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.

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

3. • Supraglottis:
– Laryngomalacia, Web, Saccular cyst, Congenital Laryngocele,
Cleft
• Glottis:
– Vocal cord paralysis, Web, Stenosis, Cri-du-chat syndrome
• Subglottis:
– Stenosis, Web, Hemangioma
• Trachea and bronchi: Web, Stenosis, Tracheo -malacia , Vascular
compression, Cysts
Etiology

4. Common laryngeal causes
• Laryngomalacia (60%)
• Congenital vocal cord paralysis (20%)
• Congenital subglottic stenosis (15%)
• Subglottic hemangioma (1.5%)

5. Supraglottic abnormalities

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

9. Omega shaped epiglottis in flexible
Laryngoscopy

10. Inspiration vs. Expiration

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

12. Epiglottoplasty

13. Medial collapse of A.E. fold Removing wedge of A.E. folds

14. Long tubular epiglottis Trimming the epiglottis

15. Medial collapse of
corniculate
and cuneiform cartilages
Removing corniculate and
cuneiform cartilages and
redundant arytenoid mucosa

16. Posterior epiglottis displacement Epiglottopexy

17. Short A.E. folds Division of A.E. Folds

18. Pre-operative Post-operative

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

20. Saccular cyst

21. Congenital Laryngocele
• Air filled dilatation of ventricular sinus of Morgagni
• Types: Internal, external, mixed
• C/F
– Hoarseness or respiratory distress
– Neck swelling increases on Valsalva maneuver
• Investigations:
– Plain X-ray Soft Tissue Neck AP view on Valsalva
– Flexible laryngoscopy
• Treatment: Endoscopic / External Excision

22. Swelling increasing with Valsalva suggestive of
laryngocele

23. X-ray neck A.P. view with Valsalva showing
air filled space in lateral neck

24. Flexible laryngoscopy

25. Supraglottic web

26. Supraglottic cleft

27. Glottic abnormalities

28. Etiology
• Idiopathic : most common
• C.N.S. Lesions
– Arnold- Chiari malformation, cerebral palsy, spina
bifida, hydrocephalus, myelomeningocele
• Birth trauma
– Cervical spine, recurrent laryngeal nerve
• Mediastinum lesions: tumors, vascular malformation
Congenital vocal cord palsy

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

30. Management
• Diagnosis:
– Flexible laryngoscopy : vocal fold paralysis
– Rigid bronchoscopy  GA to r/o other anomalies
• Treatment
• Bilateral paralysis
– Vocal cord lateralization
– Subtotal Arytenoidectomy
– Tracheostomy
• Unilateral paralysis: Observation

31. Flexible laryngoscopy

32. Vocal cord lateralization

33. Laser-assisted Subtotal
Arytenoidectomy

34. Posterior Cordotomy + Submucosal
dissection

35. Thyroarytenoid muscle vaporization
and subtotal arytenoidectomy

36. Pre-op vs. post-op

37. Glottic web
• Treatment:
– Endoscopic division
with knife / laser
and insertion of Mc
Naught laryngeal
keel

38. Glottic stenosis
Treatment:
Endoscopic division
with knife / laser and
insertion of
Mc Naught laryngeal
keel

39. McNaught Keel

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

41. Subglottic abnormalities

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

43. Flexible laryngoscopy

44. Radiology

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

46. Tracheostomy

47. Laryngo- tracheoplasty

48. Subglottic web
Treatment:
Endoscopic
division with knife
/ laser & insertion
of McNaught
laryngeal keel

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

50. Flexible laryngoscopy

51. Management
• Observation: small lesions without stridor
• Tracheostomy for significant airway obstruction
• Tube kept till 5 years
• Specific treatment
– Laser ablation
– Cryosurgery
– Sclerosing agent: intra-lesional injection
– Open surgical excision

52. Tracheo-bronchial
abnormalities

53. Tracheomalacia

54. Tracheal stenosis

55. Evaluation of Stridor

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

57. Etiology
• Nasal
– Choanal atresia, Ethmoidal polyps
• Mandibular
– Pierre Robin Syndrome
• Tongue
– Macroglossia, Lingual thyroid
• Pharynx
– Adeno-tonsillar hypertrophy, Retropharyngeal
abscess, Neoplasm
• Miscellaneous
– Ludwig’s angina, Maxillofacial fracture, G.E.R.D.,
Mediastinal mass

58. Larynx and Trachea
Congenital
 Laryngomalacia
 Vocal cord palsy
 Subglottic stenosis
 Subglottic hemangioma
 Laryngeal web & atresia
 Laryngeal cyst
 Vascular compression
Acquired
• Inflammatory
– Acute Epiglottitis, Croup,
Laryngeal edema, T.B.
• Traumatic
– Accidental, iatrogenic, heat,
chemical
• Neoplastic
• Foreign body
• B/L vocal cord palsy

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

60. • Respiratory timing of stridor
– Inspiratory  supraglottis
– Biphasic  glottis, subglottis or cervical trachea
– Expiratory  lower trachea, bronchi or alveoli
• Airway resistance
– Nasal flaring
– Intercostal, subcostal , supraclavicular recession
– Cyanosis
Physical Examination (1)

61. Physical Examination (2)
• Fever: inflammatory cause
• Stridor disappears in prone position
– Laryngomalacia, macroglossia, micrognathia,
vascular compression
• Resting respiratory rate ( tachypnea)
• Resting heart rate (tachycardia)

62. Investigations
• Arterial blood gas analysis
• X-Ray soft tissue Neck AP and Lateral view
• X-Ray Chest
• Flexible laryngoscopy & bronchoscopy
• Direct laryngoscopy and Rigid bronchoscopy
• C.T. scan of Neck & chest
• M.R.I. of Neck and chest
• Barium Swallow and Esophagoscopy