When an encircling aortic arch anomaly hides behind respiratory and digestive symptoms in children

peer reviewedLes anomalies de l’arc aortique, relativement fréquentes, représentent 15 à 20 % de toutes les maladies cardiovasculaires congénitales. Elles peuvent être découvertes face à des symptômes de compression oesophagienne et/ou des voies respiratoires, tels que dysphagie, toux chronique, stridor, wheezing, voire infections respiratoires à répétition. Nous rapportons deux cas d’anomalie encerclante des arcs aortiques. Le premier patient, âgé de 3 ans, présentait, depuis l’âge de 4 mois, des symptômes respiratoires avec multiples épisodes étiquetés de laryngites et d’asthme. Le deuxième, âgé de 20 mois, présentait un stridor intermittent, de la dysphagie ainsi que des vomissements fréquents. Chez ces deux patients, le scanner cervico-thoracique démontra un arc aortique droit avec une artère sous-clavière gauche rétro-oesophagienne au départ d’un diverticule de Kommerell. Dans les deux cas, la cure chirurgicale fut suivie de la disparition des symptômes. La compréhension du développement embryologique normal et anormal des arcs aortiques, ainsi que la connaissance des manifestations cliniques des compressions vasculaires sont indispensables à leur diagnostic précoce et traitement adéquat.Aortic arch anomalies are relatively frequent and account for 15 to 20 % of all congenital cardiovascular malformations. They can be discovered in case of symptoms of airway- or esophageal compression such as dysphagia, chronic cough, stridor, wheezing and recurrent respiratory infections. We report the cases of two children with encircling aortic arch anomaly. The 3-year-old boy had complained of chronic respiratory symptoms such as laryngitis and asthma since the age of 4 months. The 20-month-old boy presented with intermittent stridor, dysphagia and frequent vomiting. In both patients, the cervico-thoracic CT-scan showed a right aortic arch with retro-esophageal left subclavian artery and Kommerell’s diverticulum. Surgery was curative. The understanding of normal and abnormal embryologic development of the aortic arch, and the knowledge of the different types of vascular compression and their clinical signs are mandatory for the early diagnosis and adequate treatment of such malformations

Recent advances in pediatric anesthesia

Writing about advances in a field of medicine normally includes some pride about progress which one was witness to or even a participant in. The younger one is, the more enthusiastically every advance is lauded and welcomed. This is human nature and nothing to be complained about. However, when anesthesiologists, having worked and struggled in the field of pediatric anesthesia for about 40 years, look back to past advances, a more realistic, even painful picture comes to mind. There was a price which a considerable number of patients had to pay for progress, ruined health or even death. This experience of decades of practice is rarely presented in the literature but should not be forgotten when we proudly remember advances in pediatric anesthesia

Respiratory distress or eating disorder could: it be a vascular ring ?

peer reviewe

Anatomical In Vitro Investigations of the Pediatric Larynx: A Call for Manufacturer Redesign of Tracheal Tube Cuff Location and Perhaps a Call to Reconsider the Use of Uncuffed Tracheal Tubes

BACKGROUND: Some in vivo studies question the traditional funnel-shaped infant larynx; further anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal and upper tracheal specimens and multiple measurements was needed to determine consistency between current tracheal tube designs and anatomic observations. METHODS: Larynges from 19 males and 11 females (Caucasian term newborn to 126 months) were examined by the same forensic pathologist. Measurements included anterior/posterior (A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of safe tracheal tube placement was assessed using manufacturer recommended cuffed Microcuff (Kimberly-Clark, Koblenz, Germany) tubes. RESULTS: In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1 to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children. The A-P/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all specimens. The CTM could be minimally distended in all specimens. CONCLUSIONS: First, despite being marketed as a safer tracheal tube design, the proximal end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing potential cuff-induced injury when using the VC markings for positioning. Our data suggest that the optimal cuff free distance (VC-CO) would be similar to 13.5 mm for a Microcuff internal diameter (ID) size 3.0, similar to 15 mm for size 3.5, and similar to 16 to 19 mm for greater sizes. Second, the CO was virtually circular in all specimens, suggesting that appropriately sized uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding the potential for cuff-related necrosis injury. Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx is the nondistensible cricoid cartilage and not the easily distended glottis. Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion markings, particularly for neonates and toddlers. Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical airway access with most currently available emergency airway devices

Tracheoscopic Findings and Their Impact on Respiratory Symptoms in Children with Esophageal Atresia

Introduction Esophageal atresia (EA) is often accompanied by tracheobronchial malformations leading to stridor, recurrent bronchitis, and occasionally to life-threatening obstructive apnea after surgical repair. The aim of this study was to identify the presence of tracheomalacia in patients with EA and tracheoesophageal fistula (TEF) pre- and postoperatively and to find endoscopic correlates leading to clinical airway symptoms. Methods In a cohort of 362 patients with EA-TEF who underwent 595 tracheoscopies at the Children's Hospital of Cologne between January 1983 and December 2002, impaired tracheal lumen, localization of TEF, tracheal pulsations, and corresponding clinical symptoms were retrospectively analyzed. Results The incidence of tracheomalacia was higher in patients with EA and TEF (Gross B-D) compared with patients with EA alone (Gross A) and average tracheal collapse does not significantly change before and after surgical repair of the esophagus in all types. Patients with cyanosis while eating and obstructive apnea presented with an average tracheal collapse of 89%. The presence of respiratory symptoms such as cough, stridor, or bronchitis was not associated with a higher grade of tracheal collapse compared with patients without any airway symptoms (average tracheal collapse of 37% in symptomatic patients vs. 33% in nonsymptomatic patients). Conclusion Tracheomalacia tends to be present independently of surgical procedure. Tracheomalacia should be measured by tracheoscopy (in % of tracheal collapse). Patients with a tracheal collapse of >80%, a ventral pulsation, and obstructive apnea or cyanosis in combination, are at risk for life-threatening situations and further surgical treatment should be considered