International Journal of Pediatric Otorhinolaryngology 151 (2021) 110931

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Prognostic factors in the management of pediatric subglottic stenosis☆

Sarah Debs a, Aasif A. Kazi a, Dustin Bastaich b, Leroy Thacker b, Rajanya S. Petersson a, c, *
a
Department of Otolaryngology – Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA, USA
b
Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
c
Department of Otolaryngology – Head and Neck Surgery, Children’s Hospital of Richmond at VCU, Richmond, VA, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: We report outcomes of endoscopic interventions in the management of pediatric subglottic stenosis
Subglottic stenosis (SGS), and factors that lead to open airway reconstruction.
Direct laryngoscopy Methods: A retrospective cohort review of all pediatric patients with SGS, treated by a single surgeon, at a tertiary
Laryngotracheal reconstruction
academic medical center from 2012 to 2020 was conducted. Variables recorded included patient demographics,
Pediatric
Endoscopic procedures
initial grade of stenosis, gestational age, length of intubation, comorbidities as well as total number of
Acid reflux interventions.
Bronchopulmonary dysplasia Results: A total of 47 patients were included in the study, of which 51% (n = 24) were female. Laryngotracheal
Chromosomal abnormalities reconstruction (LTR) was performed in 49% (n = 23) of patients. Decannulation was achieved in 25 of 32 tra­
Airway reconstruction cheostomized patients. Fifteen patients did not have tracheostomy. There was a significant difference in gesta­
tional age (28.7 ± 5.36 vs 33.2 ± 6.13), initial grade of stenosis (2.3 ± 0.82 vs 1.6 ± 0.88), and total number of
interventions (5.7 ± 2.8 vs 2.3 ± 1.5) when stratifying patients proceeding to LTR versus not (p < 0.05). There
was no significant difference, however, in the length of intubation between the two groups. Of the comorbidities
recorded, none were found to have a significant impact on the outcome.
Conclusion: Subglottic stenosis is a challenging condition to treat, often requiring multiple interventions
including LTR. We propose a set of risk factors that may assist in the treatment of SGS patients with certain
comorbidities to minimize interventions and maximize outcomes.

1. Introduction
Subglottic stenosis (SGS) is narrowing of the airway that occurs be­
tween the level of the true vocal folds to the lower border of the cricoid
cartilage. Because the subglottis is the narrowest part of a pediatric
airway, stenosis can result in significant morbidity in a child. Prior to the
1960s, pediatric SGS was most commonly congenital in nature due to a
failure of development during pregnancy, and congenital SGS is often
associated with genetic disorders such as CHARGE association, trisomy
21, and 22q11.2 deletion syndrome. However, with medical advances,
earlier gestation premature infants are delivered successfully. As pro­
longed intubation of these premature infants became more common, the
prevalence of acquired SGS increased. This was found to be due to
pressure ischemia caused by inflated endotracheal tube (ETT) cuffs.
Because the amount of pressure required to stop laryngeal mucosal
microcirculation was less than the upper limit of optimal cuff pressure
(30 mmHg), pressure ischemia was common, which resulted in scarring
and, ultimately, SGS [1]. In the 1970s, improvements to ETTs resulted in
high-compliance, low-pressure cuffs in order to combat the prevalence
of SGS [2]. This led to the identification of multiple factors which are
thought to play a role in the development of SGS including prematurity,
difficulty of intubation, endotracheal tube size, duration of intubation,
and presence of inflammation, such as from respiratory infection or
gastroesophageal reflux disease [3,4].
The gold standard for assessment of SGS is endoscopic evaluation
using direct laryngoscopy and tracheoscopy [4]. This allows for sizing of
the subglottis using endotracheal tubes which can then be categorized
using the Myer-Cotton Scale based on the level of obstruction: <50%
obstruction is grade 1, 51–70% is grade 2, 71–99% is grade 3, and 100%
is grade 4 (Fig. 1) [4–6]. A variety of endoscopic and open procedures
are available depending on the severity of disease as classified by the
Myer-Cotton scale. Balloon dilation, first described in 1984, is one of the

This work was presented as a poster at the American Bronchoesophageal Association Annual Meeting in April 2021, and received the 3rd place award.
