Safety and utility of direct laryngoscopy and bronchoscopy in patients hospitalized with croup.

Acute croup is a common admitting diagnosis for pediatric patients. If a patient is not responding to medical management for presumed croup, the otolaryngology team is occasionally consulted for direct laryngoscopy and bronchoscopy (DLB) to rule out tracheitis or another airway pathology. We conducted a study to determine if inpatient DLB in acute croup is safe and efficacious and to correlate preoperative vital signs with intraoperative findings. We reviewed the charts of 521 patients with an admitting diagnosis of acute tracheitis, acute laryngotracheitis, or croup. Of this group, 18 patients-11 boys and 7 girls, aged 1 month to 3.3 years (mean: 1.3 yr)-had undergone inpatient DLB. Comorbidities, complications, and level of care were also analyzed. Five patients (28%) had gastrointestinal reflux disease (GERD), and 4 had previously undergone intubation (22%). Eleven patients (61%) had concurrent airway pathology, 7 of whom (39%) required operative intervention. Preoperative mean body temperature and the increase in mean temperature were significantly higher in tracheitis patients than in the non-tracheitis patients. Preoperative change in respiratory rate was elevated when another airway pathology was present (p = 0.047). Only patients who were in the intensive care unit (ICU) preoperatively were intubated in the operating room, and only 1 patient required a postoperative escalation in the level of care. Our study found that performing inpatient DLB in patients hospitalized with croup is reasonably safe and provides a sufficient yield for identifying tracheitis or other airway pathology in selected populations. Preoperative vital signs can be suggestive of tracheitis or additional unexpected airway pathology. Recurrent croup, a history of GERD or previous intubation, and preoperative admission to the ICU increase the yield of DLB.

Recurrent croup and persistent laryngomalacia: Clinical resolution after supraglottoplasty.

OBJECTIVES: To determine if children with recurrent croup (RC) and persistent laryngomalacia (LM) clinically improve after supraglottoplasty (SGP). MATERIAL AND METHODS: Retrospective chart review cohort at tertiary care children's hospital consisting of patients diagnosed with LM and RC that underwent SGP from July 2011 to August 2014. Clinical history, demographics, clinical outcomes, and operative complications were reviewed. Specifically, the episodes of croup requiring systemic steroids were compared pre- and post-SGP with statistical analysis. RESULTS: Out of 107 patients undergoing SGP for LM, 6 patients (5.6%) were diagnosed with RC. Mean age at first croup episode was 11.5 months. Mean age at SGP was 4.3 years. Mean number of emergency department visits was 3.2 (range 2-6 visits) prior to SGP. Mean number of episodes of croup requiring systemic steroids before and after SGP was 9.8 vs. 0.2 (p=0.003). Mean length of followup after SGP was 30.5 months (range 18-46 months). There were no surgical postoperative complications. CONCLUSIONS: This is the first series to describe the clinical resolution of croup episodes in children with LM corrected by SGP. Recurrent croup should be added among other conditions associated with late-onset or persistent laryngomalacia.

The role of larygotracheal reconstruction in the management of recurrent croup in patients with subglottic stenosis.

OBJECTIVES: To determine the role of laryngotracheal reconstruction for recurrent croup and evaluate surgical outcomes in this cohort of patients. METHODS: Retrospective chart review at a tertiary care pediatric hospital. RESULTS: Six patients who underwent laryngotracheal reconstruction (LTR) for recurrent croup with underlying subglottic stenosis were identified through a search of our IRB-approved airway database. At the time of diagnostic bronchoscopy, all 6 patients had grade 2 subglottic stenosis. All patients were treated for reflux and underwent esophageal biopsies at the time of diagnostic bronchoscopy; 1 patient had eosinophilic esophagitis which was treated. All patients had a history of at least 3 episodes of croup in a 1 year period requiring multiple hospital admissions. Average age at the time of LTR was 39 months (range 13-69); 5 patients underwent anterior graft only and 1 patient underwent anterior and posterior grafts. Patients were intubated for an average of 5 (range 3-8) days and hospitalized for an average of 12 (range 7-20) days post-operatively. One patient experienced narcotic withdrawal post-operatively, but there were no other post-operative complications. All patients underwent follow-up airway endoscopy within 4 weeks and none required any further dilation procedures. Average post-operative follow-up was 24 months (range 10-48) and none of the patients experienced any further episodes of croup. CONCLUSIONS: Single stage LTR is a safe and effective treatment for recurrent croup in the setting of underlying subglottic stenosis, and should be considered in patients who are refractory to medical management.

