Guest: Dr. David R. White - Pediatric Otolaryngology
Host: Dr. Linda Austin – Psychiatry
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin and I am interviewing Dr. David White, who is a pediatric ear, nose, and throat doctor here at MUSC. Dr. White, one of the conditions that you treat is subglottic stenosis or noisy breathing. What are some of the signs and symptoms of subglottic stenosis that a parent might observe in their child?
Dr. David R. White: One of the red flags for this type of condition would be a child that previously has had a breathing tube in place whether it’s something as quick as having a breathing tube in place for a procedure in the operating room or if they have had a breathing tube in place for a longer period of time either in a neonatal intensive care unit or a pediatric intensive care unit. If a child starts to develop noisy breathing anytime within the first few months after that and then one would suspect problem with subglottic stenosis, the way that a parent might know about this would be that the child would have very noisy breathing when they breathe in especially and oftentimes and if things get severe enough when they breathe out. The other thing that a parent might notice is that the child seems to be working hard to breathe or notice his indentations above the chest or at the base of the neck or below the ribs where the child is really pulling in to breathe and kind of sucking in their chest in their efforts to breathe.
Dr. Linda Austin: What causes that?
Dr. David R. White: Well, subglottic stenosis is one of many causes of noisy breathing. The thing that causes subglottic stenosis specifically is either a long-term intubation so a child that has been in the ICU for a longtime either like a neonatal ICU and children that are born too early or if a child comes from a pediatric intensive care unit and has a breathing tube in place for a long period of time, they can develop scarring around the breathing tube, which then once the tube is removed, causes narrowing or constriction of the airway.
Dr. Linda Austin: Could we break those words down just to clarify, subglottic means what?
Dr. David R. White: Subglottic means below the vocal cords and stenosis means narrowing and so this is narrowing below the vocal cords. In another way that it becomes apparent sometimes as in children, who are born with an abnormally narrow airway below the vocal cords and that would be congenital subglottic stenosis, so a child that is born with that problem.
Dr. Linda Austin: Are there other causes in children?
Dr. David R. White: There are lots of other causes of noisy breathing in children and so if a child has noisy breathing, they would need to be evaluated by a pediatric otolaryngologist to workout exactly, which one of these things it could be and if it’s something more serious like subglottic stenosis that needs treatment versus something more common like something called laryngomalacia, which is floppiness of the cartilage above the vocal cords can cause a very squeaky type of breathing, primarily seen in children between three and nine months of age. That by and large gets better on it’s own with time, sometimes requires some medical treatment, but very rarely requires any surgical treatment.
Dr. Linda Austin: How do you treat subglottic stenosis?
Dr. David R. White: The first thing that we do is to evaluate the airway itself and this would be done with a procedure called microlaryngoscopy and bronchoscopy. Basically, this is an evaluation of the airway with telescopes in the operating room with a child to sleep. Additionally, we would also plan to evaluate the movement of the vocal cords, which would be done with a flexible telescope through the patient’s nose when the child is awake, and we take the information of these two evaluations and put them together to come up with the best options for treating the child.
Dr. Linda Austin: You are a pediatric ENT doctor. Is there is a procedure that in other cities where they don’t have medical centers, a regular adult ENT could do or do these kids have to come to the specialist?
Dr. David R. White: A lot of times these children are identified by general otolaryngologists see they are in the community or at other hospitals generally for treatment; however, they are referred to a specialist like myself and usually at a larger tertiary institution like MUSC. The reason for this is that any treatment of the airway, there is a risk that it can make things worse and almost always this requires the help of a very strong pediatric intensive care unit team, which fortunately we have here.
Dr. Linda Austin: What operation do you do to help these kids?
Dr. David R. White: There are several operations that are available and this is tailored to the severity of a child’s problem and so if there is a very severe problem, there may be expansion of the airway, it is done by introducing cartilage graphs made out of the child’s rib or ear that can actually help open up the airway. If it is a more mild version of the subglottic stenosis, endoscopic treatment with a laser using a microscope may also be another option. In children, who have had longstanding subglottic stenosis over the course of time, it has been shown that the endoscopic approach is once they fail two or three or four times don’t give a good long-term result and so then generally the definitive procedure would be opening up the airway either by introducing a graft to help expand the airway or simply by taking the narrow part out and 05:21 the two good parts together and that will be called a resection.
Dr. Linda Austin: How long is the recovery period from these surgeries?
Dr. David R. White: From the endoscopic procedures, its? just a couple of days. The other operations do require about a week long stay in the intensive care unit and then another week in the hospital and so it’s a relatively involved situation that does a very well connected group of experts working together.
Dr. Linda Austin: Dr. David White, thank you very much.
Dr. David R. White: Thanks.
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