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It is estimated that half of the adult population older than 60 years snores. This article discusses the many aspects of snoring, including impacts on bed partners, the individual who snores, and when and how to appropriately evaluate, diagnose, and treat the perpetrator. The goal is for clinicians to expand their knowledge regarding diagnosis and treatment of the phenomenon of snoring.It is estimated that half of the adult population over the age of 60 years of age snores. This chapter discusses snoring, including the impact on bed partners, the individual that snores and when and how to treat the snorer. The goal is for clinicians to expand their knowledge regarding diagnosis and treatment of patients who snores., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Infantile hemangiomas (IHs) of the airway are far less common than their cutaneous counterparts, and their symptoms mimic those of viral croup. As a result, by the time these lesions are diagnosed, they are often advanced and causing airway compromise. Fortunately, the evolution of propranolol as an effective and safe pharmacotherapy has simplified management of IH and reduced the likelihood of complications previously seen with steroid therapy and surgery. Nevertheless, the otolaryngologist must be prepared with an alternate plan to manage lesions refractory to pharmacotherapy. This article reviews the clinical presentation and current management of IHs of the airway., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Vascular malformations may affect nearly all aspects of the upper airway. Each type of malformation has a characteristic pattern of disease. These lesions may be focal or diffuse, and require directed management strategies. Physicians treating these entities should have a high level of suspicion to consider airway evaluation even in the absence of overt symptoms. However, cutaneous head and neck venous malformations or other lesions affecting the lips, oral cavity, or tongue can herald the presence of coexisting airway lesions. A multidisciplinary approach is critical in achieving comprehensive treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.

Pediatric stridor is an important symptom of upper airway obstruction, and must be recognized early by evaluating physicians. Proper evaluation and management, both acutely and chronically, can provide improved outcomes and better quality of life for patients. This article discusses the physiology of stridor and its intimate relation to airway anatomy, the work-up of the stridorous child, and recent advances in treatment, and provides illustrative examples of common lesions., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyngeal reflux, allergic and sinus disease, sicca, and possibly obstructive sleep apnea). The following is a discussion of the history, terminology, epidemiology, diagnosis, comorbid conditions, and treatment of this entity., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This article reviews some of the otolaryngologic manifestations of skeletal dysplasias. Achondroplasia is discussed most comprehensively. Skeletal dysplasias are bone and cartilage disorders that disrupt the development of the long bones, craniofacial skeleton, and vertebral column, with the most notable characteristic being short stature. Children with skeletal dysplasias have various medical problems. These children often develop head and neck manifestations of their disorders. Hearing loss, middle ear disease, and respiratory difficulties are seen in these children. Otolaryngologists must be knowledgeable about these disorders to diagnose, treat, and appropriately refer children with skeletal dysplasias., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Securing the airway in a dyspneic patient is a challenging task because of the myriad causes and presentations. Initial assessment may demonstrate factors indicative of upper airway abnormalities; however, they may not be specific nor sensitive enough to accurately predict difficult intubation. A well-equipped airway cart must be immediately available. A standardized escalating approach to secure the airway in a difficult situation begins with a rapid sequence of attempts at standard intubation, followed by attempted tube introduction over a bougie or using a flexible endoscope or laryngeal mask, and finally surgical interventions including cricothyrotomy or tracheotomy.

Obstructive sleep apnea (OSA) syndrome in infants and children is one of the more common problems treated by the otorhinolaryngologist-head and neck surgeon. The authors discuss diagnostic studies, nonsurgical and surgical therapies, and perioperative care, including indications for inpatient stay following surgery. Most children are successfully treated for obstructive breathing by adenotonsillectomy. An awareness of the wide range of treatment modalities, with attention to careful postoperative care, should allow for successful management of nearly all children with OSA.

Since the final common pathway for obstructive sleep apnea is obstruction of the upper airway during nocturnal respiration, examination and assessment of the anatomy of the upper airway plays a central role in patient evaluation. Since the upper airway begins at the nose and lips and ends at the larynx, a complete assessment of the upper airway evaluates this entire length of this anatomic region including the bony framework and soft tissue. Though office assessment of these structures does not necessarily mimic the appearance of behavior of these structures during physiologic sleep, the office examination can give important information as to the site of obstruction during sleep that can help direct therapy.

