Subglottic cysts in children: a 10-year review

Congenital subglottic cyst: a rare cause for sudden airway compromise in a newborn

A full-term infant developed stridor, respiratory distress and hypercarbia shortly after birth requiring urgent airway intervention. The patient underwent urgent intubation via rigid bronchoscopy. The diagnosis of congenital subglottic cyst was made. The cyst was decompressed and the patient was extubated the following day. On repeat laryngoscopy 1 month later, there was no residual disease and the patient remained symptom free. Congenital subglottic cysts are extremely rare and the diagnosis can be either missed or misdiagnosed with more common causes of stridor, such as laryngomalacia. Subglottic cysts may cause total airway obstruction and even death if they are large enough and not treated immediately.

[A case of subglottic cysts in monochorionic monoamniotic twins]

The first observation in the world literature of the development of subglottic cysts in the larynx in monochorionic monoamniotic twins is presented. The girls were born prematurely at 34 weeks of gestation, from the first day of life for 7 and 8 days, respectively, were transferred to mechanical ventilation. At the fourth month of life, symptoms of laryngeal stenosis appeared and began to gradually progress, conservative therapy had no effect. The diagnosis of subglottic cysts was established on the basis of fibrolaryngoscopy; after endolaryngeal surgery, breathing returned to normal. This case demonstrates the importance of timely endoscopic examination of the respiratory tract in children with stridor.

[Laryngeal cysts in children]

Laryngeal cysts in children are relatively rare, occupying the 4-5th place in the structure of congenital malformations. The paper presents the combined experience of two Russian pediatric otorhinolaryngological clinics traditionally involved in the rehabilitation of patients with congenital and acquired pathology of the larynx.

OBJECTIVE

To analyze the features of the clinic, diagnosis and treatment of laryngeal cysts in children.

MATERIAL AND METHODS

The study included 68 children with laryngeal cysts aged from 3 days to 16 years (on average 39.5±37.0 months, Me=15.5 months). The cyst was localized in the vestibular region of the larynx in 15 (22.1%) patients, in the vocal region - in 15 (22.1%) patients, and in the sub-vocal region - in 38 (55.9%) patients. Data on the presence of a history of tracheal intubation were available in 35 (89.7%) children, including 35 (92.1%) of 38 children with a subfold cyst. 11 patients were admitted with a previously applied tracheostomy.

RESULTS

The main reasons for going to the clinic were signs of laryngeal stenosis (stridor, signs of obstruction of the upper airways) in 60.3% of patients, dysphonia - in 33.8%, and in 5.9%, the detection of a cyst became an accidental finding. To eliminate the cyst, the method of laser marsupialization was used in 10 patients, coagulatory ablation - in 2 patients, in the remaining 56 patients, decortication was performed with microinstruments, followed by laser treatment of the cyst bed. In the follow-up, children were traced from 6 months to 7 years. We did not observe a recurrence of a cyst in any case.

CONCLUSION

Currently, the lining department is the "favorite" localization of the cyst in childhood. Subclavian cysts are more common in preterm infants who need tracheal intubation. A necessary condition for radical elimination is the resection of the cyst walls.

Acquired subglottic cysts in children: A rare and challenging clinical entity. A systematic review

INTRODUCTION

Subglottic cysts (SGCs) are a rare cause of laryngeal stenosis that mainly seem to affect preterm infants with an intubation history.

PURPOSE

To review the related literature and compare different management protocols for patients presenting SGCs, as well as briefly report our clinical case treated at Verona University Hospital by Pediatric Airways Team.

METHODS

The articles resulting from a PubMed and MEDLINE search were analysed and selected using previously established criteria. A systematic review of the selected papers was conducted following PRISMA guidelines.

RESULTS

The search yielded 571 related articles; cross-checking of articles led to the identification and exclusion of 239 duplicates. The remaining 332 papers were screened according to previously established eligibility criteria. The final number of selected articles was 13.

CONCLUSIONS

Well-planned teamwork, with active collaboration between the ENT specialists, pediatricians and anesthesiologists, is the key to achieve multidisciplinary management of patients diagnosed with SGCs. Long-term follow-up is crucial considering the high recurrence rate of this disease.

Anesthesia for patients with subglottic cysts

Acquired subglottic cysts can cause rapid development of respiratory distress. Subglottic cysts are a disease of premature infants and other pathologies of prematurity should be anticipated. Perioperative success is dependent on communication between surgeon and anesthesiologist. Contingency plans for an emergency surgical airway should be in place in the event of total airway obstruction.

