Evaluation of Etiology in Infants with Recurrent Pneumonia and Chronic Stridor

Received: 22.12. 2013 Accepted: 10.04. 2014 This investigation was presented in the 5th National Pediatric respiratory disease Congress at 4-6 May 2008, in Adana, Turkey. Address for Correspondence: Şit Uçar, Clinic of Pediatrics, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Diseases Training and Research Hospital, Ankara, Turkey Phone: +90 312 343 31 35 E-mail: situcar@mynet.com ©Copyright 2014 by Turkish Thoracic Society Available online at www.toraks. dergisi.org 122 Laryngoscopy was applied to the patients for whom laryngeal pathology was considered. Rigid bronchoscopy was conducted in order to diagnose and treat the patients having been suspected of foreign body. Flexible bronchoscopy was applied for the patients having recurrent pulmonary infection and stridor with unknown etiology. Written informed consent was obtained from the parents of the patients participated in the study. Moreover, ethics committee approval was received from the Ethics Committee of Keçiören Training and Research Hospital, Ankara, Turkey on the date of August 19, 2013. statistical Analysis For the categorical variables, the values of number and percentage were used. In addition, standard deviation (SD) values were employed as a measure of variability when the means were given. resULTs The mean age of the evaluated cases was 5.1±2.7months SD (2-8 months) and the ratio of male/female (7/5) was found to be 1.4. All patients were hospitalized in order to treat acute community-acquired pneumonia and to evaluate the etiology of recurrent pulmonary infection and chronic stridor. Early onset of patients’ complaints, recurrent pneumonia symptoms with respiratory distress despite providing appropriate treatment and the presence of associated chronic stridor led to further examination. Five patients were diagnosed with vascular ring and other patients were diagnosed with tracheomalacia, severe laryngomalacia, cervical hamartoma, cervical bronchogenic cyst, foreign body aspiration, H-type tracheoesophagial fistula (TEF), and congenital subglottic stenosis. Demographic, clinical, laboratory, radiological and bronchoscopic findings of the patients and also treatment methods are shown in Table 1. Of the patients with chronic stridor who were involved in the study, 85% had persistent stridor and 15% had recurrent stridor. Seven patients (58%) had the complaints beginning from the birth, whereas the complaints of 5 patients (42%) became clear in the first or second months. The complaints of 3 patients (25%) were related to position and they decreased in lying position. Feeding difficulty and malnutrition were found in six patients (50%). Chronic stridor and accompanying cardiac anomalies in the patients with recurrent pulmonary infection are demonstrated in Table 1. Sweat test results and Ig M, A, G, E levels were found to be normal for the patients having the history of recurrent pulmonary infection. On the other hand, the result of tuberculin test, which was applied to all patients, was positive for one case. Tuberculosis was excluded with the examinations for this patient. Of the cases evaluated, vascular ring was the most frequently diagnosed defect (42%). Common characteristic of these cases was that symptoms were not associated with position and/or nutrition. In the esophagography conducted with the pre-diagnosis of vascular ring, various indentation patterns were observed in all cases (Figure 1). The final diagnosis was made by defining vascular pathology via MR angiography. In a case with recurrent upper and lower respiratory tract symptoms and malnutrition, flexible laryngoscopy results were found to be consistent with laryngomalacia results. For this patient with the history of developmental delay and recurrent lower respiratory tract infection, flexible bronchoscopy was performed to evaluate accompanying tracheobronchial pathology and the result was found to be normal. Table 1. Clinical, laboratory, radiological, bronchoscopic and treatment features of the patients Age of Age initial PPd Bronchoscopy diagnosis (month) complaint stridor esophagography (mm) eCHo (type) Treatment Aberrant right 5 congenital inspiratory indentation 0 No right not performed Follow-up subclavian artery* subclavian exit Severe laryngomalacia 2 congenital inspiratory not performed 0 N laryngomalacia (flexible) surgery Double aortic arch* 4 2-month biphasic indentation 2 ASD pulsation (flexible) surgery Double aortic arch * 2 congenital inspiratory indentation 1 N not performed surgery H-type TEF 6 congenital inspiratory fistule 0 N not performed surgery Right aortic arch 5 congenital inspiratory indentation 1 VSD not performed surgery accompanied by ligamentum arteriosum* Cervical bronchogenic 4 congenital inspiratory not performed 12 N not performed surgery cyst Cervical hamartoma 7 3-month inspiratory not performed 0 VSD not performed surgery Subglottic stenosis 6 congenital biphasic not performed 0 N not performed surgery Tracheomalacia 7 1-month expiratory N 3 N Tracheomalacia (flexible) Follow-up Vascular sling 7 congenital biphasic indentation 0 Silent ductus N (flexible) surgery Foreign body 6 4-month inspiratory not performed 0 N Foreign body (rigid) Removal of aspiration foreign body ECHO: echocardiography; ASD: atrial septal defect; VSD: ventricular septal defect; TEF: tracheoesophageal fistula; N: normal *Vascular Ring 123 Turk Thorac J 2014; 15: 122-7