Breathing Difficulties

There is no more frightening feeling than having a hard time getting your breath. As a parent, watching a child with
breathing problems is twice as difficult. In this section, we try to get you familiar with normal breathing and then
describe the various breathing problems your child may have.
What is the airway?
Airway refers to the tube that allows air to pass in and out of the body. This tube starts at the voice box (larynx) and
branches into many tiny little tubes in the lungs. Each tube ends as a tiny "bubble" called an alveolus, where air
(oxygen) is transferred into the blood and carbon dioxide is released.
How do we breathe?
Through the airway, we move in air (inhale) from the environment to the lungs.
Inhaling involves the use of breathing (respiratory) muscles. This inhaled air is rich in oxygen (a gas that our body
needs to function). Oxygen is then transferred from the lungs into the bloodstream and is exchanged with a "waste"
gas (carbon dioxide) that we then breathe out (exhale). We can get more oxygen into our bodies by breathing faster
(increase the respiratory rate) or by taking a larger breath by using the respiratory muscles. Although we can control
the amount of air we breathe voluntarily, the amount of oxygen our body needs at any given time is also registered
in the brain in the respiratory center. This is why we don't have to think about breathing, for example, while we
sleep.
The brain, the heart, lungs, respiratory (breathing) muscles, and the airway must all work well together to keep the
body breathing normally. A problem with any of these can cause breathing difficulties. The body also gives us clues
to the location of the problem by causing a certain kind of sound.
What are some causes of difficulty breathing?
1. The brain - if the respiratory center in the brain isn't working normally, even if everything else is working
well, breathing difficulty can occur. Causes for this include trauma to the brain, increased pressure in the
brain, some drugs (narcotics for example), and problems with chemical balances in the blood.
2. The heart - if the heart has problems pumping blood to the lungs or throughout the body, the body will not
get enough blood with oxygen and will cause difficulty breathing. Examples include "holes" in the heart,
valve problems, or a heart that can't keep up with the amount of blood that needs to be pumped (congestive
heart failure).
3. The lungs - even though the blood can get to the lungs, and oxygen can get to the lungs, the lungs don't work
well and can't transfer the oxygen. Examples include infection or fluid in the lungs (pneumonia), and
diseases like cystic fibrosis.
4. The respiratory muscles - if the muscles that are used to help breathe are weak or paralyzed (don't work at
all), breathing difficulties can occur. Reasons for this can include some medications causing muscle
paralysis, damage to the nerves that go to these muscles, and neurologic diseases like Guillian-Barre
syndrome.
5. The airway - anything that blocks any part of the airway restricts air from getting to the lungs. Examples of
this include infections, foreign bodies, and some birth (congenital) abnormalities of the airway.

















How does a patient LOOK when they are having difficulty breathing?
For the patient, difficulty breathing is usually described as a feeling of being "out of breath" or "needing more air".

For an observer, the way a patient looks can depend on the cause of difficulty, as well as the age of the patient.
Generally, a patient who is having difficulty breathing appears anxious. He/she is usually breathing faster than
normal, may be making various noises during each breath. In severe cases, the patient's tongue, lips, or even skin
may look bluish in color and the patient may become less responsive. In children, the ribs may be more noticeable
during each breath, the belly may stick out, and/or the nose holes (nostrils) may flare out.
How does a patient SOUND when they are having difficulty breathing?
The airway can be divided into the upper airway, which consists of the nasal passages, mouth, upper throat
(pharynx), and the lower airway, which contains the voice box (larynx), windpipe (trachea), and the larger branches
of the airway (bronchi) in the lungs.
The lower airway is made up of the smaller branches of the airway in the lungs (bronchioles) and the air sacs or
"bubbles" of air called alveoli.

