1 Congenital Larynx Lesions & Stridor Evaluation Dr. Vishal Sharma
2 Epidemiology80 – 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
6 Laryngomalacia Most common congenital laryngeal anomaly Etiology: Exact cause is not known1. Mal-development of cartilaginous structures2. Gastro-esophageal reflux disease3. Immaturity of neuromuscular control
7 Clinical 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.
8 Flexible 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
28 Types 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.
35 Congenital 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
36 Anterior saccular cyst Smaller in size, project into laryngeal lumen inanterior ventricular region
37 Lateral saccular cystLarger, present as bulge in false vocal fold or ary-epiglottic fold, extend into neck
38 Treatment 1. Emergency tracheostomy for acute stridor 2. Endoscopic de-roofing or marsupialization: cold knife Laser-assisted3. Endoscopic incision & drainage4. Total excision: endoscopic laryngofissure approach
55 Cri-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
57 Congenital 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.
60 Treatment 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.
63 Subglottic 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
65 Management 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
66 Subglottic web Treatment: Endoscopic division with knife / laser & insertionof McNaughtlaryngeal keel
68 Stridor 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
69 Etiology 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 #
73 History Taking 1. Congenital or acquired after birth 2. Present only during sleep stertor3. Related to feeding aspiration due to laryngeal paralysis, esophageal obstruction4. Foreign body, blunt injury, endoscopy, intubation5. Sudden onset foreign body, injury, infection6. Long standing + progressive Laryngomalacia, laryngeal stenosis, neoplasm
74 Physical Examination 1. Respiratory timing of stridor: Inspiratory supraglottis or pharynxBiphasic glottis, subglottis or cervical tracheaExpiratory lower trachea, bronchi or alveoli2. Signs of airway resistance: nasal flaring, intercostal / subcostal / supraclavicular recession, cyanosis
75 Physical Examination 3. Associated fever: inflammatory cause 4. Stridor disappears in prone position: laryngomalacia, macroglossia, micrognathia, vascular compression of trachea5. Resting respiratory rate: look for tachypnoea6. Resting heart rate: look for tachycardia
76 Investigations Arterial blood gas analysis: for hypoxia X-Ray soft tissue neck: for epiglottitis, stenosisX-Ray chest: for mediastinal lesionFlexible laryngoscopy & bronchoscopyDirect laryngoscopy & rigid bronchoscopyC.T. scan of neck & chestM.R.I. of neck & chestBarium swallow & esophagoscopy