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62
E. K. Yardımcı et al.
essential to thoroughly examine the endolarynx, including a careful grading of the CSS [40, 55].
The standard treatment for a newborn with subglottic stenosis is to perform a tracheostomy and evaluate the infant’s airway every 3 months to determine if reconstructive surgery is necessary. Under general anesthesia, a cricoid split can be performed anteriorly or posteriorly to widen the cricoid lumen. Laryngotracheal reconstruction is the gold standard treatment for subglottic stenosis that has devel­oped over time. In laryngotracheal reconstruction, the larynx is exposed from the hyoid above to the tracheostomy below by a second incision made above the tra­cheostomy at the cricoid level. The larynx is incised precisely down the middle, and the lumen is entered above the superior thyroid notch. A graft of costal carti­lage widens the cricoid ring. The graft is kept from collapsing with the use of a silastic stent. It is crucial to precisely oppose the anterior commissure during inci­sion closure [56].
4.4.6 Subglottic Hemangioma
Premature infants often develop subglottic infantile hemangiomas, a benign vascu­lar abnormality. The occurrence of cutaneous hemangiomas in more than half of patients with a subglottic hemangioma suggests the presence of a synchronous sub­glottic lesion [40]. The likelihood of developing a subglottic hemangioma is higher in patients whose hemangioma is located in the beard distribution (i.e., the chin, jawline, and preauricular areas) [57]. Infantile hemangiomas occur in females at a rate of 2:1 compared to males [2]. Pathologically, these tumors are characterized by uniform, signicantly positive staining for erythrocyte-type glucose transporter pro­tein isoform 1 (GLUT-1) and endothelial proliferation. Biphasic stridor with retrac­tions are symptoms, and they are most noticeable when the youngster is angry or eating. There may also be a barking cough, like that of croup. Apnea, cyanosis, and “dying spells” can happen with severe airway obstruction.
Transnasal exible laryngoscopy with the patient awake is preferable for the initial assessment. It may make it possible to see the damaged subglottis, and more importantly, it should eliminate other potential causes of neonatal stridor, such as laryngomalacia and paralysis of the vocal folds. A laryngoscopy and bronchoscopy performed in the operating room under general anesthesia are necessary for a child with increasing stridor and a standard glottic and supraglottic evaluation. A radio­graphic examination of the neck and an MRI scan (T2-weighted gadolinium con­trast) can help diagnose the narrowing of the subglottis [2, 40].
Most people need some treatment, and doctors often use multiple approaches. Subglottic hemangiomas are traditionally treated with systemic steroids, which often cause at least partial hemangioma regression in most children [2]. Subglottic hemangiomas can cause airway obstruction, and typical surgical treatment involves performing a tracheotomy and hoping for spontaneous involution. Reports of success using a CO2 laser to decannulate a tracheostomy have been mixed.
4 Congenital Anomalies oftheUpper Respiratory Tract
63
4.4.7 Laryngeal Cysts
Rare causes of respiratory obstruction in children include saccular cysts and laryn­goceles [2]. It is located superiorly between the vestibular fold and the inner side of the thyroid cartilage, and the laryngeal saccule is a tiny diverticulum containing many mucous glands at the anterior end of the laryngeal ventricle [58]. Mucus-lled congenital saccular cysts extend laterally into the false vocal and aryepiglottic fold. In the initial few days of birth, babies with these cysts often have trouble breathing, their cries are muted, and they have trouble swallowing [59]. Internal, external, or combined dilatation and herniation of the saccule characterize a laryngocel. Sometimes there are air-uid levels within laryngoceles, giving the appearance of spherical lumps in the neck or supraglottic region [2]. Saccular cysts generate per­sistent symptoms due to mucoid uid within the cyst, whereas laryngoceles cause occasional upper airway blockage and hoarseness due to episodic lling with air.
The results of needle aspiration, marsupialization, or endoscopic excision for managing saccular cysts have historically been unsatisfactory, often necessitating repeated surgeries and tracheotomy installation. The author prefers an anterior cervical approach, with the superior border of the thyroid alar cartilage being found and the thyrohyoid membrane being incised along its superior border. This method allows the cyst to be reached and carefully dissected free before removal. Thyroid cartilage may be removed to facilitate cyst removal and reattachment [40, 59].