The noise associated with a breathing difficulty often depends on the location in the airway. As we said before, this
allows us some clues to the cause of the problem.
UPPER AIRWAY
Nasal Passages - results in snoring type noises. The medical term for this is STERTOR. This is a congested, stuffy
nose sound that is very common in infants. Please see NASAL OBSTRUCTION, NASAL DEFORMITIES, and
ADENOID HYPERTROPHY for more information.
Mouth/upper throat (pharynx) - the TONSILS and ADENOIDS are located in this area.
Enlargement of the tonsils and adenoids can cause a muffled voice, snoring with pauses in the breathing (apnea) and
"Darth Vader" type breathing during the day.
In children under three to four years of age, a collection of pus in the tissue behind the pharynx (retropharyngeal
abscess) may develop. The voice may sound muffled (more quiet) in these children, as air is unable to get out from
the voice box effectively. These abscesses must be drained as soon as possible, so that the airway is not blocked
entirely or that the abscess does not break open and allow pus to drain into the lungs.
Please see DRAINAGE/ TREATMENT OF NECK ABSCESSES in "Surgeries We Perform".
Larynx - The larynx contains the voice box (VOCAL CORDS). The opening between the vocal cords is called the
glottis.
The larynx can be divided into three areas in relation to the glottis:
1. Above the glottis (supraglottic) - blockage in this area usually results in a muffled voice, as air cannot move
through the voice box normally.
Probably the most serious disorder in this area involves enlargement of the epiglottis. The epiglottis is a flap
that covers the glottis during eating, so that food will not go down the airway. If the epiglottis becomes
enlarged, usually as a result of a bacterial infection (epiglottitis), the entire airway may become blocked.
Luckily, bacterial epiglottitis is rarely seen any more because of the immunizations children receive today.
The symptoms and an x-ray of the neck are usually all that is needed to make this diagnosis. Antibiotics and
carefully putting in a breathing tube (intubation), is usually involved in treating this condition.

In addition to a muffled voice, sounds produced while breathing in (inspiring) can also identify breathing
problems at the supraglottic level. These coarse sounds are called inspiratory STRIDOR.

The most common cause of inspiratory stridor in infants is LARYNGOMALACIA produced by floppiness
of and around the epiglottis.
2. At the glottis - the second most common cause of stridor in infants is vocal cord paralysis. If one vocal cord
is paralyzed, the voice may be weak or breathy. If both cords are paralyzed, the voice is normal but the
stridor is very loud and the child will easily become distressed. Please see HOARSENESS and VOCAL
CORD DISORDERS for additional information.
3. Below the glottis (subglottic) - obstruction in this area results in a high-pitched noise while breathing. The
noise occurs when breathing in and out (biphasic stridor). One of the more common causes of an obstruction
here is a viral infection called laryngotracheobronchitis (croup). It is usually identified by symptoms
(especially a characteristic barking cough) and an x-ray. This infection requires careful observation of the
patient, fluids, and treatment as in other viral infections. However, if the obstruction becomes more severe,
hospitalization, inhaled medications, and rarely, a breathing tube may be needed until the infection resolves.
Other causes of obstruction here are narrowing of the airway (subglottic stenosis), webs of tissue across the airway
(webs), hemangiomas (collection of blood vessels), or foreign bodies.
Situations in which a breathing tube cannot be inserted into the airway due to obstruction require a tube to be placed
directly into the trachea from outside the neck (TRACHEOTOMY) to secure the airway first and allow careful
evaluation of the problem. This is a temporary tube, so removal is planned once the obstruction is resolved.
Trachea - obstruction in this area of the airway can result in noisy breathing out. This is called expiratory stridor.
Causes of obstruction in this area include infections (tracheitis), foreign bodies, abnormal blood vessels that wrap
around the trachea (vascular ring), or congenital (at birth) abnormalities resulting in a floppy or too narrow trachea.
An x-ray can help identify a problem in this area.
However, examining the airway directly is the only way to completely evaluate the cause of breathing problems.
This is called MICROLARYNGOSCOPY AND BRONCHOSCOPY. Magnetic resonance imaging (MRI) and high
speed Computed Tomography (CT) scanning also may be used to confirm a diagnosis.
Bronchi - once the trachea splits into the bronchi, the sound of an obstruction here changes to a more musical type
wheeze. This wheeze is best heard on expiration and often requires the use of a stethoscope. Severe obstructions
may be heard both on inspiration and expiration, or not at all if the airway is entirely blocked.
Infections of the bronchi (bronchitis) or foreign bodies are the more common causes of obstruction in this area. X-
rays and possibly direct visualization of the bronchi (BRONCHOSCOPY) may be used to evaluate obstructions in
this area.
LOWER AIRWAY
Bronchioles - These small branches off of the bronchi start the lower airway. Less severe obstructions in this area
can cause expiratory wheezing, which is usually heard only with a stethoscope. More severe obstruction of these
tiny airways may result in both inspiratory and expiratory wheezing. Even more concerning is no air movement at
all.
Conditions that may result in obstruction at this level are bronchiolitis (inflammation of these small airways usually
caused by a virus) and asthma (a temporary narrowing of these airways as a result of allergies, smoking, genetics
and other reasons). These conditions are usually identified by symptoms and characteristic findings on x ray.
Treatment includes oral medications, breathing treatments, providing extra oxygen and rarely, placement of a
breathing tube.
Alveoli - obstruction at the level of these tiny sacs of air requires the use of a stethoscope to hear. The sounds picked
up are usually like a crackle noise as these air sacs pop open and closed during breaths. An infection in the lungs
(pneumonia) is one of the more common causes of this, but anything that allows fluid to build up in the lungs
(pulmonary edema) would cause obstruction in the alveoli.

