Laryngomalacia

Question 1

Define

Answer 1

Congenital abnormality that predisposes to dynamic supraglottic collapse during the inspiratory phase of respiration, resulting in intermittent upper airway obstruction and stridor

Aetiology

Due to a floppy epiglottis which folds into the airway on inspiration
* Type 1- aryepiglottic folds are tightened or foreshortened
* Type 2- redundant soft tissue in any area of the supraglottic region
* Type 3- epiglottis completely covering the opening - associated with other disorders e.g. neuromuscular disease, GORD

• Not entirely understood but theories such as abnormalities in supraglottic anatomy
• Possibly underlying immaturity and flaccidity in the laryngeal cartilage that improves with age
• Possibly neuromuscular incoordination

Risk factors: GORD, neurological abnormalities, laryngeal anatomical abnormalities, males

One of the most common causes of stridor in infants

Question 2

Sings and symptoms

Answer 2

Signs & symptoms:

• 2-6 weeks old with noisy respiration and inspiratory stridor – worse supine, when feeding or if agitated
• I.E. not present at birth
• GORD ± feeding difficulties, slow, ↑ cough/choking, ↑ respiratory noise
• Normal cry → no abnormality with vocal cords
• Baby otherwise comfortable
• Intercostal or subcostal recession
• Abdominal respiration
• Tracheal tug
• Resolution by 2 years of age
• Normally self-limiting but if stridor becomes severe with signs of respiratory distress or there is failure to thrive (due to poor feeding), then surgery is recommended to improve the airway

Question 3

Investigations

Answer 3

• Cardiorespiratory examination
• Basic observations (O2 monitor)
• XR
• Flexible laryngoscopy

Question 4

Management

Answer 4

Conservative (close observation and monitoring of growth) -> resolve by 18-24 months (70% by 1-year-old)

• May initially worsen with age, max at 6-8 months

URGENT REFERRAL TO ENT:
* Life threatening apneas - stop breathing
* Sig blue spells
* Failure to thrive
* Sig chest/ neck retractions
* Secondary heart and lung disease

Complications: respiratory distress, failure to thrive, cyanosis

Endoscopic supraglottoplasty if airway compromise or feeding disrupted sufficiently to prevent normal growth

Question 5

Complications/ Prognosis

Answer 5

Complications

• GORD exacerbation
• Life-threatening airway obstruction
• Supraglottoplasty-related complications
• Failure to thrive
• Cyanosis
• Resp distress
• Aspiration

Prognosis
* Most severe between 6-8 months of age
* Usually good prognosis, with gradual worsening after onset and then spontaneous resolution before 2 yrs