1. Laryngocele and Saccular Cyst LaryngoceleLaryngocele oAbnormal dilation of the saccule that communicates with the lumen of the larynx oFilled with air =/- mucous Saccular CystSaccular Cyst oCystic dilation of the saccule that does not communicate with the laryngeal lumen oThought to develop due to nonpatent saccular orifice oCyst is distinctly submucosal and are covered with normal mucosa

2. Saccular Cyst

3. Subglottic Hemangioma Classic scenarioClassic scenario o“Croup” symptoms generally begin 6-8 weeks of age No fever, good cryNo fever, good cry o“Croup” recurs several weeks later oMean age of diagnosis is 4 months oDelay due to misdiagnosis of symptoms Proliferative phase (Birth to 1 year) then involutional phase (usually by 3-5 years)Proliferative phase (Birth to 1 year) then involutional phase (usually by 3-5 years) 50% of children with Subglottic hemangioma also have cutaneous hemangioma (esp. facial)50% of children with Subglottic hemangioma also have cutaneous hemangioma (esp. facial) Female:Male= 2:1Female:Male= 2:1

4. Subglottic Hemangioma

5. Subglottic Hemangioma- Treatment Medical treatment: oSystemic corticosteroids oIntralesional steroids oInterferon alpha-2A oPropranolol Surgical treatment: oEndoscopic excision oLaryngofissure with complete resection

6. Subglottic Hemangioma- Propranolol Discovered serendipitously byDiscovered serendipitously by Le´atue´-Labre`ze in 2008 when propranolol was used to treat steroid-induced hypertrophic cardiomyopathy in a patient with a large facial hemangioma Mechanism- Unknown oVasoconstriction oInhibition of VEGF or other growth factors Side Effects:Side Effects: Bradycardia, Hypotension, Hypoglycemia, and Bronchospasm Dose: 2-3 mg/kg divided tidDose: 2-3 mg/kg divided tid Leaute-Labreze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649e51.

7. Congenital Disorders of the Trachea Tracheal Anomalies:Tracheal Anomalies: oTracheomalacia45% PrimaryPrimary SecondarySecondary oInnominate artery34% oVascular Sling9% oTracheal Stenosis6% oTracheal Diverticula3% oDouble aortic arch3% Holinger, LD. Etiology of Stridor in the Newborn, Infant, and Child. Annals of ORL, 1980; 89: 397-400.

8. Tracheomalacia Flaciddity of the tracheal/ bronchial cartilage leading to collapse of the airway Cartilaginous to membranous ratio may be significantly decreased oNormal trachea Cartilaginous: Membranous trachea is 4.5:1 oPrimary tracheomalacia Cartilaginous: Membranous tracheal is 3:1 or 2:1 Incidence of primary tracheomalacia is about 1 in 2100

9. Tracheomalacia Symptoms: oTracheal wheeze/ Expiratory wheeze or stridor oHarsh, barking cough/ “Brassy” cough oFailure to thrive oIncreasing respiratory distress with growth oTransmitted vibration through the back oDifficulty clearing secretions oSymptoms exacerbated with viral infections oReflex Apnea- “Dying Spells”

10. Tracheomalacia- Treatment Supportive care oDisease resolves between ages 2-5 years Medical treatment oOnly to help manage concomittant issues CPAP/ BiPAP Tracheotomy Airway stenting Surgical options oAortopexy oTracheostomy

11. Secondary Tracheomalacia I.Aberrant innominate artery II.Vascular Rings A. Double aortic arch B. Right aortic arch with left ligamentum arteriosum III.Pulmonary artery sling IV.Aberrant right subclavian artery V.Congenital cardiac defects

12. Aberrant Innominate Artery Leftward origin of the innominate artery (brachiocephalic trunk) is common variant of normal anatomy oMost common vascular anomaly oPresent in 0.5% of humans McLaughlin R, Wetmore R, Tavill M, Gaynor J, Spray T. Vascular Anomalies Causing Symptomatic Tracheobronchial Compression. Laryngoscope. 109:312-319, February 1999.

13. Double Aortic Arch Bifurcation of the ascending aorta that surrounds the trachea and esophagus, then rejoins to form the descending aorta McLaughlin R, Wetmore R, Tavill M, Gaynor J, Spray T. Vascular Anomalies Causing Symptomatic Tracheobronchial Compression. Laryngoscope. 109:312-319, February 1999.

14. Subglottic Stenosis oFull term infant: Subglottic diameter < 4.0 mmSubglottic diameter < 4.0 mm oPremature Infant: Subglottic diameter < 3.5 mmSubglottic diameter < 3.5 mm Congenital Subglottic Stenosis: (5%) oDefined as SGS in absence of internal or external laryngeal trauma oThird most common congenital laryngeal anomaly oNo Croup in Infants Younger Than 1 Year! Acquired Subglottic Stenosis: (95%) oSecondary to laryngeal trauma External Trauma: Blunt/ Clothesline injury Internal Injury: Endotracheal tube; Nasogastric tube oOther factors contribute to progression

15. Congenital Subglottic Stenosis MembranousMembranous CartilaginousCartilaginous oCricoid Cartilage Deformity Normal shape, Small sizeNormal shape, Small size Abnormal Shape:Abnormal Shape: –Elliptical –Flattened –Laryngeal Cleft –Ossification oTrapped First Tracheal Ring