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The techniques used to visualize the adult larynx may also be used in children (Fig. 27.1). Smaller versions of fiberoptic and rigid endoscopes are available but often pale in clarity, resolution, and light delivery. As technological advances are made in endoscopy, advances are also made in the office evaluation of the pediatric larynx. It should be stated early, however, that operative endoscopy via a general anesthetic for an accurate diagnosis should be offered if sufficient visualization cannot be obtained in the clinic and if the endoscopist feels confident in his or her operative skills, support, and facility. A missed or delayed diagnosis from failure to adequately visualize the larynx is not acceptable.

The developing pediatric larynx also has a different appearance from the fully developed adult larynx. As the larynx descends into the neck of the adult, the supraglottic structures open up, exposing the true vocal folds for easier visualization. The infantile omega-shaped epiglottis and foreshortened aryepiglottic folds can at times obscure complete visualization of the child’s glottis (Fig. 27.2). The true vocal folds are also shorter in the child than in the adult. Not only are the vocal folds shorter, but also the ratio of the membranous vocal fold to the cartilaginous vocal process is nearly 1 to 1, much smaller than that in the adult (Fig. 27.3). The position and shape of the pediatric larynx dramatically differs from that of the adult.

Fig. 27.1 Normal pediatric larynx seen during direct rigid endoscopy.

The introduction of fiberoptic endoscopy has added tremendously in the evaluation of the aerodigestive tract in all age groups. With advancing technology, smaller fiberscopes are becoming available. This has allowed for the use of fiberscopes in even the youngest neonates for visualization of the functioning velopharynx, hypopharynx, and larynx. It is the rare case when a child cannot be evaluated by flexible endoscopy. Small, distal chip camera endoscopes, allowing for a more functional evaluation of the larynx, will likely someday completely replace the rigid angled telescope for laryngoscopy. This will especially hold true as optical quality improves (Fig. 27.4).

The choice of fiberoptic endoscope is based on its size, optical clarity, ability to couple with the video-recording source, and its durability. The endoscopist should trial each prospective endoscope with his or her own video system to be certain that the image is acceptable. Smaller endoscopes allow for more comfort for the patient and therefore a longer and more agreeable evaluation, although their durability and optical quality at times are an issue.

If a child is unable to sit comfortably alone for flexible endoscopy, the parent may be enlisted to help with gentle restraint. With the parent seated in the endoscopy chair, the child can sit on the parent’s lap. The parent can then give the child a gentle hug and control the hands and arms. An assistant can also help steady the head. The amount of physical restraint is kept light as long as the child does not move or reach for the fiberscope (Fig. 27.5). Demonstration of the action of the endoscope, capturing a head shot of the patient with the endoscopic camera and allowing the child to feel the fiberscope prior to insertion, can also be helpful to induce trust of the child.

Once the endoscopy has begun, stops along the way can be made to accommodate the child. With brief stops during insertion at the child’s request, the child gains the understanding that he or she has some control during the endoscopy, and the procedure can then generally proceed with fewer interruptions. Once the endoscope is positioned, it should be left in place until the child can settle. When the movement of the scope ceases, discomfort and anxiety decreases and cooperation increases giving a better assessment.

Again, videotaping the examination allows for later explanation of the visualized structures to both the child and the parent. Frame-by-frame analysis can also be used when only brief glimpses of the desired anatomy are seen. Biofeedback can also be used and demonstrated with the videoendoscopy.

The advantage of the flexible endoscope is its nearly universal utility. It would be extremely unlikely that a child could not be examined by a fiberscope. It also allows for the functional evaluation of the nasal cavity, velopharynx, hypopharynx, larynx, and swallow, which cannot be done with the rigid endoscope. The disadvantage to the fiberscope lies in its relatively poor optics and at times inadequate light delivery for videostroboscopy.

Cooperative children, generally over the age of 5, can also be examined by the rigid endoscope. The advantages of the rigid angled endoscope are its clarity, quality, and brightness. Videostroboscopy has been found to be helpful in evaluating mucosal and submucosal lesions (Fig. 27.6). The typical 10-mm angled rigid endoscope can be used in most instances. Occasionally, the oropharyngeal inlet is narrowed by tonsillar hypertrophy. This can make insertion of the 10-mm endoscope difficult. Smaller angled telescopes are available and have been found to be useful. A 4-mm narrow-view angled endoscope with the light post on the viewing side has been helpful in children with large tonsils. The narrower or less blunt tip of the smaller endoscopes, however, can feel sharper in the posterior pharynx if the mucosa is touched, and so care must be taken to avoid contact with the pharyngeal walls. Superior light and optics, however, are provided by the rigid endoscopes.

The techniques and preparation for rigid indirect laryngoscopy in children are similar to those used in adults. A clear, age-appropriate explanation of the procedure is very helpful in obtaining patient compliance. Although it is up to the endoscopist’s preference, fiberoptic endoscopy is often performed first to obtain an image of the larynx. If tolerated reasonably well, then rigid endoscopy can be introduced. This guarantees that some images of the larynx will be obtained yet it affords a chance to record images of the larynx with greater clarity, as well. Again, it should be emphasized that video recording during the endoscopy is extremely useful.

