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Zalzal & Zalzal

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Patients will also have low-grade fever with negative blood cultures and normal white blood cell counts. Radiographic evaluation will show subglottic narrowing. The condi tion presents mostly in children 6 to 24 months of age and usually is preceded by an upper-respiratory infection. Therapy is mostly supportive care with humidification and nebulized racemic epinephrine. Children with recurrent croup in the setting of repeated hospitalizations and history of endotracheal intubation should undergo workup by an otolaryngologist for underlying anatomic abnormality. 4 Epiglottitis is another bacterial inflammation of the larynx, typically caused by Hae mophilus influenzae type B, that usually occurs in children 3 to 6 years of age during the winter season. Thankfully, the incidence of epiglottitis in children has been reduced dramatically because of the widespread use of the H influenzae vaccine and is rarely seen in the neonatal age group. 4,28,37 Foreign Body Although not a congenital condition, foreign body obstruction should be considered an acute cause of stridor. Aspiration is most common between the ages of 1 to 3 years old. Foreign body obstruction in the postcricoid space and esophagus can also result in airway compromise owing to tracheal compression, typically producing a biphasic stridor. Patient history typically follows an episode of choking after placement of food or foreign body in the mouth, followed by gagging or wheezing alongside hoarseness, stridor, or complete airway obstruction. In situations of unwitnessed aspiration or mild symptoms, a delayed presentation may occur with cough, fevers, malaise, and signs of pneumonia. Definitive treatment involves operative extraction with direct laryngos copy and rigid bronchoscopy. Laryngomalacia resolves with conservative management for most children, and the vast majority will not need operative intervention. Routine follow-up to monitor symptoms is adequate to prevent adverse developments, such as worsening stri dor or BRUEs. Most patients will improve in some fashion before 12 to 18 months of age. Medications to manage acid reflux have been helpful in conservative manage ment. 34 Acid suppression therapy, consisting of either a histamine receptor blocker or a proton-pump inhibitor, has been linked to improved stridor, reduced respiratory distress, and a shorter symptom course. 5,10 Recently, safety concerns regarding the link of acid reflux medication to cancer and dementia have arisen in the literature, but studies linking short courses of the medication with adverse effects in children have not been established. 38,39 Discussions with both the parent and the primary care provider should occur before starting acid reflux medication for long-term treat ment of laryngomalacia owing to these safety concerns. At the time of this writing, famotidine has been the therapy of choice for treatment of children with reflux. Surgical Treatment Up to 10% of children with laryngomalacia will require surgical management because of severe disease. If not treated promptly, complications, such as apnea, feeding dif ficulties and failure to thrive, cor pulmonale, and even death, may occur owing to un treated respiratory obstruction. Historically, these children were treated with tracheotomy for most of the twentieth century, and this procedure may still be neces sary depending on there being an underlying neurologic component. 4 MANAGEMENT OF LARYNGOMALACIA Conservative Management

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