Laryngeal stenosis in children

Acute inflammatory stenosis of the larynx is a common and severe childhood disease that requires emergency intensive care.

The main cause is respiratory infections, especially influenza and parainfluenza, which in 5-10% of cases are accompanied by stenosing laryngitis or laryngotracheitis.

The clinical picture of acute laryngitis and laryngotracheobronchitis with laryngeal stenosis depends on the degree of stenosis, its localization, length, speed of development, nature of inflammation and its prevalence. The course of laryngitis and laryngotracheitis is significantly influenced by the premorbid background, severity of the underlying disease, presence and nature of complications.

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Symptoms and degrees of laryngeal stenosis

Laryngeal stenosis grade I (compensated stenosis)

Clinically manifested by noisy breathing during inhalation, slight prolongation of inhalation with shortening of the pause between inhalation and exhalation. When the child is restless, moderate retraction of the pliable parts of the chest, slight cyanosis of the nasolabial triangle, and flaring of the wings of the nose appear. The child's voice is hoarse, less often clear. Laryngitis usually occurs as a catarrhal, less often purulent inflammation. The lumen of the subglottic larynx is narrowed by 1/4-1/3.

Laryngeal stenosis grade II (subcompensated stenosis)

Characterized by signs of incomplete compensation of the respiratory function. Patients are agitated, sometimes lethargic and capricious. Noisy breathing with retraction of the pliable parts of the chest, flaring of the wings of the nose, tension of the neck muscles. Movements of the larynx are noticeable synchronously with inhalation and exhalation. The voice is hoarse. The cough is rough. The skin is moist, pinkish or pale, the nasolabial triangle is cyanotic. Tachycardia is characteristic, sometimes the pulse wave drops out in the inhalation phase. These signs become more pronounced when the stenosis lasts more than 7-8 hours. The lumen of the subglottic cavity of the larynx is narrowed by 1/2.

Laryngeal stenosis grade III (decompensated stenosis)

The patient's condition is serious. Anxiety, fear, or apathy are noted. Inspiratory dyspnea with prolonged inspiration accompanied by stenotic (laryngeal) noise, sharp retraction of the supraclavicular and suprasternal fossae, epigastric region, and intercostal spaces are noted. Maximum downward (during inspiration) and upward (during expiration) excursions of the larynx are noted, with no pause between inspiration and expiration. The skin is pale, covered with cold sticky sweat, there is cyanosis of the nasolabial triangle, lips, and distal phalanges. The pulse is rapid, weak, there is a loss of the pulse wave in the inspiration phase, hypotension, and muffled heart sounds. With ongoing stenosis, these symptoms become more pronounced over a short period of time, breathing is shallow and rapid, a grayish tint of the skin of the face appears, and the lips, tip of the nose, and fingers become cold. The pupils dilate. Laryngoscopy reveals a narrowing of the lumen of the subglottic cavity of the larynx by almost 2/3.

Laryngeal stenosis grade IV (asphyxia)

The child's condition is extremely serious, cyanosis is pronounced, the skin is pale gray. Consciousness is lost, the temperature is low, the pupils are dilated, convulsions, involuntary urination, feces may occur. Breathing is frequent, very shallow or intermittent, with short pauses followed by a deep breath or rare attempts to inhale with retraction of the sternum, epigastric region. Respiratory noises in the lungs are barely audible. A decrease in cardiovascular activity is noted - hypotension, muffled heart sounds, tachycardia or bradycardia (the most ominous sign), thready pulse. Often, the pulse in the peripheral vessels is not determined. These phenomena precede cardiac and respiratory arrest. The lumen of the subglottic cavity of the larynx is narrowed by more than 2/3.

In acute inflammation of the larynx, in most cases, stenosis is caused by three factors simultaneously: organic narrowing (inflammatory edema), functional factors (spasm of the laryngeal muscles) and accumulation of inflammatory exudate. Sometimes, significant stenosis can be associated with obstruction of the lumen of the larynx, trachea with purulent discharge, fibrinous films and crusts against the background of edematous, infiltrative narrowing of I-II degree. In such cases, after laryngoscopic or laryngotracheobronchoscopic sanitation, breathing is restored or significantly improved.

