1/445. Understanding airway disease in infants. Large airway diseases manifest in ways distinct from those of small airway diseases. Noisy breathing that begins early in life suggests a congenital lesion of the large airways. The findings of elevated respiratory rate, in conjunction with subcostal retractions, hyperinflation to percussion, and musical wheezes, are diagnostic of small airway obstruction. Differentiating large from small airway disease is crucial, because each disease has a distinct diagnosis, and treatment of the 2 disease types can be quite different. When these principles are applied to a patient with wheezing or other signs of airway compromise, it becomes fairly easy to differentiate large from small airway disease. The treatment of patients with large airway disease can be substantially different from that of patients with small airway disease. Being able to differentiate the two is critically important. With the use of the history, physical examination, and radiographic evaluations described earlier, nearly every patient can be given an accurate diagnosis and treated appropriately. ( info) |
2/445. Forced expiratory wheezes in a patient with dynamic expiratory narrowing of central airways and an oscillating pattern of the flow-volume curve. Forced expiratory wheezes (FEW) are common and the pathogenesis of this phenomenon might involve fluttering of the airways, but this theory has not been confirmed in patients. We report a case of a patient with FEW and a normal FEV1 that showed a bronchoscopically confirmed collapse of the trachea and main stem bronchi during forced expiration. Superimposed to the flow-volume curve was an oscillating pattern with a frequency that corresponded well with the wheeze generated during forced expiration. The oscillating pattern in the flow-volume curve and the collapse of the major airways supports the theory of wheezes generated by fluttering airways during forced expiration. Although FEW may be found also in healthy subjects, flow limitation is essential for the generation of FEW. The inclusion of a forced expiratory maneuver in the clinical examination might therefore be helpful in guiding the diagnosis towards airways obstruction. ( info) |
| herpes simplex virus (HSV) infection in the neonatal period may be confined to the eyes, skin and upper aerodigestive tract or may be widely disseminated to other organs, with particular recognition of involvement of the central nervous system (CNS) causing herpes encephalitis (Whitley et al., 1980a, b; Andersen, 1987). Primary laryngeal HSV infection is extremely uncommon. We present a case of acute neonatal stridor secondary to such localized disease and discuss its management. ( info) |
4/445. Double epiglottis in Weyer's acrofacial dysostosis. While evaluating a 61-year-old patient for stridor we incidentally detected a double epiglottis. The patient was also diagnosed of having Weyer's acrofacial dysostosis which is characterized by hexadactyly affecting all four extremities, small and deeply set nails, dental deformities with small, conical teeth and mandibular hypoplasia. The double epiglottis was not the cause for the stridor. Because of the covert symptomatology of double epiglottis it is suggested that the association with Weyer's syndrome is common. Embryological evidence and a review of the literature on laryngeal abnormalities is discussed. ( info) |
5/445. Psychogenic stridor: a cause of acute upper airway obstruction. A 17-year-old boy was seen in the emergency department with signs and symptoms of acute upper airway obstruction, closely resembling epiglottitis. Immediate management consisted of induction of general anesthesia with spontaneous ventilation. Because no organic pathologic process was found, and in combination with subsequently known psychosocial stressors, a diagnosis of psychogenic stridor, a conversion disorder, was made. Conversion disorders may be seen by the busy family practitioner or pediatrician and are frequently underdiagnosed. ( info) |
| Antileukotriene drugs are new therapeutic agents that have recently been approved for the treatment of asthma. Several cases of eosinophilic conditions including churg-strauss syndrome have been reported to be associated with zafirlukast, a cysteinyl leukotriene type 1 receptor antagonist. So far no other leukotriene modifier has been associated with the syndrome. The case history is presented of a man with allergic rhinitis and asthma who had received intermittent pulse therapy with oral corticosteroids. pulmonary eosinophilia developed while he was receiving treatment with montelukast, a chemically distinct cysteinyl leukotriene type 1 receptor antagonist. After discontinuation of montelukast therapy and administration of systemic corticosteroids the patient's symptoms reversed rapidly and there was prompt resolution of the pulmonary infiltrates. We believe that cysteinyl leukotriene type 1 receptor antagonists are safe and effective drugs for most patients with asthma but caution is needed for those with more severe disease who require systemic corticosteroids, especially if they show characteristics of the atypical allergic diathesis seen in the prodromal phase of churg-strauss syndrome. ( info) |
