Stenosis of larynx in children

Acute inflammatory stenosis of the larynx is a frequent and severe disease of childhood, requiring 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 laryngotraheobronchitis with laryngeal stenosis depends on the degree of stenosis, its location, extent, rapidity of development, the nature of inflammation and its prevalence. The flow of laryngitis and laryngotracheitis is significantly affected by the premorbid background, the severity of the underlying disease, the presence and nature of the complications.

[1], [2], [3], [4], [5],

Symptoms and degrees of stenosis of the larynx

Stenosis of larynx of the 1st degree (compensated stenosis)

Clinically manifested by noisy breathing with inspiration, a slight extension of inspiration with a shortening of the pause between inhalation and exhalation. When the child is restless, there is a moderate pull in the supple places of the chest, a slight cyanosis of the nasolabial triangle, swelling of the wings of the nose. The child's voice is hoarse, less often clean. Laryngitis usually proceeds according to the type of catarrhal, less often purulent inflammation. The lumen of the podgotosal larynx is narrowed by 1 / 4-1 / 3.

Stenosis of the larynx of the 2nd degree (subcompensated stenosis)

Characterized by signs of incomplete compensation of respiratory function Patients are excited, sometimes sluggish and capricious. There is noisy breathing with the pull of pliable places of the chest, swelling of the wings of the nose, tension of the neck muscles. Noticeable movements of the larynx are synchronous with the inhalation and exhalation. Voice hoarse Cough coarse Skin wet, pink or pale, nasolabial triangle cyanotic Characteristic tachycardia, sometimes loss of pulse wave in the inspiratory phase. These signs become more pronounced with a duration of stenosis of more than 7-8 hours. The luminal cavity of the laryngeal cavity is narrowed by 1/2.

Stenosis of larynx of the third degree (decompensated stenosis)

The patient's condition is severe. There is anxiety, a sense of fear or apathy. Expressed inspiratory dyspnea with an extended inhalation accompanied by stenotic (guttural) noise, a sharp entraining of the supraclavicular and supragastral pits, epigastric region, intercostal spaces. The maximum excursions of the larynx are noted downwards (with inspiration) and upwards (with exhalation), loss of a pause between inhalation and exhalation Skin covers are pale, covered with cold sticky sweat, cyanosis of nasolabial triangle, lips, nail phalanges is expressed. The pulse is frequent, weak filling, there is a pulse wave in the inspiratory phase, hypotension, deafness of heart sounds. With continued stenosis for a short time, these symptoms become more pronounced, breathing - shallow, frequent, a grayish shade of the skin of the face, a coldness of the lips, the tip of the nose, fingers. The pupils dilate. Laryngoscopically, the narrowing of the lumen of the podgotosal cavity of the larynx is revealed by almost 2/3.

Stenosis of the larynx of the fourth degree (asphyxia)

The condition of the child is extremely severe, cyanosis is expressed, the skin is pale gray. Consciousness is lost, the temperature is lowered, the pupils are dilated, there may be convulsions, involuntary departure of urine, feces. Breathing is frequent, very shallow or intermittent, with short stops followed by a deep breath or rare attempts of inspiration with retraction of the sternum, epigastric region. Breathing noises in the lungs are barely audible. There is a drop in cardiovascular activity of hypotension, deafness of heart sounds, tachycardia or bradycardia (the most formidable symptom), a threadlike pulse. Often the pulse on the peripheral vessels is not determined. These phenomena precede cardiac arrest and respiration. The luminal cavity of the larynx is narrowed by more than 2/3.

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

Classification of acute stenosis of the larynx

Localization of the inflammatory process is distinguished:

• epiglottitis,
• naslozdochny laryngitis,
• liningal lining,
• laryngotracheitis,
• laryngotraheobronchitis

Forms by the nature of inflammation:

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

Course of the disease:

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

Degree of stenosis of the larynx

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

[6], [7], [8], [9], [10],

Diagnosis of laryngeal stenosis in children

Diagnosis of acute stenosis of the larynx is based on history, clinical picture of the disease and examination of the larynx. It is necessary to specify in detail the initial symptoms, the time and circumstances under which they appeared, the dynamics of development and character (wave-like, paroxysmal, permanent, progressive). On examination, attention is drawn to external clinical manifestations of stenosis - shortness of breath, retraction of the pliable areas of the chest, changes in the voice, cough, the presence of cyanosis.

[11], [12], [13],

Treatment of stenosis of the larynx in a child

I degree (compensated stenosis)

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

II degree (subcompensated stenosis)

• Infusion therapy with 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% solution of novocaine in ratio 1 1 from the calculation of 4-5 ml / kg).
• A warm alkaline drink.
• Antihistaminic preparations of chloropyramine in a daily dose of 2 mg / kg in 2-3 injections intramuscularly or intravenously, clemastin daily dose of 25 mcg / kg in 2 doses intramuscularly or intravenously.
• Hormone therapy with prednisolone 2-5 mg / kg intramuscularly or intravenously every 6-8 h, hydrocortisone 10 mg / kg intramuscularly every 6-8 h, inhakort (beclomethasone, ipratropium bromide) through the nebulizer It should be noted that the effectiveness of hormone therapy has not been proven.
• Antibacterial therapy aminopenicillins, cephalosporins II-III generation intramuscularly.
• Stay in the steam-oxygen tent for 6-8 hours with an interval of 1.5-2 hours.
• Mucolytics inside and in inhalations
  • Ambroxol (by mouth)
    • children under two years of 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 (Inside)
    • 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 twice a day,
    • over 14 years - 200 mg 3 times a day.
• Stimulation of cough and removal of the secretion from the larynx by an electro pump.

III degree (decompensated stenosis)

• Hospitalization or transfer to the intensive care unit.
• Direct laryngoscopy followed by nasotracheal intubation.
• Stay in the steam-oxygen tent until the relief of respiratory failure.
• Continuation of therapy corresponds to the treatment of stenosis of the larynx of the second degree.

IV degree (asphyxiation)

• Resuscitative measures.