[size=20px]Three months after repair of esophageal atresia with a blind proximal pouch and distal tracheoesophageal fistula, a full term infant returns for postoperative follow-up. His mother describes worsening inspiratory stridor - particularly with feeding, agitation or crying. The infant has generally been feeding and growing without emesis or other respiratory distress.

 

The most appropriate diagnostic test for this esophageal atresia patient with inspiratory stridor is

 

A fiberoptic laryngobronchoscopy.

 

B direct laryngoscopy.

 

C modified barium swallow.

 

D contrast esophagogram.

 

E airway computerized tomography scan.[/size]

(Untitled)

 

a

a

correct

 

Laryngomalacia is the most common cause of newborn stridor and airway obstruction. The stridor is typically aggravated by feeding, agitation or supine positioning. Symptoms usually worsen over the first several months of life, but most often improve thereafter with resolution by 18 months of age. The diagnosis is suspected by history but most accurately confirmed by flexible fiberoptic laryngoscopy. Pictured below is a case of severe laryngomalacia showing the omega shaped epiglottis with prolapse and supraglottic collapse causing airway obstruction.

 

In such circumstances, supraglottoplasty may be accomplished using the laser to release the shortened aryepiglottic folds.

 

While tracheomalacia may be more common in the child with a history of esophageal atresia, this scenario with inspiratory stridor suggests a supraglottic lesion rather than tracheomalacia. Such pathology would be best diagnosed with flexible laryngoscopy on a spontaneously breathing patient and could be missed under general anesthesia and bronchoscopy alone. Inspection of the more distal airway may be warranted to rule out other pathology in a child with a history of esophageal atresia. Contrast studies of the esophagus may be appropriate if symptoms persist and are found not to be due to laryngomalacia as recurrent or missed fistulas and strictures may cause respiratory symptoms but are usually not associated with stridor.

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