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Resume La laryngomalacie est l’affection laryngee la plus frequente du nourrisson. Dans 10 % des cas, elle est mal toleree. Cette mauvaise tolerance conduit a la realisation d’un bilan et a une prise en charge qui sera le plus souvent chirurgicale. La chirurgie est souvent une section des replis aryepiglottiques avec de tres nombreuses variantes techniques decrites. Cette chirurgie, pratiquee dans un environnement adapte, permet le controle des signes subjectifs dans une grande majorite des cas avec une morbidite faible. Toutefois, les donnees concernant les evaluations objectives sont rares : il faut realiser, si possible, une evaluation objective preoperatoire et postoperatoire de ces nourrissons. Certains nourrissons ont des pathologies intriquees ou ne repondent pas au traitement chirurgical : c’est la place de la ventilation non invasive.

SummaryLaryngomalacia is the most common laryngeal disease of infancy. It is poorly tolerated in 10% of cases, requiring assessment and management, generally surgical. Surgery often consists of supraglottoplasty, for which a large number of technical variants have been described. This surgery, performed in an appropriate setting, relieves the symptoms in the great majority of cases with low morbidity. However, few data are available concerning the objective results: preoperative and postoperative objective assessment of these infants is therefore necessary whenever possible. Noninvasive ventilation (NIV) may be indicated in some infants with comorbid conditions or failing to respond to surgical management.

Resume La laryngomalacie est le collapsus a l’inspiration des structures supraglottiques. C’est l’affection laryngee la plus frequente du nourrisson. La laryngomalacie se manifeste par un stridor, bruit inspiratoire de tonalite aigue, musicale, vibrante, multiphasique, apparaissant des les dix premiers jours de vie. Des signes de gravite sont presents dans 10 % des cas : retard de la croissance ponderale (element sans doute le plus contributif), dyspnee avec tirage intercostal ou xyphoidien permanent et important, episodes de detresse respiratoire, apnees obstructives du sommeil, et/ou episodes de suffocation lors de l’alimentation ou une difficulte a la prise alimentaire. Le diagnostic repose sur la fibroscopie pharyngolaryngee systematique effectuee en consultation qui affirme la laryngomalacie et qui permet d’eliminer les autres causes d’obstruction supraglottiques. L’endoscopie sous anesthesie generale est realisee uniquement dans les cas suivants : absence de laryngomalacie lors de l’examen fibroscopique pharyngolarynge, existence d’une laryngomalacie avec signes de gravite, recherche d’une seconde lesion associee avant la realisation d’un eventuel geste chirurgical, discordance entre la gravite des symptomes et l’aspect fibroscopique, et/ou symptomes atypiques (fausses routes au premier plan). Le bilan doit etre adapte a chaque enfant ; la recommandation preconise toutefois des explorations respiratoires objectives en cas de signes de gravite.

Objective Preliminary assessment of the efficacy of propranolol on subglottic hemangioma in children on a nation-wide scale. Methods Multicentric, retrospective study of clinical files of 14 children; pre- and post-treatment endoscopies. Results Mean age at diagnosis was 2.3 (0.7–4) months. Mean percentage of airway obstruction was 68% (15–90) before propranolol introduction. Propranolol was started at 5.2 (0.7–16) months of age. This treatment was effective in all cases with a mean regression of the stenosis to 22% after 2 weeks and 12% after 4 weeks. Other medical treatments (steroids) could be stopped. In one patient, a side effect of propranolol motivated the switch to another β-blocker. In four patients, treatment was stopped after 5.2 (1–10) months with a relapse in 2 (50%) cases. One of these two patients developed a resistance to propranolol and required a surgical procedure by external approach. Conclusion This preliminary nation-wide survey confirms propranolol high effectiveness against airways’ localization of infantile hemangiomas. Propranolol also allows alleviation or cut-off of previous medical treatments. However, recurrences are possible after early treatment interruption.