☆

* Corresponding author. FACS Department of Otolaryngology - Head and Neck Surgery Virginia Commonwealth University Health System PO Box 980146
Richmond, VA, 23298, USA.
E-mail address: rajanya.petersson@vcuhealth.org (R.S. Petersson).

https://doi.org/10.1016/j.ijporl.2021.110931
Received 14 June 2021; Received in revised form 12 September 2021; Accepted 28 September 2021
Available online 30 September 2021
0165-5876/© 2021 Elsevier B.V. All rights reserved.
S. Debs et al.
most common forms of endoscopic intervention today, especially for
those patients with mild disease (e.g., grade 1 or 2), as it has been shown
to decrease the need for open surgery by as much as 80% [4]. Despite the
minimally invasive nature of balloon dilation, it is not without risk, and
the utility of balloon dilation in curing severe SGS is limited.
In addition to balloon dilation, other treatment options for SGS range
from minimally invasive techniques and adjuncts including traditional
rigid dilation, intralesional injection of steroids, lysis of adhesions using
a sickle knife, and/or the use of a carbon dioxide laser, to more invasive
procedures such as tracheostomy or open airway reconstructive pro­
cedures, including laryngotracheal reconstruction (LTR) [7].
The goal of our study was to determine if patient specific charac­
teristics such as gestational age, intubation length, or comorbidities
including the presence of acid reflux, pulmonary hypertension, bron­
chopulmonary dysplasia, chromosomal abnormalities, and chronic lung
disease had an impact on the outcome of the various endoscopic treat­
ment options available and determine predictive risk factors for pro­
ceeding to LTR.
2. Materials and methods
We conducted a retrospective cohort study that included all pediatric
patients (<18 years old) who received management for subglottic ste­
nosis at our tertiary care academic medical center from 2012 to 2020.
We compared two cohorts, non-LTR and LTR patients, to identify factors
for eventual LTR. Upon staging direct laryngoscopy, patients received
various treatment modalities including balloon dilation, steroid injec­
tion, lysis of scar band with sickle knife, laser excision, or eventual
laryngotracheal reconstruction. If patients had more than one modality
used during the same procedure, it was counted as one intervention. The
intervention or combination of interventions used was up to the
discretion of the senior author (RSP) based on exam findings and past
experience. No endoscopic grafting was performed. All LTRs performed
during the study period were performed single-stage. In patients who
were initially ventilator-dependent, LTR was performed once mechani­
cal ventilation was no longer necessary. No other open airway proced­
ures (e.g. cricoid split, cricotracheal resection) were performed. In
general, anterior graft LTR was performed in patients with grade 1 or
low-grade 2 SGS, and anterior and posterior graft LTR was performed for
those with high-grade 2 and grade 3 SGS.
Demographic data were noted in the chart review. Gestational age
and length of intubation as well as the presence of comorbidities
(chronic lung disease, bronchopulmonary dysplasia, chromosomal ab­
normalities, gastroesophageal reflux, and pulmonary hypertension) was
recorded. Comorbid diagnoses were made by the appropriate services
also following the patients (e.g., neonatology, pediatric pulmonology,
pediatric gastroenterology). The total number of interventions was also
recorded. Using SAS v9.4 (Cary, NC), two-sample t-test and logistic
Fig. 1. Subglottic stenosis. A) Grade 1. B) Grade 2. C) Grade 3.
2
International Journal of Pediatric Otorhinolaryngology 151 (2021) 110931
regression was used to examine the relationship between variables.
Values with p < 0.05 were considered significant. Categorical variables
were reported as means and percentages. This study was approved by
the Institutional Review Board at Virginia Commonwealth University.
