Laryngeal foreign bodies in children: first stop before the right main bronchus

Laryngeal foreign bodies may produce either complete or incomplete airways obstruction. In complete airways obstruction the presentation is with calamitous respiratory difficulty. However incomplete laryngeal obstruction may present with less severe symptoms, resulting in possible misdiagnosis and confusion with other causes of upper airway obstruction such as infectious croup. This report describes three cases of incomplete laryngeal obstruction secondary to inhaled foreign bodies. In each case, the diagnosis of an inhaled foreign body was initially missed, resulting in delay in diagnosis and in one case prolonged recovery. The importance of considering laryngeal foreign bodies, both in cases of suspected foreign body inhalation and clinical cases of incomplete laryngeal obstruction are discussed.     

Evaluation and management of upper airway obstruction

This review provides an overview of acute and chronic upper airway obstruction. Glottic or subglottic obstruction affects the airway when it is a single channel. This is potentially life-threatening and presents with stridor and/or respiratory distress. Supraglottic airway obstruction generally affects the nasal or nasopharyngeal airway and tends to predominantly affect breathing during sleep. There are a number of different causes for each of these clinical problems.In acute glottic or subglottic obstruction, management consists of a rapid assessment and the establishment of a secure airway when the obstruction is life-threatening. Thereafter the management will be targeted on the underlying condition. In supraglottic airway obstruction it is important to recognize that symptoms may be subtle and a high index of suspicion is needed, particularly when there are co-morbidities which make sleep-disordered breathing more likely. In severe supraglottic obstruction causing significant sleep-disordered breathing adenotonsillectomy is usually the treatment of choice, but other measures including non-invasive continuous positive airway pressure (CPAP) or ventilation may be necessary if this is unhelpful.     

Successful stenting for Budd–Chiari syndrome after pediatric liver transplantation: a case series and review of the literature

Hepatic venous outflow obstruction, known as Budd–Chiari syndrome, is a rare but serious complication of orthotopic liver transplantation and may lead to graft loss. Our aim was to describe a single center experience of percutaneous interventional management of hepatic outflow obstruction post liver transplantation in children. Three children with post-transplant hepatic venous outflow obstruction were treated successfully with percutaneous stent placement. This resulted in long-term resolution of symptoms and was superior to balloon angioplasty both in our series and in cases reported in the literature. Stenting may be the treatment of choice for hepatic venous obstruction after pediatric liver transplantation, particularly if there is a recurrence of stenosis after balloon dilatation.     

Meconium obstruction of prematurity

Meconium obstruction of prematurity is an entity primarily affecting very low birthweight or extremely low birthweight babies causing low intestinal obstruction. Its presence may at best delay establishment of enteral feeding and compromise nutrition and at worst lead to mechanical obstruction requiring surgery or to intestinal perforation. There are considerable challenges in the recognition, diagnosis and management of this condition. Awareness of the disease and understanding of its pathogenesis may lead to early detection of affected babies and allow proactive measures to decrease the associated morbidity and mortality.     

Visualization of pulmonary vein obstruction by pulmonary artery wedge injection

Summary One of the major postoperative complications of total anomalous pulmonary venous connection is obstruction of the pulmonary veins. This event may be apparent immediately after surgery when it is usually due to congenitally obstructed veins or later when it may be the result of failure of commensurate growth of the left atrium-common vein anastomosis or of scarring at the anastomotic site. The exact location of the obstruction becomes, then, of paramount importance in deciding if the patient can be helped by further surgery. At cardiac catheterization, pulmonary artery wedge injection was the only angiographic technique that visualized the site and degree of pulmonary venous obstruction in the case reported here.     

Neonatal nasal obstruction]

Because neonates are obligate nose breathers, neonatal nasal obstruction may have serious consequences. Prompt diagnosis and appropriate treatment are essential to avoid severe hypoxia. The most common cause of neonatal nasal obstruction is rhinitis. However, it is essential to first rule out anatomical causes such as choanal atresia and stenosis, pyriform aperture stenosis, traumatic deformation or tumors, as these conditions may be life-threatening and require prompt surgical treatment.     

Upper airway obstruction

The airways in infants and children are anatomically different from adults, thus predisposing them to more acute upper airway obstruction. The causes of upper airway obstruction may be infective or non-infective. The presence of dysphonia, dysphagia, abnormal respiratory pattern, cough and abnormal posture suggests upper airway obstruction. The general management consist of supportive care with minimal invasive procedures. The specific treatment depends on the causes and is discussed in text.     

Assessment of pulmonary mechanics and breathing patterns during posturally induced glossoptosis in infants.

