Pediatric Subglottic Stenosis Surgery 

Updated: Mar 28, 2018
Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD 

Overview

Background

Subglottic stenosis (SGS) is a narrowing of the subglottic airway (see the image below). The subglottis is defined as the airway directly below the level of the vocal folds and encased in the cricoid cartilage. The subglottic airway is the narrowest area of the airway because it is encased in a complete, nonexpandable, and nonpliable ring.  In contrast, the trachea has a posterior membranous section, and the larynx has a posterior muscular section.

Intraoperative endoscopic view of a normal subglot Intraoperative endoscopic view of a normal subglottis.

The term SGS implies a narrowing of the subglottic airway that is either congenital or acquired in etiology, though the term is applied to both congenital lesions of the cricoid ring and acquired SGS.

Acquired SGS is the most common acquired anomaly of the larynx in children and the most common abnormality requiring tracheotomy in children younger than 1 year. Correction of this abnormality requires expanding the lumen of the cricoid area to increase airflow and decrease obstructive breathing. Surgical correction of SGS has been performed with various techniques over the years.

Early in the 20th century, acquired SGS was usually related to trauma or infection from syphilis, tuberculosis, typhoid fever, or diphtheria. Often, the treatment itself for SGS at this time, a tracheostomy, led to further damage to the airway  

The incidence of acquired SGS increased in the late 1960s through the 1970s, after McDonald and Stocks introduced long-term intubation as a treatment method for neonates in need of prolonged ventilation.[1] The increased incidence of SGS focused new attention on the pediatric larynx, as well as the need for development of novel treatment modalities.

Pathophysiology

The exact pathophysiology of congenital SGS is unknown, though there is a known association of SGS with syndromes such as Down syndrome.  

Acquired SGS, on the other hand, is most freqently associated with intubation or airway trauma. Mechanical trauma from an endotracheal tube, as it passes through or remains for long periods in the narrowed neonatal and subglottic airway, can lead to mucosal edema and hyperemia. These conditions then can progress to pressure necrosis of the mucosa. These changes have been observed within a few hours of intubation and may progress to expose the perichondrium of the cricoid cartilage. Infection of the perichondrium can result in a subglottic scar.

This series of events can be hastened if an oversized endotracheal tube is used. Always check for an air leak after placing an endotracheal tube because of the risk of necrosis of the mucosa, even in short surgical procedures. Usually, the pressure of the air leak should be less than 20 cm H2O, so that no additional pressure necrosis occurs in the mucosa of the subglottis.

Etiology

The exact etiology of congenital SGS is unknown.

The etiology of acquired SGS is related to trauma of the subglottic mucosa. Injury can be caused by infection or mechanical trauma, usually from endotracheal intubation but also from blunt, penetrating, or other trauma. Historically, acquired SGS has been related to infections such as tuberculosis and diphtheria. Over the past 40 years, the condition has typically been related to mechanical trauma.

Factors implicated in the development of SGS include the size of the endotracheal tube relative to the child's larynx, the duration of intubation, the motion of the tube, and repeated intubations. Additional factors that affect wound healing include systemic illness, malnutrition, anemia, and hypoxia.[2]

Local bacterial infection may play an important role in the development of SGS. Gastroesophageal reflux (GER) may play an adjuvant role in the development of SGS because it causes the subglottis to be continually bathed in acid, which irritates and inflames the area and prevents it from correctly healing. A systemic or gastrointestinal (GI) allergy may cause the airway to be more reactive, creating a greater chance of developing stenosis.

Epidemiology

United States statistics

No known frequency has been reported for congenital SGS; the incidence of acquired SGS has greatly decreased over the past 40 years. In the late 1960s, when endotracheal intubation and long-term ventilation for premature infants began, the incidence of acquired SGS was as high as 24% in patients who required such care. In the 1970s and 1980s, estimates of the incidence of SGS were 1-8%.

In 2000, Choi reported that the incidence of SGS had remained constant at the Children's National Medical Center in Washington DC, accounting for approximately 1-2% of the children who had graduated from the neonatal intensive care unit (NICU).[3]

Walner reported that of 504 neonates who were admitted to the level III NICU at the University of Chicago in 1997, 281 were intubated for an average of 11 days; over a 3-year period, no patients developed SGS.[4]

International statistics

International frequency is the same as that of the United States.

In 1996, a report from France also described no incidence of SGS in the neonatal population who were intubated with very small endotracheal tubes (2.5 mm internal diameter) in attempts to prevent trauma to the airway.

Age-, sex-, and race-related demographics

SGS is observed more often in premature infants because they may require mechanical ventilation for other system or pulmonary problems secondary to their prematurity. The mechanical ventilation can result in airway trauma and, potentially, SGS.

Equal sex distribution is noted. No racial predilection is noted.

Prognosis

The symptoms and prognosis of SGS can be highly variable, mostly depending on the severity of the SGS.  Difficulty in breathing and exercise intolerance can occur with mild, moderate, or severe SGS.  In moderate-to-severe cases of SGS, respiratory insufficiency can lead to failure to thrive, acute life threatening events (ALTE), and even death.

The outcome of laryngotracheal reconstruction depends on its grade and the procedure performed. Most authors report success rates of 80-90% when the patient has undergone successful preoperative evaluation and when the appropriate operation has been performed (see the images below).

A 3-month postoperative subglottic view of the pat A 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.
A 1-week postoperative subglottic view of the surg A 1-week postoperative subglottic view of the surgical repair with an anterior graft of a congential elliptical subglottic stenosis. The white areas to the left and right are the true vocal cords. The graft is seen at the superior and mid area.

The presence of acute or chronic respiratory illness, GER, or a reactive larynx may decrease the success rate. Choi and Zalzal showed that age can affect success rates; scars are more likely to recur in children younger than 2 years than in others.[5] Success is more likely with localized SGS than with extensive SGS.[6]

Zalzal noted that in any child with voice abnormalities before surgery, those abnormalities persisted after surgery.[7] Subglottic pressure is required to produce a strong voice. If the narrowed subglottic airway is expanded, subglottic airflow and pressure increase, and the voice usually is stronger (see the images below). Voice therapy may help relieve nonsevere glottic stenosis over time.