3. Results
A total of 47 patients were included in the study, of which 51% (n =
24) were female. The average gestational age was 31 ± 6.14 weeks
(range 26–41 weeks), and prematurity, defined as gestational age <37
weeks, was seen in 66% (n = 31) of patients. The most common
comorbidities were bronchopulmonary dysplasia (60%, n = 28) fol­
lowed by the presence of reflux (55%, n = 26). The average intubation
length was 61.5 days ± 57.2 days (range 0–180 days). The average grade
of stenosis on initial direct laryngoscopy was 1.94 ± 0.92. The average
number of interventions performed per patient was 3.93 ± 2.81. Lar­
yngotracheal reconstruction was performed on 49% (n = 23) of patients
(Table 1). The following comorbidities were not found to have a sig­
nificant association with requiring LTR: bronchopulmonary dysplasia,
chronic lung disease, chromosomal abnormalities, reflux, and pulmo­
nary hypertension. Interestingly, the length of intubation was also not
found to be associated with a significantly higher rate of LTR (Table 1).
When comparing the LTR group to the non-LTR group, while there
was no difference in the total number of premature patients, there was a
significant difference in the average gestational age (28.7 weeks vs 33.2
weeks respectively, p < 0.05, Table 2). Patients who were premature
were almost 5 times more likely to have an LTR than those with a
gestational age >37 weeks (OR = 4.75, 95% CI = 1.24, 18.2). With each
week of increased gestational age, the odds of needing an LTR decreased
by a 12% (OR = 0.88, 95% CI = 0.79, 0.97). There was a significant
difference in the average initial grade of stenosis between the LTR and
non-LTR group (2.3 vs 1.6 respectively, p < 0.05). LTR is almost 10
times more likely in patients with an initial SGS grade of 3 compared to 1
(OR = 9.6, 95% CI = 1.4, 63) and 6 times more likely than an initial SGS
grade of 2 (OR = 6.4, 95% CI = 1.6, 26). There was a significant dif­
ference in the rate of decannulation between the two groups (95.2%
[20/21 patients] in the LTR group vs 45.5% [5/11 patients] in the non-
LTR group, p < 0.001, Table 3).
The one LTR patient who was counted as not decannulated under­
went a single-stage LTR, had tracheostomy replaced 2 weeks later after
failure to extubate, and was decannulated one year later without further
intervention. She had a history of 25-week prematurity, subglottic
hemangioma (the only patient in our cohort) effectively treated with
propranolol, acquired subglottic stenosis in addition to hemangioma due
to prolonged intubation, bronchopulmonary dysplasia, pulmonary hy­
pertension, and tracheomalacia. Despite clearance from her pediatric
pulmonologist at time of LTR at approximately 2 ½ years of age, it was
felt that underlying unresolved pulmonary issues prevented extubation
S. Debs et al. International Journal of Pediatric Otorhinolaryngology 151 (2021) 110931

Table 1 Table 2
Patient characteristics. Univariate odds ratios.
