Subglottic stenosis: Another challenge for intubation and potential mechanism of airway obstruction in Pierre Robin Sequence

Knapp, Kolin; Powitzky, Rosser; Digoy, Paul

doi:10.1016/j.ijporl.2011.05.012

Cited by 15 publications

(3 citation statements)

References 3 publications

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“…Based on the results of this study, to avoid these complications we would recommend the clinician consider a slightly longer endotracheal tube for patients with RS or substitution of a straight tube when possible. However, the risks of a larger tube diameter should also be weighed, including tracheal injury or subglottic ischemia, especially in the subset of patients with concomitant subglottic stenosis 26 . Unfortunately, the preformed tubes currently available may not optimally balance these risks in this patient population.…”

Section: Discussionmentioning

confidence: 99%

Longer upper airway lengths in Robin Sequence: A case‐control study using computed tomography

Perez

Hottinger

Evans

et al. 2020

Pediatric Anesthesia

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Background Direct laryngoscopy and intubation are often difficult in children with Robin Sequence. Previous research characterizing anatomic airway differences has focused on parameters influencing airway patency; there is a paucity of data pertaining to intubation trajectories and depth. Such information could impact airway management approaches and decrease the incidence of endotracheal tube malpositioning. Aim The study goal was to examine whether longitudinal airway parameters pertaining to intubation are different in children with Robin Sequence compared with age‐matched controls. Method This case‐control study compared patients with RS <4 years of age who had computed tomography scans of the head and neck to age‐ and sex‐matched controls. Measurements were made of the nasopharynx, oropharynx, hypopharynx, tongue, hyoid, and the front teeth to vocal cord, nares to vocal cord, and nasion‐basion distances. Statistical analysis was performed using multiple ANCOVA models with the categorical predictor of Robin Sequence vs control and potential covariates including subject height/length, weight, and age. Results Thirty‐three patients with Robin Sequence and 33 control subjects were included. After controlling for subject height/length, mean front teeth to vocal cord distance was 1.2 cm longer (95% CI: 0.9 to 1.6 cm, P < .001) and mean nares to vocal cord distance was 0.8 cm longer (95% CI: 0.4 to 1.2 cm, P < .001) in patients with Robin Sequence than in controls. The tongue was positioned on average 0.5 cm higher (95% CI: 0.3 to 0.8, P < .001) and 0.9 cm more posterior (95% CI: 0.6 to 1.0 cm, P < .001) in cases than in controls. Moreover, in patients with Robin Sequence, the hyoid was positioned on average 0.5 cm more inferiorly (95% CI: 0.2 to 0.8 cm, P < .001) and 0.2 cm more posteriorly (95% CI: 0.1 to 0.4 cm, P < .01) than controls. Conclusion In patients with Robin Sequence under 4 years of age, the mean front teeth to vocal cord distance was found to be 1.2 cm longer while the mean nares to vocal cord distance was found to be 0.8 cm longer controlling for subject length. Clinicians should account for these differences when selecting and placing endotracheal tubes, particularly those with a preformed bend.

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Section: Discussionmentioning

confidence: 99%

Longer upper airway lengths in Robin Sequence: A case‐control study using computed tomography

Perez

Hottinger

Evans

et al. 2020

Pediatric Anesthesia

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“…At our establishment, the pros versus cons of forward invasive attachment of tongue to lower lip and mandibular callus distraction were reviewed with the parents, and an interdisciplinary unit method was employed to reach the concluding invasive therapy method depending on the predicted span of breathing aid, unsuccessful conventional control, and the surgeon's analytical acumen. Tracheotomy [28] is still a benchmark for definitive air passage preservation and is the exclusive alternative for infants with related hindrance below the glottis [29] and partial hindrance of trachea during increased airflow. [30]…”

Section: Decision-making In the Treatment Of Prsmentioning

confidence: 99%

Pierre Robin syndrome: A case report and review of literature and multidisciplinary approach in management updates