4.4.8 Laryngeal Cleft
Clefts of the larynx, esophagus, or windpipe are extremely unusual congenital dis­abilities. Failure of the laryngotracheal groove to fuse during development causes laryngeal clefts [2]. Associated defects affecting the patient’s airway or other organ systems are common. Tracheomalacia (present in >80% of patients) and tracheo­esophageal stula (TEF) formation (present in 20% of patients) are two of the most common airway abnormalities seen in these patients. GER and anogenital abnor­malities have been linked to a lack of airway development. Opitz-Frias syndrome, which includes hypertelorism, anogenital abnormalities, and posterior laryngeal clefting, is the most prevalent syndrome involving this congenital disability [4]. Benjamin and Inglis [2, 60] suggested a helpful anatomic classication and divide posterior laryngeal clefts into the following four subtypes [2, 60]:
Type 1: supraglottic inter arytenoid cleft present to, but not below, the level of the
true vocal folds. This cleft could also be considered a deep inter arytenoid notch. Type 2: Partial cricoid cleft that extends into, but not through, the posterior cricoid
cartilage. Type 3: Total cricoid cleft with or without extension of the cleft into the cervical
trachea. Type 4: Cleft extending to the thoracic trachea [2, 60].
64
E. K. Yardımcı et al.
Coughing (particularly during eating), difculty feeding, and respiratory dis­comfort (depending on the depth of the split) are some of the earliest signs of a laryngeal cleft. Cyanosis (especially in those with other underlying health problems or abnormalities), aspiration, recurrent lung infections, stridor, wheezing, failure to thrive, and cyanosis are some of the other symptoms that may be present. Clefts of types III and IV are linked to more severe respiratory symptoms, including frequent episodes of pneumonia and increased mucus production. In most cases, types III and IV symptoms appear within the rst week of life [2, 60].
Rigid bronchoscopy and esophagoscopy are the gold standard for diagnosis. In con­trast, other methods such as exible nasopharyngoscopy, beroptic endoscopic evalu­ation of swallowing, video uoroscopy-barium swallow, and exible bronchoscopy are helpful. The cleft is frequently missed or misinterpreted during initial evaluation with exible or rigid bronchoscopy due to redundant mucosa in the posterior glottis [40].
Several surgical methods have been explored in recent decades for treating laryn­geal cleft. In 1967, Evans [61] stated that Jahrsdoerfer and colleagues described the anterior method, which entails exposing the cleft via thyrotomy, cricoidotomy, and trachea-ssure to the rst and second rings to provide direct access to the posterior cleft and permit microsurgical closure. Due to the potential for laryngeal instability and long-term laryngeal development problems, some publications have recommended avoiding the anterior approach [61, 62]. Avoiding the laryngossure has also been described for the lateral pharyngotomy approach [61]. According to other researchers [63], the risk of laryngeal instability with the anterior approach can be reduced with careful closure under magnication, correct stenting with a nasotracheal tube, and appropriate post-operative care in the intensive care unit. A lateral pharyngotomy with a right thoracotomy approach or an anterior approach with a median sternotomy has been employed for a more extensive cleft involving the thoracic trachea [64].

4.5 Conclusion

Assessing a newborn with respiratory distress requires expert knowledge of upper airway embryological development and congenital abnormalities. Most infants experiencing respiratory distress (58%) were in the 1–6 months age range. Laryngomalacia, subglottic stenosis, laryngeal web, and vocal fold paralysis were not strongly associated with age, sex, family history, or other congenital disabilities. Diagnosis is typically made through endoscopy. The severity of an illness deter­mines how it is treated.

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67
Immunological Defense Mechanisms oftheRespiratory System
NeslihanEdeerKaraca, AyseAygun, andTsvetelinaVelikova
The respiratory tract continuously faces inhaled air containing microbial organisms, airborne pollutants, particles, noxious gases, and allergens. The pulmonary immune system must also cope with potentially harmful threats and react rapidly to protect the host [13]. Different physical, secretory, and cellular factors are involved in the immune response in the lung parenchyma and airways, constituting the two func­tional areas of the respiratory system.
