An unusual cause of stridor.

A 12-month-old infant was referred with a 6-week history of recurrent admissions with worsening stridor. On each previous admission, the stridor responded well, but transiently, to oral dexamethasone. At this presentation, he required high-dependency unit care with high flow oxygen due to marked increased work of breathing.He was born at term, previously well, and up to date with immunisations. There was no significant family history. There were no smokers and two cats at home.He was afebrile with moderate subcostal recession and tracheal tug. On auscultation, breath sounds were normal with transmitted sounds of inspiratory and expiratory stridor. The rest of his examination was normal.He commenced dexamethasone 0.15 µg/kg three times a day, which was weaned as his clinical status improved.Blood tests showed total white cell count 9 x 10ˆ9/L, CRP <1 mg/L, lactate dehydrogenase level and blood film normal. Chest radiograph showed left lung hyperexpansion and apparent right-sided bronchial narrowing (figure 1). Flexible nasendoscopy was unremarkable. Microlaryngoscopy and bronchoscopy showed external airway compression at the level of the carina (figure 2). CT thorax demonstrated a non-enhancing mediastinal mass extrinsic to the airway, approximately 3cmx2.5cmx1.5cm, compressing the carina and main-stem bronchi (figure 3).

Recent advances in paediatric sleep disordered breathing.

This article reviews the latest evidence pertaining to childhood sleep disordered breathing (SDB), which is associated with negative neurobehavioural, cardiovascular and growth outcomes. Polysomnography is the accepted gold standard for diagnosing SDB but is expensive and limited to specialist centres. Simpler tests such as cardiorespiratory polygraphy and pulse oximetry are probably sufficient for diagnosing obstructive sleep apnoea (OSA) in typically developing children, and new data-processing techniques may improve their accuracy. Adenotonsillectomy is the first-line treatment for OSA, with recent evidence showing that intracapsular tonsillectomy results in lower rates of adverse events than traditional techniques. Anti-inflammatory medication and positive airway pressure respiratory support are not always suitable or successful, although weight loss and hypoglossal nerve stimulation may help in select comorbid conditions. Educational aims: To understand the clinical impact of childhood sleep disordered breathing (SDB).To understand that, while sleep laboratory polysomnography has been the gold standard for diagnosis of SDB, other diagnostic techniques exist with their own benefits and limitations.To recognise that adenotonsillectomy and positive pressure respiratory support are the mainstays of treating childhood SDB, but different approaches may be indicated in certain patient groups.