RESUMO

El estridor corresponde a un signo altamente frecuente, sin embargo, es heterogéneo e inespecífico. Existen múltiples causas conocidas y manejadas por el otorrinolaringólogo. Los quistes subglóticos constituyen una entidad infrecuente de estridor en pediatría, siendo la población más frecuentemente afectada, niños con antecedentes de prematurez e intubación por períodos prolongados. Su manifestación clínica es variada, desde cuadros asintomáticos a pacientes con riesgo inminente de pérdida de la vía aérea. El diagnóstico suele ser tras largos períodos desde el antecedente de intubación. Su resolución suele ser quirúrgica, teniendo como principal complicación asociada la estenosis subglótica y las recurrencias. Se presenta el caso de una preescolar con un episodio de estridor y distrés respiratorio rápidamente progresivos, cuyo diagnóstico intraoperatorio resultó en quistes subglóticos submucosos bilaterales, que requirieron resolución quirúrgica.

Stridor corresponds to a highly frequent sign; however, it is heterogeneous and nonspecific. There are multiple causes that are widely known and managed by the otorhinolaryngolo-gist. Subglottic cysts are an infrequent entity of stridor in pediatric patients, where the most frequently affected population are childrens with history of prematurity and intubation for long periods. It's clinical manifestations are wide, from asymptomatic cases to patients with imminent risk of airway loss. Their manifestation its often after long periods after the moment of intubation. The management often involves surgery, and the main associated complication is subglottic stenosis and recurrences. We present the case of a preschool girl with an episode of rapidly progressive stridor and respiratory distress; whose intraoperative diagnosis was bilateral subglottic submucosal cysts that required surgical resolution.

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Abstract Objective To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. Method Children who required endotracheal intubation for >24 h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. Results A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72 h or starting more than 72 h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). Conclusions Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72 h or started more than 72 h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72 h following extubation.

Resumo Objetivo Analisar a precisão do estridor em comparação com o exame endoscópico no diagnóstico de estenose subglótica pós-intubação em crianças. Método Foram incluídas neste estudo de coorte prospectivo crianças que necessitaram de intubação endotraqueal por mais de 24 horas. Elas foram monitoradas diariamente e submetidas à nasofibrolaringoscopia flexível após a extubação. As crianças com anomalias moderadas foram submetidas a outro exame sete a 10 dias depois. Caso as lesões persistissem ou os sintomas evoluíssem, a laringoscopia era realizada com anestesia geral. Os pacientes foram avaliados diariamente quanto ao estridor após a extubação. Resultados Participaram 187 crianças. A incidência de estridor após a intubação foi de 44,38%. O estridor apresentou uma sensibilidade de 77,78% (intervalo de confiança de 95% [IC]: 51,9-92,6) e especificidade de 59,18% (IC: 51,3-66,6) na detecção de SGS. O valor preditivo positivo foi de 16,87% (IC: 9,8-27,1) e o valor preditivo negativo (VPN) foi de 96,15% (IC: 89,9-98,8). O estridor que persistiu por mais de 72 horas ou que começou 72 horas após a extubação teve uma sensibilidade de 66,67% (IC: 41,2-85,6), especificidade de 89,1% (IC: 83,1-93,2), valor preditivo positivo de 40,0% (IC: 23,2-59,3) e valor preditivo negativo de 96,07% (IC: 91,3-98,4). A área sob a curva de característica de operação do receptor (ROC) foi de 0,78 (IC: 0,65-0,91). Conclusões A ausência de estridor foi adequada para descartar a estenose subglótica pós-intubação. A especificidade desse critério melhorou quando o estridor perdurou por mais de 72 horas ou começou mais de 72 horas após a extubação. Assim, a endoscopia com anestesia geral pode ser utilizada para confirmar a estenose subglótica somente em pacientes que desenvolveram ou continuaram com estridor por mais de 72 horas após a extubação.

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OBJECTIVE: To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. METHOD: Children who required endotracheal intubation for >24h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. RESULTS: A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72h or starting more than 72h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). CONCLUSIONS: Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72h or started more than 72h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72h following extubation.