The airway epithelium and submucosa serve as the respiratory primary defense system as both a mechanical and immunological barrier [4]. Pulmonary host defense has evolved innate and specic immune mechanisms. The airway epithelium mainly comprises ciliated columnar cells and secretory (goblet) cells that provoke mucocili­ary elimination of inhaled antigens. Apart from providing a physical barrier, the epi­thelium is immunologically active by secreting diverse antimicrobial peptides, releasing chemokines, cytokines, and growth factors, modulating adaptive immunity, and remodeling with tissue repair. In the mucosa, there are macrophages, dendritic cells (DCs), plasma cells, innate lymphoid cells (ILC), natural killer (NK) cells, and T lymphocytes [13]. Epithelial T lymphocytes in the mucosa are mainly CD8+ T cells; in the lamina propria, CD4+ T cells are abundant [1, 3, 5]. There are also areas of lymphoid tissue (LT) in the airway mucosa, namely, nasal mucosa-associated LT (NALT) and bronchus-associated LT (BALT) [6]. This tissue is not encapsulated and is in direct contact with epithelial mucosa. In the lung parenchyma, there are alveolar macrophages and small proportions of T and B lymphocytes and dendritic cells. Innate and adaptive immunity have signicant protective and therapeutic roles against infections and inammation in the respiratory tract (Fig.5.1).
5
N. E. Karaca (*) · A. Aygun Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Türkiye
T. Velikova Soa University, Faculty of Medicine, “St. Kliment Ohridski”, Soa, Bulgaria
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_5
69
70
N. E. Karaca et al.
Fig. 5.1 Immune response in the respiratory tract. Mucosa in the upper and lower airways is constantly exposed to environmental and infectious agents, such
as LPS, agellin, pilin, and other bacterial antigens, as well as various allergens (dust, etc.). Epithelial cells are central in defending respiratory mucosal mem-
brane by both secreting type I and II interferons, lactoferrin, defensins, nitric oxide, etc. into the airway lumen, and communicating with the immune cells in
the mucosa by releasing chemokines (such as MP-1, IL-8, MCP-1, and RANTES) and cytokines (IL-6, IL-1b, TNF-α, etc.) to activate immune cells into the
mucosa. Epithelial cells along with macrophages, dendritic cells, mast cells, and neutrophils are the rst line of defense, involved in direct pathogen clearance
(via IFN-γ production, phagocytosis, etc.) and via direct attraction, recruitment, and activation of effector cells (innate lymphoid cells, tissue-resident T cells,
NK, and NKT cells). This two-tiered immune response eventually leads to pathogen clearance and tissue repair. Furthermore, because of the proinammatory
signals, naïve T cells along with FoxP3+ T regulatory cells predominantly differentiate into Th17 cells, which are engaged in the clearance of pathogens. (Parts
of the gure were drawn by using pictures from Servier Medical Art. Servier Medical Art by Servier, licensed under a Creative Commons Attribution 3.0
Unported License. https://creativecommons.org/licenses/by/3.0/)
5 Immunological Defense Mechanisms oftheRespiratory System
71

5.1 Innate Immunity

The initial phase of lung defense involves the innate immune system, including defensive structures throughout the airway lumen and lung parenchyma, antimicro­bial agents, alveolar macrophages, DCs, neutrophils, NK cells, and ILCs [13].
1. The airway epithelium is at the interface of the human body between the external
inhaled environment and the internal tissues. It forms a complex physicochemi­cal and mechanical barrier supplemented by mucociliary clearance to provide the rst line of defense against inhaled pathogens. The airway mucus covering the respiratory tract’s luminal surface entraps inhaled pathogens, including infectious agents, and eliminates them by the coordinated beating of the cilia. Epithelial cells maintain epithelial integrity by attaching to their neighbors by tight junctions, adherens junctions, gap junctions, and desmosomes [7]. These structures form an impermeable and effective mechanical barrier to most patho­gens and permit the maintenance of an ionic gradient for the directional exchange of many nutrients, water, and gases [7, 8]. The upper airway epithelial cells ef­ciently prevent microparticles >10μm and a large percentage of particles >5μm from reaching the lower airways via direct prevention of their passage through the nasopharyngeal mucosa [8, 9]. The particles entrapped are either exhaled with cough or ingested with mucus into the gastrointestinal tract. If pathogens crack structural defenses, the innate immune system mediators of the upper respiratory tract, including salivary lysozyme, peroxidase, and lactoferrin, func­tion with antimicrobial activity. Lower respiratory system airways are also lined with epithelial cells and beating cilia. Approximately 90% of particles >2–3μm trapped within the mucus are transported through the mucociliary escalator from the bronchioles to the trachea and exhaled with the help of a cough [7].