Classification of acute laryngeal stenosis

Depending on the localization of the inflammatory process, a distinction is made between:

• epiglottitis,
• supraglottic laryngitis,
• subglottic laryngitis,
• laryngotracheitis,
• laryngotracheobronchitis

Forms by the nature of inflammation:

• catarrhal,
• fibrinous,
• purulent,
• ulcerative necrotic,
• hemorrhagic,
• herpetic,
• mixed.

Course of the disease:

• sharp,
• subacute,
• protracted,
• complicated.

Degree of laryngeal stenosis

• I - compensated stenosis,
• II - subcompensated stenosis,
• III - decompensated stenosis,
• IV - asphyxia.

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Diagnosis of laryngeal stenosis in children

Diagnosis of acute laryngeal stenosis is based on anamnesis data, clinical picture of the disease and examination of the larynx. It is necessary to specify in detail the initial symptoms, time and circumstances under which they appeared, the dynamics of development and nature (wave-like, paroxysmal, constant, progressive). During examination, attention is paid to the external clinical manifestations of stenosis - difficulty breathing, retraction of pliable areas of the chest, voice change, cough, presence of cyanosis.

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Treatment of laryngeal stenosis in a child

I degree (compensated stenosis)

• Inhalation through a nebulizer (ipratropium bromide 8-20 drops 4 times a day).
• Stay in a steam-oxygen tent for 2 hours 2-3 times a day.
• Fractional alkaline inhalations.
• Warm alkaline drink.
• Fenspiride 4 mgDkgxut) orally.
• Mucolytics (ambroxol, acetylcysteine).
• Antihistamines in age-appropriate doses.
• Bronchodilators (aminophylline tablets).
• Stimulates cough.

II degree (subcompensated stenosis)

• Infusion therapy taking into account enteral loads (100-130 ml/kg) glucose-salt solutions (10% glucose solution, 0.9% sodium chloride solution), glucose-novocaine mixture (10% glucose solution + 0.25% novocaine solution in a ratio of 1:1 at the rate of 4-5 ml/kg).
• Warm alkaline drink.
• Antihistamines: chloropyramine at a daily dose of 2 mg/kg in 2-3 doses intramuscularly or intravenously, clemastine at a daily dose of 25 mcg/kg in 2 doses intramuscularly or intravenously.
• Hormone therapy: prednisolone at a dose of 2-5 mg/kg intramuscularly or intravenously every 6-8 hours, hydrocortisone 10 mg/kg intramuscularly every 6-8 hours, Ingacort (beclomethasone, ipratropium bromide) via a nebulizer. It should be noted that the effectiveness of hormone therapy has not been proven.
• Antibacterial therapy: aminopenicillins, cephalosporins of the II-III generation intramuscularly.
• Stay in a steam-oxygen tent for 6-8 hours with an interval of 1.5-2 hours.
• Mucolytics for oral and inhalation use
  • Ambroxol (orally)
    • children under two years of age, 2.5 ml 2 times a day,
    • 2-6 years - 2.5 ml 3 times a day,
    • 6-12 years - 5 ml 2-3 times a day,
    • 12 years and older - 10 ml 3 times a day
  • Acetylcysteine (orally)
    • up to 2 years - 50 mg 2-3 times a day,
    • 2-6 years - 100 mg 4 times a day,
    • 6-14 years - 200 mg 2 times a day,
    • over 14 years old - 200 mg 3 times a day.
• Stimulation of cough and removal of secretions from the larynx using electric suction.

III degree (decompensated stenosis)

• Hospitalization or transfer to the intensive care unit.
• Direct laryngoscopy followed by nasotracheal intubation.
• Stay in a steam-oxygen tent until respiratory failure is relieved.
• Continuation of therapy corresponds to the treatment of grade II laryngeal stenosis.

IV degree (asphyxia)

• Resuscitation measures.