Pediatric Anesthesiology 2006 PBL Management of a child with laryngeal papillomas

Goals for participants 1. The participant should understand the signs and symptoms of the child with pre- and intraoperative laryngeal obstruction and be able to describe a coherent plan for managing airway obstruction. 2. The participant will understand the etiology, epidemiology and natural course of this disease including current medical and surgical treatments and anesthetic implications. 3. The participant will be able to discuss the specific anesthetic concerns of carbon dioxide laser airway management including specific anesthetic techniques, waste gas and pollution issues, and airway fire. STEM CASE and KEY QUESTIONS A four year old child with a three month history of worsening stridor was started on an albuterol inhaler by her family physician, without improvement. She now has a hoarse, whispery, “hot potato ” voice. An otolaryngologist tried to evaluate her airway with a fiberoptic nasopharyngoscope, but she was not cooperative. His working diagnosis is vocal cord papillomas. ROS: She was a full term infant, previously healthy, although she was treated for gastroesophageal reflux from age 3 months to six months. Physical exam: 20 kg child, BP 80 sys, p100, RR22, SpO2 97%, T 37oC Hoarse voice, barely speaks above a whisper, being held on her mother’s lap HEENT: baby teeth, normal jaw, mild retractions above the sternal notch with inspiration Pulm: inspiratory and expiratory stridor audible over the suprasternal notch Cor: RSR; normal S1 and S2; no S3 or S4; no murmurs. Extremities: Nailbeds pink, no clubbing. Superficial veins easily seen on dorsum and volar aspects of hands. 1. Is this a typical presentation for vocal cord papillomas? Why? What other entities might present this way? What makes you put these lower on your list of differential diagnosis? 2. What will you look for on physical exam to help assess her degree of airway compromise? How reliable is the degree of stridor? The respiratory rate? Should you obtain an arterial blood gas before you start? How about a venous blood gas? Why or why not? Does she need any preoperative laboratory work at all? How about a chest x-ray