Preoperative view of glottic stenosis and small gl Preoperative view of glottic stenosis and small glottic chink in a 2-year-old child who underwent anterior and posterior grafting. The child's glottic narrowing is tight, and scarring of the right arytenoid has occurred.
Preoperative endoscopic subglottic view of a 2-yea Preoperative endoscopic subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis.
Postoperative view of the glottic larynx in a chil Postoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. The child had glottic narrowing that is more open and in neutral position after the surgery. The scarring of the right true vocal cord appears improved, and her voice is more normal.
Postoperative close-up view of the true vocal cord Postoperative close-up view of the true vocal cords in the patient with congenital and acquired vertical subglottic stenosis.
A 3-month postoperative subglottic view of the pat A 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.

The voice of a patient with SGS, especially those who require reconstruction, may never return to its preoperative state, because the following are possible:

  • Glottic stenosis
  • Imperfect closure of a laryngofissure through the anterior commissure
  • Potential vocal cord weakness or tension caused by other laryngeal pathologic conditions

Because reconstructive techniques have improved over the past few decades, the focus of attention in patients with SGS who require reconstruction has switched from decannulation to decannulation with improved voice outcome.

Avelino et al reported a 100% success rate with balloon laryngoplasty in children with acute subglottic stenosis, though they found the procedure to be less successful in chronic subglottic stenosis.[8]  Factors that predicted a good outcome were as follows:

  • Acute stenosis
  • Less severe grades of stenosis
  • Younger patient age
  • Absence of tracheotomy

Patient Education

Teaching parents life-saving maneuvers for a child with a tracheotomy or airway stent following laryngotracheal reconstruction is critical. It is also important to teach parents cardiopulmonary resuscitation (CPR) before their child leaves the hospital.

For further information, see Subglottic Stenosis in Children. For patient education resources, see Bronchoscopy.

 

Presentation

History

Children with subglottic stenosis (SGS) have an airway obstruction that may manifest in several ways.

In neonates, SGS may manifest as stridor and obstructive breathing after extubation that requires reintubation. At birth, intubation in most full-term neonates should be performed with a 3.5-mm pediatric endotracheal tube. If a smaller-than-appropriate endotracheal tube must be used, narrowing of the airway may be present, which could suggest SGS.

The stridor in SGS is usually on inspiration. Inspiratory stridor can be associated with supraglottic, glottic, subglottic, and upper tracheal narrowing. Expiratory stridor is usually associated with tracheal, bronchial, or pulmonary lesions.

The severity of airway symptoms depends on the type or degree of SGS. In mild SGS, only exercise-induced stridor or obstruction may be present. In severe SGS, complete airway obstruction may be present and may require immediate surgical intervention.

Depending on the severity, SGS can cause patients to have decreased subglottic pressure and a hoarse or a weak voice. Hoarseness or vocal weakness can also be associated with glottic stenosis and vocal cord paresis or paralysis.

Always assess the history of gastroesophageal reflux disease (GERD). If GERD is present, it must always be evaluated before surgical intervention.

A child who eventually has a diagnosis of SGS often has a history of either laryngotracheal trauma or intubation and ventilation. Frequently, these patients were born prematurely, have bronchopulmonary dysplasia, and may require oxygen administration. The degree of pulmonary disease and the amount of oxygen the child requires may affect the ability to perform decannulation. Before surgical intervention, the child should not require a substantial oxygen supplementation.

Physical Examination

A child's physical examination varies, depending on the degree of SGS present.

Perform a complete head and neck evaluation. Evaluate the child's initial overall appearance, including the following:

  • Comfort level
  • Presence of increased breathing difficulty, especially during periods of heightened emotion
  • Presence of suprasternal, substernal, or intracostal retractions
  • Presence of any nasal flaring

Evaluate the child's voice, with attention to the following:

  • Presence and nature of stridor
  • Abnormal or normal speaking voice

Evaluate the child's neurologic status.

In the presence of a tracheotomy, evaluate the patient's breathing while the tracheotomy is occluded. Auscultate the child's lung field and neck to elicit any airway obstructive symptoms and to evaluate the status of their pulmonary function.

Identify associated facial abnormalities, such as cleft palate, choanal atresia, retrognathia, and facial deformities.

 

DDx

Diagnostic Considerations

Consider any lesion that can cause stridor, including subglottic tumor (benign or malignant), subglottic hemangioma, laryngomalacia, vocal cord paralysis, glottic stenosis, tracheal stenosis, edema from gastroesophageal reflux (GER), acute infection (eg, croup), and foreign body.

Differential Diagnoses

 

Workup

Approach Considerations

Diagnosis of a patient with respiratory insufficiency and stridor can be quite complex. However, the fundamentals of a good history and physical examination cannot be overemphasized.  Sometimes, simply observing the patient at rest or during activity can provide valuable information regarding the severity of symptoms and the level of obstruction.

A patient with inspiratory stridor can have narrowing of the airway secondary to a static lesion of the upper airway as well as dynamic collapse of the airway.[9] Therefore, evaluation modalities must be designed to diagnose both types of narrowing of the airway. The mainstay for evaluating the airway for static and dynamic narrowing of the airway is endoscopy.

Imaging Studies

The criterion standard for evaluation of the airway is direct laryngoscopy and direct bronchoscopy (see below). However, certain radiographic examinations can help in obtaining a diagnosis and determining the severity of the disease.

Usually, the initial radiographic study used to evaluate a child with airway obstruction is anteroposterior and lateral plain neck radiography. Frequently, in a child with subglottic stenosis (SGS), the subglottis appears narrowed and peaked; this is often described as a steeple sign. In a patient with a thin web SGS, lateral plain radiography may reveal a faint line.

Fluoroscopy is often performed in children with symptoms of dynamic airway obstruction.

Computed tomography (CT) and magnetic resonance imaging (MRI) are not often used in the primary evaluation of SGS, though they are sometimes useful as adjunctive diagnostic procedures to evalute for abnormal vasculature or mediastinal masses that may compress the airway.

Endoscopy, Nasopharyngoscopy, Laryngoscopy, and Bronchoscopy

In a child with mild or moderate airway obstruction, perform flexible fiberoptic nasopharyngoscopy in the clinic or the emergency department (ED).

