Causes of stenosis of the larynx in children and methods of treatment. Laryngeal stenosis syndrome: first aid and an algorithm of actions if an attack occurs in children Laryngeal stenosis in children hospital treatment

In childhood, the body is exposed to multiple attacks of viruses and bacteria. Some infectious diseases do not pose a serious danger to the baby, while others can cause serious complications. Therefore, parents need to be especially vigilant. If the child began to choke, and his skin turned bluish, then you should seek medical help as soon as possible, because these symptoms may indicate stenosis of the larynx.

What is stenosis of the larynx

Stenosis, or narrowing, of the larynx is called a partial or almost complete decrease in its lumen, resulting in a decrease in the rate of air entry into the lungs, bronchi and trachea.

Stenosis of the larynx is a partial or complete narrowing of the larynx.

In the specialized literature there are different names for this pathology. The most popular of them are:

• false croup;
• stenosing;
• acute airway obstruction.

Most often, such a serious condition is observed in children under 3 years of age due to the following age-related features of the structure of the larynx:

1. In a small child, a large number of sensitive receptors are concentrated in this area, which sometimes leads to laryngospasms.
2. The shape of the larynx in adults resembles a cylinder, in babies it resembles a funnel.
3. In the area of ​​the anatomical narrowing of the larynx, many mucous glands are localized, which often become inflamed.
4. In the zone of the vocal cords there is a thin layer of epithelium, which is prone to damage.
5. The tissue in the region of the ligamentous space is loose, permeated with blood vessels, which is why acute respiratory viral infections and colds quickly cause swelling of the larynx and upper trachea.

Laryngeal stenosis is a disease of infants and preschoolers. When a child is 6-7 years old, the likelihood of a false croup is significantly reduced due to the improved functioning of the respiratory system.

Disease classification

For the convenience of diagnosis and treatment, otolaryngologists have developed a classification of laryngeal stenosis. The typology is based on several important indicators.

1. According to the time of development of the disease, stenosis occurs:
   • acute - the most common and dangerous type of pathology. It develops so quickly that the body simply does not have time to adapt to oxygen deficiency, which can lead to death;
   • chronic - the narrowing of the larynx occurs gradually, over several months, due to which the body has time to adapt to a reduced amount of incoming air.
2. Depending on the provoking factor, stenoses are divided into the following forms:
   • paralytic - narrowing occurs due to muscle paralysis and impaired conduction of nerve impulses, for example, when squeezing the nerves supplying the larynx;
   • cicatricial - characterized by the appearance of scars on the larynx, as a result of which the organ cavity is significantly narrowed. This type of stenosis is divided, in turn, into:
     • post-traumatic, in which scars appear due to injuries, surgery, wounds;
     • post-intubation, resulting from prolonged intubation - artificial ventilation of the lungs, carried out using a special tube inserted into the larynx;
     • post-infectious, developing due to an infectious and inflammatory disease (, middle ear).
   • tumor - appear due to a tumor process localized in the larynx.
3. According to localization and prevalence, stenosis is distinguished:
   • glottis (space in the middle part of the larynx between the two vocal folds);
   • subvocal space (the lower part of the laryngeal cavity, located between the glottis and the beginning of the trachea);
   • extended (extends to the trachea);
   • anterior (a decrease in the lumen is characteristic of the anterior wall of the larynx);
   • posterior (located on the back wall);
   • circular (narrowing appears due to circular compression of a certain part of the larynx);
   • total (all parts of the larynx are involved).

Causes of pathology

In babies, the diameter of the larynx is very small, so any provoking factor can lead to its narrowing. Causes of stenosis include:

• inflammatory processes that are formed on the basis of primary diseases (erysipelas, phlegmonous laryngitis, inflammation of the perichondrium and cartilage of the larynx);
• multiple infections of bacterial or viral origin, which include scarlet fever, measles, diphtheria, typhoid fever, parainfluenza, tuberculosis;
• congenital pathologies of the larynx (children born with genetic disorders are at risk);
• allergic reactions that contribute to the development of edema;
• injuries of the larynx, which include the ingress of a foreign body, surgical procedures, thermal or chemical burns;
• tumors localized in the esophagus, throat and larynx (thyroid cancer, goiter);
• impaired innervation (connection of the central nervous system with tissues and organs through nerves) caused by paralysis and pathological changes in the muscles of the larynx, laryngospasms.

It should be emphasized that in the vast majority of cases (about 98%) laryngeal stenosis in children is a response to inflammatory and infectious diseases. Other provoking factors are much less common.

Symptoms and stages

The severity of the external signs of the disease largely depends on the age of the child, the severity of the underlying disease, and the degree of narrowing of the respiratory tube. Otolaryngologists determine 4 stages of stenosis, which successively (sometimes very quickly) replace each other in the absence of qualified medical assistance.

A child, especially a small one, is not able to explain what is happening to him, or his voice disappears altogether. The main symptom of the disease is impaired breathing. If the baby is breathing often, he has shortness of breath, you should immediately call an ambulance and start first aid.

Signs of stenosis of the larynx in a child - table

Diagnostics

In the acute form of pathology, there is usually no time left for research. Doctors establish a diagnosis based on a survey of parents, an external examination of a small patient, palpation (palpation) of the throat.

After eliminating the threat to the life of the child in a hospital, an examination is carried out to identify the cause of stenosis of the larynx. The main diagnostic measures are:

• laryngoscopy (visual examination of the larynx) - in order to determine the degree of narrowing of the respiratory tube, the presence or absence of a tumor in the larynx;
• fibrolaryngoscopy - a method of examining the larynx with a flexible endoscope with a video camera (allows you to display the resulting image directly on the computer screen);
• chest x-ray - to exclude heart disease, one of the symptoms of which is shortness of breath;
• radiological methods of study (MRI, computed tomography) - in case of difficulties in making an accurate diagnosis;
• the study of smears from the pharynx - to determine the nature (viral or bacterial) of an infectious disease;
• Ultrasound of the thyroid gland.

Differential diagnosis allows you to exclude breathing problems due to bronchial asthma, foreign body in the throat, traumatic brain injury, heart disease, tumor formations in the throat and larynx.

