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Laryngomalacia Paediatric ENT presentation
- 1. Laryngomalacia Purushotman Ramasamy, MBBS(Malaya) Dept CME 18th June 2019
- 2. Laryngomalacia •LM is acongenital softening of the tissue sof the larynx and the commonest cause of stridor in infants
- 3. How would youapproach ? : History • Histrory on Stridor : nature , factors aggravating, relieving • Feeding : ? BM / FM / Volume vs Frequency/ Regurgitation • Dusky spells : ?Cyanosis: peripheral/ central / duration/ sleep • Birth Hx : Term / Weight / Apgar Score/ mode of delivery • Perinatal Hx – TORCHES • Other medical condition(s)
- 4. Laryngomalacia: History • InspiratoryStridor • may sound like nasal congestion, with which they are initially confused. • No nasal secretions are present. • Worsened in : supine, crying or agitation, URTI episodes , during and after feeding. • In mild cases crying may improve symptoms • The baby's cry is usually normal • Usually, no feeding intolerance is noted • The infant is usually happy and thriving (30% feeding problem with poor wt gain)
- 5. Laryngomalacia : Pathophysiology •1.Neuromuscular hypotonia • Neurologic disorder, laryngeal collapse •2. Altered sensorimotor integrative function • Lack of laryngeal adductor reflex •3. Anatomic abnormalities •4. Gastroesophageal reflux
- 6. Differential Diagnosis 1.Valleculae cyst 2.SaccularCyst 3.VC palsy – second commonest after Laryngomalacia 4.Subglottic Stenoses – third commonest 5.Vascular malformation 6.Anterior glottic Web
- 7. Physical Signs inLaryngomalacia •General appearance •Inspiratory stridor •increased RR •nasal flaring •air hunger during feed •chest recession •pectus excavatum
- 8. Flexible Nasolaryngoscopy • Sufficein most cases • Supraglottic collapse can be easily elicited • Child can be followed up in 4 weeks • Mostly isolated finding in otherwise healthy infant 15 – 20 % may have other co-existing lesions : subglottic stenoses or laryngomalacia
- 9. Indications for MLBin Laryngomalacia 1. Symptoms that do not correlate with degree of laryngomalacia noted on FNL 2. Evaluate for co-existing airway lesions (12- 27%) 3. Evaluate for surgical intervention
- 10. Long & CurledEpiglottis : Ω shaped
- 11. Short AE fold- Tightly tethered to Epiglottis
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- 13. Layngomalacia : Holinger’sClassification • Type 1: collapse of AE folds • Type 2: tubular epiglottis with inward collapse • Type 3: anteromedial collapse of the arytenoids, corniculates & cuneiform • Type 4: posterior collapse of the epiglottis • Type 5: shortened AE folds
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- 15. Aspiration in Laryngomalacia •25-72% of patients with severe laryngomalacia also have aspiration • Clinical swallow exam • Video fluoroscopic swallow study (VFSS) • Fiberoptic endoscopic evaluation of swallowing (FEES) • Symptoms of aspiration: • Coughing and choking with feeds • Cyanosis, apnoeic episodes, respiratory distress around meal times
- 16. Laryngomalacia : Management •90% of children sx resolved by 2 yo • Flexible scope in clinic is adequate • BD PPI & reflux precaution (80% have GERD) • DL & bronchoscopy (for severe cases): spontaneous breathing to allow a complete, dynamic assessment of airway
- 17. Laryngomalacia : Indicationsfor surgery 1. failure to thrive (<5%) 2. cyanotic episodes and persistent stridor with accessory muscle usage 3. significantly elevated carbon dioxide or hypoxemia 4. severe obstructive sleep apnea 5. pulmonary hypertension 6. cor pulmonale
- 18. Surgical Approach 1.Supraglottoplasty a.k.aaryepiglottoplasty • Cold steel, microdebrider, CO2 laser 2. Epiglottopexy 3. Tracheostomy
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- 21. Supraglottoplasty : Benefits •Well tolerated procedure • High success rate • 69-94% with resolution of airway and feeding symptoms • Improvement of reflux, aspiration and sleep apnea • Low failure rate • 1-3% need tracheotomy • Typically patients with associated neurologic disorder or syndrome • Discoordinate pharyngolaryngomalacia
- 22. Supraglottoplasty : Complications •Laryngeal webs, granulation tissue • Preserve interarytenoid tissue to avoid web • Supraglottic stenosis (4%) • Transient dysphagia (10-15%) • Aspiration • ?Newly diagnosed • ?persistent from preoperative aspiration
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- 24. Further Work up 1.Assessment of swallowing • Barium swallow/ MLB/ FEES • Assessment for reflux and aspiration 2.. Airway Fluoroscopy • Dynamic study • Supplement to endoscopy to evaluate subglottis and trachea 3. CXR / Neck XR • Croup • Foreign body • Pneumonia 4. PSG • To evaluate apnoea • Central obstructive 5. Echocardiogram • Check for cardiac origin of cyanosis • Preoperative clearance • Effects of OSA
- 25. Take home messages •Congenital inspiratory stridor – most due to supraglottic collapse • 80-90% resolve by 1-2 years of age with conservative mx • Strong association with GERD • Aspiration and sleep apnoea are common cx • Silent chest and diminished RR Raise red flag • More severe symptoms warrant surgical intervention
Editor's Notes
- #14 The relationship is proven with operative specimen histological studies
- #15 Altered anatomy and neuromuscular reflexes :dysfunction of suck-swallow-breathe sequence Disruption of Laryngeal Adductor Reflex (LAR) : laryngeal penetration Failure of Closure of vocal cords and cessation of breathing as food passes into pharynx Rapid feeding aspiration: Increased metabolic demands, weight loss, hunger
- #22 Richter, Thompson et al: 31/36 pts had resolution from pre-op aspiration Supraglottoplasty doesn’t cause post op aspiration ; 0/14