Evaluation of the Efficacy of Supraglottoplasty in Obstructive Sleep Apnea Syndrome Associated With Severe Laryngomalacia

Obstructive Sleep Apnea in Neonates

Neonates have distinctive anatomic and physiologic features that predispose them to obstructive sleep apnea (OSA). The overall prevalence of neonatal OSA is unknown, although an increase in prevalence has been reported in neonates with craniofacial malformations, neurological disorders, and airway malformations. If remained unrecognized and untreated, neonatal OSA can lead to impaired growth and development, cardiovascular morbidity, and can even be life threatening. Polysomnography and direct visualization of the airway are essential diagnostic modalities in neonatal OSA. Treatment of neonatal OSA is based on the severity of OSA and associated co-morbidities. This may include medical and surgical interventions individualized for the affected neonate. Based on this, it is expected that infants with OSA have more significant healthcare utilization.

Changes in Breathing Patterns after Surgery in Severe Laryngomalacia

Background: Most of the studies regarding the surgical treatment of severe laryngomalacia (LM) have been aimed at describing the efficacy of the treatment in terms of improvement of clinical symptoms or anatomical findings. There are no studies specifically aimed at analyzing the changes in breathing patterns following surgical treatment for severe LM. Objective: To review the breathing pattern changes before and after corrective surgery in infants with severe LM. Study design: A series of retrospective cases at a tertiary referral children’s hospital. Methods: Retrospective chart review of 81 infants who underwent supra-glottoplasty (SGP) for severe laryngomalacia between 2011 and 2020 at Bambino Gesù Children’s Hospital of Rome, Italy. Among the patients, 47 (58%) were male and 34 (42%) were female. Twenty-one patients (26%) had one or more comorbidities condition. The data collected included age, symptoms, a polysomnography/pulse oximetry study, growth rate, the findings from flexible endoscopy, pre- and post-supra-glottoplasty (SGP) pulmonary function tests (PFTs) and, when indicated, 24 h pH-metry. Breathing patterns were studied during restful, normal sleep, using an ultrasonic flow-meter (Exhalyzer, Viasys) which measured: Tidal Volume (Vt), Respiratory Rate (RR), time to peak expiratory flow/expiratory time ratio (tPTEF/Te, an index of the patency of the lower airways) and mean expiratory/mean inspiratory flow ratio (MEF/MIF, an index of the patency of the upper airways) evaluated before surgical procedure (T1) and 3–6 weeks after (T2). Pre- and post-operative mean data were calculated and comparisons made with a Student T-test. Results: The surgical procedure was well tolerated by all infants and no intraoperative or post-operatory long-term complications were noted. In T1, breathing patterns were characterized by low tidal volume and high tPTEF/Te and MEF/MIF ratios, suggesting a severe reduction in the patency of the upper airways in all patients. After surgery (T2), all the previously mentioned variables significantly improved, reaching normal values for the child’s age. Conclusions: Supra-glottoplasty, as already described in several studies, is a safe and efficient procedure to treat severe laryngomalacia during infancy. The improvement in breathing patterns after surgery was reliably confirmed by a lung function test in our study, which showed the diagnostic value of testing respiratory functionality in the laryngomalacia and comparing them to clinical and endoscopic data. Moreover, considering the results obtained, we also propose the use of this available, dependable test to verify its therapeutic effects (post-surgery) and to monitor future respiratory development in these infants. Moreover, we believe that further studies will provide detailed grading guidelines for gravity of the LM, based on these functional lung tests.

Prevalence and natural history of obstructive sleep apnea in pediatric patients with laryngomalacia

OBJECTIVE

Laryngomalacia is the most common cause of infant stridor, and obstructive sleep apnea (OSA) is sometimes found concurrently in patients with laryngomalacia. OSA has been shown to improve after surgical treatment of laryngomalacia, but the majority of laryngomalacia patients have spontaneous resolution of symptoms. It is unknown whether their comorbid OSA also resolves. This study seeks to define the incidence of OSA in laryngomalacia and assess for resolution of OSA with polysomnography data.

