for a tube. If it's needed, you still can perform the treatment that you want to perform.

(7) Treatment Options for Mild Laryngomalacia

[Dr. Gopi Shah]
Yes. Yes. Usually, unless you're super young, which is not common, but I think it's very similar, where usually without a tube, and hopefully by the end of the case we can send them they're breathing spontaneously and they're doing okay. We're going to switch gears for a second. Let's say the laryngomalacia is very mild. Let's say actually when you size the airway, let's say there's some supraglottic stenosis, tell me what you do in that situation.

[Dr. Briac Thierry]
If the laryngomalacia is mild, I will say that I won't perform a DLB.

[Dr. Gopi Shah]
That you won't?

[Dr. Briac Thierry]
Yes. In case of a mild laryngomalacia.

[Dr. Gopi Shah]
Oh, meaning symptomatically they have more symptoms than what your scope looks like, and you feel like, okay, there's a secondary lesion or hey, there might be something else going on. They're symptomatic, but your exam some-- That happens a lot too.

[Dr. Briac Thierry]
This is very important. If you're looking at a child with a stridor and then you perform a fibroscopy and you don't find anything, then there is something and you need to perform a DLB. This is very important because if you're not, well, it means that you didn't understand that something is happening, so you will perform the DLB. If I found a supraglottic stenosis, it means, well, usually, that the patient has a medical history, and quite often, a story of intubation. You can perform, well, the diagnosis quite easy, and you can per-- I do like section and dilation with balloons.

[Dr. Briac Thierry]
Your section meaning do you like to use a cold knife and cut the scar?

[Dr. Briac Thierry]
Yes, if it's completely inflammatory, you don't need to perform any section because it won't help.

[Dr. Gopi Shah]
Because it's still soft.

[Dr. Briac Thierry]
Because it's still soft and because there's plenty of inflammation, well, it won't help. You can have some dilation, you can put some glucocorticoid into the inflammatory region, and then, well, I've got tips about this. If I see an inflammatory region in the supraglottic area, I will inject some glucocorticoid into the lesion and then I will have some dilatation so that the glucocorticoid that you've put into the inflammatory agent, will spread all over. Then probably, I will have the patient intubated for a few days and we will have the extubation in the IQ and then see how it's going.

[Dr. Gopi Shah]
In terms of the steroid injection, is that just for the hard scarred supraglottic stenosis or do you also use the steroid injection for the ones that are soft and inflammatory?

[Dr. Briac Thierry]
No, most of the time, we only use it for the inflammatory. Well, not when it's fibrosis and because it's not useful anymore.

[Dr. Gopi Shah]
Then when you do your balloon, how long do you stay inflated for? Is that just how long the baby can tolerate or what's your?

[Dr. Briac Thierry]
Yes, pretty much, say it's about one minute usually, but if we can see the desaturation before, then we'll stop and then have the intubation. There is something also, I've got a tip about this. When you perform a DLB, you are the pediatric ENT, you are the one that they call when they are performing a difficult intubation. In the room, you are the best one to perform the ventilation of this child. You don't need to be kicked out by the anesthesiologist to perform the ventilation because you are the most accurate person to perform the intubation. This is very important. Well, I tell you this because we changed, I don't know, seven or eight years ago. Before this, they would perform the--

[Dr. Gopi Shah]
Oh, the mask.

[Dr. Briac Thierry]
Ventilation with the mask. I think it's not useful because you are just in front--

[Dr. Gopi Shah]
Of the baby.

[Dr. Briac Thierry]
Yes.

[Dr. Gopi Shah]
Yes. Plus, I want their hands free to bag to adjust the anesthesia gas, to push whatever medication they need to push. I don't need their-- Yes, 100%. It's more helpful when they have that and I'm okay and if I need help, I'll ask. I agree, when the baby, it's your airway at that point, if you're performing the DLB, the masking, to everything, 100%. When you do a balloon dilation, do you just dilate once or do you ever inflate more than once? Is there ever a role for that?

[Dr. Briac Thierry]
Well, usually two or three, and each time, it's going to last for 30 seconds to one minute, and after, I think it's not useful.

