Optimizing the Diagnosis and Management of Pediatric Inducible Laryngeal Obstruction.

BACKGROUND: Pediatric inducible laryngeal obstruction (ILO) is difficult to diagnose and treat. Patients often undergo multiple specialist referrals, and long-term outcomes are not well reported. OBJECTIVES: To investigate the patterns of presentation, workup, and management of children who were diagnosed with ILO at the Stollery Children's Hospital. METHODS: Retrospective review with a prospective cohort of pediatric patients diagnosed with ILO from 2015 to 2023. We collected the demographic data, diagnostic tests, specialist referrals, time to diagnosis, symptom burden, associated comorbidities and aggravating factors, management, and treatment outcomes. A subset of patients was followed prospectively to determine treatment outcomes. A basic descriptive analysis was performed, and factors associated with time to resolution were studied. RESULTS: Seventy-eight patients met the criteria for inclusion, with 22 completing prospective questionnaires. The average age was 14 years old, and 75% were female. The majority required multiple specialist referrals. The majority were associated with exercise. Thirty-two (41%) patients had a presumed diagnosis of asthma, despite only four pulmonary function tests being consistent with asthma. Abortive breathing exercises were the most commonly employed (95%) and most successful (61%) nonsurgical management technique. Surgery was highly successful in a small cohort of patients. Median time to symptom resolution was 12 months, with 36% reporting symptoms persistent beyond 3 years. CONCLUSIONS: Pediatric ILO often goes undiagnosed for prolonged periods. Exercise-related symptoms are the most common. Management strategies have varied levels of success and a large proportion of patients have prolonged symptoms despite treatment, as supported by other recent evidence. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Control of salivary secretions in esophageal atresia with laryngeal cleft using Botulinum toxin Type A.

A baby born with esophageal atresia and a laryngeal cleft is presented. Retained salivary secretions and aspiration were a constant management problem whilst the baby was waiting for delayed primary repair of the atresia. The use of anticholinergic agents resulted in thickening of secretions which were difficult to suction and ultimately led to increasing respiratory compromise. Intraglandular salivary gland injection of Botulinum toxin type A was performed using ultrasound guidance. The mean daily salivary flow output prior to treatment was 59 ml. On glycopyrrolate the mean daily salivary output on glycopyrrolate was 16 ml. After Botulinum injection the mean daily salivary output was 7 ml in the 3 weeks after injection. Over the next 14 weeks this increased to 34 ml. There were no adverse effects or significant thickening of secretions after BTX injection. This is the first reported use of Botulinum toxin injection in the management of salivary aspiration in esophageal atresia with laryngeal cleft.

Plastic laryngeal foreign bodies in children: a diagnostic challenge.

OBJECTIVE: To review Children's Hospital and Regional Medical Center experience with pediatric airway foreign bodies, and examine the incidence and treatment of laryngeal foreign bodies. To determine if plastic laryngeal foreign bodies present differently than other laryngeal foreign bodies. METHODS: A retrospective review of all cases of children (1874 patients) undergoing direct laryngoscopy and/or bronchoscopy from 1st January 1997 to 9th September 2003 at a tertiary care children's hospital. Patients with endoscopically documented laryngeal foreign bodies were identified and the medical record reviewed in more detail. Patient age, gender, foreign body location, foreign body type, duration of foreign body presence, radiographic findings, endoscopic findings and treatment complications were recorded. RESULTS: One hundred and five aspirated foreign bodies were identified. The nine laryngeal foreign bodies included five clear plastic radiolucent items, two radiolucent food items, and two sharp radioopaque pins. Time to diagnosis and treatment was on average 11.6 days with 17.6 days for thin/plastic foreign bodies and 1.6 days for metal/food foreign bodies. CONCLUSION: Laryngeal foreign bodies represent a small portion of all pediatric airway foreign bodies. Difficulty in identifying laryngeal foreign bodies, especially thin, plastic radiolucent foreign bodies can delay treatment. Thin plastic foreign bodies can present without radiographic findings, can be difficult to image during endoscopy and can be particularly difficult to diagnose. A history of choking and vocal changes is associated with laryngeal foreign bodies. Laryngeal foreign bodies should be in the differential diagnosis of all children presenting with atypical upper respiratory complaints especially if a history suggestive of witnessed aspiration and dysphonia can be obtained.