METHODS

Retrospective cohort study at a tertiary care academic medical center. All pediatric patients with diagnoses of laryngomalacia or stridor were reviewed, and patients with laryngomalacia confirmed by Otolaryngologist exam were included. All patients with laryngomalacia were recommended to undergo polysomnography.

RESULTS

A total of 108 patients had laryngomalacia confirmed by an Otolaryngologist. Of those patients, 56 completed a polysomnogram, and 44 (79%) were diagnosed with OSA. Among the OSA patients, 34 had no surgery, 5 underwent supraglottoplasty, and 5 underwent adenoidectomy or adenotonsillectomy. Follow-up polysomnograms were performed for 9 non-surgical patients, 4 supraglottoplasty patients, and 4 adenoidectomy or adenotonsillectomy patients. Mean change in AHI was -2.81 without surgery, -8.18 after supraglottoplasty, and -2.94 after adenoidectomy or adenotonsillectomy.

CONCLUSION

OSA is often present in patients who have laryngomalacia, and the proportion in this population was higher than previous reports. The only significant predictor for obstructive sleep apnea was race, specifically Black/African American. Among patients with follow-up polysomnograms, the largest OSA improvement was in supraglottoplasty patients, but all patients improved.

Coagulation of the lateral surface of aryepiglottic folds as an alternative to aryepiglottic fold release in management of type 2 laryngomalacia

OBJECTIVE

Endoscopic supraglottoplasty is the procedure of choice in treatment of laryngomalacia with CO2 laser and cold steel being the most common instruments used with excellent results. However, bleeding, supraglottic stenosis and aspiration may occur leading to serious complications. Using coblation in management of laryngomalacia was found to be beneficial. Therefore, we conducted this study to evaluate the outcome of supraglottoplasty done by coagulation using coblation of the lateral surface of aryepiglottic folds as an alternative technique to aryepiglottic fold release in management of type 2 laryngomalacia.

METHODS

Retrospective study was conducted at Mansoura University Hospitals; Egypt from November 2017 to March 2018 included patients diagnosed with severe type 2 laryngomalacia. Supraglottoplasty was done by using coblator applied to the lateral surface of aryepiglottic folds allowing for lateral scarring thus widening the airway, preventing supraglottic collapse and avoiding re-stenosis. Outcome measures included assessment of presence or absence of the following symptoms preoperatively and postoperatively: inspiratory stridor, failure to thrive, choking and cyanosis. Preoperative and postoperative lowest oxygen saturation levels, weight-by-age percentile, and need for tracheostomy were assessed.

RESULTS

Nine patients were included in this study with a mean age of 3.78 ± 1.20 months (range 2-6 months). Overall success rate was 89%. The most significantly improved symptom was stridor (p-value 0.008). Significant improvement in lowest oxygen saturation levels (from 89.11 ± 3.06% pre-operatively to 96.44 ± 3.50% post-operatively) and weight gain (from 4288.9 ± 643.1 gm. preoperatively to 5505.55 ± 1017.4 gm. 1 month postoperatively) was achieved. No detected re-stenosis on follow up and none of our cases needed tracheostomy.

CONCLUSION

Supraglottoplasty by coagulation of the lateral surface of aryepiglottic folds using coblation is an effective and safe technique and can improve airway symptoms and weight gain in patients with type 2 laryngomalacia.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis

OBJECTIVE

To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia.

DATA SOURCES

PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase.

REVIEW METHODS

Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed.

RESULTS

A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011).

CONCLUSION

Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

Complete polysomnographic parameters in infants with severe laryngomalacia prior to and after supraglottoplasty

INTRODUCTION

Laryngomalacia is the most common congenital laryngeal anomaly. Because of supraglottic prolapse, laryngomalacia may be associated with obstructive sleep apnea (OSA) and sleep disturbances. The effects of OSA and sleep disorders in children include failure to thrive, cognitive and behavioral disturbances, cardiovascular compromise, and an association with sudden infant death syndrome.

