Airway Outcomes

  • Wade G. McClain
  • Gita M. Fleischman
  • Amelia F. DrakeEmail author
Part of the Respiratory Medicine book series (RM)


Obstruction of the upper airway commonly contributes to respiratory distress in the premature neonate. It is a multifactorial problem that can present heterogeneously and requires accurate anatomical and pathophysiological diagnosis for effective treatment. In this chapter, the diagnosis and treatment options, as well as outcomes, of upper airway obstruction in the premature neonate are discussed. As presentation and treatment vary widely based on lesion location, our discussion is organized by anatomical subsite.


Airway obstruction Glossoptosis Laryngomalacia Subglottic stenosis Laryngoplasty Tracheostomy 


  1. 1.
    Cotton RT, Seid AB. Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheotomy. Ann Otol Rhinol Laryngol. 1980;89(6 I):508–11.CrossRefPubMedGoogle Scholar
  2. 2.
    Izumi K, Konczal LL, Mitchell AL, Jones MC. Underlying genetic diagnosis of pierre robin sequence: retrospective chart review at two children’s hospitals and a systematic literature review. J Pediatr [Internet]. 2012;160(4):645–50.e2. Available from: Mosby, Inc.CrossRefGoogle Scholar
  3. 3.
    Reddy VS. Evaluation of upper airway obstruction in infants with Pierre Robin sequence and the role of polysomnography – review of current evidence. Paediatr Respir Rev [Internet]. Elsevier Ltd; 2016;17:80–7. Available from:
  4. 4.
    Papoff P, Guelfi G, Cicchetti R, Caresta E, Cozzi DA, Moretti C, et al. Outcomes after tongue-lip adhesion or mandibular distraction osteogenesis in infants with Pierre Robin sequence and severe airway obstruction. Int J Oral Maxillofac Surg [Internet]. International Association of Oral and Maxillofacial Surgery. 2013;42(11):1418–23. Available from:
  5. 5.
    Lee JJ, Thottam PJ, Ford MD, Jabbour N. Characteristics of sleep apnea in infants with Pierre-Robin sequence: is there improvement with advancing age?. Int J Pediatr Otorhinolaryngol [Internet]. 2015;79(12):2059–2067. Elsevier Ireland Ltd. Available from:
  6. 6.
    Murage KP, Tholpady SS, Friel M, Havlik RJ, Flores RL. Outcomes analysis of mandibular distraction osteogenesis for the treatment of Pierre Robin sequence. Plast Reconstr Surg [Internet]. 2013;132(2):419–21. Available from:
  7. 7.
    Olney DR, Greinwald JH, Smith RJ, Bauman NM. Laryngomalacia and its treatment. Laryngoscope. 1999;109(11):1770–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Richter GT, Thompson DM. The surgical management of laryngomalacia. Otolaryngol Clin North Am. 2008 Oct;41(5):837–64.Google Scholar
  9. 9.
    Yuen HW, Tan HKK, Balakrishnan A. Synchronous airway lesions and associated anomalies in children with laryngomalacia evaluated with rigid endoscopy. Int J Pediatr Otorhinolaryngol. 2006;70(10):1779–84.CrossRefPubMedGoogle Scholar
  10. 10.
    Rifai HA, Benoit M, El-Hakim H. Secondary airway lesions in laryngomalacia: a different perspective. Otolaryngol Head Neck Surg [Internet]. 2011;144(2):268–73. Available from:
  11. 11.
    Adil E, Rager T, Carr M. Location of airway obstruction in term and preterm infants with laryngomalacia. Am J Otolaryngo Head Neck Med Surg. Am J Otolaryngol. 2012 Jul– Aug;33(4):437–40.Google Scholar
  12. 12.
    Giannoni C, Sulek M, Friedman EM, Duncan III NO. Gastroesophageal reflux association with laryngomalacia: a prospective study. Int J Pediatr Otorhinolaryngol [Internet]. 1998;43(1):11–20. Available from: Scholar
  13. 13.
    Schumacher RE, Weinfeld IJ, Bartlett RH. Neonatal vocal cord paralysis following extracorporeal membrane oxygenation. Pediatrics [Internet]. 1989;84(5):793–6. Available from:
  14. 14.
    Strychowsky JE, Rukholm G, Gupta MK, Reid D. Unilateral vocal fold paralysis after congenital cardiothoracic surgery: a meta-analysis. Pediatrics [Internet]. 2014;133(6):e1708–23. Available from: Scholar
  15. 15.
    Rukholm G, Farrokhyar F, Reid D. Vocal cord paralysis post patent ductus arteriosus ligation surgery: risks and co-morbidities. Int J Pediatr Otorhinolaryngol [Internet]. 2012;76(11):1637–41. Elsevier Ireland Ltd. Available from: Scholar
  16. 16.
    Zbar RIS, Chen AH, Behrendt DM, Bell EF, Smith RJH. Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus. Ann Thorac Surg. 1996;61(3):814–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Pham V, Connelly D, Wei JL, Sykes KJ, O’Brien J. Vocal cord paralysis and Dysphagia after aortic arch reconstruction and Norwood procedure. Otolaryngol Head Neck Surg [Internet]. 2014;150(5):827–33. Available from: Scholar
  18. 18.
    Wilson MN, Bergeron LM, Kakade A, Simon LM, Caspi J, Pettitt T, et al. Airway management following pediatric cardiothoracic surgery. Otolaryngol Head Neck Surg. 2013;149(4):621–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Røksund OD, Clemm H, Heimdal JH, Aukland SM, Sandvik L, Markestad T, et al. Left vocal cord paralysis after extreme preterm birth, a new clinical scenario in adults. Pediatrics [Internet]. 2010;126(6):e1569–77. Available from: Scholar