First aid

At the first symptoms of a dangerous condition, it is necessary to provide the child with emergency care. You should also call a team of doctors, even if the attack has passed on its own. Before the ambulance arrives, parents need to:

• take the child in your arms so that he calms down. Often, after the crying stops, breathing is restored;
• provide an influx of fresh air by opening the window, freeing the baby from clothes that restrict breathing;
• humidify the room in which the patient is located as much as possible;
  

  If you don't have a humidifier, you can hang wet sheets and towels around the room.

• make a hot foot bath, massage children's feet to ensure the outflow of blood from the inflamed larynx to the lower limbs.

Then you should move on to therapeutic measures. If the child has a high temperature, you will need an antipyretic. If an allergic origin of stenosis is suspected, it is necessary to give the baby an age dose of any suitable antihistamine medication:

• Fenistil;
• Zyrtec;
• Zodak;
• Suprastin.

To relieve swelling, inhalation procedures are carried out with mineral water or soda solution. They are shown even to newborn babies. If there is no special apparatus, the child can breathe over a bath of hot water. The ideal option is inhalation with a nebulizer. They are made with such means as:

• saline solution 0.9% (to moisturize the mucosa);
• Pulmicort (for shortness of breath);
• Berodual (to prevent spasms).

Moms and dads, whose children often get colds, allergic diseases, or have suffered laryngeal injuries, need to keep a nebulizer, antihistamine and antispasmodic medicines at home. Such forethought will help to immediately begin to provide assistance in case of an attack of stenosis of the larynx.

Treatment of the disease in a hospital

The decision on hospitalization is made by the doctor, guided by the severity of the symptoms, the general condition of the child. At the first stage of stenosis, treatment at home is acceptable after a set of diagnostic measures. In this case, the therapy of the underlying disease continues. The pediatrician prescribes anti-inflammatory, antipyretic drugs, a course of antihistamines and antibacterial drugs.

Subcompensatory stage of narrowing of the larynx is treated only in stationary conditions. Treatment of the underlying disease is shown, as well as:

1. Inhalation measures using pure oxygen (with an interval of 8 hours).
2. Intramuscular or intravenous administration of sedative medications prescribed by a doctor (Droperidol, etc.).
3. The use of glucocorticosteroids (for example, Prednisolone) for several days with a gradual dose reduction.

If these procedures did not bring relief, and the child's condition only worsens, we can conclude that the stenosis has passed into the stage of decompensation. In this case, emergency methods are used: tracheal intubation or tracheostomy.

A tracheostomy involves cutting the front wall of the trachea and inserting a tube into it, which will ensure the flow of air into the lungs. We hasten to reassure parents, this method is used only in extreme cases.

In the chronic form of stenosis, surgical intervention is also used, which consists in removing scars and tumors from the laryngeal cavity. Recently, laser endoscopic surgery has been used in the treatment of children.

Children with end-stage laryngeal narrowing usually go straight to the intensive care unit. First of all, doctors carry out pulmonary-cardiac resuscitation, as well as prevent or relieve cerebral edema.

Komarovsky on the treatment of false croup - video

Treatment prognosis

Subject to a timely visit to the doctor, the prognosis is usually favorable - children quickly recover. However, parents should take care to prevent subsequent attacks of laryngeal stenosis.

In the case of a chronic form of the disease, the child's body does not receive the necessary amount of oxygen, which is fraught with disturbances in the work of the central nervous system, the cardiovascular system. Unrecognized in time stenoses cause such respiratory diseases as:

• acute stenosing laryngotracheitis;
• chronic bronchitis;
• frequent inflammation of the lungs;
• bronchiectasis (irreversible expansion of individual sections of the bronchi).

In addition, the predisposition to stenosis often leads to the fact that every respiratory infection or even a common cold causes an acute narrowing of the larynx.

Prevention

The most effective method of preventing this dangerous condition is the prevention of viral and colds. For this purpose it is necessary:

• strengthen the child's body;
• protect the baby from contact with sick people;
• conduct timely therapy of the initial signs of a cold.

A properly formulated diet of the child will also help prevent seizures. The menu should include natural yoghurts, dairy products, cereals, meat and fish, fresh vegetables and fruits. In this case, allergenic foods, food additives and various preservatives should be excluded.

If attacks of stenosis recur, it is necessary to consult an allergist and an immunologist. Experts will tell you how to reduce the likelihood of relapse in each case.

Stenosis of the larynx in a child is a serious pathology that poses a danger to children's health. Therefore, when the first symptoms of the disease appear, it is necessary to call an ambulance. The prognosis of treatment largely depends on the provoking factor, the stage of the disease, the individual characteristics of the baby, but the sooner qualified assistance is provided, the lower the risk of complications. Be healthy!

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Stenosis of larynx (J38.6)

Otorhinolaryngology for children, Pediatrics, Surgery for children

general information

Short description

Approved by the Expert Commission

For Health Development

Ministry of Health of the Republic of Kazakhstan

Stenosis of the larynx- this is a pathological process associated with a significant decrease or complete closure of its lumen, leading to difficulty in the passage of air during breathing and impaired voice formation that occurs over a quick or long time.

I. Introduction

Protocol name: Stenosis of the larynx in children
Protocol code:

ICD-10 code(s):

J38.6. Stenosis of the larynx

Abbreviations used in the protocol:

BP - blood pressure

AST - aspartate aminotrasferase

ALT - alanine aminotransferase

HIV - human immunodeficiency virus

IVL - artificial lung ventilation

IT - intensive care

ELISA - enzyme immunoassay

CT - computed tomography

MRI - magnetic nuclear tomography

KLA - complete blood count

OAM - general urinalysis

SARS - acute respiratory viral infection

Ultrasound - ultrasonography

ECG - electrocardiography

I/G - worm eggs

Protocol development date: year 2014.

Protocol Users: general practitioners, pediatricians, infectious disease specialists, pediatric otorhinolaryngologists of polyclinics and hospitals.

Classification

Clinical classification.