To specify the characteristics of the thulium laser and to evaluate the advantages and possibilities of treatment with this laser in laryngotracheal diseases in children.Fiber-based lasers have facilitated a new style of surgery. When performing therapeutic airways endoscopies there is the possibility of good control of lesions and adequate visualization of the surgical field using the telescope. Different types of laser may be used but the 2013-nm thulium laser shows promise as a laser that is efficient in soft tissues with the advantages of the other lasers without their problems. The thulium laser has been described in treating urinary tract abnormalities and recently airways diseases in adults, but there are no reports of other uses for this technique in the pediatric airway.The thulium laser appears to be an interesting tool in the management of laryngotracheal diseases such as subglottic stenosis, tracheal granuloma and laryngomalacia. The use of this laser in laryngotracheal diseases in children will probably progress in the future.

To discuss management of postcricoid and upper esophageal hemangiomas in infants. Four children presenting with progressive feeding and/or respiratory disturbance underwent endoscopy including systematic esophagoscopy revealing the hemangioma of the postcricoid area and extending to the lumen of the upper esophagus. In the three children with severe disturbance, systemic steroids were insufficient and open surgical excision brought the hemangioma under control. No significant stenosis occurred despite prolonged progressive oral feeding up to 1 month after surgery. The fourth child whose disturbance was moderate, was managed by intralesional steroids. Various solutions have been proposed for the treatment, i.e. conservative approach or partial or complete destruction or excision, management of postcricoid hemangioma by intralesional steroids or by open surgical excision. Indications will require greater series.

Objectives: We assessed the intermediate-term and long-term efficacy of intralesional injection of cidofovir used with surgical excision in juvenile-onset recurrent respiratory papillomatosis. Methods: The protocol was revised during the study, from endoscopy at 4-week intervals with intralesional injection of cidofovir at 5 mg/mL, to a 2-week interval and a 7.5-mg/mL dosage. Partial surgical excision of hypertrophic papillomas was performed before the initiation of injection. Further injections at 4-week (or 2-week) intervals were performed until complete remission. Results: Sixteen patients received a mean 8.9 injections. Complete remission was obtained in 12 patients (75%) after a mean 7.2 endoscopic treatments. Remission was stable at a mean 33.6 months' follow-up. Five of these 12 patients received 5.2 injections and remained disease-free at a mean 39.3 months' follow-up. Seven of the 12 had 1 relapse; they needed complementary treatment to become disease-free, and remained so thereafter over a mean 27.3 months' follow-up. The other 4 of the 16 patients (25%) continued to present active disease. Conclusions: Active endoscopic treatment until complete remission led to a higher-than-expected complete remission rate on intermediate-term to long-term follow-up, with or without relapse. Transient relapse was associated with a long delay in initiating cidofovir treatment.

SummaryLaryngomalacia is defined as collapse of supraglottic structures during inspiration. It is the most common laryngeal disease of infancy. Laryngomalacia presents in the form of stridor, a high-pitched, musical, vibrating, multiphase inspiratory noise appearing within the first 10 days of life. Signs of severity are present in 10% of cases: poor weight gain (probably the most contributive element), dyspnoea with permanent and severe intercostal or xyphoid retraction, episodes of respiratory distress, obstructive sleep apnoea, and/or episodes of suffocation while feeding or feeding difficulties. The diagnosis is based on systematic office flexible laryngoscopy to confirm laryngomalacia and exclude other causes of supraglottic obstruction. Rigid endoscopy under general anaesthesia is only performed in the following cases: absence of laryngomalacia on flexible laryngoscopy, presence of laryngomalacia with signs of severity, search for any associated lesions prior to surgery, discrepancy between the severity of symptoms and the appearance on flexible laryngoscopy, and/or atypical symptoms (mostly aspirations). The work-up must be adapted to each child; however, guidelines recommend objective respiratory investigations in infants presenting signs of severity.

