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Fig. 4. A vallecular cyst ( A ) and a saccular cyst ( B ).

appear in children less than 1 year of age. Symptoms depend on the extent of the dis ease. Presenting symptoms are hoarseness and stridor. Treatment is with laser or microdebridement. There is no curative treatment other than periodic surgical removal. There is significant promise using the antiangiogenic agent bevacizumab for adjuvant treatment of papillomatosis, with both local injection and systemic use. 23,24 In addition, with the 2006 approval of the quadrivalent HPV vaccine, a 2018 study out of Australia found decreasing incidence of RRP in children born to vaccinated mothers over a 5-year period. 25 With the 2014 approval of the 9-valent HPV vaccine, which adds 5 more viral-like particles to the vaccine containing HPV 6, 11, 16, and 18, evidence remains to be seen if the new formulation will also lead to improved incidence rates of RRP. 26 Vocal Cord Paralysis The second most common cause of stridor in neonates is vocal cord paralysis. 19,27 Unilateral vocal cord paralysis and bilateral vocal cord paralysis can both present as stridor at birth, but typically bilateral vocal cord paralysis presents with much more severe respiratory distress. Unilateral vocal cord paralysis typically occurs more commonly on the left side because of the longer course of the recurrent laryngeal nerve around the aortic arch, making it more prone to iatrogenic injury and congenital cardiovascular anomalies. 28 Awake fiber-optic endoscopy of the child will allow for

Fig. 5. RRP before ( A ) and after ( B ) removal with microdebridement.

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