Laryngeal and Tracheal disorders
Key points
Embryology
Laryngotracheal groove develops day 9
Anatomy of the larynx
Anterior compartment of the neck
Suspended from Hyoid bone
Opens superiorly to laryngo pharynx
Continuous inferiorly with trachea
Between C3 to C6
Anterior: Infra hyoid muscles
Lateral: Thyroid glands, major vessels
Posterior: Oesophagus
Supraglottis, Glottis and Infraglottis compartments
Lined by pseudostratified ciliated columnar epithelium except vocal cords lined ny stratified squamous epithelium
All laryngeal muscles are innervated by recurrent laryngeal nerve except cricothyroid innervated by superior laryngeal nerve
Tracheal anatomy
Extends from vocal cords down to carina
Cricoid cartilage is narrowest part of trachea
Layers:
Inner mucosa
Submucosa
Cartilage and muscle - Anterior trachea is composed of 16 - 22 cartilaginous rings
Outer adventitia
Segmental blood supply
Congenital high airway obstruction (CHAOS)
Can be due to web, stenosis or atresia in larynx or trachea
Hydrops may require foetal surgery
During Delivery: Consider EXIT procedure at week 30 (only 1/3 survive till this point)
Later, problems with phonation and speech defects.
Congenital laryngeal stenosis
75% at glottic level
Failure of recanalisation
Webs
Associated with 22q11 deletion
Laryngeal papillomatosis
Vertical transmission
HPV types 6-11
Narrowing of airway, stridor, chronic cough, dyspnoea, dysphagia, sleep apnoea,
Change in voice quality
Laryngoscopy
Laser Surgery
For Recurrence: Anti-viral therapy, HPV vaccine, chemotherapy, photodynamic therapy, GORD treatment.
Tracheostomy for rapidly growing lesions
Laryngeal cysts
Cause airway obstruction, feeding issues
Congenital, Mucous or Haemorrhagic
Hoarseness of voice
Respiratory distress, obstruction, dyspnoea, distress, stridor
Needle aspiration, Endoscopic deroofing, Laser, Surgery
Tracheostomy
Infections
Epiglottitis - Haemophilus influenza (HiB) - tripod posture - sniffing position
Croup - parainfluenza
Tracheitis - staph aureus, HiB, streptococcus
Extrinsic compression - atypical mycobacteria
Tracheal agenesis
High mortality
Survival relies on tracheo-oesophageal fistula - oesophageal intubation - stenting oesophagus as neotrachea - gastric pull up
Subglottic haemangioma
Associated with segmental haemangiomas in 'beard' distribution
Manage with systemic propranolol
Other options -
Systemic steroids or vincristine
Intralesional steroids
Laryngeal clefts
Congenital
Usually diagnosed in infancy
Suspected after a video swallow
Posterior tracheo-laryngeal wall
25% have TOF
Feeding intolerance, aspiration, cyanosis, coughing, gagging, respiratory infections
Associations: CHARGE, VACTERL, OPITZ, Cleft lip, Cleft palate
Bronchoscopy
CT with 3D reconstruction
Laryngoscopy
Rigid bronchoscopy
Swallow study
Types:
Type 1: Up to vocal cords
Type 2: Up to cricoid cartilage
Type 3: Up to cervical trachea
Type 4: Up to Thoracic trachea
Management:
Type 1: Thickening feeds, suture
Type 2: Endoscopic repair
Type 3: Repair via neck
Type 4: Crico tracheal resection
50% survival
Pierre Robin sequence
Triad:
Micrognathia,
Glossoptosis (downward displacement of tongue)
Upper airway obstruction caused by 2 and 3
Associated with cleft palate
Isolated Pierre Robin sequence (PRS): Chromosomal mutations, SOX9
Syndromic PRS: Stickler syndrome, Velocardiofacial, Treacher Collins
Tracheostomy is more frequently required in syndromic PRS as opposed to isolated PRS
Page edited by Mrs Charnjit Seehra BSc January 2025
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. January 2025
References
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 21 Management of Laryngotracheal obstruction in children
Baxter D, Shanks AL. Pierre Robin Syndrome. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562213/