If extreme airway obstruction is observed or if an active supraglottic infectious process is suspected in a young child, flexible endoscopy may be deferred in favor of formal rigid bronchoscopy in the operating room (OR) so that the airway can be managed definitively and under controlled circumstances. However, flexible fiberoptic nasopharyngoscopy and bronchoscopy may be performed in a controlled setting in the OR, in that this allows better visualization of the dynamic nature of the airway and of possible dynamic collapse of the airway.  

Flexible fiberoptic nasopharyngoscopy and laryngoscopy

During flexible fiberoptic nasopharyngoscopy and laryngoscopy, topical anesthesia and decongestion can be accomplished in older infants and children with topical oxymetazoline and lidocaine. A 3-mm endoscope can be used, even in an infant. Pass the endoscope into both nasal cavities to access pyriform aperture stenosis, midnasal stenosis, choanal atresia or stenosis, lesions of the nose and nasopharynx, and the adenoid pad.

Pass the endoscope into the superior oropharynx and hypopharynx. The hypopharynx and larynx can be assessed. Identify the structure and position of the supraglottis. Evaluate the epiglottis and arytenoids for malacia or stenosis. Evaluate the position and movement of the true vocal cords. Evaluate edema or erythema of the true vocal cords, epiglottis, and arytenoids.

Flexible endoscopy

This can be performed with the patient in the supine or sitting position. The supine position often results in the obstruction of certain supraglottic processes. If the goal is to obtain the best visualization of the true vocal cords and supraglottis, place a child (even an infant) in the sitting position with his or her neck extended.

If the child is older, the voice can be evaluated, and videostroboscopy can be performed to assess the vocal cord waveform and vocal cord mobility.

Occasionally, the subglottis can be visualized with flexible endoscopy; however, rigid laryngoscopy and bronchoscopy are the safest procedures and offer the best visualization for the subglottis and tracheobronchial tree.

Rigid laryngoscopy and bronchoscopy

Rigid laryngoscopy with bronchoscopy is the best single test for evaluating airway obstruction in children, especially for static lesions such as SGS.

The otolaryngologist must have knowledge of the pediatric airway, and the OR must have adequate bronchoscopes and telescopes of various sizes. Prepare all equipment for bronchoscopy, including laryngoscopes, light sources, video documentation equipment, telescopes, and bronchoscopes before the child's arrival in the OR. Throughout the procedure, maintain good communication among anesthesiologists, surgical nursing staff, and physicians, so that any potential airway obstruction can be quickly assessed and addressed.

Do not further injure the pediatric airway. This point is of paramount importance. Use the smallest bronchoscope or telescope alone for evaluation of the subglottis in a child who does not require ventilation throughout the procedure. This practice allows good visualization without iatrogenic injury to the area. If ventilation is required throughout the evaluation, use a bronchoscope-telescope combination.

If a child has a tracheotomy or is not in extreme distress, he or she can breathe spontaneously and inhale oxygen and anesthetics through an endotracheal tube in the pharynx while the airways are visualized with a laryngoscope and large telescope. Frequently, the true vocal cords are anesthetized with lidocaine prior to evaluation to help prevent laryngospasm.

Determine the size of the child's airway by using endotracheal tubes. Myers and Cotton established a scale for SGS severity that is based on the child's age and the size of the endotracheal tube that can be placed in the airway with an air leak pressure of less than 20 cm H2O.

Evaluate the subglottis and glottis for fixation, scarring, granulation, edema, paralysis or paresis, and other abnormalities. Evaluate the distance and caliber of the stenosis. Apply the Myers and Cotton staging system only to circumferential SGS. Glottic stenosis and SGS often occur together and must be considered when reconstruction is planned.

Evaluate the maturity of the stenosis. If a firm white scar is present, the stenosis is mature. If the stenosis has a granular or erythematous appearance, gastroesophageal reflux (GER) disease (GERD), viral infection, allergic esophagitis, or another inflammatory process may be present.

Examine the area below the subglottis into the trachea and bronchi for secondary lesions. The suprastomal area is important because pathological stenosis or malacia can influence the choice of surgical procedure. In severe SGS, viewing the suprastomal area requires the passage of a tiny telescope through a narrow subglottis or a telescope or bronchoscope through a tracheotomy site, if available.

Other Tests

Investigate any indication of GERD. Walner showed that children with SGS have a threefold increase in GERD as compared with the general pediatric population.[10]

Currently, the best test in evaluating for GER is dual-channel pH probe testing. One probe is placed above the lower esophageal sphincter, and another is placed at the area of the cricopharyngeus near the larynx.

Walner and Cotton recommend treating GER for 1 month before and 12 months after airway reconstructive surgery, even if only mild disease is present.[10, 11]  If moderate or severe GERD is diagnosed, start medical therapy and confirm disease resolution with another pH probe test prior to surgery.

Do not perform laryngeal reconstruction until GER has resolved. If reconstruction is being considered, pediatric laryngologists frequently perform tests to rule out GER, even in the absence of symptoms, because the disease may affect the outcome.

An "allergic" esophagitis may occur and may affect the outcome of surgery. To evaluate for this entity, esophagogastroduodenoscopy (EGD) is performed with biopsies of the proximal and distal esophagus, stomach, and duodenum. If more than 15 eosinophils are found in the mucosa per high power field, the patient may have "allergic" esophagitis. Evaluation and treatment for GERD must have taken place prior to this evaluation because reflux may elicit eosinophils as well.

If "allergic" esophagitis is discovered, then treatment with weeks to months of oral steroids or orally applied inhaled steroids is performed to help diminish the affects of the disease and possibly improve the success rate of laryngeal reconstruction.

Staging

Myers and Cotton devised a classification scheme for grading circumferential subglottic stenosis on a scale of I to IV. The scale is based on a percentage of stenosis established by the age of the patient and the size of the endotracheal tube that can be placed in the airway with an air leak less than 20 cm H2O.

The percentage of stenosis is evaluated by using endotracheal tubes of different sizes. The largest endotracheal tube that can be placed with an air leak less than 20 cm H2O is recorded and evaluated against a scale that has previously been constructed by Myers and Cotton. This grading system mainly applies to circumferential stenosis and does not apply to other types of SGS or combined stenoses, although it can be used to obtain a rough estimate.