Characteristics, n Overall Laryngotracheal No p-value Risk Factors Odds 95% Confidence P-
(%) Reconstruction Reconstruction Ratio Limits Value
(N = 23) (N = 24)
Gender (Male vs Female) 0.917 0.292 2.879 0.8816
Gender 0.8815 Preemie (<37 weeks) 4.750 1.240 18.189 0.0229
Male 23 11 (47.8%) 12 (50.0%) Chronic Lung Disease (Y vs N) 1.833 0.564 5.959 0.3136
(48.9%) Bronchopulmonary Dysplasia (Y vs N) 3.348 0.979 11.444 0.0540
Female 24 12 (52.2%) 12 (50.0%) Chromosomal Abnormalities (Y vs N) 2.190 0.185 25.952 0.5342
(51.1%) Reflux (Y vs N) 0.550 0.172 1.760 0.3136
Preemie (<37 0.0184 Pulmonary Hypertension (Y vs N) 0.286 0.051 1.595 0.1533
weeks) Comorbidities (Y vs N) 2.100 0.346 12.759 0.4204
Yes 31 19 (82.6%) 12 (50.0%) Initial Grade of Stenosis 0.0118
(66.0%) 2 vs 1 9.600 1.451 63.500
No 16 4 (17.4%) 12 (50.0%) 3 vs 1 6.400 1.573 26.034
(34.0%) Gestation Age (Weeks) 0.877 0.790 0.974 0.0140
Chronic Lung 0.3115 Intubation Length (Days) 1.010 0.998 1.021 0.0908
Disease Number of Interventions 2.316 1.443 3.718 0.0005
Yes 19 11 (47.8%) 8 (33.3%)
(40.4%)
No 28 12 (52.2%) 16 (66.7%) tracheostomy prior to the reconstruction; one patient had grade 1 SGS
(59.6%)
with 2 endoscopic interventions and the other grade 3 SGS with 5
Bronchopulmonary 0.0499
Dysplasia
endoscopic interventions. Both patients were symptomatic and LTR was
Yes 28 17 (73.9%) 11 (45.8%) performed to avoid tracheostomy.
(59.6%)
No 19 6 (26.1%) 13 (54.2%) 4. Discussion
(40.4%)
Chromosomal 0.5255
Abnormalities Up to 90% of SGS is acquired, most commonly from endotracheal
Yes 3 2 (8.7%) 1 (4.2%) intubation, while the remainder is congenital in etiology [8]. Regardless
(6.4%) of the cause, the most common presenting symptom is biphasic stridor
No 44 21 (91.3%) 23 (95.8%) with increased work of breathing with or without a cough. Nevertheless,
(93.6%)
Reflux 0.3118
SGS can be asymptomatic to mildly symptomatic, manifesting as
Yes 26 11 (47.8%) 15 (62.5%) recurrent or prolonged respiratory infections such as recurrent croup.
(55.3%) Unlike congenital SGS however, acquired SGS does not improve with
No 21 12 (52.2%) 9 (37.5%) time and is usually noted after extubation [4]. In addition, certain
(44.7%)
comorbidities have been associated with SGS including the presence of
Pulmonary 0.1371
Hypertension acid reflux, pulmonary hypertension, bronchopulmonary dysplasia,
Yes 39 21 (91.3%) 18 (75.0%) chromosomal abnormalities, and chronic lung disease [3]. Reflux is
(83.0%) thought to contribute to SGS formation through direct irritation of the
No 8 2 (8.7%) 6 (25.0%) laryngeal mucosa resulting in inflammation, as well as through indirect
(17.0%)
Comorbidities 0.4130
stimulation of laryngeal reflexes such as cough and bronchoconstriction
Yes 41 21 (91.3%) 20 (83.3%) [9]. Alternatively, pulmonary hypertension and chromosomal abnor­
(87.2%) malities have been shown to be associated with SGS, but not a cause of it
No 6 2 (8.7%) 4 (16.7%) [10]. The most common chromosomal abnormality associated with SGS
(12.8%)
is trisomy 21; SGS has also been reported in patients with 22q11.2
Initial Grade of 0.0077
Stenosis deletion syndrome [11,12]. Patients with chronic lung disease of in­
1 21 5 (21.7%) 16 (66.7%) fancy, also known as bronchopulmonary dysplasia (BPD), tend to have
(44.7%) premature lungs requiring mechanical ventilation and supplemental
2 8 6 (26.1%) 2 (8.3%) oxygen in order to sustain life. Not only does repetitive trauma and/or
(17.0%)
3 18 12 (52.2%) 6 (25.0%)
prolonged intubation increase the risk for pressure ischemia, but the use
(38.3%) of positive pressure respiratory support can result in airway damage in
Gestational Age 31.0 28.7 (5.36) 33.2 (6.13) 0.0102 the form of increased tracheal diameter, thinning of airway cartilage and
(Weeks)b,c,d (6.14) smooth muscle, disruption of the musculocartilaginous junction, and
Intubation Length 61.5 78.9 (53.82) 48.4 (57.22) 0.0875
focal abrasion of the airway epithelium [13]. This damage can ulti­
(Days)a,b,d (57.19)
Number of 3.9 5.7 (2.82) 2.3 (1.45) <.0001 mately result in disruption of the growth and differentiation of the
Interventionsb,e (2.81) airway.
a Our study found that there is an increased likelihood of requiring
Missing: n = 5.
b
Continuous variables presented as mean (SD).