Endoscopic airway findings in children with or without prior endotracheal intubation

BACKGROUND

Airway alterations found after endotracheal intubation are usually associated with mechanical trauma from the tube. However, no studies are available concerning alterations in airways that have never been intubated before. It was the aim of the study to compare endoscopic findings in the larynx and trachea of children who had undergone prior endotracheal intubation with findings in children who had not been intubated before.

METHODS

In 1021 children aged from 0 to 6 years, rigid endoscopies were performed before planned elective endotracheal intubation. The anonymized endoscopy videos were reviewed and graded by five international airway experts. Data was compared between the two groups using the chi-square test (P ≤ 0.05).

RESULTS

Endoscopic records of 971 children (473 with prior intubation; 498 without prior airway intubation) were included in the final calculations. Most patients (93.7%) with prior intubation had been intubated with a cuffed tube. The number of intubations ranged from 1 to 27. The median interval between intubation and endoscopy was 0.53 years (0.003-5.57 years). Abnormal findings were observed in 31.7% and 26.8% of patients with and without prior intubation, respectively (P = 0.063). Glottic granulomas were significantly more common after intubation (3.6% vs 1.4%; P = 0.028). The incidence of other abnormal findings was similar in both groups.

CONCLUSION

Endoscopic airway alterations can be observed in about one-quarter of children presenting for routine surgery without prior intubation. Except for glottic granulomas, the abnormalities are found with similar frequency in patients with and without prior intubation. No relevant airway damage from short-term endotracheal intubation was found.

Acquired subglottic cysts: management and long term outcome

OBJECTIVES

To assess the diagnostic strategy, treatment and outcome of acquired subglottic cysts.

MATERIALS AND METHODS

Retrospective, monocentric, tertiary referential center study of 172 preterm neonates assessed by endoscopic examination over a 10 years period. Identification of patients presenting with subglottic cysts.

RESULTS

17 children were diagnosed with subglottic cysts. Among them, 98% were prematurates (28 ± 4 weeks of gestation), and 76% had a history of hyaline membrane disease or a bronchopulmonary dysplasia. All patients were intubated during the neonatal period, for a mean duration of 14 days. Mean age at diagnosis was 8 months. An associated laryngotracheal anomaly was diagnosed in 30% of cases. Six procedures, including flexible controls, were needed to achieve full recovery. We used cold steel microinstruments, CO(2) or Thulium LASER. Mean follow up was 3 years.

CONCLUSIONS

Acquired subglottic cysts concern early preterm infants. Children treated for subglottic cysts should undergo a long term follow up, as there is a trend for cysts to recur, as well as a risk of secondary subglottic stenosis.

Subglottic cyst: the role of narrow-band imaging

A subglottic cyst is a rare cause of neonatal upper airway obstruction, which may be misinterpreted as a subglottic hemangioma. With the advent of narrow-band imaging, the application of its unique features in analyzing the mucosa surface's vascular structures in pediatric subglottic lesions remains to be investigated. Here, we report the case of a preterm baby who developed two subglottic cysts when he was 3-months old. Both traditional endoscopic examination and narrow-band imaging were performed pre-operatively. Both the potential impact of this new technique and the diagnosis and management of this disease are discussed.

Evaluation of pediatric subglottic cysts

INTRODUCTION

Subglottic cysts (SGCs) are increasingly recognized as a cause of upper airway obstruction in previously intubated infants. Endoscopic marsupialization with cold steel instruments or CO(2) laser has been reported to be the standardised treatment method for SGCs. SGC case series of 9 patients who were treated with endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation are presented.

PATIENTS AND METHODS

Retrospective study of 9 cases of subglottic cysts treated between 2003 and 2010 was done. Diagnoses were made by performing flexible nasopharyngolaryngoscopy and surgical treatment was done through endoscopic marsupialization with cold steel instruments or CO(2) laser.

RESULTS

The age range of SGC patients were between 3 months and 36 months (average 12, 11 months). Two of the patients were female (2/9), 7 of them were male (7/9). SGC diagnoses were made by flexible nasopharyngolaryngoscopy. History of intubation was noted in 3 of the patients (3/9). Duration of intubation was 28 days, 6 days, and 8 days respectively. Cysts were multiple in all cases, and located posteriorly and laterally at the subglottic area and upper trachea. The patients presented with were stridor, fail to thrive, and recurrent croup attacks. Treatment methods preferred for these patients were endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation. The follow-up period after treatment ranged between 8 months and 3 years. Recurrence of the SGCs did not happen and re-evaluation under general anesthesia was reserved for the symptomatic patients.

CONCLUSION

Diagnostic laryngoscopy and bronchoscopy are important in diagnosing SGC. History of premature birth and intubation are not 'sine qua non' of SGC as SGC may be congenital as well. Symptoms of SGCs may mimic the characteristic features of chronic obstructive lung disease, so evaluation of the airway should be considered in such infants if they have stridor or hoarseness not responding to routine treatment. Laryngoscopy and bronchoscopy are routinely indicated for airway evaluation in at-risk infants.

