23. Peds Airway

Question 1

Difference between stertor, stridor, wheezing

inspiratory vs. expiratory, cause

Answer 1

Stertor: grunting/snorting due to blocked nose/nasopharynx or oropharynx

Stridor: high pitched grunt
Inspiratory when blockage is supraglottic
Biphasic when blockage is glottic/subglottic
Expiratory when tracheobronchial
(insp extrathoracic, exp in chest)

Wheezing: Expiratory, pulmonary

Question 2

Function of nose in neonates

Common areas of foreign body impaction

Sx of foreign body impaction for pts less than or older than 18 months old

Answer 2

Neonates are OBLIGATE nasal breathers

Common areas: inferior turbinate, middle turbinate, choana (back opening of nose to nasopharynx)

<18mo: obligate nasal breather = significant airway obstruction
>18mo: cause unilateral rhinorrhea, risk dislodging to larynx (then obstructs airway), or aspiration to trachea/esophagus

Question 3

What are the 2 nerves that innervate the larynx and what do they innervate?

What 5 ways protect the airway during swallowing?

Answer 3

Superior Laryngeal N. - sensory to larynx, motor to cricothyroid

Recurrent Laryngeal N. - motor to rest of larynx

1. Hyolarynx complex elevates sup and ant
2. Vocal cords adduct (close)
3. Pharynx contracts
4. Soft palate elevates to seal off nasopharynx
5. upper esophageal sphincter opens

Question 4

Laryngeal Pathology
Vocal Cord Paralysis v. Laryngomalacia v. Vallecular Cyst
(CP, management)

Answer 4

Vocal cord paralysis: one or both stay open, evaluate for CNS/brain damage (bilateral is rare due to injury to BOTH recurrent laryngeal nerves)

Laryngomalacia: omega-shape epiglottis, narrowed supraglottic opening, inspiratory stridor, dysphagia, FTT, GERD, apnea, variable sx severity
MOST COMMON CAUSE of stridor/airway obstruction in neonates
Tx: cut both ary-epiglottic folds to open airway

Vallecular Cyst: on back of tongue - pressure on voicebox - larynx compression, sleep apnea, feeding problems

Question 5

Subglottis:
Where is it?
What is the problem with airway edema here?
What are the two main etiologies of subglottic stenosis with examples?
What are the features and tx of subglottic hemangioma?

Answer 5

Below vocal folds - cricoid cartilage (only complete cartilage ring in airway - narrowest space)

Airway edema follows Poiseulle’s law - tiny decrease in radius = huge difference in airway obstruction (R^4)

Acquired (long-term intubation) vs. Congenital (Down Syndrome)

Subglottic hemangioma - 50% occur with cutaneous hemangioma, CP: biphasic stridor (4-6wks old), barky cough, hoarseness, recurrent croup, sx improve with steroids, but treated with propanolol

Question 6

Anatomy of trachea - what is the carina?

What are some congenital anomalies of the trachea? How is tracheomalacia treated?
What arteries (normal and abnormal) could compress the trachea?

Answer 6

Trachea: U-shaped cartilage rings connected to trachealis muscle
Carina: split point of bronchi, usually sharp

1. Complete tracheal ring
2. Tracheomalacia - malformed cartilage rings become easily compressible (tx: Slide Tracheoplasty - use trachea to make it wider but shorter)
3. Tracheoesophageal Fistula
4. Innominate Artery Compression - R. Brachiocephalic Artery or Double aortic arch could compress trachea