The four grades of the Myers-Cotton system are as follows:

  • Grade I - Obstruction of 0-50% of the lumen
  • Grade II - Obstruction of 51-70% of the lumen
  • Grade III - Obstruction of 71-99% of the lumen
  • Grade IV - Obstruction of 100% of the lumen (ie, no detectable lumen)

Evaluate the subglottis and the glottis for any fixation, scarring, granulation, edema, paralysis or paresis, or other abnormalities. Evaluate the distance and the caliber of the stenosis.

Only apply the Myers-Cotton staging system to circumferential SGS. Often, glottic stenosis and SGS occur together and must be considered in the planning of reconstruction.

 

Treatment

Approach Considerations

No medical therapy for mature subglottic stenosis (SGS) is known. If a granular or immature SGS is noted, treatment of the inflammatory process with oral or inhaled steroids sometimes can decrease the severity of disease.

Perform surgical repair of SGS if the child has SGS and is symptomatic. Typically, children with grade I (see the image below) or mild grade II stenosis do not require surgical intervention. Children with these conditions may have intermittent airway symptoms, especially when infection or inflammation causes mucosal edema.

Subglottic view of very mild congenital subglottic Subglottic view of very mild congenital subglottic stenosis. Laterally, the area looks only slightly narrow. When endotracheal tubes were used to determine its size, it was found to be 30% narrowed.

Surgical intervention may be avoided if periods of airway obstruction are rare and can be treated on an inpatient or outpatient basis with anti-inflammatory and vasoconstrictive agents, such as oral, intravenous, or inhaled steroids and inhaled epinephrine (racemic treatment). If children with these conditions continue to have intermittent or persistent stridor and airway obstructive symptoms when they are well, or if they frequently become ill, surgical intervention may be necessary.

Development of upper respiratory symptoms during routine infections can indicate whether a child with SGS requires surgical reconstruction. Viral infections of the upper respiratory tract can create swelling in any area of the respiratory epithelium from the tip of the nose to the lungs. If a child with SGS has a cold, bronchitis, or both but does not have significant symptoms of stridor or upper airway obstruction, the airway may be large enough to tolerate stress, and reconstruction may not be needed. A history of recurrent croup suggests SGS.

Occasionally, older children have exercised-induced airway obstruction. At evaluation, these children may have grade I or grade II SGS. Expansion of the airway with cartilage augmentation may allow them to lead a healthy and active lifestyle.

Children with grade III (see the images below) or grade IV SGS need surgical management.

Endoscopic view of the true vocal cords in the for Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of the picture.
Preoperative view of a 4-month-old infant with acq Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.

Medical Care

Findings from animal studies showed that treatment with antibiotics and steroids can help improve an immature or granular SGS (see the image below); however, the optimal treatment duration is unknown. Evaluate each case on an individual basis. Once SGS is mature, medical therapy is almost always unsuccessful. However, suspected gastroesophageal reflux (GER) must receive aggressive medical treatment preoperatively and postoperatively for optimal surgical results.

An intraoperative view of granular subglottic sten An intraoperative view of granular subglottic stenosis in a 3-month-old infant who was born premature, weighing 800 g. The area is still granular following cricoid split. This patient required tracheotomy and eventual reconstruction at age 3 years. True vocal cords are shown in the foreground (slightly blurry).

No special diet is necessary in the treatment of pediatric SGS. The need for restriction of activity is evaluated on an individual basis.

Endoscopic Procedures

For mild or granular SGS, investigators have reported success with serial endoscopic dilation, with or without steroid injections.[12, 13] Endoscopic balloon dilation has only limited applicability to severe SGS.[14, 15]

Healy popularized the use of the carbon dioxide laser as an option for soft circumferential SGS. This procedure involves incisions made in four quadrants, followed by dilation. The technique is best used in conjunction with steroids when an immature or granular SGS is present. Normally, use of a laser causes recurrence of the scar in a mature stenosis; however, in unusual types of mature SGS (eg, spiraling SGS), improvement may be accomplished with a few serial carbon dioxide laser excisions (see the images below).

Intraoperative laryngeal view of the true vocal co Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy. Under the vocal cords, a spiraling subglottic stenosis can be seen.
A close-up view of the stenosis in a 9-year-old bo A close-up view of the stenosis in a 9-year-old boy with spiraling subglottic stenosis. This spiraling subglottic stenosis is not complete circumferentially. Laser therapy was the treatment choice and was successful after 2 laser treatments.
Continued lasering of the subglottic stenosis in a Continued lasering of the subglottic stenosis in a 9-year-old boy with spiraling subglottic stenosis. The reflected red light is the aiming beam for the CO2 laser.
Endoscopic view of the same patient (9-year-old bo Endoscopic view of the same patient (9-year-old boy with spiraling subglottic stenosis) two months after surgery. Some mild residual posterior subglottic stenosis remains, but the child is asymptomatic and the airway is open overall.

Although controversial (no good placebo-controlled studies have been performed to back up results), mitomycin-c has been reportedly used after carbon dioxide lasering of a mature SGS with presumed improved results over lasering alone, with or without the use of oral steroids. The author has used topical mitomycin-c after lysing an immature stenotic web, with results seemingly superior to those achieved with lysing and oral steroids alone.

Options for Open Reconstruction

The approach to open reconstruction of SGS should be based on the location and degree of scarring. Reconstruction often may be unnecessary for SGS classified as grades I and II on the Myers-Cotton scale (ie, ≤70% obstruction of the subglottic airway).

When surgery is necessary on the basis of symptom severity, perform an open reconstruction in mature circumferential SGS. The surgical technique depends on adjacent areas of scarring and on the location and appearance of SGS. For severe SGS, classified as grades III and IV (ie, >70% luminal obstruction), laryngeal expansion is almost always necessary.

The goals of open reconstruction are decannulation or resolution of symptoms, with preservation of the voice by expanding the subglottic airway and stabilizing the expanded frame.

For SGS classified as grade II (50-70% stenosis), surgical reconstruction depends on many factors, including symptoms, environment, and associated medical conditions.