LTR for those SGS patients with a gestational age <33 weeks, those with
c
Imputed Missing: n = 5. an initial Myer-Cotton grade of 3 or higher, or those who require more
d
Pooled variance was used for t-test. than 3 interventions, suggesting that they might be better served
e
Satterwaite approximation was used for t-test. through earlier intervention with LTR. Maresh et al. had similar results
in a recent study comparing the outcomes of balloon dilation with open
requiring tracheostomy rather than surgical site issues. One LTR patient airway surgery. They found a significant difference in the rate of dec­
was initially decannulated with grade 1 SGS, had intermittent follow-up annulation in patients with mild (grade 1 or 2) versus severe (grade 3 or
for one year thereafter with postponement of tracheocutaneous fistula 4) disease depending on the modality chosen, i.e., LTR was more suc­
closure per parent request, and then noted to still have a sizeable fistula cessful in patients with severe disease while balloon dilation was a better
almost one year later. Subsequent direct laryngoscopy showed low- option for patients with mild disease [14]. Balloon dilation has a number
grade 2 SGS. Only two patients underwent LTR who did not have of advantages over traditional rigid dilation: decreased trauma because

3
S. Debs et al.
Table 3
Decannulation rate.
Decannulation Overall Laryngotracheal Reconstruction (N = 23)
Yes 25 (78.1%) 20 (95.2%)
No 7 (21.9%) 1 (4.8%)
No tracheostomy 15 2 13
it exerts radial forces as opposed to shearing forces, allows the surgeon
to adjust the force applied to the stenosis through the use of a pressure
gauge, and allows for intervention even on severe SGS because of the
low profile of the balloon catheter [4,7,15]. The goal of balloon dilation
is not always to cure SGS. Instead, often the aim is to improve the grade
of stenosis to allow for a less complicated LTR if necessary.
As expected, we have a higher rate of decannulation in the LTR
group, 95.2% versus 45.5% in the non-reconstructed group. As single-
stage LTR is used to definitively decannulate patients in our practice
once the need for mechanical ventilation is obviated, we expect high
decannulation rates after LTR. It should be noted that the 6 patients in
the non-LTR, non-decannulated group likely still have need for me­
chanical ventilation due to underlying pulmonary issues preventing
decannulation. Additionally, there is one patient in this group with mild
grade 1 SGS whose parent is refusing decannulation. The one LTR pa­
tient who was counted as not decannulated underwent a single-stage
anterior graft LTR, had tracheostomy replaced 2 weeks later after fail­
ure to extubate, and was decannulated one year later without further
intervention. She had a history of 25-week prematurity, subglottic
hemangioma (the only patient with this diagnosis in our cohort) treated
with propranolol, acquired subglottic stenosis in addition to hemangi­
oma due to prolonged intubation, bronchopulmonary dysplasia, pul­
monary hypertension, and tracheomalacia. Despite not requiring
mechanical ventilation and obtaining clearance from her pediatric pul­
monologist at time of LTR at approximately 2½ years of age, it was felt
that underlying unresolved pulmonary issues, and not surgical site is­
sues, prevented extubation postoperatively, requiring revision trache­
ostomy. She remains decannulated. One LTR patient was initially
decannulated with grade 1 SGS, had intermittent follow-up thereafter
with postponement of tracheocutaneous fistula closure per parent
request, and then noted to still have a sizeable fistula almost one year
later. Subsequent direct laryngoscopy showed low-grade 2 SGS, and he
successfully underwent single-stage anterior graft LTR. Only two pa­
tients underwent LTR who did not have tracheostomy prior to the
reconstruction; one patient had grade 1 SGS with 2 endoscopic in­
terventions and the other grade 3 SGS with 5 endoscopic interventions.
