Laryngospasm

LARYNGOSPASM, laryngospasmus (from Latin larynx—larynx and spasmus—contraction, convulsion), is a spasmodic contraction of the glottis; it is a frequent, most typical manifestation of the overt form of spasmophilic diathesis and is one of the three main types of convulsions associated with it (laryngospasm, eclampsia, and tetany). In mild cases, laryngospasm is detected as difficult breathing due to involuntary spasmodic contraction of the laryngeal muscles and is expressed by a sonorous or groaning, pulling, sobbing, loud inspiration; this inspiration resembles the crowing of a rooster and appears during any excitement of the child, crying, laughing, and sometimes without any cause. Such sounds during laryngeal spasm are audible from a distance, give the physician reason to look for spasmophilia, and are so characteristic that they can hardly be confused with anything else. Mild convulsions of the glottis, if not paid attention to, can repeat and be replaced by severe attacks that threaten the child's life. In typical cases, suddenly in a seemingly healthy child, in a state of complete well-being or sometimes after screaming, crying, or coughing, the face turns pale, the head is thrown back, and a deep, noisy, whistling inspiration appears, indicating difficult air passage through the spasmodically narrowed larynx. The child unsuccessfully attempts to take a series of breaths, but breathing stops—apnea (inspiratory). At the same time, the neck muscles are tense, the mouth is open, individual movements appear in the lower jaw, the gaze is fixed with an expression of fear, the eyeballs are red and protruding, the eyelids are open, the pupil does not react to light, and severe cyanosis sets in. The arms hang helplessly or are straightened and are in a state of severe rigidity, the skin is covered with cold sweat, consciousness is briefly impaired, urine and feces are passed involuntarily, the pulse is barely palpable and strongly accelerated; sometimes there are twitchings at the corners of the mouth and eyes. The epigastric region is often protruding and hard due to the simultaneous spasm of the diaphragm and abdominal muscles; the temperature is normal. The impression is created that the child may suffocate and death is inevitable; but suddenly the laryngeal spasm ceases, a sharp inspiratory sound appears, then individual expiratory movements occur, consciousness returns, breathing is restored and assumes its normal rhythm. After a severe attack, the child becomes somewhat lethargic, sleepy, as if stunned, but soon calms down, feels well, and returns to play. The subsequent state of sleep does not always occur; if it is encountered, it usually lasts only a short time. An attack of laryngospasm can cease at any moment and at any stage of its development. Convulsion of the respiratory muscles is sometimes encountered without the involvement of the laryngeal muscles in the process, when expiratory dyspnea and cessation of breathing in the expiratory phase (expiratory apnea) appear; it can occur unnoticed by those around and lead to death. General convulsions in children can in this case alternate with spasms of the glottis or join them as a consequence of CO₂ poisoning. Attacks of laryngospasm last from a few seconds to one minute, but their frequency, strength, and duration vary greatly. In some, they may repeat 1-2 times in a few days, in others there are 2-3 attacks per day, in other children the number of attacks per day reaches 15-20 or more. Laryngospasm usually appears no earlier than the 3rd month of life and is not encountered after 2 years, whereas other symptoms of spasmophilia (eclampsia, carpopedal spasms) occur, although rarely, even after 2 years. Attacks arise during the day, less often at night upon waking with a cry. The time of their appearance often relates to the end of winter and the first months of spring. The etiological moment for laryngospasm is the spasmophilic soil with its increased nervous excitability and tendency to spasms. Hence it is understandable that attacks of laryngospasm in a large number of cases arise in connection with various external moments (fright, psychic excitement, laughter, crying, trauma, etc.). A trigger for the manifestation of laryngospasm can be a full stomach, infection, intoxication, or high temperature. Laryngospasm is encountered almost exclusively in rachitic, anemic, nervous children suffering from prolonged nutritional disorders; all these states are undoubtedly accompanied by an increase in nervous excitability. Simpson believes that in some cases the child reacts to external stimuli (exogenous factors) by using a motor reflex that has become habitual along well-trodden paths. Laryngospasm occurring during various diseases (measles, croup)—see the corresponding diseases. Pathological anatomy: there are no changes in the larynx; its mucous membrane is normal, and everything boils down to the spasmodic contraction of the laryngeal muscles under the influence of nerve impulses. The course of laryngospasm is usually chronic. The strength and frequency of attacks slowly increase, remain at a peak for some time, and then gradually decrease. Thus, in the course of laryngospasm, one can distinguish, as it were, 3 periods: increase, high state, and disappearance of laryngeal convulsions. The course depends on the underlying ailment. Mild attacks can continue for several days and weeks with a tendency to recur. Under the