Laryngomalacia Flashcards
Definition of laryngomalacia
A common congenital abnormality that predisposes to dynamic supraglottic collapse during the inspiratory phase of respiration, which can result in intermittent upper airway obstruction and stridor. It is the most common laryngeal anomaly and the most frequent congenital cause of stridor in infants.
Peak age of incidence of laryngomalacia
Generally, presents in early infancy (around 4 weeks- when inspiratory flow rates are sufficient to produce stridor) with maximal symptoms seen between 6 and 8 months before gradual improvement and spontaneous resolution within 12 to 24 months (70% by 12 months, almost all by 24).
Risk factors for laryngomalacia
Male, GORD (50-100% of cases), neurological dysfunction (e.g cerebral palsy), anatomical abnormalities, genetic syndromes (e.g Down’s)
Reflux in GORD may lead to laryngeal mucosal inflammation and oedema, causing increased obstruction
Presentation of laryngomalacia
- Inspiratory stridor: Will be intermittent and of variable intensity, worse when crying, feeding, lying supine. It may lessen with prone positioning or chin lift/ jaw thrust
- Features of airway obstruction: suprasternal, intercostal or subcostal recession, abdominal respiration and tracheal tug. Child will likely seem comfortable and systemically well despite the obstruction (will likely not present with acute respiratory distress)
- Normal cry
- Feeding difficulties (limited by obstruction) which may lead to poor weight gain or loss of weight. May have associated choking and will seem to ‘run out of breath during feeding. May lead to failure to thrive in severe cases. These features are often compounded by presence of GORD.
Investigations for laryngomalacia
A flexible laryngeal endoscopy should be performed in all patients to assess laryngeal anatomy and related comorbidity. Will show:
* Dynamic collapse of the supraglottic tissues on inspiration
* Visible narrowing and obstruction of the supraglottic airway
* Anatomical anomalies in some
* Evidence of GORD in most
May also consider: ECG, echo (to assess for comorbid cardiac abnormality), polysomnography (for OSA), FEES (for swallow), rigid laryngobronchoscopy (if severe)
Differentials for laryngomalacia
Vocal cord palsy (flexible laryngeal endoscopy will show immobility in 1 or both vocal cords), subglottic stenosis (ruled out by rigid), laryngeal cleft, cyst, or web
Characteristics and management of mild larygomalacia
Co-existent GORD should be assessed and treated appropriately in all patients, with either changes to feeding techniques or surgical intervention in severe cases (1st line thickened feeds, 2nd line omeprazole, 3rd line Nissen fundoplication)
Mild disease: audible stridor and endoscopic features of LM, but no respiratory distress and no evidence of failure to thrive
* Observation and reassurance
* Patient should be fed upright and kept under regular review until the condition resolves.
Characteristics and management of moderate laryngomalacia
Associated with stridor, increased work of breathing, progressive feeding difficulties and either weight loss or inadequate weight gain:
* Conservative approach is preferred with close observation for worsening airway obstruction and feeding difficulties (regular weight + height check)
* Surgery: Endoscopic Supraglottoplasty (1st line) or tracheostomy (2nd line) is appropriate If the child has significant airway obstruction or feeding difficulties affecting growth
* BiPAP may be used in patients with OSA where surgery has failed to improve airway obstruction or in non-surgical candidates.
Characteristics and management of severe larygnomalacia
Occurs in 10-15% of patients with significant SOB and airway obstruction, failure to thrive, marked dysphagia, associated apnoea , hypoxia, pulmonary HTN etc.
* 1st line: Surgery- Endoscopic Supraglottoplasty (1st line) or tracheostomy (2nd line)