  20. 20.
    Walner DL, Loewen MS, Kimura RE. Neonatal subglottic stenosis – incidence and trends. Laryngoscope. 2001;111(1):48–51.CrossRefPubMedGoogle Scholar
  21. 21.
    Sato K, Nakashima T. Histopathologic changes in laryngeal mucosa of extremely low-birth .... Ann Otol Rhinol Laryngol. 2006;115(11):816.Google Scholar
  22. 22.
    Cotton RT, Myer CM, Bratcher GO, Fitton CM. Anterior cricoid split, 1977-1987: evolution of a technique. Arch Otolaryngol Head Neck Surg [Internet]. 1988;114(11):1300–2. Available from: Scholar
  23. 23.
    Rotenberg BW, Berkowitz RG. Changing trends in the success rate of anterior cricoid split. Ann Otol Rhinol Laryngol [Internet]. 2006 [cited 2016 Feb 2];115(11):833–6. Available from:
  24. 24.
    Richardson MA, Inglis AF. A comparison of anterior cricoid split with and without costal cartilage graft for acquired subglottic stenosis. Int J Pediatr Otorhinolaryngol. 1991;22(2):187–93.CrossRefPubMedGoogle Scholar
  25. 25.
    Younis RT, Lazar RH, Astor F. Posterior cartilage graft in single-stage laryngotracheal reconstruction. Otolaryngol Head Neck Surg. 2003;129(03):168–75.CrossRefPubMedGoogle Scholar
  26. 26.
    Morita K, Yokoi A, Bitoh Y, Fukuzawa H, Okata Y, Iwade T, et al. Severe acquired subglottic stenosis in children: analysis of clinical features and surgical outcomes based on the range of stenosis. Pediatr Surg Int [Internet]. Springer Berlin Heidelberg; 2015;31(10):943–7. Available from:
  27. 27.
    McQueen CT, Shapiro NL, Leighton S, Guo XG, Albert DM.. Single-stage laryngotracheal reconstruction: the great ormond street experience and guidelines for patient selection. Arch Otolaryngol Neck Surg [Internet]. 1999;125(3):320–2. Available from:
  28. 28.
    Saunders MW, Thirlwall A, Jacob A, Albert DM. Single-or-two-stage laryngotracheal reconstruction; comparison of outcomes. Int J Pediatr Otorhinolaryngol [Internet]. 1999;50(1):51–4. Available from:
  29. 29.
    Cohen Mervyn D, Weber TR, Rao CC. Balloon dilatational of tracheal and bronchial stenosis. AJR Am J Roentgenol. 1984;142(3):477–8.CrossRefGoogle Scholar
  30. 30.
    Hebra A, Powell DD, Smith CD, Biemann OH. Balloon tracheoplasty in children: Results of a 15-year experience. J Pediatr Surg [Internet]. 1991;26(8):957–61. Available from: Scholar
  31. 31.
    Avelino M, Maunsell R, Jubé WI. Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis. Int J Pediatr Otorhinolaryngol [Internet]. 2015;79(4):532–6. Available from: Scholar
  32. 32.
    Whigham AS, Howell R, Choi S, Peña M, Zalzal G, Preciado D. Outcomes of balloon dilation in pediatric subglottic stenosis. Ann Otol Rhinol Laryngol [Internet]. 2012;121(7):442–8. Available from:
  33. 33.
    Chueng K, Chadha NK. Primary dilatation as a treatment for pediatric laryngotracheal stenosis: a systematic review. Int J Pediatr Otorhinolaryngol [Internet]. Elsevier Ireland Ltd; 2013;77(5):623–8. Available from:
  34. 34.
    Mirabile L, Serio PP, Baggi RR, Couloigner VV. Endoscopic anterior cricoid split and balloon dilation in pediatric subglottic stenosis. Int J Pediatr Otorhinolaryngol [Internet]. Elsevier Ireland Ltd; 2010;74(12):1409–14. Available from:
  35. 35.
    Zoumalan R, Maddalozzo J, Holinger LD. Etiology of stridor in infants. Ann Otol Rhinol Laryngol. 2007;116(5):329–34.CrossRefPubMedGoogle Scholar
  36. 36.
    Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and tracheobronchomalacia in children and adults. Chest. 2005;127(3):984–1005. PMID: 15764786.CrossRefPubMedGoogle Scholar
  37. 37.
    Doull IJ, Mok Q, Tasker RC. Tracheobronchomalacia in preterm infants with chronic lung disease. Arch Dis Child Fetal Neonatal Ed [Internet]. 1997;76(3):F203–5. Available from: Scholar
  38. 38.
    Dave S, Currie BG. The role of aortopexy in severe tracheomalacia. J Pediatr Surg. 2006 Mar;41(3):533–7.Google Scholar
  39. 39.
    Van Der Zee DC, Straver M. Thoracoscopic aortopexy for tracheomalacia. World J Surg. 2015;39(1):158–64.CrossRefPubMedGoogle Scholar
  40. 40.
    Greenholz SK, Karrer FM, Lilly JR. Contemporary surgery of tracheomalacia. J Pediatr Surg. 1986;21(6):511–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Chetcuti P, Phelan PD. Respiratory morbidity after repair of oesophageal atresia and tracheo-oesophageal fistula. Arch Dis Child. 1993;68(2):167–70.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Jacobs IN, Wetmore RF, Tom LWC, Handler SD, Potsic WP. Tracheobronchomalacia in children. Arch Otolaryngol Head Neck Surg [Internet]. 1994;120(2):154–8. Available from: Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Wade G. McClain
    • 1
  • Gita M. Fleischman
    • 1
  • Amelia F. Drake
    • 1
    Email author
  1. 1.Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina School of MedicineChapel HillUSA

Personalised recommendations