Objective To evaluate the efficiency of diffusion-weighted magnetic resonance imaging (MRI) and high-resolution computed tomographic (CT) scan coregistration in predicting and adequately locating primary or recurrent cholesteatoma in children. Design Prospective study. Setting Tertiary care university hospital. Patients Ten patients aged 2 to 17 years (mean age, 8.5 years) with cholesteatoma of the middle ear, some of which were previously treated, were included for follow-up with systematic CT scanning and MRI between 2007 and 2008. Interventions Computed tomographic scanning was performed on a Siemens Somaton 128 (0.5/0.2-mm slices reformatted in 0.5/0.3-mm images). Fine cuts were obtained parallel and perpendicular to the lateral semicircular canal in each ear (100 × 100-mm field of view). Magnetic resonance imaging was undertaken on a Siemens Avanto 1.5T unit, with a protocol adapted for young children. Diffusion-weighted imaging was acquired using a single-shot turbo spin-echo mode. To allow for diagnosis and localization of the cholesteatoma, CT and diffusion-weighted MRIs were fused for each case. Results In 10 children, fusion technique allowed for correct diagnosis and precise localization (hypotympanum, epitympanum, mastoid recess, and attical space) as confirmed by subsequent standard surgery (positive predictive value, 100%). In 3 cases, the surgical approach was adequately determined from the fusion results. Lesion sizes on the CT-MRI fusion corresponded with perioperative findings. Conclusions Recent developments in imaging techniques have made diffusion-weighted MRI more effective for detecting recurrent cholesteatoma. The major drawback of this technique, however, has been its poor anatomical and spatial discrimination. Fusion imaging using high-resolution CT and diffusion-weighted MRI appears to be a promising technique for both the diagnosis and precise localization of cholesteatomas. It provides useful information for surgical planning and, furthermore, is easy to use in pediatric cases.

Objectives: A prospective study was performed to assess the intermediate and long-term efficacy of intralesional cidofovir therapy associated with surgical excision in laryngeal papillomatosis in adults. Methods: Endoscopy with intralesional injection of cidofovir 5 mg/mL was performed 3 times at 4-week intervals. The concentration was later increased to 7.5 mg/mL and the interval between injections shortened to 2 weeks. Further treatment was performed at 3 or 6 months, depending on the evolution of the papillomas. After complete remission, the treatment was stopped and the patients were reviewed every 6 months. Results: Nineteen patients completed the protocol, with a mean of 4.5 injections each. Complete remission was obtained in 17 cases (89%) after a mean of 3.8 procedures. Remission was stable after a mean follow-up of 24 months (range, 8 to 57 months). With higher cidofovir concentrations at shorter intervals, patients needed fewer injections to achieve remission (mean, 2.1 versus 4.7 injections). Conclusions: The effectiveness of intralesional cidofovir therapy in adult-onset recurrent respiratory papillomatosis was impressive. Once obtained, complete remission was stable on intermediate or long-term follow-up. The concentration and the interval between injections seemed to influence the number of injections necessary to achieve remission.

Objective To evaluate the risk of subglottic stenosis after surgical excision of congenital subglottic hemangioma. Design Retrospective analysis and case series. Setting Tertiary care teaching hospital. Patients A total of 13 pediatric patients diagnosed with subglottic hemangioma with unilateral, bilateral, or circular lesions and more than 50% airway obstruction between 1992 and 2001. Intervention Open surgical excision was performed as a single-stage procedure either as primary or secondary intention. The cricoid cartilage was left open at the end of the procedure. Postoperative intubation was carried out in a pediatric intensive care unit. Main Outcome Measure An adequate airway after surgical excision. Results All patients were successfully extubated. No recurrence was noted. Three patients developed subglottic stenosis, two grade 1 and one grade 2. All 3 showed a favorable outcome and did not require reintubation. One needed endoscopic management of the stenosis. Of these 3 cases, 2 occurred after carbon dioxide laser treatment (out of 3) and 1 after circumferential dissection (out of 3). Conclusions Extubation after surgery was successful in all cases of subglottic hemangioma. Risk of subglottic stenosis was limited and occurred only after circumferential dissection, especially if associated with prior traumatic laser damage of the hemangioma.