Both patients were symptomatic from SGS, had no underlying pulmo­
nary pathology, and LTR was performed to avoid tracheostomy.
Interestingly, we found that the length of intubation in days did not
have a significant impact on whether a patient would ultimately need an
LTR. Patients who went on to have an LTR had a mean length intubation
of 78.9 ± 53.8 days compared to 48.4 ± 57.2 days in the non-LTR group
(p > 0.05). Although a difference might have been noted with a larger
sample size, this finding may also be due in part to advances in neonatal
intensive care airway management. Measures taken to minimize airway
trauma with intubation in neonates include video laryngoscopy, pre­
medication with sedative medication prior to intubation, smaller ETTs,
low-profile cuffs or uncuffed ETTs, and maintaining cuff pressure <14
mmHg [12,16]. Uncuffed ETTs are favorable in children less than 8
years old as it allows for an air leak indicating the tube is not com­
pressing tracheal mucosa against the cricoid [2]. Current efforts towards
minimizing neonatal intubation trauma appear to be effective in pre­
venting subglottic stenosis [17].
Overall, our findings suggest that, once a certain number of conser­
vative interventions has been reached, the patient will be better served
by LTR and thus should proceed to open repair. This approach can spare
the patient from repeated interventions with diminishing returns and
4
International Journal of Pediatric Otorhinolaryngology 151 (2021) 110931
No Reconstruction (N = 24) p-value
<.0001
5 (45.5%)
6 (54.5%)
lead to a robust outcome. Similar to recent literature from Whigham
et al., our data suggests that once a patient has failed 3 conservative
interventions, LTR should be considered [18]. Other factors that are
considered, that may extend the number of endoscopic interventions
prior to LTR include time of year (e.g. avoiding reconstruction during
cold and flu season), social circumstances of the family, schedule con­
straints of the surgeon and family, readiness of the family to proceed,
etc.
Limitations of the study include a lack of control patients due to the
procedural nature of our study group, small sample size, and retro­
spective study design from a single center with all patients treated by
one surgeon. We chose this design to share our institutional results with
the aim to compare outcomes across centers in future studies. Addi­
tionally, further prospective multi-center studies with longitudinal
follow-up would be beneficial to understanding SGS treatment outcomes
and affirm our findings. Future research directions include evaluating
maternal health, socio-economic factors, and environmental exposures
in pediatric SGS patients. Assessing these may elicit additional risks that
deepen our understanding of external factors and their effects on
respective SGS treatment outcomes.
5. Conclusion
Pediatric SGS remains a challenging condition to manage. While a
variety of treatment options are available, including conservative ther­
apy with endoscopic techniques or more invasive procedures such as
LTR, determining the role each procedure has in the therapeutic ladder
has yet to be fully elucidated. Our study suggests that patients with a
gestational age <33 weeks, an initial Myer-Cotton SGS grade of at least
3, or at least 3 failed conservative interventions were more likely to
require LTR. This can help guide treatment plans and improve outcomes
while decreasing morbidity and unnecessary interventions for patients,
especially for those with more severe disease or specific comorbidities
who may eventually need LTR.
Disclosures
None.
Declaration of competing interest
The authors have no competing interests to declare.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
References
[1] E. Jaillette, I. Martin-Loeches, A. Artigas, S. Nseir, Optimal care and design of the
tracheal cuff in the critically ill patient, Ann. Intensive Care 4 (1) (2014) 7.
[2] C.J. Newth, B. Rachman, N. Patel, J. Hammer, The use of cuffed versus uncuffed
endotracheal tubes in pediatric intensive care, J. Pediatr. 144 (3) (2004) 333–337.