By etiology:

Congenital

Acquired

With the flow:

. Acute

A) with false croup;

B) with acute laryngotracheobronchitis;

C) phlegmonous laryngitis;

D) foreign body of the larynx;

D) in case of injury;

E) allergic edema of the larynx;

. Chronic

A) cicatricial changes after injuries;

B) post-intubation;

C) with chondroperichondritis;

D) with scleroma, diphtheria, syphilis;

D) with tumors of the larynx;

According to the degree of stenosis of the larynx

I degree - compensation (participation in the act of breathing of the wings of the nose, auxiliary muscles, deep breathing, not less than usual);

II degree - subcompensation (breathing speeded up, the child is restless, pale, cyanosis of the nail phalanges);

III degree - decompensation (intermittent breathing, retraction of the intercostal spaces, supraclavicular and subclavian fossae, sallow complexion, cold sweat, cyanosis of the nasolabial triangle);

IV degree - asphyxia (disorder of cardiovascular activity, drop in blood pressure, respiratory arrest).

Classification of chronic stenosis according to the degree of prevalence

Limited cicatricial stenosis - a process within one anatomical region with a length of up to 10 mm;

Widespread - a process that covers more than one anatomical region of the larynx and extends more than 10 mm.

Classification of chronic stenosis according to the degree of narrowing of the lumen

I degree - up to 50% obstruction;

II degree - 51-70% obstruction;

III degree - 71% - 99% obstruction;

IV degree - no clearance.

Classification of chronic stenoses by anatomical localization

Anterior commissural synechia;

Synechia of the posterior section;

Scar-granulation visor along the upper edge of the tracheostomy;

Complete or almost complete occlusion of the lumen;

Ring-shaped cicatricial narrowing.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

The main diagnostic examinations carried out at the outpatient level:

pharyngoscopy;

Indirect laryngoscopy;

Palpation of the submandibular areas;

Thermometry.

Additional diagnostic examinations performed at the outpatient level:

Consultation of a pediatrician;

Consultation with an otorhinolaryngologist;

Allergist consultation;

Infectionist consultation.

The minimum list of examinations that must be carried out when referring to planned hospitalization:

UAC (6 parameters);

Biochemical blood test (total protein, bilirubin, AST, ALT, urea, creatinine);

ELISA for hepatitis B;

ELISA for hepatitis C;

ELISA for HIV;

Examination of feces for I / g;

Consultation of a pediatrician;

R-graphy of the chest organs (children under 3 years old);

Feces for pathological flora (children under 2 years old).

The main diagnostic examinations carried out at the hospital level:

Determination of blood group and Rh factor;

Determination of clotting time and bleeding time;

Direct laryngoscopy;

Fibrolaryngoscopy;

Fibrotracheoscopy;

Anesthesiologist consultation.

Additional diagnostic examinations carried out at the hospital level:

R-graphy of the chest organs;

CT scan of the larynx and chest;

neck MRI;

ultrasound of the head;

Tracheobronchoscopy;

Coagulogram;

Consultation with a cardiologist;

Consultation of a neurologist;

Hematologist consultation;

Oncologist consultation;

Optometrist's consultation;

Consultation with a pulmonologist;

Consultation of a thoracic surgeon;

Physiotherapist's consultation;

Consultation of a clinical pharmacologist.

Diagnostic measures taken at the stage of emergency care:

Measurement of blood pressure;

Determination of respiratory rate;

Pulse measurement;

pharyngoscopy;

Thermometry.

Diagnostic criteria

Complaints and anamnesis:

Complaints:

Labored breathing;

Aphonia;

regurgitation;

Dysphagia;

Cough;

Anamnesis:

Frequent SARS;

Long IVL;

neck injury;

Larynx injury;

Burn of the laryngopharynx;

Operations on the organs of the neck, mediastinum.

Physical examination:

Signs of stridor;

Dyspnea;

Cyanosis;

Flaring of the wings of the nose when breathing;

Participation in the act of breathing auxiliary muscles.

Laboratory research:

There are no distinguishing features in blood tests.

Instrumental research:

Indirect laryngoscopy - the presence of a narrowing at the level of the larynx and the nature of this stenosis are determined;

Direct laryngoscopy - the level of stenosis and features of the anatomical structure of the larynx are assessed;

Fibrolaryngotracheobronchoscopy - the length of the narrowing and the presence of pathology of the underlying parts of the respiratory tract are determined;

X-ray examination of the larynx - in the lateral projection against the background of the air column, scar tissue is visualized;

Computed tomography of the larynx - the localization and topography of stenosis is specified; CT provides information on the degree and extent of the narrowing, allows you to assess the diameter of the lumen of the larynx and trachea above and below the stenosis, thickening, compaction and deformation of the walls, to identify changes in the paratracheal tissue, organs of the anterior and posterior mediastinum;

MRI of the larynx - an important advantage is its high resolution, as well as high sensitivity in the image of soft tissues. This method, in contrast to X-ray tomography, allows you to get an image of an organ in any section.

Indications for expert advice:

Consultation of a hematologist - in case of pathological changes in the parameters of coagulation and the duration of blood bleeding;

Consultation with a cardiologist - indicated for changes in the ECG;

Consultation with a pulmonologist - to exclude pathology from the bronchopulmonary system;

Consultation of an oncologist - if a malignant process is suspected;

Consultation of a neuropathologist - in case of respiratory failure of central origin;

Consultation with a physiotherapist - for the choice of physiotherapy treatment;

Consultation of an ophthalmologist - examination of the fundus of the eye;

Consultation of a thoracic surgeon - to determine the tactics of surgical intervention in case of ineffectiveness of endoscopic methods of treatment;

Consultation of a clinical pharmacologist - for the purpose of rational pharmacotherapy.

Differential Diagnosis

Differential Diagnosis: carried out with laryngospasm, hysteria, bronchial asthma and specific lesions of the respiratory system. Careful history taking and correct interpretation of the data obtained with objective diagnostic methods make it possible to make an accurate diagnosis.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment Goals: Elimination of stenosis of the larynx with the restoration of spontaneous breathing.

Treatment tactics

Non-drug treatment

Mode- depending on the patient's condition (free, ward, bed, strict bed).

Diet- depending on the age of the patient.