Surgical approaches to the treatment of SGS include the following:

  • Anterior cricoid split (ACS)
  • Single-stage procedure involving anterior cartilaginous grafting with costal, thyroid, or auricular cartilage
  • Multistage procedure applying (a) anterior and posterior cartilage grafting, usually with costal cartilage, (b) anterior cartilaginous grafting with a posterior cricoid split and stent placement, (c) posterior grafting with costal cartilage, and (d) anterior and posterior costal cartilage with lateral cricoid splits
  • Cricotracheal resection

Anterior Cricoid Split

In 1980, Cotton and Seid described the use of ACS to avoid tracheotomy in neonates with SGS, good pulmonary and cardiac function, and airway obstructive symptoms after extubation.[16]  ACS allows decompression of the edematous submucosal glands of the subglottis and thus expansion of the airway.[17]

Criteria developed to identify children who are likely to benefit from ACS include the following:

  • Patient weight of more than 1500 g
  • Failure to extubate in identified SGS
  • Oxygen requirement of less than 30%
  • No active respiratory infection
  • Good pulmonary and cardiac function

Transport the already intubated child from the intensive care unit (ICU), and make horizontal incisions over the cricoid cartilage. Divide the strap muscles in the midline, and identify the thyroid cartilage, costal cartilage, and upper tracheal rings (see the image below). Place polypropylene stay sutures (4-0) around each side of the anterior component of the cricoid ring. Use a double-sided beaver blade to make an incision in the cricoid ring as far as the tracheal rings and the inferior third to half of the laryngeal cartilage.

An intraoperative view of a split cricoid in a pat An intraoperative view of a split cricoid in a patient with elliptical congenital subglottic stenosis. The open airway can be seen in the center of the picture. The wound extends to the inferior one third of the thyroid cartilage. The first 2 tracheal rings also are divided.

Then, reintubate the child with an endotracheal tube appropriately sized for his or her age. Do not expand the airway more than necessary; doing so can lead to pressure on the mucosa and persistent SGS.

Loosely close the skin over the wound, and place a rubber band drain. Mark the sutures in the cricoid as left and right. Generally, leave the nasal tube in place for 7-10 days. If self-extubation occurs, reintubate from above.

Should the endotracheal tube protrude through the airway into the neck during reintubation, the stay sutures can be lifted and crossed to block the cricoid split incision and to direct the endotracheal tube down the trachea. If this procedure is unsuccessful, the stay sutures can be pulled up to the neck and opened so that a tracheal or endotracheal tube can be placed in the airway until the child can be returned to the operating room (OR) for intubation through the mouth.

Administer antibiotics and antireflux medication during the intubation period. Begin the administration of steroids 24 hours before extubation, and continue for 48 hours afterwards. Usually, the tube can be removed after 7-10 days.

If an air leak around the endotracheal tube is present with a pressure of less than 20 cm H2O, extubation should be successful. If airway obstruction that is not amenable to medical therapy (including racemic treatments and steroids) occurs after extubation, return the patient to the operating room (OR) for evaluation, or immediately reintubate in the intensive care unit (ICU) if necessary. Complications of ACS are unusual and include pneumothorax, pneumomediastinum, subcutaneous emphysema, wound infection, and persistent SGS.

The images below were obtained in a 4-month-old infant born 3 months premature who required intubation and ventilation for 3 months.

Preoperative view of a 4-month-old infant with acq Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.
An endoscopic subglottic view of a 4-month-old wit An endoscopic subglottic view of a 4-month-old with grade III subglottic stenosis born premature at 26 weeks' gestation and intubated for 3 months.

She had a grade III SGS and underwent ACS with intubation and ventilation for 1 week in the ICU. The image below shows the subglottis 1 week after extubation.

Postoperative view in a 4-month-old infant with ac Postoperative view in a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Following cricoid split, the patient had been intubated for 1 week and extubated for 1 week.

The size of the larynx was determined with an endotracheal tube, and subsequent dilation of the soft mild restenosis is depicted in the images below.

Postoperative view in a 4-month-old infant with ac Postoperative view in a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Following cricoid split, the patient had been intubated for 1 week and extubated for 1 week.
A subglottic view of the same patient (a 4-month-o A subglottic view of the same patient (a 4-month-old infant with acquired grade III subglottic stenosis from intubation) following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids.

The child received oral steroids for 5 days and underwent follow-up bronchoscopy 2 weeks later (see the image below).

Postoperative view of the same patient (a 4-month- Postoperative view of the same patient (a 4-month-old infant with subglottic stenosis following cricoid split). This picture is 2 weeks after lysis of scar and steroids. Notice very mild recurrence of scaring at the site of previous scar. Overall, the airway is open and patent. The anterior superior area can be seen, with a small area of fibrosis where the cricoid split previously healed.

Single-Stage Laryngotracheoplasty With Cartilage Expansion

The second option is single-stage laryngotracheoplasty (LTP) with cartilage expansion.[18, 19]

In 1991, Seid et al reported the use of single-stage LTP.[20] Their approach to the airway resembles ACS; however, instead of leaving the area anterior to the fibrosis, they placed a piece of costal cartilage. The procedure was performed in 13 patients with SGS grades I-IV. However, the procedure failed in a patient who had complete glottic and subglottic stenosis (grade IV). The researchers indicated that grade IV SGS was a contraindication to single-stage LTP. Two patients had grade III SGS and a successful result.

Seid et al stressed the postoperative course in these patients.[20]  Instead of leaving the endotracheal tube in place for 7-10 days, they checked the air leak surrounding the endotracheal tube on a daily basis and removed it when the pressure of the leak was less than 20 cm H2O.

The authors were also concerned about the transient weakness of the extremities caused by neuromuscular blockade and hydrocortisone.[20] They used vecuronium and benzodiazepines for sedation. Aggressive pulmonary toilet was stressed because wandering atelectasis can be present in a patient who is ventilator-dependent for as long as 10 days. The authors stressed the repeated use of a full range of passive extremity motions to decrease the likelihood of transient muscle weakness during the period of induced paralysis for long-term intubation.

Seid et al believed that selection of patients was critical and that any child with difficulties in addition to SGS (eg, tracheal problems, true vocal cord paralysis) was not a good candidate for single-stage LTP.[20]  The procedure could fail after extubation for reasons other than the newly repaired SGS.