Role of direct laryngoscopy and bronchoscopy in recurrent croup.

OBJECTIVE: To determine risk factors in children with recurrent croup that predict moderate/severe findings on direct laryngoscopy and bronchoscopy and need for further operative interventions. STUDY DESIGN: Retrospective chart review cohort. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Retrospective chart review of 103 patients diagnosed with recurrent croup who underwent diagnostic laryngoscopy and bronchoscopy from January 2004 to August 2013. Statistical analysis determined risk factors significantly associated with moderate/severe operative findings. A probability tree was formulated. RESULTS: Of 103 patients, 30.1% had history of intubation, 6.8% had a history of subglottic stenosis, 6.8% had a history of previous airway procedure, 11.7% consultations were inpatient, 64.1% had asthma, 47.6% had seasonal allergies, 60.2% had gastroesophageal reflux disease, 15.5% were aged ≤ 12 months, and 51.5% were ≤ 36 months. Statistically significant risk factors in predicting moderately/severely abnormal operative findings included consultation location (P = .010), history of intubation (P = .003), age younger than 36 months (P = .013), and seasonal allergies (P = .035). When using location of consultation, history of intubation, and age in a statistical model, diagnostic accuracy equaled 93.5%. Of children without history of intubation but who underwent inpatient otolaryngology consultation, 28.6% had moderate/severe findings. Likewise, 41.2% of children with a history of intubation who were younger than 36 months of age had moderate/severe findings. CONCLUSION: Moderate to severe operative findings are encountered in only 8.7% of children with recurrent croup. Using statistical modeling, 2 high-risk groups are (1) patients without a history of intubation but inpatient consultation and (2) patients with a history of intubation and age younger than 36 months.

[Armand Trousseau, laryngologist]. / Armand Trousseau laryngologiste.

Trousseau's contribution to laryngology was considerable, but it was eclipsed by his reputation in other fields. His work in the field was not limited to the diffusion of tracheotomy for the treatment of croup, despite opposition from certain surgeons. He totally transformed the intervention, which up until then had been undertaken without any specific methodology, into a controlled procedure with principles that still apply today. He undertook the study of chronic diseases of the larynx and wrote the first work dedicated to this pathology, before the arrival of laryngoscopy. He reported the first recorded and illustrated case of laryngeal cancer for which he himself performed a tracheotomy. Laryngeal pathology was an important centre of interest throughout his career. With the arrival of laryngoscopy at the end of his professional life, Armand Trousseau had left a lifetime's work that facilitated the expansion of the new generation of laryngology. He could be considered as the first medico-surgical laryngologist, mastering both an in-depth knowledge of the organ, its medicine, and surgery, which at that time was limited to tracheotomy.

Tracheostomy in human immuno-deficiency virus infected children at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa.

UNLABELLED: Tracheostomy in adults with HIV/AIDS has been reported to be associated with both high and early mortality of 47-100%. There is minimal data regarding the role of tracheostomy in HIV infected children. We did a retrospective analysis of HIV positive children that underwent tracheostomy at our institution over a 5-year period, 2002-2006. A total of 70 tracheostomies were done during the period and 15 (21.4%) of these children were confirmed as HIV infected. The average age at presentation for HIV infected children with upper airway obstruction resulting eventually in tracheostomy was 9.4 months and 60% were under 1 year of age. Only three (20%) were on Anti-Retroviral Therapy (ART) prior to presentation. The cause of upper airway obstruction was croup in 14 (93%) of these 15 children. Following tracheostomy all were treated with ART. To date six children have been successfully decannulated (40%) and there have been three deaths (20%) which were unrelated to tracheostomy. CONCLUSION: Tracheostomy in HIV positive children is not associated with the high mortality that has been reported in adults provided such children are started on treatment with antiretroviral therapy.

