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Zalzal & Zalzal

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in neck extension or when placed prone. Symptoms typically begin at birth, with an average age of presentation of around 2 weeks, but it is not uncommon for symptoms to develop later in the neonatal period. 5,11 Airway obstruction presenting as stridor, apnea, chest/abdominal retractions, and/ or BRUEs is the most obvious constellation of symptoms for severe disease. Issues related to feeding and weight gain are the second most common indication for sur gery. 12 Feeding difficulty, such as slow feeding, regurgitation, choking, or spitting up with feeds, in the setting of poor weight gain and inspiratory stridor should clue the physician to an underlying laryngeal disorder. Obstructive sleep apnea and gastro esophageal reflux disorder are commonly associated conditions with laryngomalacia that may require further evaluation. Synchronous lesions may also exist in patients with laryngomalacia and lead to multilevel obstruction. Report in the literature varies widely on the prevalence of synchronous lesions, but patients with severe laryngoma lacia are more likely to have these findings than patients with milder disease. 5,13–15 Diagnostic Testing Flexible fiber-optic endoscopy should be the first examination performed in these pa tients, with the child awake and positioned upright to have an adequate visualization of the entire supraglottis and glottis. This can be performed safely in the office. Severity of the obstruction is graded by visualization of the vocal cords, where complete inability to visualize the vocal cords because of laryngeal inlet collapse of the epiglottis is a clear indication for supraglottoplasty. 16 If less than half of the vocal cords are seen, this is moderate laryngomalacia, and surgery is left to physician discretion. If more than 50% of the vocal cords are seen on flexible endoscopy, supraglottoplasty should not be performed. 16 If no laryngomalacia is identified, or if mild disease seen on flex ible endoscopy does not correspond to clinical symptoms, a synchronous lesion cannot be ruled out, and direct laryngoscopy with bronchoscopy will be needed. The incidence of a synchronous lesion is around 15%, but only 5% have a significant second lesion on bronchoscopy. 13–15 Radiologic studies, such as airway fluoroscopy, have limited diagnostic utility owing to poor sensitivity. 17 Tumors and Cysts Masses within the airway may also present with stridor. Subglottic hemangiomas are one such rare anomaly, typically found in infancy and mostly along the left side of the subglottic airway ( Fig. 3 ). They are absent at birth but develop to peak size at 4 to 6 months. 1 Cutaneous lesions along the anterior neck or “beard distribution” should raise suspicion of airway hemangioma development in children who have not yet pre sented with airway symptoms. 18 Stridor in these patients is biphasic owing to location of the hemangioma and worsens with crying or straining as the vascular lesion be comes engorged. Historically, airway hemangiomas were treated with steroids and laser excision following diagnostic laryngoscopy and bronchoscopy. 19 Propranolol is now the mainstay of therapy for these lesions because of effectiveness and safety profile, but in recalcitrant lesions, operative intervention may still be necessary. 20 After the first year of life, most subglottic hemangiomas undergo spontaneous involution. Supraglottic cysts, such as vallecular cysts, are congenital thin-walled mucous retention cysts that arise from the supraglottic larynx on the lingual epiglottis DIFFERENTIAL DIAGNOSIS OF STRIDOR The differential for noisy breathing is wide ranging and varied depending on both age of the patient and location of the obstruction ( Table 2 ; see Fig. 2 ).

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