Subglottic cysts: a cause of pediatric stridor.

We evaluated a 16-month-old boy after his parents noticed that he had become increasingly stridorous over the previous 2 months. Before that time, his breathing had been loud but not high-pitched. The child also had difficulty feeding. His breathing symptoms were worse with activity and crying, but they were also present when he was sleeping. His history was significant for congenital hypoplasia on the left side of the heart, for which he had undergone surgical correction resulting in two separate intubations. The longer period of intubation lasted 3 consecutive days.

On physical examination, the child exhibited both inspiratory and expiratory stridor that worsened when he cried. His breathing was labored when he was excited. His cry was strong, and his voice was neither hoarse nor breathy. Suprasternal and intercostal retractions were noted. A lateral neck radiograph revealed that a 3-mm lesion in the subglottis had narrowed the airway (figure 1).

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The child was taken to the operating room for flexible fiberoptic laryngoscopy and direct laryngoscopy and bronchoscopy. This examination revealed the presence of two obstructing subglottic cysts, a Cotton class I subglottic stenosis, and an elliptically shaped cricoid cartilage (figure 2, A). With a suspension laryngoscopy technique, the cysts were aspirated with a 22-gauge syringe; they were subsequently decompressed further with a 3.0-mm and a 3.5-mm ventilating bronchoscope (figure 2, B). After decompression, the child's airway symptoms resolved. At the 3-month follow-up, the patient exhibited no signs of recurrence, and a scheduled repeat airway endoscopy revealed that the airway was widely patent (figure 2, C). Subglottic lesions are one of the causes of stridor in infants. (1) The most common congenital airway conditions are subglottic stenosis, laryngomalacia, hemangioma, and true vocal fold paralysis. Acquired lesions of the airway are often associated with endotracheal intubation (2) and prolonged periods of ventilation. The stridor in our patient was attributed to the earlier periods of intubation.

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Subglottic cyst is a relatively recent finding in pediatric airways, being first reported in the 1960s. (1) In 2003, Lim et al reported the largest cohort of subglottic cyst patients to date: 55 patients. (3) All of those children had a history of intubation during the neonatal period, and the vast majority of them required intervention at the time of direct laryngoscopy and bronchoscopy. Lim et al reported a high incidence of fixed subglottic stenosis, as 38 patients (69.1%) displayed airway narrowing secondary to scarfing.

For treatment, most authors recommend marsupialization with a laser, cup forceps, or microlaryngeal scissors. We took a different approach to removing the lesions in our patient. His cysts were initially drained with a micro-laryngeal needle. Once drainage was accomplished, we were better able to assess the subglottic airway. Then we passed a ventilating bronchoscope to complete the decompression. Postoperatively, it is recommended that patients be reevaluated endoscopically in 1 to 3 months---earlier if symptoms recur.

References

[1.] Wigger HJ, Tang P. Fatal laryngeal obstruction by iatrogenic subglottic cyst. J Pediatr 1968;72(6):815-20.

[2.] Couriel JM, Phelan PD. Subglottic cysts: A complication of neonatal endotracheal intubation? Pediatrics 1981;68(1):103-5.

[3.] Lira J, Hellier W, Harcourt J, et al. Subglottic cysts: The Great Ormond Street experience. Int J Pediatr Otorhinolaryngol 2003;67(5):461-5.

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Freed) and the Department of Pediatrics (Dr. Derkay), Eastern Virginia Medical School, Norfolk.