When would you be referred to an ear, nose, and throat specialist for evaluation and/or treatment of a breathing
difficulty?
Many times, the only way to make an accurate DIAGNOSIS of the cause of a breathing difficulty is to look directly
at the airway.
The ear, nose, and throat specialist is uniquely qualified to do this through MICROLARYNGOSCOPY AND
BRONCHOSCOPY. With this technique, a foreign body can be removed at the same time as it is visualized. Please
see REMOVAL OF AIRWAY FOREIGN BODIES. In other cases, a sample of fluid in the lungs can be obtained
for culture or other tests.
Causes of stridor such as LARYNGOLMALACIA and VOCAL CORD PARALYSIS, as well as causes of
HOARSENESS can be evaluated by FLEXIBLE LARYNGOSCOPY or VIDEO STROBOSCOPY.
TREATMENT of the many causes of breathing problems is individualized to your child's specific circumstances.
Every child is different and presents with unique challenges. After careful evaluation, your pediatric ear, nose and
throat surgeon will outline the options for treatment.

Copyright 2000-2009. All Rights Reserved.
Website designed and maintained by GUI Visions.

Where is the adenoid?
The adenoid is a lump of tissue at the back of the nose above the tonsils. In order to see them, your physician can
look through your mouth and view the back of your nose using a mirror, may choose to look with a flexible camera
in the nose, or may use an x-ray.
What is the adenoid?



















Copyright 2000-2009. All Rights Reserved.
Website designed and maintained by GUI Visions.

What Causes Hearing Loss in a Normal Ear?
The ear is commonly divided into three segments: the external ear which includes the ear lobe and ear canal, the
middle ear which includes the ear drum and the ear bones, and the inner ear which houses the hearing organ and the
nerve that travels from the ear to the brain. the middle and inner ear represent delicate structures that, when exposed
to long term infection and disease, can lead to hearing loss. This hearing loss can either be temporary or permanent.
Many times, your doctor will be unable to guarantee the return of your child's hearing loss. However, many times a
good estimate of hearing "reserve" can be made from the initial hearing test.
What are Ear Drum Perforations and Ear Drainage?
The ear drum may develop a hole, (or perforation), due to trauma or infection. In most instances, ear drum
perforations caused by infection will close after the infection resolves. However, some perforations are too large to
close spontaneously and will become infected causing drainage from the ear. When this occurs, your doctor's first









