127
Pediatric Otolaryngology
www.entnet.orgnarrowing 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
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.