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Stridor in the Infant Patient

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diagnosis of this condition, but a rigid endoscopic examination also assists to rule out a pseudoparalysis, which can occur owing to vocal fold fixation rather than neurologic injury. 19 Unilateral dysfunction can be secondary to birth trauma, iatrogenic injury sec ondary to thoracic surgery, or masses of cardiac, pulmonary, esophageal, thyroid, or lymphoid origin. Bilateral paralysis is more likely secondary to central nervous condi tions, such as Arnold-Chiari malformation, perinatal asphyxia, hydrocephalus, or ce rebral hemorrhage. 28 Workup of idiopathic vocal cord paralysis should include a CT scan or MRI scan following a course of the vagus nerve from brain to chest to rule out any lesions or ab normalities resulting in nerve compression. If no anatomic abnormality is seen, and the patient does not have a previous history of trauma or cardiovascular anomaly, a laryn geal electromyography can be performed to rule out electrical silence, but this is not necessary in neonates. 4 Approximately 73% of unilateral and 63% of bilateral vocal fold paralysis will resolve spontaneously within the first few months of life. 29,30 Recov ery is typically complete if it occurs in the first 2 to 3 years of life, but afterward, there is risk of laryngeal muscle atrophy, cricoarytenoid fixation, and/or synkinesis, which will result in incomplete vocal fold motion. 21 Some children with unilateral paralysis will require vocal fold injection to prevent aspiration with feeds and improve dysphonia, but this is not typically the case in pa tients with respiratory symptoms. In patients with bilateral paralysis and respiratory distress, vocal fold lateralization, cricoid split, or tracheotomy may be necessary to create a definitive airway within the first few weeks of life. When the child is older and tracheotomy is no longer needed for ventilation purposes, both static (posterior cricoid graft, lateral cordotomy, arytenoidectomy) and dynamic (vocal fold reinnerva tion with muscle pedicle or ansa cervicalis-to-recurrent laryngeal nerve grafting) sur gery can be offered to widen the glottic aperture. 21 Subglottic Stenosis Biphasic stridor can be significant for subglottic stenosis, a narrowing of the trachea just below the vocal cords at the level of the cricoid cartilage. Children typically pre sent with stridor, cough, and recurrent croup. For example, a low-pitched barky cough that acutely develops during a viral illness may signal an underlying subglottic patho logic condition. Subglottic stenosis is more commonly acquired secondary to long term intubation or trauma but can also present as a congenital abnormality, and it requires a direct laryngoscopy with bronchoscopy for definitive diagnosis. Acquired lesions are typically more severe than congenital subglottic narrowing, and concom itant lesions can be discovered on bronchoscopy. 4 Depending on symptoms, trache ostomy may be necessary if respiratory distress persists. Endoscopic management with balloon dilation and laser excision of stenosis may prevent need for tracheotomy and further airway surgery. However, open airway reconstruction is typically the defin itive treatment in patients who have failed previous management or have narrowed segments too severe for endoscopic therapy. Laryngeal Web Stridor at birth can also be secondary to a laryngeal web/partial atresia, a rare congen ital anomaly secondary to failure of the embryonic glottic airway to recanalize. This condition occurs on a spectrum of severity, extending from thin membranous webs that can be lysed versus thick cartilaginous webs resulting from laryngeal atresia. 31 The disorder can also be associated with genetic conditions, such as DiGeorge syn drome. Most laryngeal webs are anterior in location partially affecting motion of the vocal cords. Patients present with voice disorder or stridor during the neonatal period.

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