In 1995, Rothschild et al reviewed the effectiveness and complications of single-stage LTP in 104 patients from the Children's Hospital of Cincinnati.[21] Repair was successful in 86-92%, depending on the year of correction. The authors did not use paralysis during the 5- to 10-day period of endotracheal tube placement; they used sedation with chlorohydrate and benzodiazepines instead. In fact, if patients could tolerate nasotracheal intubation without much difficulty, they were allowed to engage in their usual activities (eg, eating, playing, and walking). A modified cap placed on the endotracheal tube prevents crust formation in the tube and airway during these activities.

Rothschild et al believed that younger children require heavier sedation and increased ventilation secondary to decreased respiratory effort.[21] Neuromuscular paralysis usually was avoided. Among their 104 patients, the researchers found neuromuscular weakness in only one. They did not comment about the presence or absence of pulmonary atelectasis.

The average duration of endotracheal tube placement in their patients was 9 days.[21] They did not explain why endotracheal tubes were in place longer than 10 days (as long as 26 days) in 37 children. Twenty-three children, however, had a posterior costal cartilage graft, which normally necessitates the use of stents for at least 2 weeks to stabilize the cartilaginous framework.

Seid and Cotton agreed that ICU staff who are knowledgeable and attentive are important to the success and safety of the procedure.

In 1991, Lusk et al also described a single-stage LTP in which auricular cartilage is used for reconstruction when an anterior SGS is repaired.[22] Patients had endotracheal tubes in place for 7-10 days, similar to the duration of intubation in patients in whom an ACS was performed. The authors sutured the cricoid to the strap muscles to help maintain airway patency; their success rate was similar to that of other procedures (ie, ~80-90%).

This author's experience with the use of auricular cartilage has been less successful. If significant anterior SGS is present, use of cartilage that is rigid enough to maintain the splay of the cricoid cartilage is usually necessary to ensure continued expansion after extubation.

Zalzal added to the efficiency of the anterior cartilage single-stage procedure by describing the technique of carving the harvested rib into the shape of a boat with flanges on each end (see the images below).[23]

Rib graft for reconstruction of subglottic stenosi Rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft. The diamond-shaped internal intraluminal component with perichondrium still present is seen on the top section of the rib and the shape of the rib is seen on the backside of the carved out diamond shape.
Anterior rib graft with a diamond shape. Note it m Anterior rib graft with a diamond shape. Note it measures approximately 1.7 mm in length. Intraluminal site is facing up. Flanges of rib are carved to remain on the outside of the trachea to prevent prolapse into the trachea.

In this technique, cartilage extends outside the lumen of the trachea, over the cricoid and tracheal rings, to help prevent the lumen from prolapsing into the airway (see the image below). With this technique (once any air leak is sealed during the surgery), extubation can be performed without fear of the cartilage requiring further stabilization or prolapsing into the airway.

An intraoperative aerial view of an anterior carti An intraoperative aerial view of an anterior cartilage graft in place over the wound. Note external component of the graft still looks like a portion of the rib. The internal component has been carved in a diamond shape. This is an intraoperative photo of the patient with elliptical congenital subglottic stenosis. The cartilage graft (rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft) was used in this patient for reconstruction.

After the procedure has been performed and the child has been admitted to the ICU, air leaks from the neck are checked on a daily basis. Usually, the air leak seals within 48-72 hours; extubation can be accomplished with confidence that the graft is stabilized. In this way, children can avoid the complications of long-term intubation.

The use of a superior section of the thyroid cartilage, as well as the septal cartilage, as grafting material has been reported. These materials, along with the auricular cartilage, usually do not provide much support. Instead, they act mainly as a patch over the divided area of the cricoid region. In these situations, the stent provides most of the force necessary to keep the lumen open while the surrounding area heals. Some of the other types of cartilage can be used in conjunction with ACS to improve the success rate of that procedure, which has traditionally been 70-80%.

Richardson and Inglis performed a prospective study to compare the cricoid split procedure with and without costal cartilage grafting for the treatment of acquired SGS in infants younger than 6 months in whom extubation in the ICU failed.[24]  They reported improved results in 90% of patients in whom cartilage was placed between the cricoid rings to expand the airway, compared with 56% in whom cartilage was not placed. This study was prospective and included only 20 patients, but its findings indicate that placing the lumen expander at the time of surgery greatly improves the likelihood that extubation succeeds and adequate airway is maintained.

However, Zalzal and Choi pointed out that when the results of laryngotracheal reconstruction were evaluated in 48 patients aged 4 years or younger, the success was lower in children younger than 25 months than in those aged 2-4 years.[25]  (Note that the patients younger than 2 years had SGS that was less severe than that of the older patients.) Zalzal and Choi still recommended laryngotracheal reconstruction in younger patients, on the grounds the procedure may aid the child's speech and language development and help prevent tracheotomy complications.

Multistage Procedure With Anterior and Posterior Grafting

For severe SGS (grade III-IV), anterior and posterior cricoid splitting with costal cartilage grafts placed anteriorly and posteriorly has been effective in expanding the lumen and allowing decannulation. Most authors, including Zalzal and Cotton, agree that when a posterior graft is used, cartilage of sufficient strength must be placed posteriorly to keep the airway expanded.[26]  Both Zalzal and Cotton have reported success rates higher than 90% with decannulation, frequently achieved with a single procedure. Occasionally, revision surgery is needed.

Often, the posterior graft is formed into an ellipse or elongated hexagon and placed so that the perichondrial side of the graft is flush with the mucosa of the posterior subglottic and tracheal wall.

Occasionally, flanges can be fashioned on the posterior graft that can be placed posteriorly and outside the lumen in a manner similar to that of the boat graft (described by Zalzal), which is placed anteriorly. For a posterior graft, sutures to the posterior cartilage split are all placed individually prior to sliding the graft in position (see image below), at which time the sutures can be tied. Seid described using fibrin glue in an animal study to keep a posterior graft in place, avoiding the arduous task of suturing it in.

An intraoperative side view of the neck with carti An intraoperative side view of the neck with cartilage graft (rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft) to be placed into the posterior cricoid suspended and having all sutures in position, ready to be tied. All the sutures are placed prior to lowering the graft into position. Then, the sutures are tied.

