[Acute respiratory distress from ingestion of glitter powder in a 15-month-old child: an endoscopic emergency]. / Dificultad respiratoria aguda por ingestión de purpurina en polvo en un niño de 15 meses: una urgencia endoscópica.

Glitter is a powdered copper pigment frequently used in craft and decorative activities especially in schools and kindergartens. Ingestion or inhalation of this substance can cause acute, potentially fatal copper poisoning in children. We describe a case of a 15-month-old child with copper poisoning, presenting with acute respiratory distress, neurological impairment, and hemolytic anemia. Early onset of treatment by bronchoscopy and bronchial lavage with subsequent endotracheal intubation and mechanical ventilation, achieved complete remission of the respiratory symptoms without sequelae. In presence of glitter ingestion or inhalation, bronchoscopy with bronchial lavage should be indicated early even in the absence of respiratory symptoms.

La purpurina es un pigmento en polvo de cobre, que se utiliza con frecuencia en actividades artesanales y manualidades escolares. La ingestión o inhalación de esta sustancia provoca un cuadro de intoxicación por cobre potencialmente fatal en niños. Se describe el caso de un niño de 15 meses con intoxicación por cobre, que se presenta con dificultad respiratoria aguda, alteración del sensorio y anemia hemolítica. El inicio temprano del tratamiento mediante broncoscopia y lavado bronquial con posterior intubación endotraqueal y ventilación mecánica, lograron la remisión completa del cuadro respiratorio sin secuelas. Ante una ingestión y/o inhalación de purpurina, debe indicarse de inmediato la broncoscopia con lavado bronquial, aún en ausencia de síntomas respiratorios.

Dificultad respiratoria aguda por ingestión de purpurina en polvo en un niño de 15 meses: una urgencia endoscópica / Acute respiratory distress from ingestion of glitter powder in a 15-month-old child: an endoscopic emergency

La purpurina es un pigmento en polvo de cobre, que se utiliza con frecuencia en actividades artesanales y manualidades escolares. La ingestión o inhalación de esta sustancia provoca un cuadro de intoxicación por cobre potencialmente fatal en niños. Se describe el caso de un niño de 15 meses con intoxicación por cobre, que se presenta con dificultad respiratoria aguda, alteración del sensorio y anemia hemolítica. El inicio temprano del tratamiento mediante broncoscopia y lavado bronquial con posterior intubación endotraqueal y ventilación mecánica, lograron la remisión completa del cuadro respiratorio sin secuelas. Ante una ingestión y/o inhalación de purpurina, debe indicarse de inmediato la broncoscopia con lavado bronquial, aún en ausencia de síntomas respiratorios.

Glitter is a powdered copper pigment frequently used in craft and decorative activities especially in schools and kindergartens.Ingestion or inhalation of this substance can cause acute, potentially fatal copper poisoning in children. We describe a case of a 15-month-old child with copper poisoning, presenting with acute respiratory distress, neurological impairment, and hemolytic anemia. Early onset of treatment by bronchoscopy and bronchial lavage with subsequent endotracheal intubation and mechanical ventilation, achieved complete remission of the respiratory symptoms without sequelae. In presence of glitter ingestion or inhalation, bronchoscopy with bronchial lavage should be indicated early even in the absence of respiratory symptoms.

Edema pulmonar posobstructivo en niños: ¿por qué debería pensarlo el otorrinolaringólogo? / Post obstructive pulmonary edema in children: Why should the otolaryngologist think about it?