OBJECTIVE

To evaluate the presence of OSA and sleep disturbances in children with severe laryngomalacia through complete nocturnal polysomnography, as well as to establish the effects of supraglottoplasty in each of the polysomnographic parameters.

RESULTS

Nine infants with severe laryngomalacia were included, all with a complete polysomnographic study prior to and after supraglottoplasty. The average age was 5.5 months. All patients presented an Apnea-Hypopnea Index (AHI) within the range of severe OSA. After supraglottoplasty, a significant reduction in AHI was found, from 34.87 ± 20.34 to 9.44 ± 5.28 after surgery (p: 0.022). Additionally, sleep efficiency had a significant increase, from 21.4% to 56.29% of total sleep time (p: 0.0013). All patients presented a significant decrease in obstructive apnea episodes (p < 0.0001), as well as in hypopnea episodes (p: 0.0154). The mean and minimum peripheral oxygen saturation (SpO2) had a significant increase after supraglottoplasty from 88.2% to 94.09% (p: 0.0002), and from 81.01% to 89.33% (p < 0.0001), respectively.

CONCLUSION

Polysomnography (PSG) may provide better surgical sustenance in infants with severe laryngomalacia and OSA, as well as, serving as a monitoring tool of success. However, the surgical decision should not be reduced to polysomnographic results, and a good history and examination remain as the fundamental criteria.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery

OBJECTIVE

The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system.

METHODS

Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system.

RESULTS

231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery.

CONCLUSION

This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Impact of Infant Supraglottoplasty on Quality of Life

Objectives The objective of the present study is to examine the impact of supraglottoplasty on the quality of life (QOL) of caregivers and infants with severe laryngomalacia and moderate laryngomalacia with feeding difficulties. Study Design Prospective cohort study. Setting Tertiary children's hospital. Subjects and Methods Thirty-nine infants who underwent supraglottoplasty were examined. The primary caregiver answered the 47-item short form of the Infant and Toddler Quality of Life Questionnaire-47 pre- and postoperatively; the subsection scores were compared. A 1-way analysis of variance was performed to analyze the effect of age and sex. A comparison was made between our cohort and a general population of healthy children. Results The average age at surgery was 4.0 months, and 53% of the patients were male. There was significant postoperative improvement in overall health, physical ability, growth and development, bodily pain, temperament, emotional impact on the caregiver, impact on caregiver's time, and family cohesion scores ( P < .05). The same subscale scores remained significantly improved postoperatively after age and sex were controlled. Preoperative QOL scores were significantly worse than those of the general population in nearly all categories. Postoperative physical ability ( P = .009) and temperament ( P = .011) QOL scores were higher than the those of the general population. Scores for growth and development ( P = .132), bodily pain ( P = .481), and family cohesion ( P = .717) were equivalent to those of the general population. Conclusion QOL was significantly improved after supraglottoplasty for infants with severe laryngomalacia and moderate laryngomalacia with feeding difficulties. After supraglottoplasty, QOL was similar to that of the general infant population in most categories.

ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms (e.g. snoring) and/or conditions predisposing to SDB (e.g. mandibular hypoplasia) as well as children with SDB and complex conditions (e.g. Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions (e.g. supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Treatment outcomes of supraglottoplasty for pediatric obstructive sleep apnea: A meta-analysis

OBJECTIVE

To comprehensively review changes in sleep parameters and the success rate of supraglottoplasty for treating obstructive sleep apnea (OSA) in children. In particular, to elucidate treatment modalities and factors affecting treatment outcomes in children with both laryngomalacia and OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42015027053). Two authors independently searched databases including PubMed, MEDLINE, EMBASE, and the Cochrane Review database. The keywords were "supraglottoplasty," "laryngomalacia," "OSA," "polysomnography," "child," and "humans." Supraglottoplasty served as the primary treatment for OSA or secondary treatment for persistent disease after previous surgeries. Subgroup analyses were conducted for children receiving supraglottoplasty as the primary or secondary treatment for OSA, and for children with and without comorbidities.

