1) Congenital lesions of the larynx and trachea are common causes of stridor in infants under 3 years old, with laryngomalacia being the most frequent cause.
2) Evaluation of stridor involves obtaining a history, physical exam, and diagnostic tests like laryngoscopy to identify the specific anatomical abnormality and determine if it is acquired or congenital in nature.
3) Treatment depends on the diagnosis but may include watchful waiting, prone positioning, gastroesophageal reflux management, tracheostomy, or surgical procedures like epiglottoplasty or laryngeal reconstruction.
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Congenital Lesions of Larynx and Evaluation of Stridor
1. Congenital Lesions of Larynx
and Evaluation of Stridor
Dr. Krishna Koirala
2019-03-18
2. Epidemiology
• 80 – 85 % Children of < 3 yrs of age with stridor
have congenital etiology
• 60 % : Anomalies of larynx
• 20-25 % : Anomalies of Trachea and Bronchi
• 45% patients have more than 1 anomalies
6. • Most common congenital laryngeal anomaly
Etiology:
• Exact cause is not known
–Maldevelopment of cartilaginous structures
–Gastro-esophageal reflux disease
–Immaturity of neuromuscular control
Laryngomalacia
7. Clinical presentation
• Symptoms begin few weeks after birth, progress over 9-12
months and resolve by 2 years
• Inspiratory stridor:
– Increased in supine position, feeding, respiratory infection
and exertion (crying)
– Relieved in neck extension and prone position
• Phonation and cry are normal
• Feeding difficulties, failure to thrive, dyspnea and cyanosis are
rare
8. Flexible laryngoscopy
• Epiglottis : elongated and longitudinally folded (omega
shaped, ), falls postero-inferiorly on inspiration
• Arytenoids : redundant and bulky , prolapse anteriorly and
medially on inspiration
• Aryepiglottic folds : Shortening and medial collapse
• Expiration results in expulsion of these structures with free flow
of air
• Rigid bronchoscopy GA : to exclude other anomalies
11. Treatment
• Reassurance
• Sleep in prone position
• Treatment of gastro-esophageal reflux disease
• Surgical management:
– Emergency Tracheostomy: kept till 2 yrs of age
– Epiglottoplasty: cautery or laser assisted
works in 99% cases
19. Laryngeal cyst
• Commonly seen as Saccular cyst
• Usually asymptomatic
• Rapid increase in size leads to hoarseness and airway
obstruction
• Flexible laryngoscopy: Saccular swelling
• Treatment: M.L.S. excision with cold knife, cautery or
Laser, Marsupialisation, Tracheostomy
29. Clinical Features
• Unilateral paralysis (4 times more common than B/L
– Hoarse, breathy cry aggravated by agitation
– Feeding difficulty
– Aspiration
• Bilateral paralysis
– Inspiratory stridor : worsens upon agitation
– Near normal phonation
– Aspiration with recurrent chest infection
– Feeding difficulty
40. Cri-du-chat syndrome
• Cry of the cat
• Partial depletion of short arm of chromosome 5
• High pitched mewing stridor
• Diamond shaped glottic space, narrow vocal cords,
curved and elongated supraglottis
• Treatment
– Supportive care
– Genetic counselling
42. Congenital subglottic stenosis
• Definition: diameter of subglottic lumen < 4 mm in
term infant and < 3 mm in pre-term infant
• Etiology: Incomplete recanalization of laryngotracheal
tube during 3rd month of gestation
• Types:
– Membranous: more common , mild form
– Cartilaginous: less common , severe form
• Clinical presentation
– Symptoms appear in first few months of life
– Biphasic stridor
– Normal cry
45. Treatment
• Most cases resolve spontaneously by 4 years
• Tracheostomy for significant stridor
• Tube removed by 4 years when subglottic space
widens
• Laser ablation for membranous stenosis < 5 mm
• Crico -tracheal resection & Laryngo-tracheo- plasty in
patients who could not be decannulated
49. Subglottic hemangioma
• Capillary Hamartoma
• Symptoms appear by 2-12 months of age
• Biphasic stridor, barking cough & hoarse cry
• 50% have cutaneous hemangiomas of head and neck
• Flexible laryngoscopy
– Unilateral or bilateral lesion located postero-
laterally in subglottic submucosa, pink-blue in color,
sessile and easily compressible
56. Stertor vs. Stridor
• Stertor
– Noisy breathing due to turbulent air flow through
partially narrowed air passage above the larynx
• Stridor
– Noisy breathing due to turbulent air flow through
partially narrowed air passage at or below the
level of larynx
59. History Taking
• Congenital or acquired after birth
• Present only during sleep stertor
• Related to feeding aspiration due to laryngeal
paralysis, esophageal obstruction
• H/O Foreign body aspiration , blunt injury, endoscopy,
intubation
• Sudden onset foreign body, injury, infection
• Long standing and progressive Laryngomalacia,
laryngeal stenosis, neoplasm