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Iatrogenic damage to the pediatric airway occurs rather often. Most injuries will heal without any sequelae because larynx and trachea of children tolerate considerable trauma. However, sometimes the injury is penetrating the mucosa and scar formation can lead to an obstruction of the airway which is followed by a tracheostomy and long term surgery. A great problem is the early detection of trauma since noisy breathing develops often late when scar formation has occluded more than 50% of the airway. A selection of photo documents of airway endoscopy out of more than 5000 photos from the years 1987-2007 were used to explain the development of injuries from minor lesions to large areas of necrosis of the mucosa of larynx and trachea of infants and children. The visualization of airway lesions might help to prevent iatrogenic damage.

Since about a decade cuffed intubation is becoming more popular in pediatric anesthesia. Studies supporting cuffed intubation compared cuffed and uncuffed intubation by using stridor as main outcome measure after extubation. No differentiations were made between benign (oedema) and severe (ulceration of mucosa) lesions. Stridor was considered to represent all relevant injuries. Far reaching conclusions for daily practice were drawn from these studies. Pediatric endoscopists and - ENT-surgeons with extensive experience in this field have warned against this opinion because significant injury of the airway is not always accompanied by stridor! The symptom of stridor might develop weeks and months after injury when silent ulcerations of the mucosa retract to significant stenosis. Only endoscopy can evidently detect all airway injuries. Studies describing airway injury by endoscopic control are urgently needed to find the best way of preventing airway injury by intubation.