[Dr. Gopi Shah]
Yes. What's your routine post-op recommendations or orders? Are these babies on IV steroids, reflux medicine? What do you usually do?

[Dr. Briac Thierry]
Yes, exactly. If I perform a treatment during a DLB, they will have some nebulized corticoid and nebulized epinephrine for the first 12 hours. They also will have some PPI, and that's all.

[Dr. Gopi Shah]
Then do you routinely take these babies back for another look in 7 to 10 days? How do you decide what your follow-up evaluation is?

[Dr. Briac Thierry]
It's clinical. I don't perform it systematically. I don't schedule another endoscopy, but I look at the child, and if it's okay, I won't go to the OR. If it's not, definitely will perform a DLB, but it would be in an emergency setting, not a systematic one.

[Dr. Gopi Shah]
So depending on how they're doing?

[Dr. Briac Thierry]
Yes.

(8) Encountering Less Common Etiologies

[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.

[Dr. Gopi Shah]
Bring them back, take another look. Is that what you mean?

[Dr. Briac Thierry]
No. I mean, if he really has bilateral vocal fold immobility, probably is already in the NICU.

[Dr. Gopi Shah]
I've had one or two that have been outpatient in my clinic.

[Dr. Briac Thierry]
Wow.

[Dr. Gopi Shah]
They've actually done okay and they grow. Actually, I have one that I recall who was actually a colleague's baby, not an ENT, but another medical provider. I remember showing the recording to my partners because I wanted to be sure that I had the diagnosis correct, and also because the baby was doing okay, other than being noisy.

[Dr. Briac Thierry]
That's wonderful.

[Dr. Gopi Shah]
It's not common. I've had maybe one or two in a 10-year period. You're right. Majority of the time, they're in the NICU and there's respiratory distress. It’s not always going to look good.

[Dr. Briac Thierry]
The diagnosis is quite long. In fact, you're going to perform the first fibroscopy, and then a week later, you will have the second one. During this week, probably you will put some non-invasive ventilation to make them comfortable. Then the logigram that I use, if I confirm that there is a bilateral vocal fold immobility, then I will perform a cricoid split. If it's going okay, you don't need anything more. That's okay. If it's a failure, I will perform a tracheostomy because I don't want to touch the larynx because in the bilateral vocal fold immobility, there is, at some point, some recovery, like more than 50%. You don't want to harm the larynx. It's a tracheostomy for waiting. If after the age of two years you don't have any sign of mobility recovery, then I will perform a laryngoplasty.

[Dr. Gopi Shah]
Tell me about cricoid splits. What is your threshold or who's a good patient for that surgery for subglottic stenosis?

[Dr. Briac Thierry]
I think that you have two indications for cricoid split. The first one, and I think the better one, is for bilateral vocal fold immobility because the larynx is completely okay, so it's quite easy to perform. I will perform an anterior-posterior cricoid split and dilatation. Then intubation for seven days.

[Dr. Gopi Shah]
Endoscopic or do you ever do these open?

[Dr. Briac Thierry]
That's a good question. No, I perform it endoscopic, but if you have some subglottic stenosis, an inflammatory one, you can also perform a cricoid split and you can perform it endoscopically. If you want to perform an anterior-posterior, I think it's better to perform it endoscopically. If you want to perform only the anterior part of the cricoid, then you can perform it open. I think it's a good indication for a very inflammatory larynx. You just want to cut the cartilage and then it seems like the edema is going out through this incision. It works.

[Dr. Gopi Shah]
Do you ever use cartilage or do you sew anything, tack it open?

[Dr. Briac Thierry]
Not endoscopically. When I perform a--

[Dr. Gopi Shah]
When you do it open.

[Dr. Briac Thierry]
Yes, well, then it would be laryngoplasty. I will perform the cricoid split first. Then if it's not doing well, I will perform a laryngoplasty, but it would be in different cases.

[Dr. Gopi Shah]
Got it.