Ultrasound and colour Doppler in infantile subglottic haemangioma

BACKGROUND

Subglottic haemangioma causes progressive and life-threatening stridor, typically manifesting at age 2-3 months. Standard diagnosis is by laryngoscopy. Larynx sonography is rarely used but allows assessment of the presence and extension of a mass that impinges on the subglottic airway. The additional use of colour Doppler enables demonstration of the vascular nature of such masses.

OBJECTIVE

To compare US and endoscopic findings in infants with subglottic haemangioma and to evaluate accuracy of US and colour Doppler imaging in this diagnosis.

MATERIALS AND METHODS

We report eight infants with subglottic haemangioma seen in our institution over the last decade. They presented with laryngeal stridor and were all investigated with both US and endoscopy. Six infants underwent colour Doppler sonography.

RESULTS

US and endoscopic findings showed excellent anatomical correlation in lateral subglottic haemangioma. Colour Doppler imaging was deemed helpful in four infants.

CONCLUSION

Larynx sonography with complementary colour Doppler imaging was non-invasive and helpful in the diagnosis of subglottic haemangioma.

Management of subglottic cysts with Mitomycin-C-A case series and literature review

OBJECTIVES

To describe the management and outcomes of seven infants with subglottic cysts. To assess the role of Mitomycin-C in the management of subglottic cysts. To discuss the relationship of subglottic cysts with gastro-esophageal reflux. To extensively review the literature on subglottic cysts.

DESIGN

Retrospective case series and literature review.

METHODS

Case series of seven children with subglottic cysts at a tertiary care hospital. Charts were reviewed to determine birth history, gender, intubation history, comorbidities, age at presentation, presenting symptoms, interventions and follow-up.

RESULTS

Between 2001 and 2009, seven patients aged 4-13 months were diagnosed with and treated for subglottic cysts. All children had a history of intubation and had evidence of gastro-esophageal reflux. All children were treated with endoscopic marsupialization (CO(2)-laser, cupped forceps) or bronchoscopic rupture; with or without concomitant topical Mitomycin-C therapy. Infants were followed clinically and with interval endoscopy with a minimum follow-up of 6 weeks. No patients receiving topical post-marsupialization Mitomycin-C (0/4) had cyst recurrence. Those patients who did not receive Mitomycin-C therapy recurred more frequently (66% - 2/3). Cysts ruptured with the bronchoscope tip recurred (66% - 2/3) more often than cysts undergoing endoscopic marsupialization (0/6). The one bronchoscopic rupture case that did not recur was the one in which Mitomycin-C was used concomitantly. Patient follow-up was at 2, 4 and 6 weeks post-procedure.

CONCLUSION

Endoscopic marsupialization is the treatment of choice for subglottic cysts. Gastro-esophageal reflux has a strong association with subglottic cysts. The post-marsupialization application of Mitomycin-C may have a role in reducing the recurrence rate and scarring after surgical treatment of subglottic cysts.

Microdebrider resection of acquired subglottic cysts: case series and review of the literature

OBJECTIVE

Pediatric subglottic cysts (SGC) are a rare but curable cause of respiratory distress. Previous studies have described microsurgical marsupialization and carbon dioxide laser ablation to treat SGC. In this report we describe our experience performing endoscopic resection of SGC with a laryngeal microdebrider.

METHODS

A retrospective review of all patients who underwent endoscopic resection of SGC with a laryngeal microdebrider between January 2004 and October 2008 at a tertiary care children's hospital was performed.

RESULTS

Eight patients with one or more SGC were treated with microdebrider resection. All patients presented with stridor or respiratory distress, were born prematurely (mean gestational age 27 weeks), and had been intubated for between 1 and 91 days (mean 33 days). In all cases, suspension laryngoscopy was performed under general anesthesia. The SGC was visualized using a 4.0-mm Hopkins rod telescope and excised using a 2.9-mm diameter laryngeal microdebrider (skimmer blade). No patient experienced significant bleeding following excision. Mean surgical time was 36 min (range 26-59 min). Seven of eight patients (87.5%) were extubated by post-operative day 1. All patients had a follow-up bronchoscopy within 10 weeks. Six of eight patients (75%) had a single treatment, while two patients (25%) required a second resection. One patient had a symptomatic recurrence (12.5%). All eight patients are now free of disease with a mean follow-up of 21 months. No patient developed clinically significant scarring or subglottic stenosis.

CONCLUSIONS

The laryngeal microdebrider offers a safe and effective way to remove SGC with a low recurrence rate.