Respiratory mechanics were studied in nine infants with glossoptosis-apnoea syndrome to determine whether glossoptosis may account for signs of both inspiratory and expiratory airway obstruction. Airflow, oesophageal pressure, inspiratory and expiratory time (Ti and Te), and inspiratory and expiratory resistance (Ri and Re) were measured before and during ventilatory phases characterised by glossoptotic pharyngeal obstruction, induced by turning the infants onto their backs. In addition, an attempt was made to correlate the abnormalities in pulmonary mechanics with the clinical features. During partial glossoptotic pharyngeal obstruction, a significant increase was observed in Te and Re and variable changes in Ti and Ri. During severe obstruction, the infants displayed obstructed inspiratory efforts often associated with stridor, as well as obstructed expiratory efforts often associated with audible grunting and retarded expiratory flow pattern. The expiratory grunt was loudest over the neck and mimicked bronchospasm over the chest. These findings indicate that glossoptotic pharyngeal obstruction induces functional airway obstruction which may affect both inspiration and expiration. Expiratory airway obstruction seems, at least in part, to be due to active braking of expiratory flow.     

Nasal obstruction in the neonate and infant.

The neonate is a preferential nasal breather; therefore, nasal obstruction in the neonatal period may cause significant sequelae. Although the uncommon choanal atresia is the main condition to be excluded, many other possible causes exist. A systematic approach to the workings of nasal obstruction in the neonate and infant is outlined so that appropriate management can be instituted.     

Assessment of pulmonary mechanics and breathing patterns during posturally induced glossoptosis in infants

Respiratory mechanics were studied in nine infants with glossoptosis-apnoea syndrome to determine whether glossoptosis may account for signs of both inspiratory and expiratory airway obstruction. Airflow, oesophageal pressure, inspiratory and expiratory time (Ti and Te), and inspiratory and expiratory resistance (Ri and Re) were measured before and during ventilatory phases characterised by glossoptotic pharyngeal obstruction, induced by turning the infants onto their backs. In addition, an attempt was made to correlate the abnormalities in pulmonary mechanics with the clinical features. During partial glossoptotic pharyngeal obstruction, a significant increase was observed in Te and Re and variable changes in Ti and Ri. During severe obstruction, the infants displayed obstructed inspiratory efforts often associated with stridor, as well as obstructed expiratory efforts often associated with audible grunting and retarded expiratory flow pattern. The expiratory grunt was loudest over the neck and mimicked bronchospasm over the chest. These findings indicate that glossoptotic pharyngeal obstruction induces functional airway obstruction which may affect both inspiration and expiration. Expiratory airway obstruction seems, at least in part, to be due to active braking of expiratory flow.     

Endoscopic antireflux surgery leading to obstruction in pediatric renal transplant patients

To describe a multicenter experience with management of ureteral obstruction after injection of Dx/HA for VUR in pediatric renal transplant patients. The records of all pediatric renal transplant patients who underwent Dx/HA injection for VUR and had subsequent obstruction were identified, and the management and outcomes were reviewed. Follow‐up ranged from 1 to 10 years. There were four patients identified, all of whom had a history of rising creatinine, recurrent UTI, and increasing hydronephrosis which led to the diagnosis of high‐grade VUR. Obstruction was diagnosed within 24‐72 hours after injection in three patients. One patient was asymptomatic, and rising creatinine and hydronephrosis were noted 1 month after injection. One patient was managed expectantly, while three patients underwent ureteral stent placement. After the stent was removed, one patient went on to open reimplant due to delayed obstruction, the second patient with voiding dysfunction is currently managed with an indwelling ureteral stent and may require further definitive surgery, the third patient recovered, and the fourth is being observed. Our cases illustrate that despite initial successful management of the obstruction in some, delayed obstruction is possible and may necessitate open reimplant. It is imperative that these patients have close follow‐up after Dx/HA.     

Fetal lower urinary tract obstruction

Fetal lower urinary tract obstruction affects 2.2 per 10 000 births. It is a consequence of a range of pathological processes, most commonly posterior urethral valves (64%) or urethral atresia (39%). It is a condition of high mortality and morbidity associated with progressive renal dysfunction and oligohydramnios, and hence fetal pulmonary hypoplasia. Accurate detection is possible via ultrasound, but the underlying pathology is often unknown. In future, magnetic resonance imaging (MRI) may be increasingly used alongside ultrasound in the diagnosis and assessment of fetuses with lower urinary tract obstruction. Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear. It is now possible to decompress the obstruction in utero via percutaneous vesico-amniotic shunting or cystoscopic techniques. In appropriately selected fetuses intervention may improve perinatal survival, but long-term renal morbidity amongst survivors remains problematic.     

Long-term renal and neurodevelopmental outcome in infants with LUTO, with and without fetal intervention

Congenital lower urinary tract obstruction (LUTO) is a heterogeneous group of pathologies, the most common being posterior urethral valves (PUV) or urethral atresia. The bladder neck obstruction in utero leads to a spectrum of disease including mild oligohydramnios with normal renal function to a picture of severe oligohydramnios associated with chronic obstructive macro/microcystic renal parenchymal disease leading to chronic renal impairment. These anomalies may be isolated or complex; the latter being associated with other structural or chromosomal abnormalities. If isolated, the congenital bladder neck obstruction may be amenable to in-utero therapy. In a significant proportion of babies affected by LUTO there is severe oligohydramnios (occurring before 20 weeks gestation) and associated with pulmonary hypoplasia, a scenario almost always associated with perinatal death. For those babies that survive the perinatal period there is a significant risk of renal impairment, often necessitating renal dialysis or transplantation in childhood. In addition, there may be other morbidities such as chronic filling anomalies of the bladder that may require treatment.     

