Pediatric Surgery: Upper Airway Pathology

Proximal Upper Airway & Larynx

Choanal Atresia

  • Congenital Posterior Nasal Passage Obstruction
  • Presentation:
    • Poor Suckling
    • Intermittent Respiratory Distress
    • Cyanosis – Worsens with Feeding, Improves with Crying
    • Inability to Pass Nasal Tube
  • May Be Associated with CHARGE Syndrome
    • Coloboma of the Iris (Missing Part of the Iris)
    • Heart Defects
    • Atresia of the Choanae
    • Retarded Growth
    • Genitourinary Defects
    • Ear Defects/Deafness
  • Diagnosis: CT with Intranasal Contrast
  • Tx: Endoscopic Transnasal Resection of Posterior Nasal Septum

Bilateral Choanal Atresia on CT 1

Laryngomalacia

  • Soft Immature Supraglottic Cartilage Causes Collapse
  • Most Common Cause of Airway Obstruction in Infants
  • Presentation:
    • Usually Presents at Birth
    • Usually Resolves After 18-24 Months
  • Symptoms:
    • Inspiratory Stridor – Worsened by Supine Position
    • Feeding Problems
    • GERD
  • Diagnosis: Flexible Laryngoscopy
  • Treatment: Mostly Conservative Management
    • Indications for Surgery:
      • Life-Threatening Airway Obstruction
      • Chronic Hypoxia
      • Failure to Thrive
      • Pulmonary Hypertension
      • Cor Pulmonale
    • Surgery: Supraglottoplasty (Microsurgery to Remove Redundant Tissue)
      • Tracheostomy Was the Historical Procedure but Now Rarely Required

Laryngomalacia on Laryngoscopy 2

Recurrent Respiratory Papillomatosis (Laryngeal Papillomatosis)

  • Papillomas Due to Human Papillomavirus (HPV) Infection of the Upper Airway
  • Most Common Larynx Tumor in Peds
  • Source: HPV Positive Mother During Passage Through Birth Canal
  • Commonly Resolves After Puberty
  • Morbidity Can Arise from Obstruction
  • May Require Laser Ablation or Laryngeal Shaving

Laryngeal Papillomatosis on Laryngoscopy 3

Trachea & Bronchi

Tracheomalacia

  • Soft Immature Tracheal Cartilage Causes Collapse
  • Most Outgrow by Age 18 Months
  • Presentation:
    • Expiratory Stridor
      • Stridor May Be Inspiratory if Lesion is Extrathoracic in the Cervical Trachea
    • Respiratory Distress
    • Recurrent Respiratory Infections
    • “Barking” Cough
    • “Dying Spells” – Cyanosis, Apnea & Bradycardia Due to Severe Hypoxia After Feeding
  • Diagnosis: Dynamic Flexible Bronchoscopy
    • See Elliptical Tracheal Rings
  • Treatment: Mostly Conservative Management
    • Indications for Surgery:
      • Life-Threatening Airway Obstruction
      • Chronic Hypoxia
      • Failure to Thrive
    • Surgical Options:
      • Aortopexy (Suspend Aorta from the Sternum – Opening the Trachea)
      • Tracheal Reconstruction
      • Endoluminal Tracheal Stents

Tracheomalacia, (a) Normal Trachea, (c) Tracheomalacia 4

Bronchiogenic Cyst

  • Cystic Lesion of Bronchial Tissue
    • Can Be Anywhere Along the Tracheobronchial Tree
    • Usually Extrapulmonary
    • Does Not Communicate with the Tracheobronchial Tree
  • Cause: Abnormal Budding of the Foregut During Development
  • Most Often Presents as a Young Adult
  • Presentation:
    • Recurrent Cough
    • Recurrent Pneumonia
    • Rapidly Enlarging Neck or Mediastinal Mass
      • Filled with Thick Milky/Clear Fluid
    • Cyanosis
    • Respiratory Distress
  • Tx: Surgical Excision

References

  1. Aksoy F, Demirhan H, Yildirim YS, Ozturan O. Bilateral choanal atresia in an adult – management with mitomycin C and without stents: a case report. Cases J. 2009 Dec 11;2:9307. (License: CC BY-2.0)
  2. Yee-Hang WB, Theresa H, So-Lun L, Wai-Kuen H, Ignace WW. Stridor in asian infants: assessment and treatment. ISRN Otolaryngol. 2012 Feb 19;2012:915910. (License: CC BY-3.0)
  3. Bohlender J. Diagnostic and therapeutic pitfalls in benign vocal fold diseases. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013 Dec 13;12:Doc01. (License: CC BY-NC-ND-3.0)
  4. Kamran A, Jennings RW. Wikimedia Commons. (License: CC BY-SA-4.0)