The Pediatric Larynx

Holzki, Josef; Laschat, Michael; Puder, Christian

doi:10.1213/ane.0b013e3181d56abe

Cited by 7 publications

(6 citation statements)

References 4 publications

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“…Several studies have addressed that the functionally and anatomically narrowest portion of the upper airway in children is around the cricoid cartilage, and that this site is important when considering the possibility of airway damage because of its rigid nature. [ 8 , 11 , 12 ] It has also been confirmed in postmortem infants that the area around the cricoid cartilage is a commonly injured site in the pediatric larynx. [ 11 , 12 ] The use of an ETT with a large external diameter can induce mucosal edema and injuries by pressure and friction.…”

Section: Discussionmentioning

confidence: 99%

“…[ 3 – 6 ] However, the pliable and paralyzed subglottic region, acting like a curtain, is no resistance when passing a endotracheal tube. [ 7 , 8 ] Therefore, the ‘functionally’ portion of the pediatric upper airway, which may be the most vulnerable to damage during intubation, is the unyielding portion below the cricoid cartilage.…”

Section: Introductionmentioning

confidence: 99%

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Analysis of the functionally-narrowest portion of the pediatric upper airway in sedated children

Kwon

Shin²,

Gil³

et al. 2018

Medicine

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The narrowest portions of the pediatric larynx are the glottis and subglottic region. However, the pliable and paralyzed subglottic region, acting like a curtain, is no resistance when passing an endotracheal tube. Therefore, the ‘functionally’ portion of the pediatric upper airway, which may be the most vulnerable to damage during intubation, is the unyielding portion below the cricoid cartilage. We investigated the functionally-narrowest portion below the cricoid cartilage.Computed tomography (CT) was performed under deep sedation. CT images were used for measurement of dimensions and cross-sectional area (CSA) of the larynx at the level of the cricoid, subcricoid, and trachea. We analyzed the anteriorposterior (AP) diameter, transverse diameter, and CSA below the cricoid cartilage (at the cricoid, subcricoid, and tracheal levels).CT images of 46 children from 8 months to 96 months were reviewed from electric medical record (EMR). The mean ± SD of AP diameter was the shortest at the subcricoid level (cricoid, 105.7 ± 15.8 mm; subcricoid, 94.6 ± 15.3 mm; and trachea, 101.5 ± 15.7 mm; P < .001). The mean ± SD of transverse diameter was the shortest at the trachea level (cricoid, 99.8 ± 12.2 mm; subcricoid, 102.5 ± 13.7 mm; and trachea, 98.8 ± 10.7 mm; P = .01). The mean ± SD of CSA was the smallest at the subcricoid level (cricoid, 8781.5 ± 1963.3 mm2; subcricoid, 8425.0 ± 2025.7 mm2; and trachea, 8523.7 ± 1791.1 mm2; P = .02). The AP diameter at the subcricoid level was narrower than the transverse diameter at trachea level (mean difference: 4.2 mm, 95% confidence interval [CI]: 0.7–7.7, P = .02).Since the most susceptible portion for airway damage is unyielding portion, our findings suggest that, functionally, the narrowest portion of the pediatric larynx is located in the subcricoid region.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Analysis of the functionally-narrowest portion of the pediatric upper airway in sedated children

Kwon

Shin²,

Gil³

et al. 2018

Medicine

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“…Holzki et al 21 , 22 criticized the updated anatomy, proposing that movable vocal cords make the fixed cricoid the functionally narrowest laryngeal level and insisting that the cricoid is most prone to endoscopy-proven airway injury. This criticism is refuted by the following evidence: 1) autopsy reports show the narrowest level is at the glottis 21 , 23 ; 2) the subglottis, which is less distensible than the glottis, has a smaller cross-sectional area (CSA) and volume than the cricoid 20 , 24 ; 3) injury usually occurs in the posterolateral portions of the glottis or subglottis, relatively sparing the cricoid level 25 – 28 ; and 4) the conus elasticus, a soft tissue extending from the lower border of the vocal cords to the upper border of the cricoid, is prone to edema in cases of intubation or croup, owing to its lax attachment.…”

Section: Discussionmentioning

confidence: 99%

“…[17][18][19][20] The CTbased studies proved differential sections per level: the more cephalad, the more elliptical (Figure 2). [18][19][20] Holzki et al 21,22 1. Comparative benefits and limitations of cuffed endotracheal tubes over uncuffed tubes.…”

Section: Updated Laryngeal Anatomy: From the Cricoid-circular-funnel ...mentioning

confidence: 99%

Pediatric Application of Cuffed Endotracheal Tube

Kim¹,

Ahn²,

Chae³

2023

WestJEM

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A young child’s larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes (ETTs) in young children despite the benefits of cuffed ETTs, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed ETTs in young children based on our updated knowledge of pediatric anatomy and technical advances.

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“…This is especially true in the pediatric age group and borne out in clinical experience. 16 Despite a wide variety of surgical approaches, the management of SGS remains a formidable challenge for both doctor and patient. Further significant advances in the outcome of SGS will derive from an understanding of the cellular and molecular processes underlying the development of SGS following airway injury.…”

Section: Discussionmentioning

confidence: 99%