Primary Care Otolaryngology

Pediatric Otolaryngology

narrowing of the airway. This can occur acutely or over the course of sev- eral months after extubation. These patients present with stridor, which may be biphasic because it is due to a fixed obstruction in the larynx (children with subglottic stenosis are sometimes erroneously diagnosed as having asthma). In more mild cases, children with underlying subglottic stenosis may present with recurrent croup, as mentioned above. If the subglottic stenosis is severe, there are several treatment options. The first option is to place a tracheotomy to bypass the obstruction. There are many problems associated with tracheotomy in infants, including delays in speech development, chronic mucous plugging, and even risk of death due to an obstructed tube. One solution is to surgically enlarge the airway with a cricoid split . This can include simply making a vertical incision in the anterior cricoid ring, allowing it to expand while an endotracheal tube remains in the airway for a week to 10 days. This particular procedure is not used as frequently today. Instead, the expansion may be supported by transferring a small strip of cartilage harvested from the thyroid ala and secured into the incision of the cricoid. If this is inadequate and the child still has some stenosis, a formal laryngotracheal reconstruction can be performed, in which rib cartilage is grafted into the cricoid cartilage and upper tracheal rings to allow for a more dramatic expansion. The airway expansion can be stabilized with use of a stent (tube secured within the airway at the site of reconstruction) for varying lengths of time. The suc- cess rate for this procedure is good, but is inversely proportional to the extent of the original degree of stenosis. Another way of treating mild stenosis involves using a laser to incise the involved area, followed by bal- loon dilation. Subglottic Hemangioma Another cause of stridor in children can be a subglottic hemangioma . Often

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stridor presents within the two- to four- month age range, when hemangiomas go through a characteristic rapid growth phase. Classically, 50 percent of these patients will have other associated head and neck hemangiomata, which will be visible on the skin. In some situ- ations, these hemangiomas can be treated with a laser. Systemic steroids and interferon may play a role as well. Newer reports suggest the off-label use

Figure 18.3. This young child has a large hemangioma with cosmetic as well as functional symptoms.

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