1. Congenital disorders of the Larynx
―Laryngomalacia‖
By:
Zainab ahmed
Audiologist and speech languuage
pathologist

2. PART 1 ―LARYNGOMALACIA‖

3. WHAT IS LARYNGOMALACIA?
 Most common congenital anomaly of the larynx
 -characterized by partial or complete collapse of the
supraglottic structures on inspiration.
 Laryngo malacia is a congenital softening of the
tissues of the larynx (voice box) above the vocal
cords. This is the most common cause of
noisy breathing in infancy. The laryngeal structure is
malformed and floppy, causing the tissues to fall
over the airway opening and partially block it.

4. LARYNGOMALACIA..
 Etiology: Unkown
 Theories: GERD,(gastroesophageal reflux disease)
Immature neuromuscular control(the mind's attempt to
teach the body conscious control of a specific
movement. )
 Epiglottis is derived from the 3rd and 4th branchial
arches. Overgrowth of the 3rd results in elongation of
the structure and the observed laryngomalacia
 However histological studies do NOT demonstrate a
difference between the quality of the cartilage between
normal/abnormal

5. Congenital disorders of the Larynx
Organogenesis
At birth the larynx is located high in the larynx between
levels C1- C4
By age 2 the larynx begins to descend inferiorly
By age 6 the larynx reaches the adult position between
levels C4 through C7

7. CONGENITAL DISORDERS OF THE LARYNX
 The larynx develops from the endodermal lining
and the adjacent mesenchyme of the foregut
between the fourth and sixth branchial arches.
 At 20 days' gestation, the foregut is first identifiable
with a ventral laryngotracheal groove
 The laryngotracheal groove continues to deepen
until its lateral edges fuse. By day 26, this tube
descends caudally, where the trachea becomes
separated from the esophagus by the
tracheoesophageal septum with a persistent slitlike
opening into the pharynx.

9. DETECTION OF LARYNGOMALACIA
 Laryngomalacia is seen in a child’s airway
during micro laryngoscopy which is a precise type
of surgery used in the diagnosis and removal of
various lesions of the vocal folds to restore a
normal voice.

10. PART 2: LARYNGOMALACIA

12. CLINICAL DIAGNOSIS
 It is considered a benign, transient cause of
inspiratory stridor and is characterized by collapse
of arytenoids, epiglottis and aryepiglottic folds
during the inspiratory phase.
 . The clinical diagnosis comprises of identifying
three anatomic abnormalities
 (1) flaccid epiglottis prolapsing
 backwards during inspiration;
 (2) poorly supported arytenoids that prolapse
forward during inspiration;
 (3) short aryepiglottic folds.

13. NORMAL VS LARYNGO MALACIAC VIEW

14. CAUSES:
 It can be due to the relaxation or a lack of muscle tone
in the upper airway.
 Insufficient or delayed calcium deposition
 The part of the nervous system that gives tone to the
airway is most likely underdeveloped.
 Gastroesophageal reflux (GER) may play an etiological
role in laryngomalacia
 Immature neuromuscular control may be responsible for
the arytenoid prolapse observed in laryngomalacia

15. TYPES:
 Type I: Inward collapse of aryepiglottic folds
 Type II: Long tubular epiglottis infolding on itself (Omega
shaped)
 Type III: Anterior and medial collapse of corniculate and
cuneiform cartilages
 Type IV: Posterior displacement of epiglottis against
posterior pharyngeal wall or inferior collapse towards
vocal folds
 Type V: Short aryepiglottic folds

21. DEGREE OF LARYNGOMALACIA
 Laryngomalacia can be mild, moderate or severe. 99%
of infants with laryngomalacia have mild or moderate
laryngomalacia.
 Mild laryngomalacia:
 noisy breathing or inspiratory stridor.
 no significant airway obstruction, feeding difficulties or
other symptoms associated with laryngomalacia.
 The noisy breathing is annoying to caregivers, but does
not cause other health care problems.
 Infants with mild laryngomalacia usually outgrow the
stridor by 12 – 18 months of age

22. MODERATE LARYNGOMALACIA
 noisy breathing or inspiratory stridor
 Feeding difficulties without poor weight gain
 (vomiting or spitting up)
 Choking on food
 Gastroesophageal reflux)
 Mild to moderate chest and/or neck retractions
(chest and/or neck sinking in with breathing), but no
severe distres
 . Stomach acid, if it reaches the upper part of the
esophagus and voice box, can cause swelling of
the floppy tissue above the vocal cords.

23. SEVERE LARYNGOMALACIA
 Feeding difficulties with poor weight gain
 (chest and/or neck sinking in with breathing)
 Significant cyanosis (turning blue)
 Life threatening apnea (pauses in breathing)
 Heart or lung problems from chronic oxygen
deprivation (low oxygen)
 Airway symptoms severe enough to cause multiple
visits to an emergency department or hospital
 Only 1% of infants with laryngomalacia have severe
laryngomalacia. Infants with severe laryngomalacia
usually need surgery.