Fig. 27.6 Bilateral vocal nodules with posterior glottic edema and pachydermy consistent with laryngopharyngeal reflux observed via office rigid videoendoscopy.

There are times during the evaluation of the pediatric larynx when office visualization does not yield an accurate diagnosis. Children may not be able to adequately comply with the fiberoptic exam in the office while awake. An incomplete examination due to anatomic issues, poor cooperation, or if the accuracy of the diagnosis is in question due to a failure in treatment are indications for further physical examination. In these instances, it may be necessary to take the child to the operating room for further evaluation. It may be that operative endoscopy, with a general anesthetic, is required to allow a thorough and more complete visual as well as tactile examination of the larynx (Fig. 27.7).

Although the techniques are similar to adult microlaryngology, in pediatric microlaryngol-ogy the instrumentation is smaller, airway management has different concerns, and the general anesthetic is often approached differently. This tool and approach, however, should be an integral part of the assessment of the pediatric larynx. Requirements for pediatric direct laryngoscopy include the appropriate instrumentation, support staff, and expertise to perform operative endoscopy. Comfort with the management of the pediatric airway is essential to the safe and accurate assessment of the pediatric larynx during general anesthesia. Beyond the expertise of the surgeon, a well-trained operating room staff and an anesthesiologist comfortable with the pediatric patient and airway are also required.

Fig. 27.7 These are symmetric vocal nodules at the midpoint of the membranous vocal fold. Again, the membranous to cartilaginous vocal fold ratio is 1 to 1.

Telescopic examination or microscopic examination of the pediatric vocal folds may uncover pathology that was not otherwise recognized in the office. It has been shown by Dailey et al. that office endoscopy can miss or incorrectly diagnose 10 to 20% of adult laryngeal pathology.¹ Although this has not been studied in the pediatric larynx, it is likely that similar if not higher inaccuracies occur. An accurate assessment and diagnosis is required for proper treatment regimens.

There are many different techniques for operative endoscopy in the pediatric larynx. Spontaneous ventilation with direct assessment of the vocal folds by telescopes, whether zero-degree or angled, or by a microscope gives a magnified view of the vocal fold. Comfort with microlaryngeal surgical techniques is important for the evaluation of the pediatric larynx. Palpation of the vocal folds is then possible to assess for the presence of an intracordal cyst. Sulcus vocalis may also be recognized with palpation and manipulation of the vocal fold itself. Recognition of lesions other than vocal nodules is important, as these pathologic conditions may require vastly different therapies including surgery.

Common Findings in Pediatric Laryngeal Imaging

Fortunately, the most common finding in a dysphonic child is vocal nodules. Vocal nodules are a thickening of the superficial layers of the vocal fold in discrete areas generally in the middle of the membranous vocal fold. Although attributed to vocal trauma, the exact etiology for vocal nodules is not known. Quiet children can have vocal nodules, whereas screamers may not. Vocal nodules also have different appearances. Soft tissue lesions that are often diagnosed as vocal nodules may have very different physical appearances. This also confirms our lack of understanding of the etiology of vocal nodules (Figs. 27.8 to 27.15).

It is important that the pediatric voice specialist be able to recognize different lesions of the vocal fold. It may be especially difficult to distinguish between a submucosal cyst and a vocal nodule in children (Fig. 27.16). This differentiation is exceedingly important, however, as the primary treatment regiment is vastly different. Intracordal cysts may require surgical intervention or removal, whereas vocal nodules are often successfully treated with voice therapy alone (Fig. 27.17).

Fig. 27.13 Small symmetric nodules.

Sulcus vocalis is a pocket of mucosa that extends deep into the lamina propria. Sulcus vocalis lesions have been classified as superficial to very deep, with extension and occasionally scarring to the vocal ligament (Fig. 27.18). As it is in adults, the treatment of sulcus vocalis in children is controversial. Excision of this lesion without subsequent scarring is exceedingly difficult. Voice therapy alone, however, may not resolve the dysphonia. Despite the controversy in treatment modalities, an accurate diagnosis is helpful, as it may explain an inadequate or incomplete response to appropriate voice therapy.

Viral lesions from the human papilloma virus are the most common mass lesions on the pediatric larynx (Fig. 27.19). They may recur and cause significant voice disturbance as well as respiratory embarrassment. Significant airway obstruction can result from growth of these viral lesions. Office endoscopy is usually diagnostic and may also be used to follow the course of the disease, but surgical intervention is often required for debulking the viral growths to prevent obstruction of the airway.

Congenital anomalies of the larynx may present in newborns or later in children. A few examples of congenital anomalies of the larynx include glottic web, laryngotracheal cleft, laryngomalacia, and supraglottic or saccular cysts (Figs. 27.20 to 27.22). Many of these are readily identifiable with office endoscopy, but some require direct laryngoscopy for confirmation.

Fig. 27.20 A small laryngeal web is seen across the true vocal folds.

Fig. 27.21 This larynx has a large laryngotracheal cleft. There is a congenital cleft in the posterior glottis, between the arytenoids extending down through the cricoid cartilage. The tube seen is inserted into the esophagus, and the cleft is seen anterior to it.

1. Dailey SH, Spanou K, Zeitels SM. The evaluation of benign glottic lesions: rigid telescopic stroboscopy versus suspension microlaryngoscopy. J Voice 2007;21:112–118

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