RESULTS

Eleven studies with 121 patients were analyzed (mean age: 3.7 years; 64% boys; mean sample size: 11 patients). After surgery, the mean differences between the pre- and postoperative measurements were a significant reduction of 8.9 events/h in the apnea-hypopnea index (AHI) and an increase of 3.7% in minimum oxygen saturation (MinSaO2; P < 0.05). The overall success rate was 28% according to a postoperative AHI <1 and 72% according to an AHI <5. Children receiving supraglottoplasty as the primary treatment had significantly younger ages (0.6 vs 6.4 years P < 0.001) than those receiving supraglottoplasty as the secondary treatment, but the outcomes were similar (33% vs 19% for a postoperative AHI < 1, P = 0.27; 77% vs 61% for a postoperative AHI < 5, P = 0.233). Moreover, children with comorbidities, compared with those without, had a similar success rate according to a postoperative AHI <1 (25% vs 21%, P = 0.805) and postoperative AHI <5 (62% vs 84%, P = 0.166).

CONCLUSIONS

Supraglottoplasty is an effective surgery for AHI reduction and MinSaO2 increase in children with OSA and laryngomalacia. However, complete resolution of OSA is not achieved in most cases, and factors affecting treatment outcomes in these children require future studies.

Establishing a Role for Polysomnography in Hospitalized Children

BACKGROUND

Children with medical complexity have a high prevalence of sleep disorders. However, outpatient polysomnography to evaluate for these conditions may be difficult to perform because of lack of skilled nursing care. The aim of this study was to explore polysomnography indications in hospitalized children and assess its impact on patient care.

METHODS

Data from 85 inpatient polysomnographies of 70 children hospitalized between March and December 2014 were retrospectively collected.

RESULTS

Sixty percent of patients were boys with ages 6.5 ± 6 years. Chronic respiratory failure was present in 33.8%, airway obstruction due to defects of the tracheobronchial tree or craniofacial abnormalities in 54.3%, neurological complications of the perinatal period in 22.9%, genetic syndromes and neurodegenerative disorders in 31.4%, congenital myopathies in 5.7%, metabolic diseases in 4.3% and congenital cyanotic heart defects in 4.3%. Indications for polysomnography included assessment of chronic pulmonary disease (60%), ventilator requirements (41.2%), apnea/desaturation (23.5%), and acute life-threatening events (1.2%). Abnormal results were found in 89.4%. The observed diagnosis was obstructive sleep apnea in 64.7%, signs of chronic lung disease in 34.1%, hypoventilation in 9.4%, periodic breathing in 3.5%, and periodic limb movement of sleep in 4.7%. The following interventions were performed: adjustment of ventilator parameters (45.8%), positive airway pressure initiation (24.7%), otorhinolaryngology referral (30.6%), supraglottoplasty (2.4%), tracheostomy decannulation (2.4%), and tracheostomy placement (3.5%). Nine patients had available follow-up polysomnograms, all showing improvement in sleep variables after adherence to recommended interventions.

CONCLUSIONS

In individuals with complex medical disorders, inpatient polysomnographies give invaluable information to guide immediate medical decision making and should be strongly considered if resources allow this.

Supraglottoplasty for laryngomalacia with obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

To determine if apnea-hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve following isolated supraglottoplasty for laryngomalacia with obstructive sleep apnea (OSA) in children.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Nine databases, including PubMed/MEDLINE, were searched through September 30, 2015.