24. SYMPTOMS

25.  Noisy breathing (stridor) — An audible wheeze when the baby
inhales (breathes in). It is often worse when the baby is agitated,
feeding, crying or sleeping on his back.
 High pitched sound
 Difficulty feeding
 Poor weight gain
 Choking while feeding
 Apnea (breathing stoppage)
 Pulling in neck and chest with each breath
 Cyanosis (turning blue)
 Gastro esophageal reflux (spitting, vomiting and regurgitation)
 Aspiration (inhalation of food into the lungs)

27. PART : 3 ―LARYNGOMALAYCIA‖

29. CHECKLIST :
 Look out and check if the child
 has difficulty keeping food down and constantly spits it
up
 is losing weight or is not gaining weight
 begins to feed less and tires easily in the middle of
feeding
 begins to choke on food
 struggles between eating and breathing

31. PHYSICAL EXAM:
 Elongation and lateral extension of the eiglottis (omega
shaped) that falls posteroinferiorly on inspiration
 Redundant bulky arytenoids that prolapse
anteromedially on inspiration
 Shortening of the aryepiglottic folds, which results in
tethering of the arytenoids to the epiglottis
 Inward collapse of the aryepiglottic folds (cuneiform
cartilages) on inspration
 Visualization of the vocal cords, which are normal in
structure and function

32. FLEXIBLE ENDOSCOPY
 Elongation and lateral extension of the epiglottis
(omega shaped) that falls posteroinferiorly on
inspriation

33. MICROLARYNGOSCOPY AND BRONCHOSCOPY
 This test is done in the operating room under
general anesthesia by the ENT surgeon. The doctor
looks at the voice box and windpipe with
telescopes. Your doctor may recommend this test if
the X-ray test shows something abnormal or if your
doctor has a suspicion of additional airway
problems

34. ESOPHAGOGASTRODUODENOSCOPY (EGD)
 An EGD is a diagnostic test done in the operating
room under general anesthesia by the
gastroenterologist. The doctor looks at your child's
esophagus and stomach with a lighted tube.
 During an EGD, the doctor looks for signs of
chronic inflammation from acid irritation that can
occur in the stomach or the esophagus. Your doctor
may recommend this if the pH probe is significantly
abnormal or there is strong suspicion of significant
GERD based on history and clinical examination

35. TREATMENT
 In approximately 90% of reported cases, the
condition is mild, no intervention is needed and the
parents can be reassured accordingly (Lane et al.
1984)
 Medical management should include treatment of
documented gastroesophageal reflux disease
(GERD) because this condition is known to
contribute to laryngomalacia

36. SURGICAL MANAGEMENT
 Surgical management is indicated in rare instances if
respiratory complications develop if there is serious
respiratory obstruction with substantial sternal and
intercostal recession,
 feeding difficulties that may be compounded by reflux
enhanced by the high negative intrathoracic pressures
generated, and consequent failure to thrive.
 Tracheotomy can be performed for emergent episodes
of distress and should be left in place until the
supraglottic pathology resolves with age.

37. TREATMENT
 Surgical management
 -Restoration of an adequate airway can be achieved
 by performing an endoscopic aryepiglottoplasty (sometimes
 termed a supraglottoplasty; Jani et al. 1991).
 Supraglottoplasty
 1) Using cup forceps and microscissors (or alternatively the
carbon dioxide laser), each aryepiglottic fold is first divided to
release it from the edge of the epiglottis,
 2) the redundant mucosa and submucosal tissue are then
excised from over the arytenoids, together if necessary with
part or all of the cuneiform cartilages. The stridor is usually
improved immediately following

39. PART 4 : LARYNGOMALACIA

40. POST OPERATIVE CARE
 If a child has had an operation, there may still be a
requirement for treatment for gastro esophageal
reflux during and after the operation. It is also
important to monitor the child for signs and
symptoms of worsening LM.

41. POST OPERATIVE CARE
 Take the child to the hospital if
 breathing stops for longer than 10 seconds
 dusky or blue color around lips associated with noisy
breathing
 chest or neck retractions that do not stop with
repositioning your child or waking your child up
 Inform the child’s doctor if the
 child has difficulty keeping food down and constantly
spits it up.
 child is losing weight or is not gaining weight.
 child begins to feed less and tires easily in the middle of
feeding.
 child begins to choke on food.
 child struggles between eating and breathing

42. QUOTATION:
―WHEN PEOPLE DON’T EXPRESS THEMSELVES,
THEY DIE ONE PIECE AT A TIME‖.
LAURIE HALSE