An infant who has been extubated for two weeks develops a hoarse cry that has worsened over time. Which problem should you suspect?

• A. Granuloma formation
• B. Laryngomalacia
• C. Subglottic stenosis
• D. Croup

Answer: (A)

Injuries from prior endotracheal intubation can lead to granuloma formation in the larynx, and this often presents as a hoarse or weak cry that develops weeks after extubation. The tube can irritate the mucosa and promote granulation tissue at the vocal fold area, especially the posterior glottis, which gradually worsens vocal quality over time. That pattern—voice change developing weeks after removal of the tube—fits granuloma best.

Laryngomalacia would cause inspiratory stridor that often appears early in infancy and worsens with feeding or agitation, not a progressive hoarseness after extubation. Subglottic stenosis tends to produce biphasic or inspiratory stridor and respiratory distress due to narrowing below the vocal cords, not primarily a hoarse cry. Croup presents with a barking cough and viral symptoms with prominent inspiratory stridor, not the isolated post-extubation hoarseness pattern described.

So the delayed hoarseness after extubation points to granuloma formation from endotracheal injury.