Sharma¹,

Guru²,

Malviya³

2018

ijmdcr

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Pierre Robin sequence (PRS) is historically defined as a triad of small jaw, tongue retraction, and air passage hindrance, wherein infants often exhibit an immature mandible and respiration difficulties at birth. The small mandible drives the tongue backward, leading to PRS. In general, a cleft palate which is broad and U shaped is additionally related with this anomaly. PRS is not a syndrome alone, though instead various disorders, with single anomaly leading to another. Nevertheless, it is related to many other craniofacial abnormalities and may emerge together with a syndromic diagnosis, such as velocardiofacial and Stickler syndromes. PRS affected infants should be assessed by interdisciplinary unit to evaluate the skeletal findings, tracing the air passage hindrance origin, and address air passage and nourishment issues. Alignment resolves the air passage hindrance in 70% of cases, and most children are able to feed normally in the correct position. A nasopharyngeal tube placement is necessitated in case of baby persist with low oxygen blood concentration symptoms. Initial nutrition through a nasogastric tube may further lessen the proportion of energy required, facilitating early body mass. A fraction of PRS infants is unaffected by conservative measures and needs further medical mediation. The clinician should first exclude any sources of hindrance before opt for any surgical procedure, below the tongue base that would need a tracheotomy. The two generally accepted treatment procedures, surgical forward attachment of tongue to the lower lip and callus distraction of the mandible are explained.

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“…Although laryngomalacia will frequently be evident on nasopharyngoscopy, infants with moderate-severe OSA or respiratory distress should also subsequently undergo direct laryngoscopy under anesthesia to identify comorbid airway lesions. Nasopharyngoscopy and direct laryngoscopy should also be considered in infants with PRS to evaluate for nasal anomalies and subglottic stenosis (122).…”

Section: Diagnosismentioning

confidence: 99%

Obstructive Sleep Apnea in Infants

Katz

Mitchell

D’Ambrosio

2012

Am J Respir Crit Care Med

219

224

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Obstructive sleep apnea in infants has a distinctive pathophysiology, natural history, and treatment compared with that of older children and adults. Infants have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities; including a superiorly placed larynx, increased chest wall compliance, ventilation-perfusion mismatching, and ventilatory control instability. Congenital abnormalities of the airway, such as laryngomalacia, hemangiomas, pyriform aperture stenosis, choanal atresia, and laryngeal webs, may also have adverse effects on airway patency. Additional exacerbating factors predisposing infants toward airway collapse include neck flexion, airway secretions, gastroesophageal reflux, and sleep deprivation. Obstructive sleep apnea in infants has been associated with failure to thrive, behavioral deficits, and sudden infant death. The proper interpretation of infant polysomnography requires an understanding of normative data related to gestation and postconceptual age for apnea, arousal, and oxygenation. Direct visualization of the upper airway is an important diagnostic modality in infants with obstructive apnea. Treatment options for infant obstructive sleep apnea are predicated on the underlying etiology, including supraglottoplasty for severe laryngomalacia, mandibular distraction for micrognathia, tonsillectomy and/or adenoidectomy, choanal atresia repair, and/or treatment of gastroesophageal reflux.Keywords: sleep-disordered breathing; adenotonsillar hypertrophy; craniofacial; micrognathia; laryngomalacia Infants experience a wide range of sleep-disordered breathing patterns, including periodic breathing (1), apnea of prematurity (2), and central apnea, but little attention has been given to obstructive sleep apnea (OSA). Infants are particularly vulnerable to obstructive sleep-disordered breathing related to their upper airway structure (3), adverse pulmonary mechanics (4), ventilatory control (5), arousal threshold (6), laryngeal chemoreflex (7), and an REM-predominant sleep state distribution (8). The anatomical and physiological predispositions toward airway obstruction in infants are summarized in Table 1. Airway collapse may occur passively related to the balance between the viscoelastic properties of the pharynx, pharyngeal dilators, and the transmural pressure. Alternatively, obstructive apnea may result from active glottic closure, termed the laryngeal chemoreflex. The diagnosis of OSA in infants is confirmed by polysomnography and the etiology is often determined via direct endoscopic visualization of the airway. Infants with severe OSA will often have marked hypoxemia or sleep fragmentation, which is likely to result in considerable morbidity. As such, successful therapy is mandatory, even if this requires invasive treatment including nasopharyngeal tubes, continuous positive airway pressure (CPAP), supraglottoplasty, or even tracheostomy. This review focuses on the clinical features, polysomnographic patterns, pathogenesis, diagnosis, and mana...

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Subglottic stenosis: Another challenge for intubation and potential mechanism of airway obstruction in Pierre Robin Sequence

Cited by 15 publications

References 3 publications

Longer upper airway lengths in Robin Sequence: A case‐control study using computed tomography

Longer upper airway lengths in Robin Sequence: A case‐control study using computed tomography

Pierre Robin syndrome: A case report and review of literature and multidisciplinary approach in management updates

Obstructive Sleep Apnea in Infants

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