Introducción: el edema pulmonar posobstructivo (EPPO), o por presión negativa, es una entidad potencialmente mortal, que se desarrolla inmediatamente luego de una obstrucción severa de la vía aérea superior. Materiales y métodos: descripción de una serie de 4 casos de EPPO ocurridos en niños, 3 de ellos secundarios a aspiración de un cuerpo extraño y el otro como complicación de una adenoamigdalectomía. Discusión: la causa más frecuente de la obstrucción de la vía aérea es el laringoespasmo asociado con la manipulación de la vía aérea durante la intubación o las intervenciones quirúrgicas de la vía aérea. Tanto la adenoamigdalectomía, como la extracción de cuerpos extraños en la vía aérea constituyen unas de las intervenciones más frecuentes de la práctica otorrinolaringológica para el tratamiento de la obstrucción de la vía aérea; sin embargo, puede potencialmente desarrollar EPPO. Conclusión: Destacamos la importancia de que el otorrinolaringólogo tenga presente esta afección en niños que presentan dificultad respiratoria tras cualquier obstrucción o intervención quirúrgica de la vía aérea.si bien los cuerpos extraños en la vía aérea en niños suelen presentarse con crisis de asfixia, tos paroxística o dificultad respiratoria luego del evento, también debería pensarse la posibilidad de un evento de aspiración de un cuerpo extraño no presenciado ante un cuadro de edema pulmonar sin causa conocida. Si bien la adenoamigdalectomía es una de las cirugías más frecuente en la práctica otorrinolaringológica, esta potencialmente puede complicarse con EPPO.

Introduction: Post-obstructive pulmonary edema (POPE) or by Negative Pressure, is a potentially fatal entity that develops immediately after a severe obstruction of the upper airway. Materials and methods: Description of a series of four cases of POPE in children, three of them secondary to foreign body aspiration and the remaining one as a complication of adenotonsillectomy. Discussion: The most common etiology of airway obstruction is laryngospasm associated to airway manipulation during intubation or airway surgery. Both adenotonsillectomy and removal of foreign bodies in the airway are one of the most common procedures in otorhinolaryngology practice for management of airway obstruction, however, they can potentially develop EPPO. Conclusion: Although airway foreign bodies in children usually present with sudden episode of choking, paroxysmal cough and/or respiratory distress, the likelihood of an unwitnessed foreign body aspiration event in the presence of unexplained pulmonary edema should also be considered. Although adenotonsillectomy is one of the most common surgeries in ENT practice, it can potentially be complicated by EPPO. We emphasize the importance of the otorhinolaryngologist keeping this condition in mind in children who present respiratory distress after any obstruction or surgical intervention of the airway.

Manejo de la vía aérea en el neonato con síndrome de Moebius / Airway management in the neonate with Moebius syndrome

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[Aspiration syndrome due to laryngeal cleft in an infant]. / Síndrome aspirativo por hendidura laríngea en un lactante.

Aspiration is the passage of food content and endogenous secretions into the airway. Anatomical, neuromuscular or functional anomalies are among the major causes. The laryngeal cleft is a rare congenital anomaly that should be considered in the differential diagnosis of aspiration syndrome in neonates and infants. The main symptoms are stridor, recurrent respiratory infections and cyanotic crisis, cough and choking during feeding. The diagnosis is confirmed by endoscopic examination. The therapeutic behaviour will depend on the extent of the cleft, among other factors. We describe the clinical manifestations, diagnostic methods and treatment of an infant with this disease, and we emphasize the need for recognition of swallowing disorders in children in order to establish an accurate diagnosis and appropriate treatment to prevent and avoid malnutrition as well as a severe and potentially irreversible lung compromise.

[Dysphonia in children due to congenital laryngeal web. Case series]. / Disfonía del niño por membrana laríngea congénita. Serie de casos.

Dysphonia is common in children. Its main cause is the abuse or misuse of the voice. Congenital, neoplastic, infectious, neurological or iatrogenic causes are less frequent. The laryngeal web is a rare congenital anomaly resulting from an incomplete recanalization of the primitive larynx. This condition should be suspected in any newborn with dysphonic cry with or without stridor and respiratory distress. The diagnosis is confirmed by endoscopic examination. Therapy depends on the extent and thickness of the membrane and the severity of the symptoms. We describe our experience with 8 patients suffering this condition, and we emphasize the need to recognize voice disorders and to evaluate the airway for accurate diagnosis and appropriate treatment in every newborn, infant or child with persistent dysphonia.

