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© Borgis - New Medicine 3/2021, s. 67-70 | DOI: 10.25121/NewMed.2021.25.3.67
Izabela Pilarska1, Piotr Kwast2, Monika Jabłońska-Jesionowska2, *Lidia Zawadzka-Głos2
A complicated case of chronic stridor in an infant – a case study
Złożona przyczyna stridoru u niemowlęcia – opis przypadku
1Students’ Scientific Group of Pediatric Otolaryngology, Medical University of Warsaw, Poland
2Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Stridor wdechowy jest częstym objawem spotykanym u niemowląt, stanowiącym nieraz zarówno powód do niepokoju dla rodziców, jak i wyzwanie diagnostyczne dla lekarzy. Podczas gdy samoistnie ustępująca, zazwyczaj niewymagająca leczenia laryngomalacja stanowi najczęstszą przyczynę stridoru u niemowląt, inne rozpoznania powinny zawsze być brane pod uwagę przy diagnostyce różnicowej. Przedstawiamy przypadek rocznego chłopca ze stridorem, u którego różne metody diagnostyczne sugerowały rozbieżne diagnozy. Początkowe podejrzenie laryngomalacji nie potwierdziło się w badaniu endoskopowym, które ukazało kilka równolegle występujących patologii mogących odpowiadać za objawy pacjenta. Na podstawie całokształtu obrazu klinicznego oraz dodatkowych badań radiologicznych rozpoznano naczyniaka wczesnodziecięcego krtani i włączono leczenie propranololem. Opisywany przypadek podkreśla wyzwania towarzyszące procesowi diagnostycznemu u dziecka ze stridorem.
Summary
Inspiratory stridor is a common symptom in infants that may be both a cause of worry for parents and a diagnostic challenge for clinicians. While laryngomalacia, which often does not require treatment, is the most common cause for stridor, other possible diagnoses should always be taken into consideration. We present a case of a one year old boy with stridor, in which different diagnostic procedures revealed various possible diagnoses. With a history of prematurity and neonatal intensive care treatment the initial suspicion of laryngomalacia was challenged by several parallel findings during airway endoscopy. While subsequent radiological examinations suggested different diagnoses, an infantile hemangioma of the larynx was finally diagnosed and treatment with propranolol was initiated. The described case highlights various challenges of the diagnostic process in an infant with stridor.



Introduction
Inspiratory stridor is a high-pitched sound produced during the inspiratory phase of breathing and is caused usually by an obstruction of the airways at the level of the larynx or trachea. Chronic stridor in infants can be caused by various conditions with laryngomalacia, in which narrowing of the laryngeal lumen occurs on inspiration due to softness of cartilage tissue, being the most common one. In these cases stridor usually resolves spontaneously within several weeks or months, as the cartilages of the larynx develop. Other conditions, however, must always be taken into consideration when stridor is diagnosed. Subglottic laryngeal stenosis is often encountered in children who have been intubated with an endotracheal tube during neonatal period. Congenital lesions of the larynx and trachea such as infantile hemangiomas, laryngeal cysts and laryngeal webs have to be considered. In rare cases an altered course of major blood vessels in the mediastinum also may cause stridor. A prompt and accurate diagnosis is necessary as different diagnoses mandate different forms of treatment.
Case report
We present the case of a one-year-old boy admitted to our Department of Pediatric Otolaryngology for diagnosis and treatment. The main reason for admission was unresolving stridor over the period of nine previous months. The child was born in the 29th week of gestational age by Cesarean section and was initially hospitalized for three months in the Department of Neonatology with respiratory distress syndrome. Over the course of the hospitalization the patient was intubated with an endotracheal tube twice and relied on the endotracheal tube collectively for 9 days. Stridor was first noticed by the parents shortly after discharge home from the hospital, but since the child was gaining weight properly and did not show signs of respiratory distress at home, laryngomalacia was suspected and the child was referred to the otolaryngologist only after the symptoms did not relieve after several months.
On the initial admission to the Department of Pediatric Otolaryngology the main complaints reported by the parents were restless breathing and stridor appearing in various body positions, especially while lying on the left side. The boy regurgitated rarely, choked sporadically while eating and was gaining weight properly. On admission to the Department basic otolaryngological examination did not show any pathology within the neck and pharynx. The child was qualified for endoscopy under general anesthesia. Rigid laryngo-tracheo-bronchoscopy was performed, which showed an asymmetry of the aryepiglottic folds, subglottic stenosis of less than 25% of the airway lumen, a pulsating impression on the anterior wall of the middle part of the trachea, as well as an asymmetry of the main bronchi, with a slight narrowing of the left main bronchus. Flexible videoendoscopy of the larynx was performed in the department as a complimentary method for visualizing the larynx. An oval lesion in the area of the right aryepiglottic fold, covered with pink mucosa was observed (fig. 1).
Fig. 1. Lesion as initially observed in flexible endoscopy
An ultrasound of the larynx was performed, which visualized the lesion found in endoscopy and was described as most likely a laryngeal cyst. Due to the uncertain nature of the lesion subsequent contrast-enhanced computed tomography (CT) scan was performed. It showed an oval lesion 10 x 15 x 20 mm in size, exhibiting strong contrast enhancement, describes as a hemangioma (fig. 2). On the CT scan the diameter of the airway lumen at the height of the lesion was 2 mm. No apparent asymmetry of the main bronchi was described. Both the CT scan and subsequent echocardiography showed no great vessel abnormalities within the neck and mediastinum.
Fig. 2. Contrast-enhanced computed tomography image of the lesion

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Piśmiennictwo
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11. Buckmiller LM, Munson PD, Dyamenahalli U et al.: Propranolol for infantile hemangiomas: early experience at a tertiary vascular anomalies center. Laryngoscope 2010; 120(4): 676-681.
12. Kwast P, Jabłońska-Jesionowska M, Zawadzka-Głos L: Analysis of treatment in patients with infantile hemangioma in the Department of Pediatric Otolaryngology, Medical University of Warsaw. New Med 2016; 4: 107-109.
otrzymano: 2021-07-20
zaakceptowano do druku: 2021-08-12

Adres do korespondencji:
*Lidia Zawadzka-Głos
Klinika Otolaryngologii Dziecięcej Warszawski Uniwersytet Medyczny
ul. Żwirki i Wigury 63A, 02-691 Warszawa
tel.: +48 (22) 317-97-21
laryngologia.dsk@uckwum.pl

New Medicine 3/2021
Strona internetowa czasopisma New Medicine