stridor in children is usually due to airway pathology but neurological conditions causing stridor are not infrequent . in cases with an underlying neurological pathology causing stridor , the treatment of the underlying cause usually relieves the stridor .
we report the association of stridor in a child presenting with hydrocephalus and raised intracranial pressure following the repair of a lumbosacral myelomeningocele ; where the stridor resolved after the placement of a ventriculo - peritoneal ( v - p ) shunt . to the best of our knowledge ,
an 8-month - old female baby born at term by normal vaginal delivery , from a second - degree consanguinous marriage ; presented with noisy breathing and progressive increase in the size of the head for 4 weeks .
the child underwent lumbosacral myelomeningocele repair 2 months ago . on examination , she was awake , irritable and had noisy breathing that was aggravated on crying .
her heart rate was 123/min , blood pressure was 80/50 mm of hg , respiratory rate was 38/min and oxygen saturation was 99% on room air .
glasgow coma scale was 15/15 , head circumference was 48 cm and the anterior fontanelle was bulging and tense .
both upper limbs were spastic and the lower limbs were flaccid with grade 0 power .
contrast enhanced computed tomography ( cect ) brain showed dilatation of all the ventricles s / o obstructive hydrocephalus [ figure 1 ] . she was posted for an emergency v - p shunt insertion .
contrast enhanced computed tomography brain showing dilatation of all the ventricles s / o obstructive hydrocephalus informed high - risk consent was obtained from the parents for the procedure .
standard american society of anesthesiologists monitors , including electrocardiogram , noninvasive blood pressure , spo2 , etco2 and temperature monitoring were used .
the left side v - p shunt ( medium pressure chabbra system ) was placed , and tracheal extubation was uneventful .
postoperatively the child 's stridor decreased , head circumference was 47 cm , anterior fontanelle became lax , and she became active , playful and started feeding normally .
the association of myelomeningocele with hydrocephalous and stridor has been reported earlier . in the report by kirsch et al . , the child underwent myelomeningocele repair and a ventriculoatrial shunt was placed at the age of 23 days but presented with cyanosis and stridor at the age of 16 months requiring tracheostomy .
described a child presenting with hydrocephalous and stridor , 5 months after she underwent lumbar myelomeningocele repair .
solan and glaisyer described a neonate with stridor after the development of hydrocephalus secondary to surgical repair of the lumbosacral myelomeningocele . in this report ,
the stridor resolved completely after an emergency ventricular tap was performed , and the vp shunt procedure was performed only later . similar to our case , adeloye et al . described a child who presented initially with lumbar myelomeningocele and later developed hydrocephalus and severe laryngeal stridor , that resolved dramatically after the placement of a v - p shunt
stridor is defined as the sound caused by abnormal air passage into the lungs and may be caused by extra thoracic ( nose , pharynx , larynx , trachea ) or intra - thoracic airway ( tracheobronchial tree ) obstruction .
other causes include secondary airway lesions , vocal cord paralysis ( vcp ) , subglottic stenosis , tracheal anomaly , laryngeal cleft , vascular and lymphatic malformation , laryngeal papillomas , craniofacial abnormalities , and even head and neck tumors .
the stridor in our case was probably due to unilateral vocal cord palsy due to stretching of the vagus nerve as it resolved promptly after the v - p shunt was performed .
the differential diagnoses in our case could be bilateral vocal cord palsy or other congenital or infective laryngeal pathology causing stridor .
vocal cord paralysis may be idiopathic , iatrogenic , and secondary to neurological abnormality including arnold chiari malformation [ acm ] , cerebral palsy , hydrocephalus , myelomeningocele , spina bifida , or hypoxia or birth trauma .
described 21 infants and children with bilateral abductor vcp and associated meningomyelocele , acm , and hydrocephalus .
they reported a temporal relationship between increased intracranial pressure ( icp ) and vcp , apnea , aspiration , and dysphagia .
according to chen and inglis in infants with bilateral vcp , acm with hydrocephalous and myelomeningocele is the commonest neurologic finding .
various causes have been proposed for the development of vcp in patients with raised icp with neurological disorders including ; the downward displacement of the brainstem secondary to increased icp ; stretching , compression or ischemia of the vagus nerves during their course from the nuclei ambiguii to the jugular foramen ; circulatory impairment of the brainstem and primary brainstem dysgenesis with hypoplasia of the cranial nerve nuclei .
the treatment options include decompression of increased icp by temporary measures such as cerebrospinal fluid tap followed by a definitive v - p shunt or decompression of the foramen magnum to reduce the pressure difference between intracranial and intra spinal compartments .
usually , the stridor will be relieved after the decompression procedure but some authors have reported worsening of symptoms after the surgical procedure .
ideally the ventricular shunt should be performed within 48 h of onset of hindbrain dysfunction .
tracheostomy may be required if the stridor does not resolve by 48 h after the definitive surgical procedure . in the perioperative period
the avoidance of further increase in icp at the time of induction and intubation can not be over emphasized .
early visualization of the larynx is required in patients who become stridulous postoperatively , especially those who have undergone prior thoracic procedures or with neurologic disorders associated with intracranial hypertension .
stridor in children is not always due to airway pathology and clinicians should be aware of the neurological associations of this symptom .
when associated with neurological conditions , relieving the neurological condition often decreases the stridor and hence may avoid unnecessary airway intervention and evaluation .
 stridor in children is usually , but not always caused by airway pathology . 
 the anesthesiologists should have a sound knowledge of the neurological associations of stridor and its management . 
 in such cases , prompt treatment of the neurological pathology usually resolves the stridor and may prevent unnecessary airway evaluation and intervention in the child . 
Introduction
Case Report
Discussion
Conclusion