Medical treatment

Medical treatment provided on an outpatient basis

,

Hormonal agents:

Prednisolone 2-3 mg/kg IV, dexamethasone 0.6 mg/kg PO;

Antibacterial agents:

Amoxicillin + clavulanic acid 20-40 mg / kg x 3 times a day orally - 7-10 days, benzylpenicillin sodium salt 100-150 thousand U / kg / day for 4 times / m - 7-10 days;

Acetaminophenol 10-15 mg / kg - a single dose orally, ibuprofen inside 10-30 mg / kg / day in 2-3 doses;

Antihistamines:

Clemastine - syrup inside up to 1 year 1-2.5 ml, 1-3 years - 2.5-5 ml, 3-6 years - 5 ml, 6-12 years -7.5 ml, loratadine for children inside: from 2 to 12 years -5 mg / day (with a body weight of less than 30 kg), or 10 mg / day (with a body weight of 30 kg or more) - 7 days;

Mucolytics:

Ambroxol inside for children: up to 2 years, 7.5 mg 2 times / day, from 2 to 5 years, 7.5 mg 3 times / day, over 5 years, 15 mg 2-3 times / day, over 12 years old, 30 mg 2-3 times / day;

Inhalations:

Alkaline inhalations, inhalations with chymotrypsin;

Antibacterial agents:

Azithromycin 10 mg/kg 1 time/day inside - 5 days, roxithromycin 5-8 mg/kg 2 times/day inside - 5-7 days;

Antispasmodics:

Antihistamines:

Fenspiride syrup inside older than 12 years 2 times / day - 7-10 days;

Distractions:

Mustard plasters, hot foot baths.

Medical treatment provided at the inpatient level

List of essential medicines:

Antibacterial agents:

Cefazolin 20-100mg/kg - 2.3 r / day IM - 7-10 days, ceftriaxone - 20-75mg / kg / day 1 - 2 times a day IM, ceftazidime 1-6 g / day IM ;

Non-steroidal anti-inflammatory drugs:

Acetaminophenol 10-15 mg / kg - a single dose orally, ibuprofen inside 10-30 mg / kg / day in 2-3 doses;

5% dextrose solution 150-400 ml IV, 0.9% sodium chloride solution IV;

Antihistamines:

2% solution of chloropyramine in / m up to a year - 0.1-0.25 ml, 1-4 years - 0.3 ml, 5-9 years - 0.4-0.5 ml, 10-14 years - 0, 75-1 ml 1-2 times / day, diphenhydramine 1% i / m;

Antifungal medicines:

Oral suspension of fluconazole 1 teaspoon (50 mg) or tablet 3 mg / kg / day, nystatin orally up to 1 year at 100,000-125,000 IU, 1-3 years 250,000 IU, over 3 years 250,000-500,000 IU 3-4 times / day ;

Mucolytics:

Ambroxol inside for children: up to 2 years, 7.5 mg 2 times / day, from 2 to 5 years, 7.5 mg 3 times / day, over 5 years, 15 mg 2-3 times / day, over 12 years old, 30 mg 2-3 times / day,

Acetylcysteine ​​inside up to 2 years at 0.05 g, up to 6 years at 0.1 g, up to 14 years at 0.2 g, over 14 years at 0.4-0.6 g;

Angioprotectors:

Etamzilat 0.1-0.25 g orally in 2-3 doses, intramuscularly, intravenously;

Adrenomimetic substances

Epinephrine 0.18% for topical use, fenoterol 0.1% for inhalation;

Hormonal Therapy:

Analgesics:

Ketorolac intramuscularly, 50% metamizole sodium solution - 0.1 ml/kg intramuscularly;

Means for anesthesia:

Propofol, ketamine, isoflurane, fentanyl.

Muscle relaxers:

Rocuronium bromide, atracurium besilate.

List of additional medicines:

Antibacterial therapy:

Cefuroxime 30-100mg/kg -3-4r i/m, meropenem 10-20mg/kg - 3r i/v - 7-10 days, vancomycin 40-60mg/kg -4r i/v, azithromycin i/v 3 days, amikacin 3-7 mg/kg i/m, i/v 2p -5 days;

Atropine 0.1% i.m.;

Antiviral drugs:

Interferon alfa 2b 1 suppository 2-3 times a day, interferon nasally;

Antiseptics:

Chlorhexidine dihydrochloride lozenges for resorption, Gramicidin C tab.;

Hemostatic agents:

5% aminocaproic acid 100.0 i.v.;

Anticonvulsants:

Phenobarbital inside 1-10 mg/kg 2-3 times/day;

Tranquilizers:

Diazepam 0.1-0.2 mg/kg IM;

Narcotic:

Morphine i / m;

Anticoagulants:

Heparin 5000IU / ml, in / in, in / m;

Antispasmodics:

Aminophylline inside 7-10 mg/kg 3-4 times/day, 2-3 mg kg IV;

Recombinant clotting factors:

Blood coagulation factor IX 1000ME, 100ME/kg;

Diuretics:

Lasix 0.5-1.5 mg/kg IV;

Local anesthetics:

Lidocaine aerosol 10%;

Vitamins:

Ascorbic acid 5% -5ml IV, IM;

Antiemetics:

Metoclopramide 0.5%, 0.01 g intramuscularly 1-3 times a day;

Means for anesthesia:

Sevoflurane, sodium thiopental.

Drug treatment provided at the stage of emergency emergency care:

Hormonal Therapy:

Dexamethasone 1-5 mg / kg IV, prednisolone 1-3 mg / kg IV, budesonide 0.2-0.8 2-3 times / day (for inhalation);

Other irrigation solutions:

5% dextrose solution 150-400 ml IV;

Anticholinergics:

Atropine 0.1% i.m.;

Medical gases:

Oxygen.

Other treatments

Physiotherapy- inhalations with moistened oxygen, UVI, electrophoresis on the neck area.

Surgical intervention- the main method of treatment for chronic forms of stenosis, including cicatricial.

Surgical intervention provided on an outpatient basis:

In emergency cases, it is conicotomy- median dissection of the larynx between the cricoid and thyroid cartilages within the cricoid ligament. A variation of conicotomy is conicocricotomy (cricotomy) - a dissection along the midline of the cricoid cartilage arc. In children older than 8 years, a puncture variant of conicotomy is possible, when the cricothyroid membrane is punctured with a catheter on a 14-16 G needle with an attached syringe, which constantly aspirates air.