[Congenital saccular cyst of the larynx: a rare cause of stridor in neonates and infants]. / Quiste sacular congénito de laringe: una causa rara de estridor en neonatos y lactantes.

Stridor is a noise caused by the passage of turbulent air through a diminished airway caliber. Laryngomalacia is the most common congenital anomaly of the larynx and the principal cause of stridor in children under 6 months. A less common etiology of stridor and respiratory distress in newborns and infants is congenital laryngeal saccular cyst. This entity should be considered in the differential diagnosis of stridor. Early recognition and proper treatment are essential because it can cause life-threatening airway obstruction. We describe our experience with 4 patients with this disease, 3 of them successfully treated with microsurgical resection of the cyst, and we emphasize the importance of considering the endoscopic evaluation of the airway in every child exhibiting stridor with an unexpected evolution to determine the causal lesion.

Post-intubation subglottic stenosis in children. Diagnosis, treatment and prevention of moderate and severe stenosis.

INTRODUCTION AND OBJECTIVES: Subglottic stenosis is one of the most common causes of upper airway obstruction. Almost 90% of them result from endotracheal intubation. Therapy depends on the degree of stenosis, among other factors. Therapeutic approaches range from watchful waiting, in mild stenosis, to complex surgery for severe cases. We report our experience on the surgical management of post-intubation subglottic stenosis in children, emphasising the need for recognition and prevention of predisposing factors of post-intubation stenosis. METHODS: We retrospectively evaluated 71 patients with moderate to severe post-intubation subglottic stenosis, operated in the Respiratory Endoscopy Service in a period of eight years. The clinical variables analysed were age at surgery, degree of stenosis, surgical technique, complications and outcome. RESULTS: In 84.5% of patients, only 1 surgical approach was required to achieve decannulation. Three surgical techniques were implemented as therapy: laryngotracheal reconstruction, partial cricotracheal resection and anterior cricoid split. Decannulation was achieved in 70 cases. In 71.8%, ventilation, swallowing and voice qualities were good; 23.9% presented dysphonia; and 2.8% presented a mild respiratory distress. One patient died. CONCLUSION: In patients with subglottic stenosis, selection of the most accurate treatment is the key to success, reducing the number of surgeries and preventing complications.

[Treatment of acquired laryngeal stenosis in pediatrics: case series]. / Tratamiento de las estenosis laríngeas adquiridas en pediatría: Serie de casos.

Subglottic stenosis is one of the most common causes of upper airway obstruction in children. Even though it may have a congenital origin, most of them are acquired stenosis. This condition should be suspected in any child with a history of intubation, instrumentation or trauma of the airway that is having difficulty breathing. The diagnosis is suspected by clinical, history and cervical radiograph, and is confirmed by endoscopic examination. Among others factors the treatment depends on the stenosis degree. We describe our experience with 6 patients with post-intubation subglottic stenosis treated surgically with expansion technique.

[Vascular rings: airway obstruction in children. Case series]. / Anillos vasculares: obstrucción de vía aérea en niños. Serie de casos.

In children, extrinsic compression of the trachea is usually due to vascular origin, and less frequently caused by tumors, heart diseases, cysts and abscesses. Vascular rings are congenital anomalies of the aortic arch and its branches that compress the trachea and/or esophagus to varying degrees. Although these congenital anomalies are not frequent, they constitute a major cause of respiratory distress in children. Thus, these anomalies should be included in the differential diagnosis of obstruction of the upper airway. Symptoms include stridor, respiratory distress and dysphagia of different intensity. The high degree of clinical suspicion is the most important factor for diagnosis, fail to do so can cause a significant delay between symptom onset and correct diagnosis. We present four patients with different types of vascular rings in order to describe clinical manifestations, diagnosis and treatment.