7/445. An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease). Stridor is a noisy breathing caused by compromised airway in the larynx and trachea. The causes can either be due to intrinsic or extrinsic compression. Stridor resulting from extrinsic compression due to anterior cervical osteophytes is rare. We report an unusual case of acute stridor due to an osteophytic mass in the cervical vertebrae resulting in a mechanical upper airway obstruction. The underlying pathology was Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH). Stridor is a rare manifestation of DISH and it certainly represents the most life-threatening one. Only a few cases have been reported in the English literature and are mainly secondary to impaired function of the vocal folds, or postcricoid ulceration and oedema. We present such a case, in that stridor was the result of direct airway obstruction by the osteophytic mass and an emergency tracheostomy had to be performed to establish an airway. ( info) |
8/445. Stridor in a 6-week-old infant caused by right aortic arch with aberrant left subclavian artery. BACKGROUND: Persistent infant stridor, seal-like cough, and difficulty feeding can be the initial signs of right aortic arch with an aberrant left subclavian artery. This congenital cardiovascular abnormality results in the development of a vascular ring that encircles the trachea and esophagus. methods: A case report is presented that describes the evaluation and care of a 6-week-old male infant whose condition was diagnosed as right aortic arch and aberrant left subclavian artery after he was brought to the family practice clinic with a history of persistent stridor. This case report involved a patient seen in the author's outpatient clinic during a well-child check. Data were obtained from the patient's medical record and review of his radiologic diagnostic tests. medline and Index Medicus literature searches were conducted for the years 1966 to the present, using the key words "stridor" and "vascular ring," with cross-references for earlier articles. RESULTS AND CONCLUSIONS: Persistent or recurrent stridor associated with feeding difficulties should prompt an investigation for a vascular ring. In general, an anteroposterior and lateral neck radiograph and a posteroanterior and lateral chest radiograph are usually the initial diagnostic tests to evaluate stridor. Persistent stridor and new-onset regurgitation of formula in a 6-week-old infant prompted an escalation of the patient's workup to include a barium swallow, which subsequently showed compression of the esophagus caused by a vascular ring. In some cases direct observation with a laryngoscope or bronchoscope might be necessary to determine the cause of stridor. Indications for hospitalization of patients with stridor include stridor at rest, dyspnea, actual or suspected epiglottis, repeatedly awakening from sleep with stridor, a history of rapid progression of symptoms, toxic appearance, and apneic or cyanotic episodes. The primary care provider should be familiar with the evaluation and management for patients with the complaint of persistent or recurrent stridor. ( info) |
9/445. Goitre presenting as an oropharyngeal mass: an unusual finding in the elderly. Thyroid goitre presentation in the neck with extension inferiorly to the mediastinum is well-known. Extension superiorly into the retropharyngeal space is very rare and may be accompanied by change in voice and/or airway compromise. A case is described of a patient with change in voice and mild airway compromise secondary to a goitre presenting in the oropharynx. Computed tomography (CT) and physical findings are discussed with the need to recognize this rare entity. ( info) |
| Acute severe carbon monoxide poisoning is usually easy to recognize and diagnose. However, chronic or less severe exposure may produce more subtle symptoms. We report on a 31/2-year-old girl who was admitted to the hospital several times with acute, life-threatening events, acidosis, and flu-like symptoms. The diagnosis was elusive, but after careful questioning of family members and a home visit, chronic carbon monoxide poisoning was diagnosed. ( info) |