[3] K. Arianpour, S.N. Forman, P. Karabon, P.J. Thottam, Pediatric acquired subglottic
stenosis: associated costs and comorbidities of 7,981 hospitalizations, Int. J.
Pediatr. Otorhinolaryngol. 117 (2019) 51–56.
[4] N.D. Jefferson, A.P. Cohen, M.J. Rutter, Subglottic stenosis, Semin. Pediatr. Surg.
25 (3) (2016) 138–143.
[5] J. Alshammari, A.A. Alkhunaizi, A.S. Arafat, Tertiary center experience with
primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and
literature review, Int J Pediatr Adolesc Med 4 (1) (2017) 33–37.
S. Debs et al.
[6] C.M. Myer 3rd, D.M. O’Connor, R.T. Cotton, Proposed grading system for
subglottic stenosis based on endotracheal tube sizes, Ann. Otol. Rhinol. Laryngol.
103 (4 Pt 1) (1994) 319–323.
[7] J.P. Bent, M.B. Shah, R. Nord, S.R. Parikh, Balloon dilation for recurrent stenosis
after pediatric laryngotracheoplasty, Ann. Otol. Rhinol. Laryngol. 119 (9) (2010)
619–627.
[8] A.M. Wenzel, C. Schweiger, D. Manica, L. Sekine, I.C.S. Ferreira, G. Kuhl, et al.,
Impact of balloon laryngoplasty on management of acute subglottic stenosis, Eur.
Arch. Oto-Rhino-Laryngol. 275 (9) (2018) 2325–2331.
[9] R.A. Franco Jr., Laryngopharyngeal reflux, Allergy Asthma Proc. 27 (1) (2006)
21–25.
[10] R.H. Blum, F.X. McGowan Jr., Chronic upper airway obstruction and cardiac
dysfunction: anatomy, pathophysiology and anesthetic implications, Paediatr.
Anaesth. 14 (1) (2004) 75–83.
[11] R.S. Amin, M.J. Rutter, Airway disease and management in bronchopulmonary
dysplasia, Clin. Perinatol. 42 (4) (2015) 857–870.
[12] R. Sacca, K.B. Zur, T.B. Crowley, E.H. Zackai, K.D. Valverde, D.M. McDonald-
McGinn, Association of airway abnormalities with 22q11.2 deletion syndrome, Int.
J. Pediatr. Otorhinolaryngol. 96 (2017) 11–14.
International Journal of Pediatric Otorhinolaryngology 151 (2021) 110931
[13] H. Zhang, J. Zhang, S. Zhao, Airway damage of prematurity: the impact of
prolonged intubation, ventilation, and chronic lung disease, Semin. Fetal Neonatal
Med. 21 (4) (2016) 246–253.
[14] A. Maresh, D.A. Preciado, A.P. O’Connell, G.H. Zalzal, A comparative analysis of
open surgery vs endoscopic balloon dilation for pediatric subglottic stenosis, JAMA
Otolaryngol Head Neck Surg 140 (10) (2014) 901–905.
[15] M.D. Cohen, T.R. Weber, C.C. Rao, Balloon dilatation of tracheal and bronchial
stenosis, AJR Am. J. Roentgenol. 142 (3) (1984) 477–478.
[16] R.S. Park, J.M. Peyton, P.G. Kovatsis, Neonatal airway management, Clin.
Perinatol. 46 (4) (2019) 745–763.
[17] T. Sawyer, E. Foglia, L.D. Hatch, A. Moussa, A. Ades, L. Johnston, et al., Improving
neonatal intubation safety: a journey of a thousand miles, J Neonatal Perinatal Med
10 (2) (2017) 125–131.
[18] A.S. Whigham, R. Howell, S. Choi, M. Pena, G. Zalzal, D. Preciado, Outcomes of
balloon dilation in pediatric subglottic stenosis, Ann. Otol. Rhinol. Laryngol. 121
(7) (2012) 442–448.