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Zalzal & Zalzal

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examination for vascular lesions are the primary areas of concern. Breathing of the child should also be noted by the physician in the event of chest retractions (inter costal, sternal, suprasternal, supraclavicular, and subxiphoid), accessory muscle use, flaring of nasal alae, neck hyperextension, and asymmetric chest motion. Integral to evaluating the stridulous patient is the laryngeal examination. Flexible fiber-optic endoscopy to evaluate the nasopharynx and larynx has been invaluable for dynamic functional assessment of the airway in addition to rule out anatomic obstruction. The study is performed in the awake child or infant held in an upright po sition, typically by experienced nursing staff to prevent complications of the proced ure. Topical lidocaine gel is used on all patients to reduce discomfort and pain. Nasal decongestant with topical anesthesia, such as oxymetazoline with lidocaine so lution, can be applied if the nasal cavity is narrow, not allowing scope insertion, and a determination needs to be made if the reason is bony nasal stenosis or just inflamma tion impeding scope access. The fiber-optic endoscope can be attached to a video camera to record the procedure if necessary. The endoscope is then inserted through each side of the nose to assess nasal and choanal patency. Once cleared, the naso pharynx is examined to determine obstruction by the adenoid or congenital abnormal ity. The pharynx is inspected next, looking specifically at tonsillar obstruction or pooling of secretions. The supraglottic larynx is then evaluated alongside the hypo pharynx, specifically evaluating for obstruction along the base of tongue, vallecula, and epiglottis. Dynamic assessment of the supraglottic larynx and the glottic larynx, in association with any stridulous noise, will help in assessing the motion and probable cause of noisy breathing should the larynx be the source. Occasionally, the subglottis and proximal trachea can be evaluated from a supraglottic view. Radiographic studies may be performed to complement clinical examination. Plain film imaging of the anteroposterior and lateral neck are helpful in ruling out but not ac curate in showing subglottic narrowing. Modified barium swallow studies are indicated in patients who have aspiration and concern for laryngeal cleft. During the initial workup for stridor, computed tomography (CT) and MRI scans are not first-line studies unless suspicion of a specific pathologic condition is highly suspected. Operative Assessment Definitive evaluation of the stridulous patient is the operative assessment under gen eral anesthesia with direct laryngoscopy and bronchoscopy ( Table 1 ). Both dynamic and static examination can be performed in the operative suite. Once under light anes thesia, examination of the supraglottic larynx and vocal cords can take place with

Table 1 Ancillary tests during the workup of specific causes of stridor

Neck Airway Films

Airway Fluoroscopy

Barium Swallow

Flexible Endoscopy

Direct Laryngoscopy with Bronchoscopy

Laryngomalacia

1

1

1

11

11

Tracheomalacia

11

Subglottic stenosis 1

1

11

Vascular ring

1

11

11

Laryngeal web

11

11

Laryngeal cleft

1

11

Subglottic

11

hemangioma

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