Laryngomalacia: Causes, Symptoms, and Management

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Cynthia Schwartz
January 29, 2016
 
Laryngomalacia
 
What is laryngomalacia?
 
Inward collapse of supraglottic structures during inspiration
Leads to intermittent airflow obstruction
Most common cause of neonatal and childhood stridor,
account for 60-70% of cases
High pitched
Not always present at birth, usually apparent within a few
weeks
Exacerbated by crying, feeding, agitation, infections, and
supine position
 
Mechanism
 
From: https://instructions.kidshealth.org/wp/laryngomalacia-floppy-voice-box-
1404/
 
Pathophysiology
 
Histologic exams demonstrate normal fibro-elastic cartilage
in patients with symptomatic disease
Lower aryepiglottic (AE) fold to glottic length ratio in
patients with severe laryngomalacia as compared to
unaffected children
However, some children with lower AE fold to glottic length
ratio are asymptomatic
Immaturity/abnormal integration of peripheral nerves
and/or brainstem nuclei and pathways responsible for
swallowing and maintenance of airway patency
 
Relevance
 
5-20% have respiratory concerns
Obstructive sleep apnea, tachypnea. dyspnea, respiratory
distress, hypoxemia
About half of all laryngomalacia patients have some difficulty
feeding
Coughing, cyanotic episodes, regurgitation, emesis, slow
feeding
Almost all with severe laryngomalacia exhibit the above
difficulty feeding and:
Recurrent aspiration pneumonia, failure to thrive
 
Co-Morbidities
 
Most common: gastroesophageal reflux
65%-100%
May irritate the mucosa, leading to inflammation and worsening
airway collapse
Only limited causal evidence
pH studies?
Acid-blocking medication?
Neurologic disease, congenital syndromes and anomalies, and
heart disease
 
Synchronous Airway Lesions (SALs)
 
12-64% of patients
Most commonly tracheomalacia
Subglottic stenosis
Vocal cord paralysis
Additional diagnostic procedures controversial
 
Diagnosis
 
Pertinent history
Gestational age, past endotracheal intubation, congenital or
genetic abnormalities, respiratory symptoms, feeding
Physical examination
Height, weight, respiratory sounds, chest movement
http://www.youtube.com/watch?v=AIuA2zKIk2k
Flexible fiberoptic laryngoscopy (88%)
Done awake
Avoid topical anesthetics
 
Risk Factors
 
Age usually less than 2 years old, sporadic case reports of
older children and adults
Prematurity is a risk factor for dysphagia after
supraglottoplasty
Bronx study found no difference in the number of male and
female patients
Previous studies suggest male predominance
Premature African-American and Hispanic infants were at a
higher risk of laryngomalacia compared to Caucasian infants
Low birth weight was strong predictor of laryngomalacia
 
Laryngoscopy
 
Progressive airway
obstruction on
inspiration
“Omega” 
epiglottis
 
From: http://clinicalgate.com/congenital-disorders-of-the-larynx/
 
Treatment
 
Symptoms are most severe at 4-8 months of age and
generally become less severe
Most “outgrow” by two years old
Only 5-20% need surgery
 
Surgical Indications
 
Respiratory
Stridor with respiratory
distress
Dyspnea with retractions
Pectus excavatum
Pulmonary hypertension
Cor pulmonale
Severe obstructive sleep
apnea
 
Feeding
Episodic cyanosis with
feeding
Recurrent aspiration
pneumonia
Failure to thrive
 
Surgical Treatment
 
Supraglottoplasty
Partial epiglottectomy
Division of AE folds
Removal of redundant mucosa
Performed under sedation with spontaneous breathing
Use microlaryngeal instruments, such as micro-debrider or
CO
2
 laser
95.7% success rate
8.5% complications rate
Epiglottopexy sometimes used for posterior collapse
 
Post-Supraglottoplasty
 
 
From: 
Laryngomalacia: Review and Summary of Current Clinical
Practice in 2015, 
Thorne, Marc C. et al., Paediatric Respiratory Reviews ,
Volume 0 , Issue 0
 
After Treatment
 
Catch-up growth may be demonstrated
Younger infants “catch up” more than older
Smaller infants ‘catch up” more than larger
Surgery correlates with improved growth
 
References
 
https://instructions.kidshealth.org/wp/laryngomalacia-floppy-voice-box-1404/
http://www.youtube.com/watch?v=AIuA2zKIk2k
http://clinicalgate.com/congenital-disorders-of-the-larynx/
Laryngomalacia: Review and Summary of Current Clinical Practice in 2015,
Thorne, Marc C. et al., Paediatric Respiratory Reviews , Volume 0 , Issue 0
Laryngomalacia: The role of gender and ethnicity, 
Natalie E. Edmondson, John
P. Bent III, Christine Chan, International Journal of Pediatric Otorhinolaryngology,
Volume 75, Issue 12, December 2011, Pages 1562–1564
Catch-up growth in infants with laryngomalacia after supraglottoplasty.
Czechowicz JA, Chang KW. Int J Pediatr Otorhinolaryngol. 2015 Aug;79(8):1333-6.
Supraglottoplasty in premature infants with laryngomalacia: does gestation
age at birth influence outcomes? 
Durvasula VS, Lawson BR, Bower CM, Richter
GT. Otolaryngol Head Neck Surg. 2014 Feb;150(2):292-9.
Adult-onset laryngomalacia: case reports and review of management. 
Hey
SY, Oozeer NB, Robertson S, MacKenzie K. Eur Arch Otorhinolaryngol. 2014
Dec;271(12):3127-32
 
 
 
 
 
 
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Laryngomalacia is a condition characterized by the inward collapse of supraglottic structures during inspiration, leading to intermittent airflow obstruction. It is a common cause of neonatal and childhood stridor, with symptoms typically appearing within a few weeks after birth. The condition can be exacerbated by various factors such as crying, feeding, agitation, infections, and a supine position. Laryngomalacia can result in respiratory concerns, difficulty feeding, and co-morbidities like gastroesophageal reflux. Additional synchronous airway lesions may also be present in some patients, requiring further diagnostic evaluation.