Place the anterior graft in a similar fashion. Construction of the flanges on the anterior graft is not as critical as it is with a single-stage procedure, in that children require stents for a minimum of 2 weeks. Usually, stents are used for 4-6 weeks when anterior and posterior grafts are placed and the tracheotomy is maintained. Once the stent is removed, follow-up bronchoscopies are performed to confirm the stenosis has not recurred before the patient is decannulated. Maintenance of a patent airway can be is evaluated with further bronchoscopies.

Usually, an Aboulker stent (see the first, second, and third images below) or Montgomery T tube (natively, as in the fourth image below, or cut to fit and used like an Aboulker stent, which are no longer commercially available) is used. Other types of stents also have been used.

Representative (noninclusive) sample of varying si Representative (noninclusive) sample of varying sizes of Aboulker stents (range of 3-15 mm). These stents are hollow and coated in Teflon.
A glottic endoscopic view of the top of Aboulker s A glottic endoscopic view of the top of Aboulker stent in the larynx protruding through and above the true and false vocal cords. The arytenoids and epiglottic folds are seen.
End view of an Aboulker stent showing the central End view of an Aboulker stent showing the central opening. These stents are hollow and coated in Teflon.
A 7-mm Montgomery tracheotomy tube with caps A 7-mm Montgomery tracheotomy tube with caps

Often, if the collapse or scar extends into the area of the tracheotomy site, longer-term stent placement is required with an Aboulker stent that is attached to a metal Holinger tracheotomy tube with wire (see the images below) or a Montgomery T tube. Complications of short-term (4-6 weeks) stent placement, such as granulation tissue and scarring from the distal end of the short stent, can be prevented with longer-term techniques for stent use.

Diagram of a long Aboulker stent wired to a metal Diagram of a long Aboulker stent wired to a metal Jackson tracheotomy tube.
A Jackson tracheotomy tube wired to a long Aboulke A Jackson tracheotomy tube wired to a long Aboulker stent.

The surgical approach for anterior and posterior grafting is similar to the approach for ACS and anterior cartilage grafting. Specific care for the posterior cricoid split with or without grafting requires visualization of the esophagus after the posterior cricoid cartilage has been incised. During division, take care to spread the cartilage to identify the esophageal mucosa so that no inadvertent injury occurs. Additionally, make the incision in the midline to prevent injury to the recurrent laryngeal nerve and to ensure that an appropriate site is created for placement of the graft.

Partial Cricotracheal Resection

In Switzerland, Monnier first reported the use of partial cricotracheal resection in 31 pediatric patients with grade III and IV stenosis in whom decannulation with anterior-posterior grafting failed.[27]  The decannulation rate after cricotracheal resection was 97%. Cotton and others began to evaluate the use of cricotracheal resection because of failures with grade III and grade IV stenoses. Investigators in the "Cincinnati Experience" (ie, Cotton's 20 years of experience) recently reported that decannulation occurred in 90% of children with refractory grade III and IV stenoses.[28]

The best candidates for partial cricotracheal resection are patients with severe SGS (grade III-IV) without associated glottic pathologic conditions and with a margin of at least 4 mm in the healthy airway below the vocal folds and above the stenosis. This space allows resection away from the glottic larynx, with anastomosis of healthy mucosa. Expect significant glottic edema to last 4-6 weeks; use a tracheotomy or T tube during the postoperative period to protect the airway until the edema resolves.

Perform the procedure with the patient under general anesthesia. The approach to the larynx and trachea is similar to that of other laryngotracheal reconstructive procedures. Vertically enter the airway with the beaver blade in the midline at the level of the cricoid. Make the incision superior to the inferior margin of the thyroid cartilage and inferior to the second tracheal ring.

The superior extent of the stenosis can be defined at endoscopy while the open wound is simultaneously viewed directly, so that a precise view of the scarred subglottic segment can be achieved. Make a horizontal cut just above the superior extent of the stenosis, from the anterior aspect to the posterior aspect, stopping at the level of the cricothyroid joint. By staying anterior to the cricothyroid joint at this level, injury to the recurrent laryngeal nerve can be prevented.

Make lateral cuts inferior to the cricothyroid joints, and continue inferiorly through the lateral aspects of the cricoid cartilage to expose the posterior cricoid plate. Approach the inferior area of the stenosis, and place stay sutures in the distal normal tracheal segment. Incise the trachea just below the inferior aspect of the stenosis through the anterior lateral portions of the trachea down to the membranous tracheal wall, then dissect this from the esophageal wall at the superior aspect. Connect the superior incision and remove the segment. Next, suture the uninvolved part of the trachea to the anterior thyroid ala and the exposed posterior cricoid plate.

During the dissection from the inferior aspect to the superior aspect, take care to dissect in a perichondrial plane over the cricoid to prevent injury to the recurrent laryngeal nerve. If identification of the esophagus is difficult during this portion of the procedure, a palpable dilator can be placed in the esophagus to delineate the esophageal wall.

Before anastomosis, remove the scar tissue from the inner aspect of the posterior cricoid plate by using a small curet or drill. Perform a hyoid release procedure to decrease tension at the suture line. Dissect the trachea until four or five rings are mobilized to aid in decreasing tension on the suture line. In addition, place two or three additional tension-releasing sutures on the thyroid ala and the upper tracheal rings to help release tension from the suture line. Place polypropylene stitches (0-0) from the chin to the chest of the child to keep the head flexed for a week.

In an older child with minimal glottic involvement, a single-stage procedure can be performed with nasotracheal intubation of 7-10 days' duration. In younger children with more severe glottic involvement, a Montgomery T tube can be placed for 4-6 weeks. Take meticulous care to prevent plugging of the T tube and resultant airway obstruction. Stern et al reported good results with decreased morbidity with T tubes in children.[29, 30]

Complications

Failure to repair the stenosis correctly occurs more often in severe stenosis than in moderate or mild stenosis. Zalzal and Choi examined 27 patients in whom laryngotracheal reconstruction failed and found that failure was related to the following[25] :

  • Inappropriate choice of graft
  • Inappropriate choice of stent
  • Inappropriate length of stent
  • Inappropriate duration of stent placement
  • Inadequate assessment and endoscopy
  • Poor postoperative follow-up
  • Anterior suprastomal collapse
  • Slipped Aboulker stent
  • Interactive progression of gastroesophageal reflux disease (GERD)
  • Keloid formation
  • Failure to repair all abnormalities noted at preoperative evaluation

Injury to the recurrent laryngeal nerve has been reported in a single case of cricoid tracheal resection. Avoidance techniques are outlined in Surgical care.

