1Congenital Larynx Lesions & Stridor Evaluation Dr. Vishal Sharma
2Epidemiology80 – 85 % children < 3 yrs with stridor have congenital etiology for stridor60 % of these anomalies are in larynx20-25 % are anomalies of trachea + bronchi45% patients have more than 1 anomalies
6Laryngomalacia Most common congenital laryngeal anomaly Etiology: Exact cause is not known1. Mal-development of cartilaginous structures2. Gastro-esophageal reflux disease3. Immaturity of neuromuscular control
7Clinical presentation Symptoms begin few weeks after birth, progress over 9-12 months & resolve by 2 yearsInspiratory stridor: 1. increased by: supine position, feeding, resp. infection & exertion (crying). 2. relieved by: neck extension & prone position.Phonation & cry are normal. Feeding difficulties, failure to thrive, dyspnoea & cyanosis are rare.
8Flexible laryngoscopy Elongation + longitudinal folding of epiglottis (omega shaped, ), falls postero-inferiorly on inspirationRedundant bulky arytenoids prolapse anteriorly & medially on inspiration. Shortening + medial collapse of aryepiglottic folds. Expiration results in expulsion of these structures with free flow of airRigid bronchoscopy GA: exclude other anomaly
28Types of laryngocoeleInternal (20%): contained entirely within endolarynx with bulge in false vocal fold & aryepiglottic foldExternal (30%): only neck swelling without visible endolaryngeal swellingCombined (50%): Also extends into anterior triangle of neck through foramen for superior laryngeal nerve & vessels in thyrohyoid membrane. Dumbbell shaped.
35Congenital saccular cyst Due to obstruction of orifice of saccule in laryngeal ventricle40% congenital cysts found within hours of birth95% of infants have symptoms within 6 monthsC/F: Inspiratory stridor improves on extension of head, cyanosis, feeding problem & failure to thrive
36Anterior saccular cyst Smaller in size, project into laryngeal lumen inanterior ventricular region
37Lateral saccular cystLarger, present as bulge in false vocal fold or ary-epiglottic fold, extend into neck
38Treatment 1. Emergency tracheostomy for acute stridor 2. Endoscopic de-roofing or marsupialization: cold knife Laser-assisted3. Endoscopic incision & drainage4. Total excision: endoscopic laryngofissure approach
55Cri-du-chat syndrome Cri – du – chat means cry of the cat Partial depletion of short arm of chromosome 5High pitched mewing stridorDiamond shaped glottic space, narrow vocal cords, curved & elongated supraglottisTreatment: 1. Supportive care2. Genetic counseling
57Congenital subglottic stenosis Definition: diameter of subglottic lumen < 4 mm interm infant & < 3 mm in pre-term infantEtiology: Incomplete recanalization of laryngo tracheal tube during 3rd month of gestationTypes: 1. Membranous: more common & mild form2. Cartilaginous: less common & severe formClinical presentation: Symptoms appear in firstfew months of life. Biphasic stridor. Cry is normal.
60Treatment Most cases resolve spontaneously by 4 years. Tracheostomy for significant stridor. Tuberemoved by 4 years when subglottic space widens.Laser ablation for membranous stenosis < 5 mm.Crico-tracheal resection & Laryngo-tracheo-plasty in patients who could not be decannulated.
63Subglottic hemangioma Capillary hamartomasSymptoms appear by age 2-12 monthsBiphasic stridor, barking cough & hoarse cry50% have cutaneous hemangiomas of head & neckFlexible laryngoscopy: unilateral or bilateral lesionLocated postero-laterally in subglottis submucosa, pink-blue in color, sessile & easily compressible
65Management Observation: for small lesions without stridor Tracheostomy: for significant airway obstruction.Tube kept till 5 years.Specific treatment:1. Laser ablation Cryosurgery3. Sclerosing agent: intra-lesional injection4. Open surgical excision
66Subglottic web Treatment: Endoscopic division with knife / laser & insertionof McNaughtlaryngeal keel
68Stridor vs. StertorStertor is noisy respiration due to turbulent air flow through partially narrowed air passage above larynxStridor is noisy respiration due to turbulent air flow through partially narrowed air passage at or below level of larynx
69Etiology for stertor Nasal: choanal atresia, ethmoid polyps Mandible: Pierre Robin syndromeTongue: macroglossia, lingual thyroidPharynx: adeno-tonsillar hypertrophy, retro-pharyngeal abscess, neoplasmMiscellaneous: Ludwig’s angina, Maxillo-facial #