priority is to treat the infection and provide your child with a "safe" ear. This will prevent further hearing loss and
damage to the ear due to infection.
Once the child's ear infection has cleared, discussion can then take place regarding repair of the perforation.
What is Cholesteatoma?
Sometimes, a perforation has been there for several months or years and skin within the ear canal will grow into the
middle ear causing a cholesteatoma. A cholesteatoma is a cyst made up of skin. There is usually a large amount of
skin debris associated with the cholesteatoma. A cholesteatoma is a slow-growing mass that may erode adjacent
structures including the middle ear bones, (malleus: "hammer", incus: "anvil", and stapes: "stirrup") and the bone
surrounding the ear next to the brain. Cholesteatomas may also erode into the balance and hearing organs of the
inner ear. For this reason, cholesteatomas are best removed early, once they are discovered. Many times, your doctor
will try to control infection prior to removing the cholesteatoma in order to make the operation more successful.
What is Congenital Cholesteatoma?
In rare instances, a cholesteatoma may form due to skin tissue that is trapped behind the tympanic membrane during
fetal development. In this instance, there will be no history of tympanic membrane perforation or significant ear
infections.
However, the cholesteatoma can be quite extensive.
These cholesteatomas usually represent small "Pearls" or cysts that are directly attached to the inner surface of the
tympanic membrane or one of the ear bones.
Many times, these cholesteatomas can be removed in a single operation requiring no further surgical therapy.
How is Chronic Ear Disease Diagnosed?
To decide what form of therapy is best, your doctor may examine your child under an operating microscope in the
office. This will allow better visualization of the problem and give clues to the extent of your child's ear disease.
When a cholesteatoma is suspected of involving more than the area behind the ear drum, a computed tomography
(CAT) scan will be used. This is a special x-ray that allows your doctor to examine in detail the area behind the ear
drum as well as the area of the mastoid bone which is located directly behind the ear.
Your doctor will order a hearing test to assess any hearing loss that may be present prior to therapy. If your child has
signs of dizziness or unsteadiness associated with the cholesteatoma, your doctor may also order some other
specialized tests of the balance system to help determine the extent of ear disease.
What Medical Therapy is Available for Ear Disease?
In treating chronic ear infections, it is vitally important to follow your doctor's instructions and continue the
medications even if you suspect your child's ear disease is getting much better. Many times, your doctor will order
antibiotics by mouth and ear drops. He may ask you to irrigate the affected ear with a special solution in order to
rinse out debris, pus and other elements of chronic infection. Your child may require hospitalization or home








intravenous therapy in order to treat some bacteria that infect the ear and mastoid which cannot be treated with oral
antibiotics. All of these methods can result in complete resolution of chronic ear disease. It is your responsibility to
follow through with every form of therapy prescribed as well as routine follow-up visits so the doctor can assess
your child's progress.
What Surgical Therapy is Available for Chronic Ear Disease?
If medical therapy is unsuccessful, or if the extend of the disease determined by your child's evaluation is thought to
involve the mastoid, your doctor will discuss with you surgical therapy tailored specifically to your child. This
therapy may be directed at the area just behind the ear drum or to the mastoid bone behind the ear, or both.
If an operation such as this is necessary, it is important for your to fully understand the complexity and the risks
associated with these surgeries. Your doctor has been specifically trained to perform this surgery using
microsurgical instruments on the ear and mastoid. This is done with a microscope. Many times, in order to
successfully remove all the chronic disease in your child's ear, one of the ear bones will be disconnected to insure
complete removal of disease and prevent further complications. Once your child's ear disease is under control, your
doctor will be able to, in many instances, reconstruct the hearing bones and restore much of the hearing lost to the
chronic ear infection.
If your child suffers from an extensive cholesteatoma, the standard of care involves removing the cholesteatoma
during the first operation and having a follow up or "second look" operation approximately four to six months after
the initial removal. At this time, your doctor will have the opportunity to reconstruct the ear if it is appropriate.
Your doctor will discuss with you the risks of the surgery and the possible complications. Depending on the type of
operation performed, the risks of surgery may change, but basically include bleeding, infection, further hearing loss,
dizziness, tinnitus (ringing in the ear), facial paralysis and deafness.
What about Postoperative Care?
Your doctor will provide you with a separate sheet outlining the care of your child in the immediate postoperative
period. It is important that you follow these instructions closely as THIS WILL DETERMINE A SUCCESSFUL
OUTCOME FOR YOUR CHILD JUST AS MUCH AS A SUCCESSFUL OPERATION.
You are encouraged to ask questions of your doctors or the nursing staff at any time during the evaluation and
treatment of your child. Chronic ear disease is a complex and very individualized disease process and, therefore, we
encourage you to ask as many questions as you want in order to feel comfortable with your child's care.

Copyright 2000-2009. All Rights Reserved.
Website designed and maintained by GUI Visions.