[Septal perforation in children due to button battery lodged in the nose: case series]. / Perforación septal en niños debido a pila botón alojada en nariz: serie de casos.

Nasal foreign bodies are common in children. Button batteries deserve particular interest due to the severity and precocity of the injuries they cause. The button battery represents a growing danger. Its small size and brilliant appearance make them attractive to children, often being introduced in the nose, ear or mouth. It is imperative that the community and physicians are aware of the risks it poses. Early diagnosis and immediate removal is essential. Their delay can lead to necrosis of the nasal mucosa and septal perforation. We report 10 cases of septal perforation due to button battery. We emphasize the dangers of nasal impaction and the need for quick removal to avoid long-term complications.

[Congenital nasal obstruction due to choanal atresia: case series]. / Obstrucción nasal congénita por atresia de coanas: Serie de casos.

Nasal obstruction in neonates is a potential fatal condition because of their exclusive nasal breathing. The most common congenital causes include choanal atresia, dermoid cyst, glioma and encephalocele. Choanal atresia is the most common congenital nasal anomaly. When bilateral, it presents with respiratory distress at birth. Unilateral atresia is manifested by respiratory failure and unilateral rhinorrhea, and may go along unnoticed. Diagnosis is suspected in the absence of airfow in the nasal cavity and for the inability to advance a nasogastric tube. Diagnosis is confirmed by endoscopic examination and computed tomography. The definitive treatment is surgical, and there are different techniques and surgical approaches. We describe our experience with 7 patients with this disease, successfully treated by transnasal endoscopic technique.

[Laryngeal cancer in children: case report]. / Cáncer de laringe en niños: Caso clínico.

Squamous cell carcinoma of the larynx is very rare in children and adolescents. It is usually diagnosed at late stages because early symptoms are often attributed to the maturation process or other common laryngeal pediatric diseases. Early visualization of vocal cords with fexible laryngoscopy is important in children presenting suggestive symptoms of laryngeal pathology. Defnitive diagnosis of carcinoma is made by biopsy, and juvenile laryngeal papillomatosis the most important differential diagnosis. Treatment constitutes a clinical challenge. There are no established protocols, and clinicians should make a special effort to preserve the functions of the larynx, and avoid long term complications. We present a 12-years-old child with invasive laryngeal carcinoma, without prior history of juvenile papillomatosis or radiotherapy, which responded favorably to chemotherapy and radiotherapy.

Management of foreign bodies in the airway and oesophagus.

BACKGROUND: Ingestion and/or aspiration of foreign bodies (FB) are avoidable incidents. Children between 1 and 3 years are common victims for many reasons: exploration of the environment through the mouth, lack of molars which decreases their ability to properly chew food, lack of cognitive capacity to distinguish between edible and inedible objects, and tendency to distraction and to perform other activities, like playing, whilst eating. Most FBs are expelled spontaneously, but a significant percentage impacts the upper aerodigestive tract. Approximately 80% of children's choking episodes are evaluated by pediatricians. The symptoms of aspiration or ingestion of FBs can simulate different paediatric diseases such as asthma, croup or pneumonia, delaying the correct diagnosis. SYMPTOMS: There are three clinical phases both in aspiration and in ingestion of FBs: initial stage (first stage or impaction or FB) shows choking, gagging and paroxysms of coughing, obstruction of the airway (AW), occurring at the time of aspiration or ingestion. These signs calm down when the FB lodges and the reflexes grow weary (second stage or asymptomatic phase). Complications occur in the third stage (also defined as complications' phase), when the obstruction, erosion or infection cause pneumonia, atelectasis, abscess or fever (FB in AW), or dysphagia, mediastinum abscess, perforation or erosion and oesophagus (FB in the oesophagus). The first symptoms to receive medical care may actually represent a complication of impaction of FB. LOCATIONS AND MANAGEMENT: Determining the site of obstruction is important in managing the problem. The location of the FB depends on its characteristics and also on the position of the person at the time of aspiration. Determining the site of obstruction is important in managing the problem. Larynx and trachea have the lowest prevalence, except in children under 1year. They are linked with the most dangerous outcomes, complete obstruction or rupture. Bronchus is the preferred location in 80-90% of AW's cases. Esophageal FBs are twice more common than bronchial FBs, although most of these migrate to the stomach and do not require endoscopic removal. Diagnosis of FB proceeds following the traditional steps, with a particular stress on history and radiological findings as goal standards for the FB retrieval. The treatment of choice for AW's and esophageal FBs is endoscopic removal. Endoscopy should be carried out whenever the trained personnel are available, the instruments are checked, and when the techniques have been tested. The delay in the removal of FBs is potentially harmful. The communication between the endoscopist and the anaesthesiologist is essential before the procedure to establish the plan of action; full cooperation is important and improves the outcome of endoscopy. CONCLUSIONS: Ingestion and or aspiration of FB in children are multifactorial in their aetiology, in their broad spectrum of different resolutions for the same FB and in the response of each patient to the treatment. Prevention remains the best treatment, implying an increased education of parents on age-appropriate foods and household items, and strict industry standards regarding the dimensions of toy parts and their secure containers.

