At our institution, computed tomographic scanning has replaced barium swallow as the diagnostic procedure of choice for vascular ring evaluation. We recommend both preoperative bronchoscopy and echocardiography. Use of a muscle-sparing thoracotomy without routine chest drainage has decreased mean hospital stay. For patients with a right aortic arch and associated Kommerell diverticulum, we recommend diverticulum resection with left subclavian artery transfer to the left carotid artery.

Of 219 patients whose primary presenting symptom was stridor, 150 were males, 69 were females. All were under 2 1/2 years of age; more than half were four months of age or younger. Congenital anomalies caused stridor in 191 (87.2%). Congenital laryngeal anomalies accounted for the stridor in 132 (60.3%); there were 35 (16.0%) patients with congenital tracheal anomalies, 11 (5.0%) with congenital bronchial anomalies, 12 (5.5%) with infectious conditions, 12 (5.5%) with internal laryngeal trauma and 15 (6.8%) patients with other conditions. The cause of stridor was undetermined in two patients. Sixteen vascular anomalies were diagnosed and classified according to the part of the tracheobronchial tree which was involved. Twenty-six patients required tracheotomy. Fifty-eight (26.5%) were referred with an erroneous presumptive diagnosis for which they were being treated. The mean length of time from onset of symptoms to determination of the correct diagnosis by endoscopy was four months; it varied from one day to 16 months. The importance of early endoscopy for the diagnosis of conditions causing stridor cannot be overemphasized. The occurrence of more than 1 anomaly in 99 (45.2%) of the 219 patients demonstrates the importance of complete endoscopic examination of all patients with stridor.

The etiology of 389 cases of partial or complete bilateral abductor vocal cord paralysis has been determined and classified. One hundred and forty-nine were infants and children 12 years of age and under; 240 were adults, age 13 and older. In the infants and children the paralyses were congenital in 82 cases, of which 43 were associated with other congenital anomalies, and 39 were without associated anomalies. Fifty-nine cases were considered acquired, most being secondary to underlying congenital anomalies, particularly the associated findings of meningomyelocele, Arnold-Chiari malformation, and hydrocephalus. Eight cases of paralysis in this age group were of undetermined etiology. Of the 240 adult cases of bilateral vocal cord paralysis. 138 followed thyroidectomy. Fifty-two cases were associated with various neurologic disorders, including poliomyelitis, Parkinson's disease, cerebrovascular accident, Guillain-Barré syndrome, multiple sclerosis, neoplasms and other miscellaneous neurologic conditions. Sixteen cases were due to malignant neoplasms of the neck and mediastinum. The remaining 34 cases constitute a miscellaneous group which includes foreign bodies, bilateral neck dissection, infection, congenital lesions, trauma, and idiopathic paralyses. The characteristic symptoms of bilateral abductor vocal cord paralysis include normal or near normal phonation with inspiratory stridor which may progress to complete respiratory obstruction. These symptoms are due to the stationary but flaccid midline position of the vocal cords which places them in a phonating position, where they both obstruct the airway and produce a faily clear voice or cry. This paradoxical combination of symptoms was frequently found to be responsible for a failure or delay in diagnosis.

Infants and children with laryngomalacia exhibit varying degrees of upper airway obstruction and dysphagia. Although the disorder is usually self-limited, the potential exists for symptoms so severe that operative intervention cannot be avoided. Relief of progressive airway compromise traditionally has involved bypassing the obstruction with tracheotomy. Recently, endoscopic surgical management of the most severe cases has been reexamined by the authors and others. Thirteen infants and children underwent supraglottoplasty (also referred to as epiglottoplasty or partial arytenoidectomy) for severe, complicated laryngomalacia. Endoscopic laser removal of flaccid supraglottic tissue resulted in improvement of the airway in all patients. In most patients, associated symptoms improved or completely resolved. Supraglottoplasty is an effective alternative to tracheotomy in carefully selected patients with severe laryngomalacia.

The symptoms, endoscopic findings, treatment and results of 46 patients with laryngoceles and saccular cysts are presented. Thirty-four were adults; 12 were infants and children under three years of age. Twenty-two adults had anterior saccular cysts, nine had lateral saccular cysts; three had laryngoceles. Ten infants and children had saccular cysts; two had laryngoceles. A laryngocele is an abnormal dilatation of the saccule which communicates with the lumen of the larynx, fills with air but on occasion may be temporarily distended with mucus; laryngoceles may be congenital or acquired. A saccular cyst is a mucus-filled dilatation of the saccule which does not communicate with the laryngeal lumen; saccular cysts are classified as lateral or anterior. Laryngoceles and saccular cysts represent abnormalities of the laryngeal saccule; a developmental spectrum exists among the normal saccule, large saccule, laryngocele and saccular cyst. The treatment of saccular cysts in infants and children is primarily repeated aspiration. In adults, symptomatic laryngoceles and large lateral saccular cysts are treated by an external approach; endoscopic aspiration and unroofing of small lateral saccular cysts is sometimes adequate and is attempted first. Anterior saccular cysts are treated by endoscopic excision biopsy. Carcinoma of the larynx may be found in association with a laryngocele or saccular cyst and must be diligently searched for by biopsies in the region of the saccular orifice. A smooth mass involving the area of the false vocal cord and aryepiglottic fold cannot be assumed to be a lateral saccular cyst; biopsies of the ventricle and saccule and deep incisional biopsies of the mass are indicated to rule out a carcinoma originating in the ventricle or saccule.

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There is a high incidence of SALs in patients undergoing supraglottoplasty. Neurological conditions, hypoplastic mandible, SGS greater than 35%, and preexisting LE independently adversely affected the postoperative course.

Chronic cough is an important, sometimes frustrating problem, often encountered by the otolaryngologist-head and neck surgeon. Thirty-eight infants and children under age 16 with a normal chest roentgenogram were evaluated for chronic cough persisting for longer than 4 weeks. Specific therapy (rather than symptomatic treatment) of chronic cough lead to a resolution or control of the cough in 33 (87%). Cough-variant asthma was by far the most common cause of chronic cough, followed by sinusitis, aberrant innominate artery, psychogenic cough, and subglottic stenosis. In addition to a detailed history, physical examination, and chest roentgenogram, endoscopy, paranasal sinus roentgenograms, and pulmonary function studies with methacholine challenge testing were particularly effective for establishing a precise diagnosis. Chronic cough is best managed by determining the precise cause of the cough, then specifically treating the underlying disorder. Children with persistent cough and a normal chest roentgenogram should be referred promptly for evaluation by an otolaryngologist when the primary physician's initial efforts at diagnosis and treatment are unsuccessful. Endoscopy is under-utilized in practice and its importance is understated in the literature. It is particularly helpful in establishing a precise diagnosis in infants under 18 months of age.