Neonatal Stridor: Short Notes

Neonatal Stridor

Stridor is a harsh, raspy breath sounds heard during breathing that may indicate an upper airway obstruction. It may occur during inspiration, expiration or may be biphasic depending on the location of the obstruction.

Anatomic and Physiologic Considerations

-       Smaller caliber of airway

-       Higher position and longer epiglottis

-       Lower total lung capacity

-       Increased functional residual capacity dependant on:

o   Increased respiratory rate

o   Active glottic narrowing during expiration

o   Use of expiratory muslces for respiration

Assessment

Babies with stridor should be assessed further for any evidence of respiratory distress:

-       Cyanosis

-       Chest retraction

-       Tachypnea

-       Grunting

-       Nasal flaring

Some may present with difficulty in feeding, recurrent choking or cough.

Investigations:

-       Flexible direct laryngoscopy

-       Rigid direct laryngoscopy

Differential Diagnosis

Supraglottic

-       Laryngomalacia (Commonest cause)

Omega shaped epiglottis

Glottic

-       Vocal cord paralysis (Second commonest cause)

-       Laryngeal web

Subglottic

-       Subglottic stenosis

-       Subglottic hemangioma

-       Tracheomalacia

-       Trachea stenosis with complete tracheal ring

-       Pulmonary vascular ring

 Some websites for demonstrations and information:

http://www.youtube.com/watch?v=-4OhWQ8Ppko 

http://www.youtube.com/watch?v=TCaDseFmG8M

http://www.voiceproblem.org/disorders/pediatricdisorders/understanding.php

http://www.netsvic.org.au/nets/handbook/index.cfm?doc_id=912

URTI: Latest Recommendations - Nothing!

The Common Cold

The scourge of every kid and parents! Which moms wouldn't bring their kid to the nearest clinic asking for antibiotics and vitamin C?

However, evidence based reviews suggest 'wait and see' for most of these problems.

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Most URTIs are self limiting.

Persistent symptoms more than 14 days should raise suspicions of other possible diagnosis.

Latest reviews suggest supportive measures in treatment of the common cold.

• Adequate hydration
• Warm fluids (ie. hot soup, tea)
• Honey
• Saline nasal spray or irrigation
• COLD humidifier (not warm)

The above measures have no strong evidence but is safe and inexpensive for use.

Does not recommend:

• Over-the-counter cough and cold medications in children < 6 yo
• Using antibiotics in ABSENCE of secondary bacterial infections
• Antihistamines, ipratropium, decongestants in nasal congestion. Side-effects may bring more harm that benefits
• Antitussives, mucolytics or expectorants in treatment of coughs as there is no proven benefits and may cause adverse effects. WHO however recommend us of dextrometrophan in cases of severe symptoms but diagnosis needs to be reviewed and revised.
• Bronchodilators in non-asthmatic patients.
• Topical rubs containing aromatics for nasal obstruction
• Zinc and vitamin C

Symptomatic treatment initiated only even it is bothering the child or family members (ie. difficulty sleeping)

• Fever - in children > 3 mo, treated with acetaminophen or ibuprofen
• Nasal Congestion - as mentioned above.
• Cough - Ingestion of warm fluids or honey.

Prevention

• Education on hand hygiene and non-contact of affected individual.
• No immunization to prevent common cold.
• Zinc, vitamin C are not proven to prevent the common cold.

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There you have it, URTI treatment in a nutshell.

In our community I doubt parents would buy that. Perhaps placebo should do the trick?

Reference:

Pappas, D. E., et al., The Common Cold in Children, Treatment and Prevention, UpToDate Article, 2013.


Some Doses of Commonly used drugs:

Paracetamol - 15 mg/kg (max 4 g/day) oral
Dextromethorphan - 0.2 - 0.4 mg/kg 6 - 8 hourly oral
Bromhexine - 0.3 mg/kg tds oral 7 days
Actifed (Triprolidine HCl 1.25 mg, pseudoephedrine Hcl 30 mg) - > 12yo 10mL, 6 - 12 yo 5 mL, < 6yo 2.5 mL tds oral (syrup).
Benadryl (diphenhydramine Hcl 12.5mg, ammon Cl 125 mg) - > 1 yo 1/2 - 1 tsp 4 hourly (Max 6 tsp/24 hours)
Clarinase (Loratidine 5 mg, pseudoephedrine 60 mg) - > 30 kg 5 mL, < 30 kg 2.5 mL bd syrup.

Sistrunk Procedure

Walter Ellis Sistrunk described the surgery for the excision of the thyroglossal duct cyst (TGDC) in 1920.

The principle of the surgery is to remove the cyst along with its tract and the tissues surrounding it including part of the hyoid bone to reduce rate of recurrence of the cyst.

The embryological pathway for the descent of the thyroid gland starting from the foramen caecum, crossing the hyoid bone.

The patient is placed in supine position. A transverse cervical incision is made along the hyoid bone. The cyst and tract is mobilized. A portion of the hyoid bone, about 1 cm each side form the midline is excised after releasing the hyoglossus and mylohyoid muscles. Tissues surrounding the ducts are excised up to the foramen caecum of the tongue. No attempts are made at separating the ducts from the tissue as Sistrunk noted  that the duct are friable and easily broken. The defects are then approximated including the cut hyoid bones.

Cyst with parts of the ducts proximal to it.

On the right is the excised TGDC with a part of the excised hyoid bone and proximal tissues on the left.

Recurrence is about 10% after surgery. Wider excision is recommended for a recurrent cyst. Infected cysts are best drained or treated with antibiotics before proceding with surgery.


References:

1. Sistrunk, W. E., The Surgical Treatment of Cyst of the Thyroglossal Tract, Reprinted from Ann Surg 1920.

2. Coran, Arnold G., et al., Pediatric Surgery, 7th Ed., Elsevier

3. Pictures from various sites as linked.

Other Topics:

- Neck masses in children
- Embryology of the brachial arches