Meconium diseases in infants with very low birth weight

Retained meconium resulting in intestinal obstruction in infants with very low birth weight (VLBW) may cause significant morbidity and even mortality. Immature intestinal neuromuscular function, abnormal meconium composition, and maternal magnesium sulfate therapy results in delay of first meconium passage. This "normal" passage of first meconium may not occur until 1 week of life or later. A spectrum of conditions results from this delayed passage. At the most serious end of this continuum is intestinal obstruction. These patients present with abdominal distension, emesis, and reduced stool frequency. Early diagnosis of this condition using plain abdominal radiographs and contrast enemas where appropriate is imperative. Contrast enemas may be both diagnostic and therapeutic. Most patients do not need surgical intervention. Operation is indicated when enemas fail to relieve the obstruction or perforation occurs. Prompt diagnosis and appropriate management results in a good outcome. Meconium obstruction in VLBW infants does not appear to be associated with cystic fibrosis or Hirschsprung's disease.     

Disaccharidase activities and intestinal absorption in infants with congenital intestinal obstruction

The results of studies on disaccharidase activities and on intestinal absorption in cases of complete and incomplete congenital small bowel obstruction are presented. Assays of the activities of maltase, isomaltase, sucrase, trehalase, and lactase have been performed on biopsy specimens taken at the time of surgery. In specimens taken from above the site of obstruction, the activities are reduced for all disaccharidases, and are particularly low for trehalase and lactase. There was no difference between the cases with complete and incomplete obstruction. Distal to a complete obstruction, trehalase and lactase were reduced, whereas in cases of incomplete obstruction, the activities of all disaccharidases were within what is considered normal in the reference material. Two months after surgery, the disaccharidase activities were found to be normal. One month after surgery, the absorption of glucose and vitamin A was markedly impaired in cases with complete obstruction, whereas that of D-xylose was not significantly reduced from normal. In cases with incomplete obstruction, the results did not differ from those found in normal infants. The fact that failure to thrive is common during the first months after birth in patients with congenital intestinal atresia, even when surgery is successful, may be explained by deficient intestinal absorption, particularly in patients with complete obstruction.     

Acute infectious upper airway obstructions in children

There are numerous causes of acquired acute upper airway obstructions in children but most are secondary to infections, foreign bodies, and trauma. Recognizing impending airway obstructions is important because cardiopulmonary arrest rarely is a sudden event but rather follows a progressive deterioration in respiratory function. From an anatomic perspective, acute obstructions may present in the pharyngeal or laryngeal regions. In the pharynx, fascial layers create several potential peritonsillar, parapharyngeal, and retropharyngeal spaces that may accommodate abscess formation. Within the larynx and lower airways, small changes in radius dramatically affect the resistance to flow as described by Poiseuille's law, allowing for small amounts of inflammation to cause significant obstruction. The clinical presentation of acute upper airway obstruction will depend on the degree and location of the obstruction. Therapy is aimed primarily at maintaining a patent airway and prescribing appropriate antimicrobials.     

Colonic diverticulitis causing partial bowel obstruction in a child with cystic fibrosis

Children and adolescents with cystic fibrosis (CF) may manifest bowel pathology with resulting bowel obstruction. Recognized causes of bowel obstruction in CF patients include meconium ileus, intussusception, distal intestinal obstruction syndrome and postoperative adhesions. Additionally, the development of colonic strictures in children with CF has recently been described. We report an unusual cause of partial obstruction of the ascending colon in a child with CF due to pathologically proven diverticulitis. Received: 17 March 1997 Accepted: 24 July 1997     

Megacystis with an anterior urethral valve: Case report and review of literature

Fetal megacystis, an abnormally enlarged bladder identified at any gestational age, may be transient and resolve spontaneously or may be an early manifestation of bladder outlet obstruction. Anterior urethral valves are the most common cause of the rare condition of congenital obstruction of the anterior urethra. Herein is reported the prenatal observation and postnatal management of a case of megacystis with anterior urethral valves. The etiology is reviewed and strategies recommended for patients with these rare entities.     

Extraordinary cause of complete colonic obstruction in children: Urinary retention

Complete colonic obstruction in children may occur secondary to congenital, and acquired factors related to the gastrointestinal system. Herein, we report an extraordinary presentation of complete colonic obstruction due to extensive urinary retention in a 3‐year‐old boy. The possible underlying mechanism was detected as urinary infection in a child with horseshoe kidney. The treatment of the bladder symptoms and urinary infection relieved the obstruction of the colon. To our knowledge, especially in children, colonic obstruction due to urinary retention has not been reported in the literature.