Nasopharyngolaryngoscopy of this child revealed decreased motion of the left hemilarynx. The epiglottis is at the bottom of the photo and the posterior glottis is at the top. There were a supraglottic web and a very small left hemilarynx. The right arytenoid seemed relatively large to the small left hemilarynx. It was very difficult to see the vocal folds due to the supraglottic hooding
The child was taken to the operating room where inhalational anesthesia with spontaneous ventilation and insufflation. It was difficult to visualize the larynx due to the small glottic inlet posed by the supraglottic web. The child was easily intubated with a small endotracheal tube. Figure 44.2 shows the operative endoscopic findings with the supraglottic web and a left hemilaryngeal hypoplasia. The bottom right panel shows the initial visualization after intubation. The web can be seen anterior to the endotracheal tube. It appears to extend from false vocal fold to false vocal fold. The bottom left panel shows the web as it was incised with a sickle knife. The right upper panel shows the lysed web and exposure of the glottis and right vocal fold. The left upper panel shows the end result after lysis of the web has occurred. The left vocal fold is atretic. There is poor development of the arytenoid cartilage and membranous vocal fold.
Fig. 44.2
Operative endoscopy of the child with supraglottic webbing and a left hemilaryngeal hypoplasia. Anterior is at the top of the panel and posterior is at the bottom. The bottom right panel shows the initial visualization after intubation. The web can be seen anterior to the endotracheal tube. The bottom left panel shows the web as it is incised with a sickle knife. The right upper panel shows the lysed web and exposure of the glottis and right vocal fold. The left upper panel shows the end result after lysis of the web has occurred. The left vocal fold is atretic. There is poor development of the arytenoid cartilage and membranous vocal fold
Although there was left hemilaryngeal hypoplasia and therefore a smaller subglottis, after release of the supraglottic web, it appeared that there would be an adequate airway. The child was extubated. Over the years, he has had some dysphonia characterized by breathiness with poor projection. He has also had some exercise intolerance but now plays football. Figure 44.3a, b shows his laryngeal development at the age of 5. He has severe hypoplasia of the left vocal fold and little or no motion. He has been able to compensate and achieve glottic closure with his right glottis. The hypoplasia of the left vocal fold in relation to the right vocal fold at the anterior commissure can be seen in Fig. 44.3b.
Fig. 44.3
(a, b) Operative endoscopy of NK at the age of 5 years. He has a left hemilaryngeal hypoplasia best seen in (a). The release of the supraglottic web can be seen above the vocal folds. (b) The same view after intubation with an age-appropriate endotracheal tube to demonstrate the anterior commissure and the hypoplastic nature of the left glottis. There is no motion on his left side. He has compensated to achieve near total closure with his right side
His larynx has grown with him over the years, and no other reconstructive surgery has been required. He has undergone voice therapy to maximize his voicing with the laryngeal structures that he has. His initial diagnosis was difficult, and it was easy to ascribe his difference in laryngeal motion to a paralysis. It was not easy to tell without the operative endoscopy the nature of his true anatomy. It did appear at first glance to be a left-sided paralysis, but in reality, his motion impairment was from underdevelopment of the left hemilarynx and not a paralysis or fixation.
Infant Choking in the Back of a Car
A distraught mother drove to the nearest emergency room with her infant who had been choking and had hemoptysis. While driving, her rear window spontaneously shattered, covering the rear seat, the infant carrier, and her child. She pulled over and cleared the broken glass from the car seat and her child. The child appeared fine. As she drove for a few more miles, she heard the infant choking and then saw that there was some bloody froth coming from the baby’s mouth. The mom decided to drive to the closest emergency department. The infant was drooling but did not have respiratory distress. With the history of a witnessed cough choke, the ED obtained a chest radiograph seen in Fig. 44.4. A large shard of glass was seen in the infant’s cervical esophagus.
Fig. 44.4
Chest radiograph of an infant with choking and hemoptysis. The rear window he was facing in his infant carrier had spontaneously exploded and covered him and the rear seat with shards of glass. His mother had pulled over and cleared the glass from his seat, but a few miles later, he was witnessed to choke and have hemoptysis. This is the initial chest radiograph upon presentation to the ED. A large shard of glass can be seen in the proximal esophagus
The infant was sent by helicopter to our institution for management of the esophageal glass shard. It was uncertain how the shard would be removed and what damage might occur to the esophagus. Other surgical services were notified that the child would be taken to the operating room for removal of the glass shard. The child had a general anesthetic with endotracheal intubation. Rigid esophagoscopy allowed for visualization of the upper part of the glass shard in the cervical esophagus. The shard was too large to bring into the rigid esophagoscope to sheath the sharp edges of the glass. The glass was secured with an optical grasper and gently removed from the esophagus. The piece slid out of the esophagus easily through the cricopharyngeus. It was taken out as a single piece although it was safety glass and had multiple fractures. Repeated esophagoscopy did not reveal any mucosal injury or other pieces of glass. The retrieved glass shard can be seen in Fig. 44.5. Although the piece was large, close inspection of the broken edges revealed obtuse angles of fracture. This is a very fortunate feature of safety glass. Over the years, automobile manufacturers have moved from plate glass to laminated glass and now tempered glass as a safety feature in cars such as seat belts. Safety glass was added to the rear windows some years after it was introduced for the front windscreen.
Fig. 44.5
Large shard of safety glass retrieved as an esophageal foreign body. The piece was too large to sheath inside the rigid esophagoscope to protect the esophageal mucosa. The special features of safety glass, however, helped to protect this infant. Safety glass fracture with mostly obtuse or square edges, decreasing the number of sharp knifelike edges that would have lacerated the esophagus. There was no injury to the esophagus upon retrieval of this foreign body
Newborn with Imperforate Anus Repair Unable to Extubate with Square Flow Volume Loop on Ventilator
An infant with truncus arteriosus congenital cardiac anomalies underwent repair of an imperforate anus on the second day of life. The child was not ready for extubation at the end of the procedure. He was transferred to the PICU (pediatric intensive care unit) for further care. There was difficulty with ventilation, and his flow volume loop on his ventilator was square with a clipped inspiratory and expiratory loop consistent with a fixed obstruction. Consultation for airway evaluation was requested due to the flow volume loop. After discussion with the cardiothoracic and intensivist team, diagnostic rigid endoscopy was performed. He would need cardiac surgery in the near future, and it was hoped that he would be able to extubate after the imperforate anus repair. It was easy to believe, however, that the clipped flow volume loop was an artifact. At endoscopy, however, this infant was found to have long-segment complete tracheal rings spanning from above the thoracic inlet to just above the carina. There was swelling and granulation tissue developing where the tip of the endotracheal tube had been resting against the tracheal stenosis. The tracheal narrowing can be seen in Fig. 44.6.
Fig. 44.6
Operative endoscopy showing a circular pattern to the cervical trachea consistent with complete tracheal rings. This child was unable to extubate after repair of an imperforate anus and prior to his complex cardiac surgery repair. His ventilator showed a square and clipped flow volume loop suggesting a fixed obstruction
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