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La estenosis subglótica es una de las causas más frecuentes de obstrucción de la vía aérea en pediatría. El 90% son secundarias a la intubación endotraqueal. El diagnóstico se sustenta en la clínica del paciente, la evaluación radiológica, la laringoscopía flexible y la endoscopía rígida de la vía aérea bajo anestesia general. Debe sospecharse en niños con dificultad respiratoria posextubación. La conducta terapéutica dependerá de la gravedad de la estenosis subglótica y de la sintomatología del paciente. Describimos nuestra experiencia en cuanto a las etiologías de las estenosis subglóticas, el diagnóstico, el tratamiento y la evolución de pacientes con esta patología.(AU)

Subglottic stenosis is among the most common causes of airway obstruction in children, 90% of which resulting from endotracheal intubation. The diagnosis is based on the patients clinical, radiologic evaluation, flexible laryngoscopy and rigid airway endoscopy under general anesthesia. It must be suspected in children with respiratory distress after extubation. The therapeutic approach depends on the severity of the subglottic stenosis and the patients symptoms. We describe our experience with the subglottic stenosis etiologies, diagnosis, treatment and outcome of patients with this condition.(AU)

RESUMO

La estenosis subglótica es una de las causas más frecuentes de obstrucción de la vía aérea en pediatría. El 90% son secundarias a la intubación endotraqueal. El diagnóstico se sustenta en la clínica del paciente, la evaluación radiológica, la laringoscopía flexible y la endoscopía rígida de la vía aérea bajo anestesia general. Debe sospecharse en niños con dificultad respiratoria posextubación. La conducta terapéutica dependerá de la gravedad de la estenosis subglótica y de la sintomatología del paciente. Describimos nuestra experiencia en cuanto a las etiologías de las estenosis subglóticas, el diagnóstico, el tratamiento y la evolución de pacientes con esta patología.

Subglottic stenosis is among the most common causes of airway obstruction in children, 90% of which resulting from endotracheal intubation. The diagnosis is based on the patient's clinical, radiologic evaluation, flexible laryngoscopy and rigid airway endoscopy under general anesthesia. It must be suspected in children with respiratory distress after extubation. The therapeutic approach depends on the severity of the subglottic stenosis and the patient's symptoms. We describe our experience with the subglottic stenosis etiologies, diagnosis, treatment and outcome of patients with this condition.

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Introducción: la estenosis subglótica se define como un estrechamiento parcial o completo de la subglotis, la cual está localizada a nivel del cartílago cricoides, esta puede ser congénita o adquirida. Objetivo: describir la enfermedad, exponer las características clínicas y la conducta que se realizó en una paciente con estenosis subglótica. Caso Clínico:paciente con antecedentes de prematuridad y ano imperforado, con administracion de anestesia general endotraqueal en múltiples ocasiones para procedimientos quirúrgicos y ventilación mecánica postoperatoria, en la cual se realiza diagnóstico presuntivo de estenosis subglótica adquirida y se remite a consulta de otorrinolaringología para su estudio. Conclusiones: en todo paciente pediátrico que haya tenido antecedentes de intubación y ventilación mecánica prolongada, debe sospecharse de una estenosis subglótica adquirida al impedirse la progresión endotraqueal de las cánulas según su edad; y que requieran varios intentos de intubación con diámetros decrecientes, aún en ausencia de síntomas y signos clínicos.

Introduction: subglottic stenosis is defined as partial or total narrowing of the subglottis, located at the cricoid cartilage level. Subglottic stenosis may be congenital or acquired. Objective: describe the disease and present the clinical characteristics and the management of a female patient with subglottic stenosis. Clinical case: a female patient with a history of prematurity and imperforate anus, and administration of endotracheal general anesthesia on numerous occasions for surgical procedures and postoperative mechanical ventilation, is presumptively diagnosed with acquired subglottic stenosis and referred to otorhinolaryngology consultation for study. Conclusions: pediatric patients with a history of intubation and prolonged mechanical ventilation should be suspected of acquired subglottic stenosis when insertion of an endotracheal cannula suitable for their age is not possible and they require several intubation attempts with decreasing diameters, even in the absence of clinical signs and symptoms.