Revisión de los pacientes pediátricos sometidos a troqueotomía en Aragón, La Rioja y Soria. Periodo 1988-2000 / Review of pediatric patients subjected to trachetomy in Aragon, La Rioja and Soria, Spain, between 1988 and 2000

Introducción y objetivo. El avance en los conocimientos y la tecnología médica, así como la ampliación de criterios éticos para mejorar la calidad de vida de pacientes con enfermedad crónica, genera nuevas exigencias en su tratamiento, entre ellas, la mejoría de la función respiratoria. La revisión de los pacientes pediátricos sometidos a traqueotomía en los últimos años contribuirá a conocer la situación actual y a establecer una referencia, comparativa en el futuro. Pacientes y métodos: Se revisan, desde una perspectiva diagnóstica, los pacientes pediátricos de Aragón, La Rioja y Soria, sometidos a traqueotomía entre enero de 1988 y diciembre de 2000.Resultados: Se ha realizado traqueotomía a 17 pacientes. De urgencia en 5 casos: dos por laringotraqueítis aguda, dos por síndrome de Down (uno con neumopatía crónica y otro con cardiopatía congénita. intervenida) y uno por distrofia muscular deficiente en merosina. Programada en 12 casos: un síndrome de Pierre Robin, dos niños con afectación prenatal de pares craneales, una encefalopatía prenatal grave, una encefalopatía por casi ahogamiento, una anomalía de la charnela craneocervical con alteración de la unión bulbomedular, una lesión medular traumática C1-C2, un linfangioma quístico cervicomediastínico, una enfermedad metabólica no catalogada con leucodistrofia y polineuropatía neuroaxonal, una encefalopatía mitocondrial grave, una forma infantil grave de miopatía mitocondrial y una malformación de Chiari tipo II. Comentarios: Destaca la importancia de la enfermedad neurológica en cualquier zona del sistema nervioso central y de la unidad neuromuscular, como causa para realización de una traqueotomía (AU)

Adult croup--a case report.

A case of a female adult patient with croup is described. Inflammation, as well as pseudomembranes, restricting the patency of trachea, developed within several hours after the first symptoms of infection were observed. Tracheostomy was performed Bronchofiberoscopies were repeated on a regular basis several times a day over a period of two weeks, with the removal of fibrinous casts and dense secretion being the only way to save the patient's life.

Tracheostomy in the management of laryngotracheobronchitis. Red Cross War Memorial Children's Hospital experience, 1980-1985.

In the 6-year period 1980-1985 162 children required tracheostomy during treatment of laryngotracheobronchitis at Red Cross War Memorial Children's Hospital, Cape Town. This represents 4.6% of 3,500 children with this disorder and 28% of those requiring airway intervention. Fifty-eight percent of the children were decannulated within 4 weeks and 75% within 10 weeks. Fifty-four per cent of the children required one or more further procedures before decannulation, including 7 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 24 children and suprastomal collapse was a cause of decannulation failure in 29 children. Use of an expiratory valve as an aid to decannulation is discussed. Three children died of tracheostomy airway complications and 6 of a medical disorder. Another complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration.

Obstructive airway disease in infants and children.

Airway obstruction in infants and children can produce rapidly progressive life-threatening emergencies. An understanding of the common symptom complexes associated with regional obstructive abnormalities allows rapid evaluation and appropriate therapy. This article discusses the most common types of obstructive congenital and acquired airway anomalies, describes their symptomatology, and reviews the available diagnostic and treatment options.

[Experiences in the treatment of children with pseudocroup (author's transl)]. / Erfahrungen in der Behandlung von Kindern mit Pseudocroup.

In most of the own 93 cases the paediatrician could manage the syndrome conservatively. In 14 children of them the question of an active procedure was discussed in cooperation of paediatricians, laryngologists and anaesthesiologists. In most of the cases this was necessary in the first 2 to 3 hours after admission. Recommendations for the active procedure are given in detail, generally spoken a balanced manner with confined prolonged orotracheal intubation.

Airway intervention in croup and epiglottitis: the changing role of the otolaryngologist.

Recent evidence indicates that endotracheal intubation is supplanting tracheostomy for the short-term treatment of airway obstruction in epiglottitis and croup. Care should be provided by a triumvirate of physicians to include and otolaryngologist, a pediatrician, and an anesthesiologist. Intensive care facilities are also a prerequisite. Standard tracheostomy should be considered in cases requiring intubation longer than 72 hours.

Nasotracheal intubation in acute laryngotracheobronchitis.

The case histories of 150 children admitted to hospital with acute laryngotracheobronchitis (LTB) are reviewed. Relief of severe upper airway obstruction was achieved by nasotracheal intubation in 27 children (18%). There was no mortality in this series. Nasotracheal intubation is therefore a safe and effective means of treating severe LTB. In addition, the importance of meticulous nursing care is stressed.