Although allergic fungal sinusitis is rare in the pediatric population, it is an important part of the differential diagnosis of unilateral nasal masses. A brief historical review is offered. The evaluation is discussed, and treatment options are proposed.

Gastroesophageal reflux (GER) may have a role in upper airway disease such as chronic sinusitis and pharyngolaryngitis. Methods of assessment of reflux, although never absolute, are useful in selecting GER as a component in the induction of upper respiratory disease. Patients with intractable sinusitis and otitis have been found to respond to anti-reflux therapy as noted in the cases of this article.

New techniques for visualing the upper and part of the lower airway provide for efficient assessment of airway dysfunction. Equipment is available for video recording during the assessment, which can be done either in the caregiver's office/clinic or during stress testing in an exercise facility. Case reports that illustrate the diagnostic use of video laryngoscopy as well as adjunct to therapy are presented in this article.

Patients with lesions that cause obstruction of the large airways are often misdiagnosed as having chronic lung disease or reactive airways disease. Close attention to the history and physical examination provides clues to the presence of a laryngeal or tracheal lesion. Obtaining a flow volume loop in the pulmonary function laboratory is a simple and effective method of noninvasively evaluating a patient for the presence of an upper airway obstruction. Fixed lesions cause plateaus in both the inspiratory and expiratory limbs of the flow volume loop. Variable intrathoracic lesions are characterized by expiratory slowing and flattening of the expiratory limb. An important caveat is that these changes may not be present in a patient with coexisting lower airway disease such as COPD or asthma. Variable extrathoracic lesions cause inspiratory slowing and a plateau on the inspiratory limb of the flow volume loop. Finally, the clinician should remember that the quality of the flow volume loop is totally dependent on the patient's effort and cooperation and, thus, that the tracings obtained in the pulmonary function laboratory may not have the classic shapes presented in this review.

Endoscopic evaluation is a crucial component in the assessment of chronic airway obstruction. Acute airway obstruction is a potentially devastating complication of this invasive procedure. This article discusses a systematic approach to endoscopically assessing the airway safely and obtaining the information necessary for long-term management of the chonically obstructed airway.

The otolaryngologist who is called on to uncover the cause of a child's airway obstruction is a treasured consultant. Continuing technologic advances in office-based equipment have made it easier to discover pathology with a minimum of complications. However, the physician who does not do a thorough history and physical examination or is unable to develop a bond of trust with the patient and family will be without the essential tools of the profession and will be unable to make an accurate diagnosis and implement a treatment plan.

For most infants with a disorder of breathing control or airway obstruction, cause and management can be defined with a careful history and a few simple diagnostic tests. Pneumograms and multichannel studies can identify patterns of apnea and associated hypoxemia and can be used to assess therapeutic efficacy. For the majority of infants with disordered breathing, the outcome is favorable and conservative management is appropriate. More extensive diagnostic evaluation is reserved for infants with severe apnea or those with evidence of a significant contributing underlying disease. For these infants, management should be directed at the underlying cause and at identifying and preventing severe, life-threatening events.

Obstructive sleep disorders in children are not rare. Many parents will provide sufficient history to establish the diagnosis. Although there may be many causes of obstructive disorders, the most common in children is adenotonsillar hyperplasia. Aggressive treatment will result in prompt resolution of symptoms.

This article explores both sides of the controversy concerning respiratory behaviors and dentofacial development. The literature is replete with statements that airway impairment alters facial and dental growth, but there also is substantial evidence to the contrary. Much of the confusion stems from the subjective criteria frequently used in defining the terms impairment and mouth breathing. Additionally, respiratory mechanics have often been viewed simplistically rather than in the realistic sense of a complex regulation/control system. Unfortunately, lack of objectivity may lead to an incorrect diagnosis and even worse, inappropriate treatment. Newer respirometric techniques offering more quantitative assessment of respiratory behaviors are now providing more relevant information and more objective definitions of airway impairment and mouth breathing. More recent findings suggest that nasal-oral breathing per se is not necessarily harmful to growth. However, in instances when the nasopharyngeal or oropharyngeal airspace is small, exaggerated postural responses in obligatory nasal-oral breathers may be detrimental to growth.