[Unilateral nasal obstruction in children: Pai syndrome]. / Obstrucción nasal unilateral en niños: Síndrome de Pai.

Unilateral obstruction of the nasal cavity in children is mainly caused by the introduction of foreign bodies further stated with rhinorrhea and fetid odor. Less commonly, it can be traumatic, neoplastic, due to congenital malformation or iatrogenic. Symptoms of congenital intranasal mass may present at birth, or go unnoticed and be a finding in a routine pediatric examination. Patient evaluation should include imaging studies to guide the diagnosis and rule out intracranial extension. A syndrome associated with congenital nasal tumor should be suspected when other abnormalities are present. Pai syndrome is a rare genetic disorder. Its manifestations are craniofacial being congenital nasal polyp his main marker. We present a patient with unilateral nasal respiratory failure secondary to congenital nasal lipoma, with craniofacial anomalies belonging to Pai syndrome. Nasal obstruction was successfully surgically resolved.

[Stertor in the newborn due to congenital nasal pyriform aperture estenosis: case series]. / Cornaje del recién nacido por estenosis congénita de la apertura piriforme: serie de casos.

Stertor is a noise generated by the disturbance of the air flow passing through the nose. Its main cause -in newborns and infants- is inflammatory or infectious rhinitis. Congenital, neoplastic, traumatic or iatrogenic causes are less frequent. Congenital stenosis of the pyriform aperture is a rare etiology of nasal obstruction in the neonates. Early diagnosis and appropriate treatment are essential because of their exclusive nasal breathing. Suspicion might arise when a difficulty or even an impossibility to pass a probe of 2.8 mm (K30 tube) through anterior nares, exists. Diagnosis should be confirmed by a computed tomography of the craniofacial massif. The therapeutic behavior will depend on the severity of symptoms. We describe our experience with nine patients with this condition whose surgical correction was successful.

[Surgical treatment of tracheal stenosis in pediatrics]. / Tratamiento quirúrgico de la estenosis traqueal en pediatría.

Twenty patients with tracheal stenosis were surgically treated between July 2005 and May 2008; ten patients had a congenital stenosis and ten an acquired one. Global survival was 85%. Three patients died: 1 with acquired stenosis and 2 with congenital stenosis. From 17 alive patients, 15 remain asymptomatic; 2 patients operated on due to congenital stenosis, are under continuous follow-up (both with stents placed in the trachea). Surgical treatment of acquired stenosis presents less severe complications, requires less ventilatory support and hospital stay. Conversely, congenital stenosis often requires more than one procedure to control the disease, and presents a higher mortality rate.