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Pediatric Otolaryngology

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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

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.