Surgical intervention provided in a hospital:

Surgical elimination of cicatricial stenosis is determined individually and is carried out only in a hospital with two accesses - endoscopic operations and operations on the larynx with external access.

Endoscopic surgical interventions through natural pathways are indicated for short-term stenoses, for correction of the lumen of the larynx after reconstructive operations, and for endoluminal formations of the larynx.

Operations on the larynx with external access are indicated for cicatricial stenosis of the larynx III-IV degree, the length of the stenosis is more than 1.5 cm and the ineffectiveness of the ongoing conservative and endoscopic treatment.

Types of endoscopic interventions:

Balloon dilatation - carried out by a special system for dilatation;

Bougienage - is carried out with laryngeal bougies or endotracheal tubes;

Laser microsurgery - carried out with a CO2 laser conjugated with an operating microscope;

Microsurgery of the larynx - performed using a set of special microsurgical instruments for the larynx;

The use of a microdebrider is carried out using a universal console with a set of laryngeal blades.

To carry out endoscopic methods for restoring the lumen of the larynx, the following is necessary technical equipment:

Set of special pediatric surgical laryngoscopes

A system that provides support or suspension laryngoscopy

Throat microscope with a focal length of 300-400mm, providing 4-8x magnification

Rigid and flexible optical endoscopes

A set of laryngeal bougies and endotracheal tubes of various diameters

A set of laryngeal microsurgical instruments

Types of operations on the larynx with external access

Laryngoplasty with the use of an autograft from the costal cartilage is performed for III degree stenosis of the larynx with suturing of the autograft from the costal cartilage into the defect of the larynx;

Resection of the larynx - is carried out in the complete absence of the lumen of the larynx;

Reconstructive plastic surgery with stenting of the larynx - with the installation of silicone stents for a period of 1 to 2 months.

The first stage of these types of operations is a tracheostomy - opening the trachea. In children, surgery is performed under intubation anesthesia. The position of the child is lying on his back with a roller placed under his shoulders and his head thrown back. To fix the trachea before the incision, it is stitched with a strong thread through the intertracheal ligament transversely one ring above the site of the subsequent incision. Fixing the trachea with a stitched thread, the next step is stitching it again with two vertical threads parallel to the future incision of the trachea, departing from each other by no more than 0.5 cm. Pulling the threads up and to the sides, the trachea is opened with the intersection of its two rings between the stretched threads, the tracheotomy cannula is then effortlessly inserted. After the introduction of the cannula, the threads fixing the trachea are fixed on the neck with an adhesive plaster and removed 5-6 days after the formation of a stable tracheal orifice.

Preventive actions:

Avoid colds, SARS.

Avoid injury to ENT organs.

Sanitation of foci of chronic infection.

Timely imposition of a tracheostomy.

Immunostimulatory therapy.

Restorative therapy.

Further management

Postoperative period

Strict bed rest, then - ward mode;

Plentiful drink (not hot);

After discharge

Dispensary registration and further observation by an ENT doctor in a polyclinic at the place of residence 1 time per week in the first month, then 1 time in 2 weeks from the second month.

Children with chronic cicatricial stenosis are sent to MSEC for disability registration;

Control fibrolaryngoscopy in the clinic at the place of residence in 1-3 months;

Avoid caffeinated products (coffee, tea, carbonated drinks), spicy and salty foods for 2 months after surgery;

It is not recommended to carry or lift heavy things for 3 weeks after the operation;

You can sing 2-6 months after the operation (the period depends on individual characteristics);

Do not stay in places with polluted air (dust, gases, vapours).

Rehabilitation

If you have a tracheostomy:

Every 2-3 hours, two or three drops of sterile oil or 4% sodium bicarbonate solution are poured into the tracheotomy tube so that it does not become clogged with mucus. The cannula is removed from the tube 2-3 times a day, cleaned, processed, lubricated with oil and reintroduced into the outer tube.

If a patient with a tracheostomy cannot cough well, then the contents of the trachea are periodically aspirated.

For this you should:

A) 30 minutes before suction, raise the foot end of the bed and massage the chest;

B) 10 minutes before the suction of the mucus through the tracheotomy tube, pour 1 ml of a 2% solution of sodium bicarbonate to thin the mucus;

Restoration of breath through natural ways

Condition improvement

No complications

Drugs (active substances) used in the treatment

Hospitalization

Indications for hospitalization

Emergency:

False croup, acute laryngotracheobronchitis, allergic laryngeal edema - to a somatic or infectious hospital;

Phlegmonous laryngitis, foreign body of the larynx, trauma of the larynx - in the ENT department;

Planned:

Chronic cicatricial stenoses - in the ENT department or a hospital with ENT beds.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
   1. 1) Soldatov I.B. Guide to otorhinolaryngology. – M.: Medicine. -1997.-608s. 2) Preobrazhensky Yu.B., Chireshkin D.G., Galperina N.S. Microlaryngoscopy and endolaryngeal microsurgery. - M.: Medicine, 1980. - 176s. 3) Poddubny, Belousova N.V., Ungiadze G.V. Diagnostic and therapeutic endoscopy of the upper respiratory tract. - M.: Practical medicine, 2006. -256s. 4) Daihes N.A., Bykova V.P., Ponamarev A.B., Davudov Kh.Sh. Clinical pathology of the larynx. - M .: LLC "Medical Information Agency", 2009. - 160s. 5) Bogomilsky M.R., Razumovsky A.Yu., Mitupov Z.B. Diagnosis and surgical treatment of chronic stenosis of the larynx in children. - M.: GEOTAR-Media, 2007. -80s. 6) Zenger V.G., Nasedkin A.N., Parshin V.D. Surgery for injuries of the larynx and trachea. M.: Publishing house. "Medkniga", 2007.-364s. 7) Uchaikin V.F. Children's infections. M. 2004. 8) Laryngoscope.2014 Jan:124(1):207-13.doi:10.1002/Lary.24141. Epub 2013 May 13. A randomized study of suprastomal stents in laryngotracheoplasty surgery for grade III subglottic stenosis in children. 9) Balloon dilation complication during the treatment of subglottic stenosis: background of the FDA class 1 recall for the 18 x 40-mm Acclarent Inspira AIR balloon dilation system.. Achkar J, Dowdal J, Fink D, Franco R, Song P.Ann Otol Rhinol Laryngol. 2013 Jun;122(6):364-8. 10) Balloon dilatation to treat plasmacytosis of the supraglottic larynx. Mistry SG, Watson GJ, Rothera MP. J Laryngol Otol. 2012 Oct;126(10):1077-80. Epub 2012 Aug 21. 11) Management and prevention of endotracheal intubation injury in neonates. 12) Wei JL, Bond J. Curr Opin Otolaryngol Head Neck Surg. 2011 Dec;19(6):474-7. doi:10.1097/MOO.0b013e32834c7b5c. review. 13) Modalities of treatment for laryngotracheal stenosis: the EVMS experience. 14) Sinacori JT, Taliercio SJ, Duong E, Benson C. Laryngoscope. 2013 Dec;123(12):3131-6. doi: 10.1002/lary.24237. Epub 2013 Jun 28. 15) Balloon laryngoplasty in children with acute subglottic stenosis: experience of a tertiary-care hospital. Schweiger C, Smith MM, Kuhl G, Manica D, Marostica PJ. Braz J Otorhinolaryngol. 2011 Nov-Dec;77(6):711-5. English, Portuguese. 16) Williams M.A., Allen P.G., Myer C.M., Powerd instrumentation in laryngeal surgery. Oper Tech Otolaryngol Head Neck Surg 2002. 13.51-2. 17) O, Neill J., Black R. Powered microdebridement treatment for recurrent respiratory papillomatosis. Aust J Otolaryngol 2003.6.81-5.
   2. The information posted on the MedElement website and in the mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" cannot and should not replace an in-person consultation with a doctor. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
   3. The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
   4. The MedElement website and mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are exclusively information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
   5. The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

Severe and dangerous diseases of childhood include stenosis of the larynx in children. The cause of stenosis can be: acute laryngotracheitis (false croup), epiglotitis (inflammation of the epiglottis), diphtheria of the larynx (true croup), foreign body of the larynx, etc.

Among these causes, stenosis of the larynx is most common in acute laryngotracheitis. Therefore, in the future we will talk about this disease.

Acute laryngotracheitis occurs as a result of inflammation of the larynx in the region of the subglottic space and vocal cords.

The etiology is predominantly viral. Among viruses, the leading role belongs to parainfluenza (75%), less often to influenza, measles, adenovirus infection.

The bacterial flora can also cause this disease, especially in children with an allergic predisposition and background diseases (paratrophy, congenital stridor, etc.).

Acute stenosing laryngotracheitis often develops in children under three years of age.

This is facilitated by the anatomical and physiological features of the larynx in children:

The shape of the larynx in children is funnel-shaped, while in adults it is cylindrical;
The narrowest place in the larynx in children is the subglottic space, which is limited by the cricoid cartilage;
In the zone of the subglottic space there are a large number of mucus-forming glands (they are less with age);
The submucosal tissue in the area of ​​the cricoid cartilage is very well expressed.
The mucosa in the subglottic space is covered with a cylindrical epithelium, which is easily desquamated. With age, the columnar epithelium is replaced by a flat one.
In connection with the desquamation of the epithelium, a large reflexogenic zone (parasympathetic innervation) is exposed. This increases the tendency to laryngospasm.

The pathogenesis of this disease is a violation of the patency of the respiratory tract.

Factors that lead to stenosis of the larynx:

Swelling of the mucous membrane of the larynx (subglottic space).
It has been proven that mucosal edema by 1 mm reduces the lumen of the larynx and trachea by 75%, and the airway resistance increases by 16 times .;
Accumulation of mucus, exudate in the lumen of the larynx. Obturation syndrome develops .;
Spasm of the muscles of the larynx and vocal cords.

The main clinical symptoms of stenosing laryngotracheitis:

Hoarse voice (increases with increased mucosal edema up to aphonia);
Barking cough (rough, hacking, short);
Inspiratory dyspnea (difficulty inhaling). Accession of expiratory shortness of breath (difficulty exhaling) indicates an increase in the severity of stenosis.

Laryngeal stenosis usually begins suddenly (usually at night) when the parasympathetic nervous system prevails. Against the background of a hoarse voice, a dry, "barking" cough appears, to which stenotic breathing joins. With the child's anxiety and physical activity, noisy breathing and shortness of breath increase.

There are IV degrees of stenosis:

I - compensated;
II - subcompensated;
III - decompensated;
IV - asphyxia.

—At I degree stenosis shortness of breath and noisy breathing appears during emotional or physical exertion. There are no signs of hypoxia.

— At II degree stenosis shortness of breath and noisy breathing at rest. The child is restless, excited. Auxiliary muscles take part in the act of breathing (retraction of the sternum, over and subclavian fossae, intercostal spaces). Auscultatory breathing in the lungs is still audible, many dry rales appear. There are signs of hypoxia (perioral cyanosis, saturation below 90%).

— With III degree stenosis, signs of respiratory decompensation appear. The expressed anxiety of the child. An increase in the work of the respiratory muscles does not prevent the development of hypoxia. Breathing becomes arrhythmic, the retraction of the sternum increases during inspiration (almost to the spine).

A characteristic sign of grade III stenosis is the addition of apnea, which indicates physical exhaustion of the respiratory muscles. Auscultatory breathing is sharply weakened, in the lower parts of the lungs it is not audible at all. Crepitus appears at the depth of inspiration. Signs of hypoxia are expressed (cyanosis of the skin, tachycardia, paradoxical pulse).

– IV degree- asphyxia. The condition is extremely difficult. The child is in a coma. Breathing is superficial, frequent, arrhythmic with periodic apnea. There may be convulsions. Bradycardia, which may progress to asystole. At the same time, it may seem that the child is better (shortness of breath decreases, the patient calms down, body temperature drops to normal numbers), but this is a misleading impression. Hypoxia reaches extreme values, a pronounced, combined acidosis develops.