[Dr. Briac Thierry]
Not at the first time. Unless you've got bilateral vocal fold immobility and you don't have any hope for recovery. If he has some surgery for esophageal atresia and then he doesn't have any mobility of the vocal folds, maybe the laryngeal nerve has been cut also after a cardiothoracic surgery, then you can perform a laryngoplasty before the age of two years that I was talking about.

[Dr. Gopi Shah]
In cricoid splits, endoscopic, anterior-posterior for newborns or infants under six months for bilateral vocal cord paralysis, subglottic stenosis, if it's going to be only an anterior split, you might do it open. Then for babies where the core laryngeal or current laryngeal nerve may have been cut from cardiac surgery and we know that that happened, you may go ahead and perform a laryngotracheoplasty under the age of two. In such young age groups, is there anything else in your practice before-- Then we'll talk about indications for trach or what your threshold is for a tracheostomy, but in this under six months age group.

[Dr. Briac Thierry]
We have also performed laryngotracheoplasty for subglottic stenosis before six months. It's not very frequent, but yes.

(9) Tracheostomy: Conditions & Procedural Tips

[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, it 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.

[Dr. Gopi Shah]
Well, as we start to round it out and wrap things up, Briac, any final pearls or any other important points that you want to leave our listeners with?

(10) The Team Approach: Putting the Pieces Together

[Dr. Briac Thierry]
Yes, just to say that airway surgery, it could be challenging. It's not that easy because you have to develop multiple skills for the airway. You have to talk with the nurse, you have to talk with the anesthesiologist, you have to talk with the intensive care unit, you have to talk with plenty of people in the hospital, and you have to develop skills, which are surgical and non-surgical skills. It's very important. You have to be a team leader. You have to anticipate the difficulties, you have to keep calm. You have to communicate simply. Well, you have plenty of non-surgical skills that we are not, in Europe, prepared to have as a team leader. This is one of the things which was really important for me when I began the airway team that we have in Necker.

Also, there is something which has been very important for the development of the airway team, is that you have to take an interest in other people's work. You have to understand how they are working. You have to understand anesthesiology. You have to understand the challenges of the anesthesia and know what they expect from you during the DLB, for example. You have to understand this to better communicate and to make things quite right in the operating room.

[Dr. Gopi Shah]
That's a great point, Briac, especially, it is something that I feel like communication and team building, it's-- You're right. One, I don't think we emphasize on teaching it in our programs, and two, how to sort of attain that. A lot of it is all of a sudden you're out in practice and this is what's going to build it. You have to figure out how to make it all work and then what works, what doesn't, and how to put it all together for these complex babies. That's a great point. I wanted to tell you congratulations because you just finished your thesis. Can you tell us about your thesis? You just submitted it for your PhD. That's huge, congratulations.

[Dr. Briac Thierry]
Thank you very much. Yes, I've just finished it. I've just finished my manuscript and it is about tracheal replacement with a decellularized substitute. Well, I will have my defense in two months.

[Dr. Gopi Shah]
That's awesome. Well, congratulations. Then, Briac, remind me, you have a YouTube channel for some of your surgical videos. Can you tell our audience or our listeners if they ever want to watch your videos?

[Dr. Briac Thierry]
Yes. It is called voies aeriennes a Necker.

[Dr. Gopi Shah]
You're going to have to spell that.

[Dr. Briac Thierry]
I definitely know that there is also an English name for this. In the YouTube search engine, if you type Airway Necker, you will find the YouTube channel. I am especially proud of the little videos that we've made to explain the tracheostomy for the parents.

[Dr. Gopi Shah]
That's awesome.

[Dr. Briac Thierry]
To explain how to perform the suction, how to change the tracheostomy, how to take care of the stoma, how to perform the suction, how to change the tracheostomy. I think it's very important. We also have a quite good video on laryngomalacia.

[Dr. Gopi Shah]
That's awesome. For our listeners, check it out. It is Airway Necker On YouTube. Briac, thank you so much for stopping by. Thank you for sharing your experience and all your wisdom. I think it's a wrap. Abiento. Merci beaucoup.

[Dr. Briac Thierry]
Merci beaucoup, Gopi. It was a pleasure.

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.