2. The airway mucus is a viscoelastic gel secreted continuously by intraepithelial
goblet cells and by mucous cells of submucosal glands toward the surface of the epithelium. The airway lining uid is composed of different proteins, such as mucins and antimicrobial substances (lysozyme, lactoferrin, and defensins), cytokines, antiproteases, and antioxidant proteins [1012]. The airway damage can be induced from microbes as well as from several factors that are produced during inammatory reactions and phagocytosis. Lysozyme destroys the walls of the microbes and fungus. It also has the protective role of inhibiting the destruc­tive effects of oxidative factors produced during inammation [13].
Defensins are cationic peptides secreted by neutrophils (α-defensin) and epi- thelial cells (β-defensins) [10]. These peptides exhibit antimicrobial activity against various types of bacteria, mycobacteria, fungi, and some enveloped viruses by promoting chemokine production and subsequent migration of host inammatory cells, inducing phagocytosis, complement activation, and CD4+ T-cell proliferation [10, 13]. Lactoferin can bind with iron and prevent the utili­zation of elemental iron by pathogenic bacteria [14, 15].
Collectins, or collagen-like lectins, are another family of small proteins with important anti-pathogen properties [16]. Their role is to inhibit the invasion of
72
N. E. Karaca et al.
epithelial cells by several respiratory viruses and facilitate the phagocytosis and subsequent clearance of target microorganisms. These molecules exhibit a wide range of specicities. They interact with pathogens through their lectin domains and regulate the functions of T lymphocytes, macrophages, dendritic cells, and neutrophils. Important collectins are the mannose-binding lectin (MBL) and sur­factant proteins A and D [1618]. Collectins cannot destroy microbes directly; they are responsible for enhancing macrophage phagocytosis.
3. The respiratory tract microbiome, a collection of microorganisms (bacteria, viruses, fungi, and archaea) residing in the respiratory mucosa, maintains a sym­biotic relationship with the host. It acts as a barrier against the invasion of patho­gens and plays an essential role in maintaining the balance between immune tolerance and inammation [19].
4. Mast cells and plasma cells, which secrete IgA, are among the primary cells present in the lamina propria. The secretory IgA barrier facilitates the benecial local microbiome’s permanence and helps to eliminate noxious agents, such as pathogens and pollutant particles, by inhibiting their adherence to the epithe­lium [15].
5. Complement, a complex protein system, is a critical component of the innate immune response. The complement system plays a crucial role in the defense against invading pathogens through bacterial lysis, stimulation of phagocytosis, the recruitment of immune cells to infected tissue, and the promotion of the inammatory response. Although complement is well characterized in the serum, complement activity is also present in the lung [20]. Alveolar macro­phages and pulmonary alveolar type II epithelial cells synthesize and secrete complement proteins C2, C3, C4, C5, and Factor B, whereas bronchiolar epithe­lial cells can generate C3 [21]. Once complement is activated by the hydrocar­bons on the outer membrane of the microorganisms or the collectins, the cascade leads to cell death by the nal formation of the lytic membrane attack complex (C5–C9), which forms pores on the target cell membrane.
6. If the microorganism overcomes the mucociliary escalator and defensive pro­teins, it reaches its target, the respiratory epithelial cells. As mentioned before, these cells act as an effective mechanical barrier to the microorganism entry and dissemination into the submucosa. Respiratory epithelial cells produce antimi­crobial and immunomodulatory molecules such as interferons, lactoferrin, and defensins. These cells express receptors within the basolateral epithelial mem­brane, serving as an entry site for several viruses. Under steady-state conditions, the epithelial cells of both the bronchi and the alveoli have essential roles in maintaining tolerance by producing the anti-inammatory cytokines interleukin (IL)-10 and TGF-β [19]. In case of exposure to exogenous microorganisms or tissue damage of any sort, the airway epithelium senses antigens via pattern recognition receptors (PRR) such as Toll-like receptors (TLR), RIG-I-like recep­tors (RLR), Nod-like receptors (NLR), and C-type lectin receptors [2224]. When PRRs recognize the molecular structures common to pathogens, called pathogen-associated molecular patterns (PAMPs), they activate intracellular down-stream signaling pathways that ultimately result in the translocation of