Treatment of stenosing laryngotracheitis.

Treatment depends on the degree of stenosis of the larynx.

With I degree of stenosis local, distracting therapy is carried out, which is aimed at improving venous outflow and normalizing lymphatic outflow. Warm dosed drink. Dry heat on the neck. A good effect is observed from inhalations with saline, decongestant mixture (which includes hydrocortisone). There are recommendations for inhalation through pulmicort, flixotide.

Prescribed antihistamines preferably III generation.

At II degree stenosis are carried out:

Inhalation with warm, moistened oxygen (break inhalation every 8 hours);
Sedation of the child to reduce inspiratory efforts (seduxen, droperidol, sodium oxybutyrate) .;
Glucocorticoids 10 mg/kg per day for prednisolone. The dose is calculated for 4-6 doses without taking into account the biological rhythm. Therapy with glucocorticoids is carried out for several days. From the second day, their dose is gradually reduced;
Antihistamines in age doses;
appoint according to indications;
Treatment of broncho-obstructive syndrome (mucolytics, bronchodilators, chest therapy).
When infusion therapy to prevent hypervolemia. As a rule, on the first day, the volume of fluid should not exceed 80% of the physiological norm.
Sanitation of the tracheo-bronchial tree.

With III degree stenosis, the above therapeutic measures are carried out plus tracheal intubation. Intubation is performed without the use of muscle relaxants. The endotracheal tube is taken a size smaller than it should be for age.
There is no benefit of orotracheal or nasotracheal intubation.
The endotracheal tube is changed every 48 hours.

If it is impossible to intubate the trachea, a tracheostomy is done.

With stenosis IV degree cardiopulmonary resuscitation, treatment of cerebral edema.

In conclusion, I would like to note that the treatment of stenosing laryngotracheitis mainly consists in inhalation therapy and the use of glucocorticoids (the so-called "drug" intubation).
It is necessary to do everything necessary so that the degree of stenosis does not increase. There is an unspoken rule that the treatment of stenosis should be carried out a degree higher (that is, if the child just has laryngitis, treat as with grade I stenosis, if grade I, then treat as with grade II, etc.).

Acute upper airway obstruction or laryngeal edema in children

Acute obstruction of the upper respiratory tract is a narrowing of the lumen of the larynx caused by various pathological conditions, manifested by respiratory disorders and the development of acute respiratory failure. Acute upper airway obstruction is an emergency condition that requires emergency diagnosis and treatment even at the prehospital stage.

This condition most often occurs in children of early and preschool age due to the anatomical and physiological characteristics of the respiratory organs: the narrowness of the lumen of the respiratory tract, the tendency of their mucous membrane and the loose fibrous connective tissue located under it to develop edema, the features of the innervation of the larynx that contribute to the occurrence of laryngospasm, and the relative respiratory muscle weakness. Edema of the mucous membrane with an increase in its thickness by 1 mm reduces the lumen of the larynx by half.

Laryngeal edema in children - causes

There are infectious and non-infectious causes of acute upper airway obstruction.

o Infectious causes.

Viral infections caused by influenza and parainfluenza type I viruses (75% of cases), RSV, adenoviruses.

Bacterial infections: epiglottitis, pharyngeal and peritonsillar abscesses, diphtheria.

o Non-infectious causes: aspiration of foreign bodies, trauma to the larynx, allergic edema, laryngospasm, etc.

Acute obstruction of the upper respiratory tract in children - forms of the disease

In the genesis of airway obstruction, three factors play a role: edema, reflex spasm of the muscles of the larynx and mechanical blockage of its lumen by an inflammatory secret (mucus) or a foreign body (food, vomit). Depending on the etiology, the significance of these components may be different.

According to the nature of inflammatory changes in the larynx, edematous, or catarrhal, infiltrative and fibrino-necrotic forms of stenosis are distinguished.

o The edematous form most often occurs with a viral or infectious-allergic etiology; with appropriate treatment, a rapid positive trend is observed.

o Infiltrative and fibrino-necrotic changes in the larynx are associated with the addition of a bacterial infection. With them, a significant narrowing of the lumen of the larynx is associated not only with a powerful inflammatory edema of tissues, but also with the accumulation of thick sticky mucus, purulent and hemorrhagic crusts, fibrinous or necrotic deposits in the lumen of the larynx.

Laryngeal edema in children - treatment

The causes of acute upper airway obstruction are manifold. In practical work, in order to conduct adequate therapy and provide effective assistance to the child, it is important to quickly differentiate them.

Croup in children - causes

The most common cause of upper airway obstruction in young children is inflammatory changes in the larynx of viral, bacterial and mixed bacterial-viral etiology - croup (from Scot. crop- croak), manifested by a triad of symptoms: stridor, "barking" cough, hoarseness. The leading cause of the development of croup is an inflammatory process in the subglottic space and vocal cords (acute stenosing laryngotracheitis). Respiratory disorders due to narrowing of the lumen of the larynx most often occur at night, during sleep, due to changes in the conditions of the lymphatic and blood circulation of the larynx, a decrease in the activity of the drainage mechanisms of the respiratory tract, the frequency and depth of respiratory movements. Croup with ARVI develops in children of the first 5-6 years of life, children are most often ill

Everyone is used to the fact that children in the cold season often cough and suffer from a runny nose. Children's immunity is imperfect and cannot provide adequate protection against respiratory infections. But these symptoms should not be taken lightly, as they can be harbingers of stenosis of the larynx in children.

This serious condition is a complication of banal, at first glance, diseases. Therefore, every parent should know how to help a child in case of stenosis.

Description of pathology

Spasm of the larynx in children is a significant narrowing of the airway. Because of it, babies first show signs of difficulty breathing, and then suffocation.

This condition is also called "croup". In translation, this word means to croak. A croaking cough precedes a great constriction of the larynx.

The term croup is obsolete. Modern doctors use it less and less to refer to stenosis of the larynx. Increasingly, the term "stenosing laryngitis" is used instead.

