Laryngomalacia-substernal and intercostal retractions

E. Hersh-Burdick, R. Murray, M. Westermann, J. Sperling, E. Horvitz, E. Frumin, Z. Chandy
School of Medicine, University of California Irvine, and Department of Human Biology, Stanford University, CA, in collaboration with the Department of Community Health and Development, Christian Medical College, Vellore, India
 
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    Brief Description
 
This video shows inspiratory stridor, substernal retractions and intercostal retractions in a 3 month old baby. The baby was diagnosed to have Laryngomalacia. Laryngomalacia is characterized by a flaccid trachea resulting in laryngeal stridor (gasping for breath) and trachael tug (trachea is depressed following inspiration, suggestive of large airway obstruction). Laryngomalacia is the most common congenital laryngeal anomaly and most frequent cause of stridor in infants. Stridor is inspiratory, low pitched and exacerbated by exertion and is worse when the baby is on her back. There may be some gastro-esophageal reflux. Stridor results from the collapse of supra-glottic structures inwards during insipration. Symptoms usually appear during the first two weeks of life. Diagnosis is confirmed by flexible laryngoscopy.
 
    Full Description
 
Patient was born on May 12th 2009 with a birth weight of 2.14kg (4.708 lbs). Since birth, child has severe “chest indrawingl” and for the past month has begun “gasping for breath” according to her mother. Breathing distress has continued to worsen until child was brought to the ICU at the hospital of the Department of Community Health and Development, Christian Medical College, Vellore, India, on July 9th 2009. The child has failed to gain weight since birth and weighs 2.0kg (4.4 lbs). The child feeds only 6-7 times per day and pauses to gasp for breath during breast feeds. The child was brought by her mother and grandmother to CHAD in June due to child’s breathing difficulties and the doctors encouraged her to admit her child. The economic status of the family caused the mother to defer admittance and the child’s health has deteriorated to the present status.

Patient appears in respiratory distress with full-body pallor. Accessory muscles (sternocleidomastoid, infrahyoid and abdominal muscles) are used to breathe. A tracheal tug is observed (trachea is depressed following inspiration, suggestive of large airway obstruction).

Cardiovascular Examination: Heart rate: 140-150 beats/min (normal infant 70 -120 beats/min). Examination difficult due to crying and heavy breathing.

Respiratory Examination: Respiratory rate: 80-90 breaths/min. Constricted breathing and laryngeal stridor heard (gasping for breath, gruntingh). On ausculation, crepitations were heard in the left lower lobe. (PO2: 93-94% (normal = 96-100%; hypoxia:

ACKNOWLEDGMENTS: This is a patient of Professor Anuradha Bose at the Department of Community Health and Development, Christian Medical College, Vellore, India. We are immensely grateful to her and the faculty at CHAD for opening our hearts and minds to the intricacies of pediatrics. Supported by the Gold Foundation. We thank Dr. George Chandy for organizing the trip, mentoring us and editing this presentation.

 
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Masters IB. Congenital airway lesions and lung disease. Pediatr Clin North Am. 2009 Feb;56(1):227-42

 
 
 
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Sep 23, 2009 6080 VA:07:30:1523:2009
 
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