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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 31-34

Neonatal laryngeal disorders: 12-year experience of a multidisciplinary team


1 Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
2 Department of Laryngology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

Date of Submission17-Mar-2020
Date of Acceptance06-Apr-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Femitha Pournami
Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum - 695 029, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_8_20

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  Abstract 


Background: Anatomical, developmental and functional disorders of the larynx and trachea in neonates are a not so uncommon clinical conundrum that may require confirmation with fibreoptic visualisation. The Level IIIB Neonatal Intensive Care Unit of our referral hospital has been associated with an established laryngology service for several years. Aims: The objective was to study the clinical and videolaryngoscopic findings of neonates who required a laryngology consultation. Patients and Methods: This retrospective descriptive study included all neonates who were referred for laryngology evaluation over a 12-year period from 2006 to 2018. The indications for referral, clinical findings and management essentials were retrieved from electronic medical records. Clinical details of 90 infants are described. Results: The most common need for evaluation was stridor, most of whom were diagnosed to have laryngomalacia. Specific surgical interventions were performed according to diagnoses. Tracheostomy was performed with no complications in 12 infants. The absence of neurological concerns and bronchopulmonary dysplasia increased the chances of successful decannulation in the first 2 years of life. Conclusions: Stridor and laryngomalacia are common grounds for seeking subspeciality cross-consultations. Availability of expertise, trained nursing staff and parent–education programmes can improve outcomes.

Keywords: Endoscopic neonatal laryngeal examination, laryngology service, multidisciplinary care, neonatal laryngeal disorders


How to cite this article:
Upadhyay S, Pournami F, Venkata SK, Rahman S, Nandakumar A, Prabhakar J, Menon JR, Jain N. Neonatal laryngeal disorders: 12-year experience of a multidisciplinary team. Airway 2020;3:31-4

How to cite this URL:
Upadhyay S, Pournami F, Venkata SK, Rahman S, Nandakumar A, Prabhakar J, Menon JR, Jain N. Neonatal laryngeal disorders: 12-year experience of a multidisciplinary team. Airway [serial online] 2020 [cited 2020 Jul 12];3:31-4. Available from: http://www.arwy.org/text.asp?2020/3/1/31/285433




  Introduction Top


The impetus with which neonatal care has progressed is astounding. However, we seem to be hurtling towards the flip side of having to deal with difficult situations. Congenital and acquired airway problems present not only in the outpatient setting but are also sometimes associated with prolonged ventilation, neurological issues and syndromic conditions as well.[1] These cause significant morbidity and may be potentially life-threatening. Confirmation of diagnoses becomes imperative as it is associated with the possible need for prolonged intensive care and definitive surgical therapy. Multidisciplinary care teams seem to be the way forward to help these physically, fiscally and emotionally drained families. Subspeciality expertise in certain fields is not within the bailiwick of every neonatal centre. Our neonatal unit has been fortunate to be allied with a laryngology team with expertise in paediatric care for several years now. We present a retrospective analysis of 90 infants who had endoscopic evaluation of the upper airway for various reasons over 12 years. Descriptions of their clinical findings, management strategies and a focused review of literature hopes to enhance the educative value of our case series. The reasons for which these neonates were referred for evaluation and the spectrum of identified laryngeal aetiology are described. We also emphasize our ability to provide comprehensive diagnostic and therapeutic care owing to a multidisciplinary approach.


  Methods Top


All neonates requiring a laryngology consultation and fibreoptic upper airway assessment over a 12-year period between January 2006 to December 2017 were identified from the electronic medical records. Details of the investigations, clinical diagnosis and management strategies employed were systematically analysed.


  Results Top


A total of 90 neonates underwent flexible fibreoptic videolaryngoscopy for suspected upper airway disorder. Videolaryngoscopy was performed by the laryngology team on neonates in the awake state under topical nasal anaesthesia. In intubated infants, if deemed necessary and safe, the examination was carried out under close cardiorespiratory monitoring after extubating and placing the infant on transient noninvasive breathing support. These infants were reintubated promptly as dictated by the clinical condition soon after the examination. Laryngoscopy examination did not result in destabilisation or adverse events in any infant.