Children have a special structure of the larynx and trachea:

• The mucous membranes of the larynx and trachea of ​​a child are saturated with fatty tissue interspersed with lymphoid tissue. In addition, it is densely permeated with capillaries. With the development of the inflammatory process, this contributes to tissue swelling and the development of edema. The result is a rapid narrowing of the lumen of the larynx.
• The respiratory tract of the child has a small diameter. The length of the larynx is much shorter than that of an adult. In addition, in shape it resembles a funnel. The vocal cords are located higher than in adults. All this contributes to the rapid spread of inflammation.
• The nervous system in the child's body is not yet fully formed. Because of this, parasympathetic mechanisms for the transmission of nerve impulses come to the fore. In addition, this causes the presence of additional reflex areas in the respiratory organs and increased tissue excitability. Because of this, any irritants can provoke the development of laryngeal stenosis in children.

Komarovsky believes that when the first signs of pathology appear, first aid should be immediately provided. The fact is that this pathology violates several important functions at once: voice, respiratory and protective.

Stenosis classification

At one time, doctors developed several classifications of this pathology. Each of them is based on one of the characteristics of the disease.

Taking into account the rate of development and duration of the course, the following types of stenosis are distinguished:

The pace of development of pathology largely depends on how quickly the adults around the child notice the presence of a problem, and the promptness of the assistance provided.

Stenosis of the larynx also has a division into stages. The onset of a particular stage is determined by the symptoms of stenosis of the larynx in children:

At each of these stages, a sick baby needs emergency help. Parents cannot provide it on their own. They can only provide first aid, and then they must call an ambulance.

Reasons for the development of a pathological condition

Doctors divide all causes of stenosis into 2 large groups: infectious and non-infectious. Infectious causes include:

• Diseases of viral etiology: influenza, adenovirus and respiratory infections.
• Diseases of bacterial origin: diphtheria, scarlet fever, measles, etc.

There are many more non-infectious causes. The most common of these include:

• Allergic reaction. Food, plant pollen, medicines, household chemicals, etc. can act as an allergic agent. This is a common cause of throat spasms.
• Inflammatory processes occurring outside the respiratory organs. For example, in the esophagus or stomach.
• Congenital pathologies of the trachea, causing narrowing of its lumen.
• Purulent processes that capture the neck and the areas of the head closest to it. Due to the proximity of the respiratory organs, inflammation can spread to them.
• Tumors in the trachea and larynx.
• Violation of the innervation of tissues. This can happen both after an injury and due to a strong emotional outburst. The latter is typical for teenage girls.
• Injuries to the larynx received in various ways: burns with hot food, foreign body entering the trachea, damage by chemicals, blows to the neck, etc.
• Acute liver failure. This disease is accompanied by the ingestion of urea into the mucous membranes of the larynx, which, when interacting with the microflora, is converted into a poison that can provoke the appearance of foci of necrosis.
• Inflammatory processes in the respiratory organs. For example, laryngotracheitis.

With any form and stage of pathology, it is important to quickly identify the causes of its development. You can get rid of the symptoms of the disease only by eliminating negative factors.

If the attack develops at lightning speed, then diagnosis is not needed. The main thing here is to have time to help the child. Things are different when the pathology develops gradually. Doctors have time to find out the cause and get rid of it.

Diagnosis begins with an examination. The doctor examines the oral cavity, pharynx and larynx with the trachea. Allergological tests are mandatory to exclude the possibility of allergies. If a neuropathic process is suspected, a neuropathologist is involved in the examination. If signs of a tumor are detected, then the child is referred to an oncologist.

As additional research methods are used:

• Radiography. It allows you to assess the degree of narrowing of the trachea and larynx.
• Ultrasound of the thyroid gland. An enlarged organ can compress the larynx.
• Computed tomography of the neck.
• Bacteriological cultures to identify an infectious agent.

General blood and urine tests are mandatory. They allow, by indirect signs, to reveal the presence of a latent inflammatory process that can cause stenosis of the larynx in children.

Acute attacks of croup can develop very quickly. For this reason, it is very important that parents know how to provide emergency care to the child. This can save the baby's life until the doctors arrive.

When the first signs of stenosis appear, parents should do the following:

It is very useful to have Prednisone in the medicine cabinet. This drug can help when the pathology begins to move to the third stage. The medicine has a lot of side effects, but with a threat to the life of a child, you don’t have to choose. It quickly eliminates swelling and signs of allergies. Small children can inject no more than half an ampoule. Adolescents can enter a whole ampoule.

To eliminate the pathological condition, drug therapy and surgical treatment can be used. The choice of therapeutic technique is determined by the severity of the symptoms and the cause of the stenosis.

Conservative therapy

Such treatment is prescribed exclusively in the initial stages of the disease. Doctors seek to get rid of the causes of narrowing of the larynx with the help of medications. Their set is determined by the causes of pathology.

In some cases, the doctor may allow the child to be treated at home. This usually happens when the pathology is caused by laryngitis. But even at home, bed rest should be observed.

Parents should not provoke the child to talk. Excessive stress on the ligaments can adversely affect the formation of inflamed vocal cords.

You need to regularly ventilate the room. If the pathology is complicated by allergies, then compotes and food that can provoke an allergic reaction should be abandoned.

You can do inhalations with medicines and infusions of medicinal herbs.

In a hospital setting, conservative treatment is carried out using the following groups of drugs:

• Antiviral agents: Grippferon, Viferon, Alfaron, Tsitovir, Kagocel.
• Antibacterial drugs for acute inflammatory processes: Amoxicillin, Augmentin, Zinacef, Summamed, Chemotsin.
• Antiallergic drugs: Ksizal, Zodak-Express, Erius, Desal, Feksadin.
• Decongestants: Naphthyzin, Galazolin, Tizin, Delufen, Furosemide.

All drugs are prescribed by a doctor. Parents should not treat a child on their own.

With 3 and 4 degrees of stenosis, it is pointless to use medication. They simply do not have time to exert their effect before death, so doctors resort to surgical intervention.

Today, doctors in the treatment of stenosis of the respiratory tract practice the following types of operations:

Doctors may intubate the baby to restore breathing function. We are talking about placing a special tube into the trachea through the mouth.

Intubation is performed only when doctors are confident that they can eliminate the spasm with medication.