influence of treatment, attacks of laryngospasm weaken and are arrested. The diagnosis of laryngospasm is not difficult, as laryngospasm serves as a characteristic, although not mandatory, sign of spasmophilia and should prompt a search for other symptoms of this diathesis (Chvostek, Trousseau, Erb, Lust, Maslov symptoms, etc.). Typical attacks of laryngospasm are characteristic only of spasmophilia, which is why confirming them is sufficient for making a diagnosis. Laryngospasm must be distinguished from states similar to it: 1) congenital laryngeal stenosis (stridor laryngis congenitus); the anamnesis (onset from birth, laryngospasm not earlier than 3 months!) makes it possible to differentiate these diseases; 2) affective respiratory convulsions, appearing in neuropathic children aged 1-5 years and caused mainly by violent crying and excitement with cessation of breathing in the expiratory phase with phenomena of cyanosis, loss of consciousness, etc.; 3) stridor during enlargement of the thymus gland (characterized by a rapid alternation of stridor and free breathing with a clear voice); 4) inflammatory spasms of the vocal cords (differ from laryngospasm by the duration of the attacks, whereas attacks of laryngospasm are usually instantaneous). The prognosis for laryngospasm is generally favorable, but it should be stated with caution. Mild cases of laryngospasm as a rule end in recovery. Danger to life is presented by severe, frequent, and prolonged attacks of laryngeal spasm, and in unfavorable cases, the child may die during one of the first paroxysms from heart paralysis, which is more often noted in children with exudative diathesis, lymphatics, and those who are pasty (Escherich). The addition of general convulsions, complications with pneumonia, or diarrhea worsens the prognosis. Artificial feeding reduces the chances of recovery. In general, any attack of laryngospasm puts the child's life in danger, all the more so because a severe attack can always follow a mild one. Prophylaxis is aimed at preventing the possibility of the recurrence of attacks by protecting the child from agitation, establishing an appropriate regimen, nutrition, and eliminating the underlying disease, i.e., preventing rickets, anemia, and nervous and intestinal diseases as the soil for the appearance of laryngospasm. The main tasks of therapy boil down to the symptomatic elimination of the danger of the attacks themselves and to the treatment of spasmophilia and rickets. In mild cases of laryngospasm, any intervention is unnecessary. In a severe attack, if it begins to take on a prolonged character, one should splash cold water on the child's face and chest, pull out the tongue, press its root with a finger, inject camphor under the skin, and attempt to perform artificial respiration. Bendix recommends supporting the forehead of the sitting child with one hand and moderately patting the interscapular region with the other, gradually increasing and accelerating the tempo of movements. In asphyxia, besides artificial respiration, the application of electric current, intubation, or tracheotomy (Pott) are recommended, but the benefit of these measures is often doubtful, as the child dies from collapse, not from suffocation. Great importance is attached to the stimulation of cardiac activity in view of the possibility of its cessation. For this purpose, cardiac agents are widely used in the form of subcutaneous injections (camphor, Cardiazol, caffeine), and heart massage. To arrest an attack, it is possible to administer a chloral hydrate enema (0.3-0.5 per dose) as soon as possible. A single subcutaneous injection of Luminal-sodium at 0.1 in an aqueous solution gives a good effect. In threatening cases of laryngospasm, the physician uses chloroform anesthesia or injects an 8% solution of magnesium sulfate at a rate of 0.2 per 1 kg of weight (10-15 cm³) (see Spasmophilia). It is necessary to pay attention to diseases that create a predisposition to laryngospasm (rickets, anemia, nutritional disorders, etc.). It is important, in the presence of laryngospasm, to widely implement hygienic measures (use of air, light, etc.). A. Popov.

Laryngospasm is also encountered in adults as a secondary phenomenon (see also Larynx, pathology). Laryngospasm in adults manifests in the form of suddenly occurring seizures of tonic spasms of the respiratory muscles and the muscles constricting the glottis: a typical symptom of laryngospasm is wheezing respiration; the duration of the seizure varies, but it is usually very short, lasting a few seconds, thanks to which patients are able to endure the asphyxia that always accompanies laryngospasm without particularly severe consequences. This condition in adults in the majority of cases appears reflexively during diseases of various organs located in areas adjacent to those through which the inferior laryngeal nerve (recurrens) passes, and primarily during lesions of the bronchial glands, large vessels (aortic arch, right subclavian artery), beneath which the recurrent nerve passes on its way to the larynx, as well as the esophagus. Furthermore, laryngospasm can manifest in the form of a reflex from distant organs (disease of the uterus); in subjects with a neuropathic constitution, laryngospasm is encountered more frequently. Sometimes laryngospasm is observed during hydrocephalus. Lit.—see the corresponding chapters of the main manuals cited in the literature for the article Larynx.