Even though the incidence of multinodular goiter is decreasing in the United States, still we see a large number of neglected goiters causing pressure effects on the surrounding structures. Both tracheal and esophageal displacement cause compression symptoms. However, tracheal compression may lead to acute airway distress. Eighteen per cent of our patients presented with acute airway problems, requiring emergency admission or intubation. Surgical intervention has been our preferred approach whenever there are signs or symptoms of tracheoesophageal compression. Fifty-five per cent of patients had only tracheal compression, while 18 per cent had only esophageal compression. Twenty-seven per cent had compression of both trachea and esophagus. Eighty-five per cent of patients had some symptoms of compression, while only 15% were asymptomatic despite large goiters. Compression symptoms and acute problems were noticed more frequently in patients with substernal goiters. Our preoperative work-up regularly included complete history, physical examination, indirect laryngoscopy, and airway radiography. Barium studies were performed if patients had dysphagia. Computed tomography scans were utilized if there was mediastinal extension. Pulmonary flow volume studies were used to locate the site of compression. However, decisions relative to surgical intervention were based primarily on clinical judgment. Since the postoperative morbidity is minimal in surgery for thyroid abnormalities, we strongly recommend early surgical intervention in patients with tracheoesophageal compression caused by enlarged thyroids.

Acute nasopharyngitis and adenoidal hypertrophy, common causes of nasal obstruction in children, are reviewed. The less common, but equally important, congenital and neoplastic lesions that result in blocked nasal airways in children are discussed in detail.

The management of trauma to the air and food passages has been reviewed briefly, with emphasis on the management of the acute problems based upon a thorough evaluation.

Unlabelled: 1. Do not create an emergency obstruction unless you are prepared to handle it. (It may be best to do nothing until the diagnosis is clear.) 2. Support the patient with oxygen, humidity, and positioning and monitor vital signs. 3. Take as brief, concise, and accurate a history as possible. 4. Determine the anatomic level of obstruction. 5. Estimate the degree of obstruction with the maximal potential hazard. 6. Carry out a physical examination of the nose and neck and, except in suspected epiglottitis, the pharynx, larynx, trachea, and lung. 7. Special x-ray studies--lateral, neck and chest, swallowing function, and inspiratory and expiratory films--are obtained as indicated. 8. Therapeutic support: oxygen, humidity, antibiotics, steroids, and recemic epinephrine. Mechanical support: naso-oral airways, appropriate endotracheal or bronchoscopic tubes., Surgery: tracheotomy.

Attempts to find objective tests to assess nasal obstruction have a long history. The physiologic and pathologic fluctuations that occur within the nose over short periods of time have hampered these efforts, and all presently available techniques have significant drawbacks. The most commonly used is active rhinomanometry, and relatively recent standardization has led to the popularization of the anterior method. Posterior active and passive rhinomanometry are also available; other methods include plethysmography, peak expiratory flow rate, rhinohygrometry, thermography, oscillometry, echorhinometry, audiometric rhinomanometry, and rhinostereometry. A reliable technique would have many applications, particularly in pre- and post-therapeutic evaluation. At present, however, no method enjoys routine clinical usage, although there is considerable interest in future development.

The efficacy of flexible bronchoscopy reflects the technical advances that have created smaller, more flexible instruments with better lighting and improved resolution. In the future, the flexible bronchoscopes will be even more versatile with the addition of fiberoptic laser capabilities and improved ventilatory function. Their use provides a safe, dynamic view of even the smallest tracheobronchial tree without the expense of general anesthesia and use of the operating room. A familiarity with the uses of the flexible bronchoscope is important for anyone evaluating the pediatric airway.