The most common symptom warranting upper airway assessment was stridor [Table 1]. Thirty percent of examinations (27/90) were reported normal. Laryngomalacia was confirmed in 22% (20/90) of infants [Table 2]. While surgical intervention was required in 21% of neonates, tracheostomy was performed in 12 infants. Clinical information of all infants was available for analysis up to 2 years of age. Five infants expired before 2 years of age. Beyond this age, follow-up data of survivors could be obtained for only 51% (44/85) of children who had a laryngology examination in the neonatal period [Table 3].
Table 1: Indications for laryngology consultation and videolaryngoscopy (n=90)

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Table 2: Videolaryngoscopy findings and interventions done

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Table 3: Follow up details of survivors beyond 2 years of age (n=44)

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The families of infants who required tracheostomy were counselled over several sessions before informed and joint decision was made. The parents were involved in the care process soon after the procedure. They were trained by a team constituted by specially privileged nursing staff, laryngology consultants and neonatal intensivists regarding tube and stoma care, suction using portable foot suction machines, detection of mucus blocks, reinsertion of tubes and basic life support measures in emergency situations. Before discharge from hospital, a primary care physician in proximity to the home of each infant was identified and alerted for any emergent care.

Complications of tracheostomy were uncommon. Local site infection occurred in one baby. Decannulation and removal of tracheostomy was possible by 2 years of age in five out of 12 babies. The remaining infants had coexistent neurological problems or bronchopulmonary dysplasia.


  Discussion Top


'Abnormal sounds’ during breathing are a frequent clinical finding. Most cases of noisy breathing may be innocuous and require only routine follow-up.[2] Associated failure to thrive and respiratory compromise creates apprehensions in the family and the physician alike. The phase of respiration and the nature of sounds gives a clinical clue about the anatomical origin of concern. However, further delineation of aetiology and severity needs definitive assessment with laryngoscopy.[3] Rigid scopy gives ample information but is fraught with disadvantages. It requires anaesthesia and does not allow real-time evaluations of vocal cord movements; and variations with swallowing and breathing. Although flexible video-examinations allow only short evaluations with sometimes suboptimal images due to constant movements, they can be done in the awake state with minimal risks.[4] Dynamic examination is possible only with this technique. If conducted by experienced personnel, these images may be recorded for interdisciplinary use and serial monitoring.

The most common cause for the evaluation of the airway in a newborn in our unit was stridor. Laryngomalacia was detected in most. Other authors have reported similar findings.[2] Only five of these infants required surgical intervention. Aryepiglottoplasty and laser intervention are practiced and sometimes preferred.[5],[6] Other disorders such as Pierre Robin sequence, laryngeal webs, haemangiomas and vallecular cysts could be managed by specific interventions [Table 2]. However, in some situations, tracheostomy was warranted. In adults, tracheostomy is considered a stable and protected airway that allows for prolonged ventilation, better tracheal toileting, easier nursing and lesser risks of blocks and airway injuries than endotracheal tubes.[7] In neonates, all the above advantages are negated by potential risks of displacement, obstruction and sudden life-threatening loss of air flow in the respiratory tract. These tribulations make tracheostomies less desirable and are therefore often deferred in neonates.[8] We performed 12 tracheostomies with no procedure-related complications. Unal et al. have reported a case series with hypotonia being the common ground for the procedure.[9] Others described congenital respiratory tract anomalies, obstructing neck masses, subglottic stenosis, Pierre Robin sequence and laryngeal web.[10] Premature infants may also require tracheostomy due to ventilator dependence. Kraft et al. reported requirement of prolonged mechanical ventilation as the indication for tracheostomy in 32.2% of cases.[11]

The incidence of tracheostomy-related adverse events reported in literature is very wide and include early complications such as accidental decannulation, bleeding, mucus plugging, wound infections, pneumothorax and pneumomediastinum.[12] Late complications are tracheal stenosis and granulation tissue formation. We encountered few problems that could be managed conservatively with no adversities.