The voice quality of patients with glottic stenosis and SGS is decreased and is never restored to its preoperative state. However, once the SGS is repaired, subglottic pressure can be increased to increase volume and improve speech quality (see the images below). If an anterior laryngeal fissure is required to repair the SGS, voice quality can worsen, even if the anterior cartilage is displaced only mildly. Therefore, if possible, avoid dividing the anterior commissure.

Preoperative view of glottic stenosis and small gl Preoperative view of glottic stenosis and small glottic chink in a 2-year-old child who underwent anterior and posterior grafting. The child's glottic narrowing is tight, and scarring of the right arytenoid has occurred.
Preoperative endoscopic subglottic view of a 2-yea Preoperative endoscopic subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis.
Postoperative view of the glottic larynx in a chil Postoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. The child had glottic narrowing that is more open and in neutral position after the surgery. The scarring of the right true vocal cord appears improved, and her voice is more normal.
Postoperative close-up view of the true vocal cord Postoperative close-up view of the true vocal cords in the patient with congenital and acquired vertical subglottic stenosis.
A 3-month postoperative subglottic view of the pat A 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.

Complications from laryngotracheal reconstructive surgery itself include pneumothorax, pneumomediastinum, neck wound infection, chest wound infection, and emphysema.

Complications during the postoperative ICU course can include those of laryngotracheal surgery itself, as well as atelectasis of lung segments, pneumonia, and neuromuscular weakness with the use of paralytic agents and steroids.

Prevention

When a child is intubated for any reason, check for an air leak. When possible, the pressure should be less than 20 cm H2O in order to prevent pressure necrosis and SGS. Use appropriately sized endotracheal tubes when intubating a child for any reason. Treat intubated patients with antireflux medications.

Consultations

Consult a pediatric gastroenterologist if GER is suspected or present.

Consult a pediatric pulmonologist if chronic lung disease or an oxygen requirement is present.

Long-Term Monitoring

Occasionally, inhaled steroids are used to help prevent restenosis following reconstruction. Also, GER may have to be treated if it is suspected or proved, and treatment for "allergic" gastritis may be warranted.

Children who undergo various laryngotracheal reconstruction procedures may have different follow-up care and courses, depending on the procedure performed.

If a single-stage LTP or ACS has been performed, bronchoscopy at extubation is not necessarily required; such decisions are left to the surgeon. However, 1-3 weeks after the procedure, bronchoscopy can be used to assess for any complications. Some authors examine the children after laryngotracheal reconstruction only if they have difficulty. The author often performs laryngoscopy and bronchoscopy 1-2 weeks after extubation to evaluate the airway because granulation tissue often forms in this period (see the image below) and can lead to airway obstruction and scarring.

A subglottic endoscopic view of granulation tissue A subglottic endoscopic view of granulation tissue (superior center portion of the picture) that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft. Granulation tissue is at the superior center portion of the picture.

A carbon dioxide laser can be used to remove and control the granulation tissue well (see the images below). Certainly, whenever the child has airway obstructive symptoms, bronchoscopy should be considered.

Intraoperative suspended view through a subglottos Intraoperative suspended view through a subglottoscope of the subglottis, showing the granulation tissue just prior to removal with cup forceps and laser. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft.
Postexcision view of granulation tissue through th Postexcision view of granulation tissue through the subglottoscope. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft.

In a child undergoing two-stage laryngotracheal reconstruction with grafting and stent placement, the tracheotomy remains in place. The length of follow-up is determined by the duration of stent placement and the quality and quantity of symptoms after stent removal. For short-term stent placement (4-6 weeks), follow-up is 2 weeks after stent removal.

If this appears satisfactory, bronchoscopy should be performed at 4 weeks. In the interval, capping of the tracheotomy can be performed intermittently to evaluate for obstruction.

If the bronchoscopy at 6 weeks is satisfactory, attempted decannulation can be considered. Before decannulation, the tracheotomy tube usually is downsized and plugged intermittently. If the child tolerates plugging, a sleep study can be performed, or the child can be decannulated and watched in the ICU or in a regular hospital room while being monitored overnight, depending on the individual case. Various methods to evaluate adequate airway prior to decannulation are available.

Walner and Cotton recommend repeat endoscopy at 1, 3, 6, 12, and 24 months after reconstructive surgery. This pattern allows long-term evaluation and detection of a recurring stenosis before it reaches a critical stage. Walner and Cotton also recommend capping and downsizing the tracheotomy in the hospital before decannulation.

 

Medication

Medication Summary

No known medical therapy for mature SGS is recognized. If a granular or immature subglottic stenosis (SGS) is noted (see image below), treatment of the inflammatory process with oral or inhaled steroids sometimes can decrease the severity of disease. Findings from animal studies have shown that treatment with antibiotics and steroids can help improve an immature or granular SGS; however, the optimal treatment duration is unknown.

An intraoperative view of granular subglottic sten An intraoperative view of granular subglottic stenosis in a 3-month-old infant who was born premature, weighing 800 g. The area is still granular following cricoid split. This patient required tracheotomy and eventual reconstruction at age 3 years. True vocal cords are shown in the foreground (slightly blurry).

Corticosteroids

Class Summary

These strong anti-inflammatory agents also have profound metabolic and immunosuppressive effects.

Prednisolone elixir (Orapred, PediaPred, Prelone)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Orapred is said to be more palatable than Prelone. Orapred and Prelone liquid preparations contain 15 mg/5 mL prednisolone. Orapred is also available as PO disintegrating tabs. PediaPred contains 5 mg/5 mL.

Dexamethasone (Decadron)

For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.

Amoxicillin (Amoxil, Trimox)

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.

Cefprozil (Cefzil)

Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.