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Pediatric Laryngospasm
Case Synopsis
After extubation at the conclusion of adenotonsillectomy, a 5-year-old boy coughs and then develops high-pitched inspiratory stridor that progresses to silent rocking chest movements. Chest wall retractions are noted, and the breath sounds diminish until none are heard. Mask ventilation is attempted without success, and the patient desaturates rapidly.
Problem Analysis
Definition
Among other functions, the larynx protects the upper airway and lungs from aspiration of foreign materials. The glottal closure reflex is most evident during swallowing. Laryngospasm is an exaggerated form of the glottic closure reflex in response to noxious stimuli. Partial or complete airway obstruction due to laryngospasm can persist even after removal of the stimulus. Laryngospasm is mediated by the vagus nerve. The afferent limb of this reflex is the internal branch of the superior laryngeal nerve, and the efferent limb is the recurrent laryngeal nerve.
Complete laryngospasm consists of two phases: (1) glottic spasm causes adduction of the true vocal cords, causing partial airway obstruction via a “shutter” mechanism that leaves a small lumen open at the posterior commissure, followed by (2) a “ball-valve” mechanism with constriction of the ventricular cords (false vocal cords) as the paraglottis (intralaryngeal portion of the epiglottis) moves posteriorly and the arytenoid cartilages both perform a ventral movement, effectively sealing the larynx.
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