  • Laryngomalacia
  • Childhood Stridor
  • Airway Obstruction
  • Respiratory Concerns
  • Gastroesophageal Reflux

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  1. Laryngomalacia Cynthia Schwartz January 29, 2016

  2. What is laryngomalacia? Inward collapse of supraglottic structures during inspiration Leads to intermittent airflow obstruction Most common cause of neonatal and childhood stridor, account for 60-70% of cases High pitched Not always present at birth, usually apparent within a few weeks Exacerbated by crying, feeding, agitation, infections, and supine position

  3. Mechanism From: https://instructions.kidshealth.org/wp/laryngomalacia-floppy-voice-box- 1404/

  4. Pathophysiology Histologic exams demonstrate normal fibro-elastic cartilage in patients with symptomatic disease Lower aryepiglottic (AE) fold to glottic length ratio in patients with severe laryngomalacia as compared to unaffected children However, some children with lower AE fold to glottic length ratio are asymptomatic Immaturity/abnormal integration of peripheral nerves and/or brainstem nuclei and pathways responsible for swallowing and maintenance of airway patency

  5. Relevance 5-20% have respiratory concerns Obstructive sleep apnea, tachypnea. dyspnea, respiratory distress, hypoxemia About half of all laryngomalacia patients have some difficulty feeding Coughing, cyanotic episodes, regurgitation, emesis, slow feeding Almost all with severe laryngomalacia exhibit the above difficulty feeding and: Recurrent aspiration pneumonia, failure to thrive

  6. Co-Morbidities Most common: gastroesophageal reflux 65%-100% May irritate the mucosa, leading to inflammation and worsening airway collapse Only limited causal evidence pH studies? Acid-blocking medication? Neurologic disease, congenital syndromes and anomalies, and heart disease

  7. Synchronous Airway Lesions (SALs) 12-64% of patients Most commonly tracheomalacia Subglottic stenosis Vocal cord paralysis Additional diagnostic procedures controversial

  8. Diagnosis Pertinent history Gestational age, past endotracheal intubation, congenital or genetic abnormalities, respiratory symptoms, feeding Physical examination Height, weight, respiratory sounds, chest movement http://www.youtube.com/watch?v=AIuA2zKIk2k Flexible fiberoptic laryngoscopy (88%) Done awake Avoid topical anesthetics

  9. Risk Factors Age usually less than 2 years old, sporadic case reports of older children and adults Prematurity is a risk factor for dysphagia after supraglottoplasty Bronx study found no difference in the number of male and female patients Previous studies suggest male predominance Premature African-American and Hispanic infants were at a higher risk of laryngomalacia compared to Caucasian infants Low birth weight was strong predictor of laryngomalacia

  10. Laryngoscopy Progressive airway obstruction on inspiration Omega epiglottis From: http://clinicalgate.com/congenital-disorders-of-the-larynx/

  11. Treatment Symptoms are most severe at 4-8 months of age and generally become less severe Most outgrow by two years old Only 5-20% need surgery

  12. Surgical Indications Respiratory Stridor with respiratory distress Dyspnea with retractions Pectus excavatum Pulmonary hypertension Cor pulmonale Severe obstructive sleep apnea Feeding Episodic cyanosis with feeding Recurrent aspiration pneumonia Failure to thrive

  13. Surgical Treatment Supraglottoplasty Partial epiglottectomy Division of AE folds Removal of redundant mucosa Performed under sedation with spontaneous breathing Use microlaryngeal instruments, such as micro-debrider or CO2 laser 95.7% success rate 8.5% complications rate Epiglottopexy sometimes used for posterior collapse

  14. Post-Supraglottoplasty From: Laryngomalacia: Review and Summary of Current Clinical Practice in 2015, Thorne, Marc C. et al., Paediatric Respiratory Reviews , Volume 0 , Issue 0

  15. After Treatment Catch-up growth may be demonstrated Younger infants catch up more than older Smaller infants catch up more than larger Surgery correlates with improved growth

  16. References https://instructions.kidshealth.org/wp/laryngomalacia-floppy-voice-box-1404/ http://www.youtube.com/watch?v=AIuA2zKIk2k http://clinicalgate.com/congenital-disorders-of-the-larynx/ Laryngomalacia: Review and Summary of Current Clinical Practice in 2015, Thorne, Marc C. et al., Paediatric Respiratory Reviews , Volume 0 , Issue 0 Laryngomalacia: The role of gender and ethnicity, Natalie E. Edmondson, John P. Bent III, Christine Chan, International Journal of Pediatric Otorhinolaryngology, Volume 75, Issue 12, December 2011, Pages 1562 1564 Catch-up growth in infants with laryngomalacia after supraglottoplasty. Czechowicz JA, Chang KW. Int J Pediatr Otorhinolaryngol. 2015 Aug;79(8):1333-6. Supraglottoplasty in premature infants with laryngomalacia: does gestation age at birth influence outcomes? Durvasula VS, Lawson BR, Bower CM, Richter GT. Otolaryngol Head Neck Surg. 2014 Feb;150(2):292-9. Adult-onset laryngomalacia: case reports and review of management. Hey SY, Oozeer NB, Robertson S, MacKenzie K. Eur Arch Otorhinolaryngol. 2014 Dec;271(12):3127-32

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