Schlessel et al. suggested an effective home program for continuity of care.[13] This may be difficult to achieve in resource-limited settings. A smooth transition from hospital to home in our setting may necessitate a team approach centred around the family. Steadfast and relentless motivation from the medical team during hospital care may ensure optimal ongoing care following discharge. A systematic discharge checklist and structured follow-up visits could create a smooth segue.

Approximately half of our infants could be decannulated successfully in the first 2 years of life. The presence of a serious comorbidity such as hypoxic ischaemic encephalopathy, congenital neuromuscular disorders and bronchopulmonary dysplasia that required prolonged respiratory support made successful decannulation less likely. Although the presence of experienced specialists in laryngology may not be in the wherewithal of every centre, the identification of a referral service may benefit the patient and may aid in definitive diagnoses and treatment of these disorders in neonates.


  Conclusion Top


The upper airway in a neonate can be reliably and safely assessed by specialists using flexible fibreoptic videolaryngoscopy. Laryngomalacia is the most common diagnosis on evaluation. Definitive diagnoses and management are possible. When indicated, tracheostomy is a safe procedure in neonates. Parents could be taught effective care of tracheostomy tube with suitable support from the medical team.

Acknowledgements

We thank Dr Manju Isaac and Dr Ragitha Binu Krishna, Consultants, Department of Laryngology, for their prominent role in evaluation and management of these infants and the staff nurses of Neonatal Intensive Care Unit without whom training of parents in tracheostomy care would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lyons M, Vlastarakos PV, Nikolopoulos TP. Congenital and acquired developmental problems of the upper airway in newborns and infants. Early Hum Dev 2012;88:951-5.  Back to cited text no. 1
    
2.
Landry AM, Thompson DM. Laryngomalacia: Disease presentation, spectrum, and management. Int J Pediatr 2012;2012:753526.  Back to cited text no. 2
    
3.
Sittel C. Pathologies of the larynx and trachea in childhood. GMS Curr Top Otorhinolaryngol Head Neck Surg 2014;13:Doc09.  Back to cited text no. 3
    
4.
Clark CM, Kugler K, Carr MM. Common causes of congenital stridor in infants. JAAPA 2018;31:36-40.  Back to cited text no. 4
    
5.
Toynton SC, Saunders MW, Bailey CM. Aryepiglottoplasty for laryngomalacia: 100 consecutive cases. J Laryngol Otol 2001;115:35-8.  Back to cited text no. 5
    
6.
Venkatakarthikeyan C, Thakar A, Lodha R. Endoscopic correction of severe laryngomalacia. Indian J Pediatr 2005;72:165-8.  Back to cited text no. 6
    
7.
Watters KF. Tracheostomy in infants and children. Respir Care 2017;62:799-825.  Back to cited text no. 7
    
8.
Wood RE. To trach, or not to trach: That is the question. Am J Respir Crit Care Med 2015;192:1414-5.  Back to cited text no. 8
    
9.
Unal S, Bilgin LK, Gonulal D, Akcan FA. Optimal time of tracheostomy in infants. Still a dilemma. Glob Pediatr Health 2015;2:2333794×15569300.  Back to cited text no. 9
    
10.
Durbin CG Jr. Indications for and timing of tracheostomy. Respir Care 2005;50:483-7.  Back to cited text no. 10
    
11.
Kraft S, Patel S, Sykes K, Nicklaus P, Gratny L, Wei JL. Practice patterns after tracheotomy in infants younger than 2 years. Arch Otolaryngol Head Neck Surg 2011;137:670-4.  Back to cited text no. 11
    
12.
Pereira KD, MacGregor AR, Mitchell RB. Complications of neonatal tracheostomy: A 5-year review. Otolaryngol Head Neck Surg 2004;131:810-3.  Back to cited text no. 12
    
13.
Schlessel JS, Harper RG, Rappa H, Kenigsberg K, Khanna S. Tracheostomy: Acute and long-term mortality and morbidity in very low birth weight premature infants. J Pediatr Surg 1993;28:873-6.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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