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Full text of "Diseases Of The Nose Throat And Ear"

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Congenital Stridor                                                                                       *4^» *

Two misconceptions exist in the management of this condition. First, because
so many cases turn out to be laryngomalacia it is tempting not to do a
laryngoscopy on children who have inspiratory stridor which is worse on
crying and whose cry is normal. Secondly, there is occasionally the temptation
to 'wait until the child is old enough to have an anaesthetic'. It is essential to
remember that stridor means that there is an obstruction to the airflow in and
out of the lower respiratory tract. Every case of stridor should have a direct
laryngoscopy performed. In the hands of a skilled anaesthetist the procedure
carries very little risk—certainly much less risk than that taken by choosing to
remain in ignorance as to the cause. Prior to giving the infant an anaesthetic it
is important to look for various things in the conscious state. First, the child
is examined when it is asleep because, in the resting phase, the true state of the
airway can be assessed. Infants with a unilateral vocal cord paralysis and
laryngomalacia rarely make any noise when asleep. In case of micrognathia,
tilting the chin forwards will stop the stridor. On waking, the child will tend to
cry, and on the inspiratory phase of the first cry a further assessment can be
made of the effect of effort on the stridor. The quality of the cry is all impor-
tant. Any dysphonia means that cord movement or form is .not normal and
this would make one think of web, paralysis, tumour or cyst. A normal cry
would suggest laryngomalacia, subglottic stenosis, a vascular anomaly or a
cleft. The cords should be examined in the conscious state so that movement
may be assessed. The infant's breathing during feeding should also be studied.
When all this has been done, a direct laryngoscopy under general anaesthetic
is done. Thereafter, the treatment is that of the specific cause.

Acquired Stridor

The same principles apply here. Every effort must be made to find a cause for
the stridor. In the apyrexial group the problem is simpler because the history
will give a good guide as to the cause. The most difficult case is the laryngismus
stridulus patient who can often pose a diagnostic problem.

The management of the pyrexial child with stridor is one of the most
testing problems in medical practice. In the primary care situation the difficulty
is increased. The croupy infant may just be an overweight child with a pliable
larynx and an upper respiratory tract infection. On the other hand, the infant
might have developed a subglottic laryngitis, an acute epiglottitis or an acute
laryngotracheobronchitis. If the symptoms do not resolve very quickly (in a
matter of hours) with warmth, humidity and antibiotics* the child should be
sent to hospital. Primary treatment there should consist of oxygen, humidifica-
tion, antibiotics and steroids. If the stridor persists in spite of this the question
of assisting the airway arises. This is discussed at length in Chapter 35 but in
summary here it can be repeated that a tracheostomy is a difficult operation,
not without complications, when carried out on a small child by anyone other
than an experienced operator. Every effort should be made to avoid this
procedure as an emergency because the complication rate will be high. When
it becomes apparent that airway assistance is required the first step should be to
intubate the child. If the condition does not resolve in the next 48-72 hours—
and failure to resolve is the exception rather than the rule—a tracheostomy