66.1 Laryngomalacia

66.1.1 Incidence and Aetiology

• Most common cause of stridor in newborn

• May be autosomal dominant

• 68% have other respiratory disorders (as seen on flexible bronchoscopy)

66.1.2 Clinical Features

• Inspiratory stridor

• Feeding problems

• Gastric reflux (80%), regurgitation (40%)

• Worsens with increased respiratory effort

• Begins shortly after birth getting worse until 6 to 8 months

• Plateau at 9 months and steadily improve after

• Flaccid epiglottis with short and redundant aryepiglottic folds

• OSA (23%), CSA (10%)

• Aspiration pneumonitis in 7%

• May be concurrent laryngeal congenital lesions (18–60%)

66.1.3 Investigations

• Direct laryngobronchoscopy if failure to thrive

66.1.4 Treatment

• Observation sufficient in most cases

• 10 to 15% (failure to thrive/>1 lesion) may need intervention

• Supraglottoplasty and anterior epiglottoplexy

66.2 Absent/Rudimentary Epiglottis

• Rare bifid epiglottis can be associated with stridor and aspiration

• Multiple congenital anomalies common

• Direct laryngoscopy ± tracheostomy

66.3 Laryngeal Atresia

• Rarest laryngeal lesion

• Child makes strong respiratory efforts at birth but no air movement, cry, or stridor

• Marked cyanosis when cord clamped

• Most die without emergency tracheostomy

• If large TOF present they may survive

66.3.1 Laryngeal Webs

• Mostly occur in glottis

• Most located anteriorly and extend towards arytenoids

• Vary in thickness

• 5% of all congenital laryngeal lesions

• Acquired lesions more common

• Symptoms present at birth in 75% and all at 1 year

• Many asymptomatic until stressed, have an infection, or are intubated

• Vocal dysfunction and airway obstruction (inspiratory stridor)

• Needs direct laryngoscopy

• 60% require surgical intervention

• 30 to 40% require tracheostomy

• 4 types of lesions

66.4 Saccular Cysts

• Most arise in infancy

• Stridor in 90%—inspiratory (occ. biphasic)

• Respiratory difficulty in 55%

• Failure to thrive due to feeding difficulties

• Direct laryngoscopy required

• May require emergency tracheostomy

• Definitive treatment is endoscopic I&D (laryngofissure if required)

66.5 Laryngoceles

• 4/52 gestation primordium of respiratory system appears as outgrowth from the foregut

• The outgrowth expands in a caudal direction and becomes separated from the foregut by the development of 2 longitudinal ridges (oesophagotracheal ridges), which fuse to form the septum

• Failure of fusion results in a cleft

66.6.2 Types

• I: interarytenoid

• II: into cricoid

• III: through posterior cricoid

• IV: membranous trachea

66.6.3 Clinical Features

• Aspiration and cyanosis—53%

• Postpartum asphyxia—33%

• Increased mucus production—23%

• Recurrent pneumonia—16%

• Voiceless crying—16%

• Stridor—10%

• Impaired swallowing—5%

66.6.4 Investigations

• Contrast swallow

• MRI

• Laryngoscopy

66.6.5 Treatment

• Poor prognosis—due to other congenital anomalies

• 50% need a tracheostomy

• Surgical repair options include anterior laryngofissure (with rib graft)

66.7 Vocal Fold Paralysis

• Congenital (10% of all congenital) or acquired

• Bilateral more frequent

• Common association with:

Hydrocephalus

Meningomyelocoele

Arnold–Chiari malformation

Other CNS lesions

66.7.1 Incidence and Aetiology

• 1.5 to 23% = frequency

• Congenital lesions more common

Acquired Causes

• Traumatic

Vaginal delivery

Surgery for congenital malformation, e.g., TOF

• Infectious

Whooping cough

Encephalitis

Poliomyelitis

Syphilis

• Neoplastic—tumours of brain and spinal column

Congenital Causes

• Probably due to compression of vagus through foramen magnum—improves when hydrocephalus of Arnold–Chiari malformation decompressed

• Brainstem dysgenesis and traction of vagal nerve roots are other theories

66.7.2 Treatment

• Secure airway (ETT/tracheostomy) if bilateral

• Relieve compression—if within 24 h—nerve will regain function in 2 weeks; otherwise may take 1.5 years

• Periodic examinations to assess VF function

66.8 Subglottic Stenosis

66.8.1 Incidence and Aetiology