LARYNGEAL papillomatosis, the most common benign neoplasm of the pediatric larynx, is often initially misdiagnosed by pediatricians as asthma, croup, or tracheomalacia.1,2  Definitive diagnosis may not occur before an age of more than 2 yr,1  at which time the lesions may grow significantly and present to the anesthesiologist as significant airway obstruction.1,2 

A 9-yr-old girl weighing 33 kg, born at 28 weeks gestation, with a history of laryngomalacia and “almost no voice since birth,” presented to our hospital with difficulty breathing for evaluation and treatment. On examination, the patient was in no distress with a melodic tone on inspiration and exhalation. Her voice was soft and hoarse, and her saturation on room air was 99%. According to her mother, her breathing was very noisy when upset. Neck tissue radiograph (fig.) showed a soft tissue mass within the subglottic airway/larynx. Bedside flexible bronchoscopy revealed a vocal cord papilloma intermittently obstructing the airway.

The patient was at high risk for complete airway obstruction on induction.2  After a thorough discussion with the Otorhinolaryngologist regarding our plan for spontaneous mask ventilation induction and immediate availability of a rigid bronchoscope and tracheostomy kit, the patient was brought to the operating room. She received 0.5 mg IV midazolam premedication (0.015 mg/kg), dosed judiciously to provide anxiolysis and a smooth respiratory pattern while avoiding respiratory depression,3  and an inhalational sevoflurane induction proceeded as planned. A video of the obstructing, ball-valving papilloma was taken during direct laryngoscopy (see video, Supplemental Digital Content 1, http://links.lww.com/ALN/A965) during which time the patient was able to maintain saturations. A 4.0 cuffed tracheal tube was then used to uneventfully secure the airway for initial microdebridement of the lesion.

Competing Interests

The authors declare no competing interests.

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