RESULTS

A total of 517 studies were screened; 57 were reviewed; and 13 met criteria. One hundred thirty-eight patients were included (age range: 1 month-12.6 years). Sixty-four patients had sleep exclusive laryngomalacia, and in these patients: 1) AHI decreased from a mean (M) ± standard deviation (SD) of 14.0 ± 16.5 (95% confidence interval [CI] 10.0, 18.0) to 3.3 ± 4.0 (95% CI 2.4, 4.4) events/hour (relative reduction: 76.4% [95% CI 53.6, 106.4]); 2) LSAT improved from a M ± SD of 84.8 ± 8.4% (95% CI 82.8, 86.8) to 87.6 ± 4.4% (95% CI 86.6, 88.8); 3) standardized mean differences (SMD) demonstrated a small effect for LSAT and a large effect for AHI; and 4) cure (AHI < 1 event/hour) was 10.5% (19 patients with individual data). Seventy-four patients had congenital laryngomalacia, and in these patients: 1) AHI decreased from a M ± SD of 20.4 ± 23.9 (95% CI 12.8, 28.0) to 4.0 ± 4.5 (95% CI 2.6, 5.4) events/hour (relative reduction: 80.4% [95% CI 46.6, 107.4]); 2) LSAT improved from a M ± SD of 74.5 ± 11.9% (95% CI 70.9, 78.1) to 88.4 ± 6.6% (95% CI 86.4, 90.4); 3) SMD demonstrated a large effect for both AHI and LSAT; and 4) cure was 26.5% (38 patients with individual data).

CONCLUSION

Supraglottoplasty has improved AHI and LSAT in children with OSA and either sleep exclusive laryngomalacia or congenital laryngomalacia; however, the majority of them are not cured. Laryngoscope, 126:1246-1255, 2016.

Type I Chiari malformation presenting with laryngomalacia and dysphagia

We describe clinical features of an infant with laryngomalacia and dysphagia caused by type I Chiari malformation (CM-I). A 12-month-old child presented with a 6 month history of progressive stridor, dysphagia, and gastroesophageal reflux. Examination of the airway and swallowing function indicated mild laryngomalacia and aspiration with all consistencies. Magnetic resonance imaging of the brain indicated CM-I. Symptoms were resolved after posterior fossa decompression. CM-I, typically diagnosed later in life, should be considered in the differential diagnosis of laryngomalacia and dysphagia. High clinical suspicion and thorough search for abnormalities ensure early diagnosis and proper management of children with neurologic variant laryngomalacia.

Management of laryngomalacia in children with congenital syndrome: the role of supraglottoplasty

BACKGROUND/IMPORTANCE

Supraglottoplasty is the surgical procedure of choice for severe laryngomalacia and has shown to be successful in most cases; however, patients with medical comorbidities present a higher rate of failure. To date, the best management of laryngomalacia in children with congenital syndrome remains unclear.

PURPOSE

To study the outcome of supraglottoplasty in children with severe laryngomalacia, and to analyze the management and outcome in infants with a congenital syndrome.

METHODS

Retrospective medical records review from January 2003 to October 2012 of all patients who underwent laser supraglottoplasty for severe laryngomalacia at the University Children's Hospital Zurich, Switzerland.

RESULTS

Thirty-one patients were included; median age at time of surgery was 3.5 months. Three patients (10%) had a genetically proven congenital syndrome with associated neurologic anomalies. Overall success rate was 87%. Failures were observed in four (13%) of 31 cases; including all three patients presenting a congenital syndrome.

CONCLUSIONS

Supraglottoplasty is an effective and safe treatment for laryngomalacia in otherwise healthy children. Signs of a possible underlying predominant neurologic origin and discrepancy between the clinical presentation and the endoscopic findings have to be taken into account, as in children with congenital syndrome with neurologic anomalies the risk of failure is higher.

Characteristics of patients undergoing supraglottoplasty for laryngomalacia

OBJECTIVE

To examine the characteristics of patients undergoing supraglottoplasty for the treatment of laryngomalacia and to better understand the features of laryngomalacia that may predispose patients to the need for supraglottoplasty.

METHODS

Review of patients who underwent supraglottoplasty for laryngomalacia at our academic tertiary care children's hospital between 2005 and 2012 examining demographic information, medical comorbidities, symptoms, indications for surgery, operative findings and procedure, site of laryngeal obstruction, operative techniques, and surgical success rates.

RESULTS

Seventeen patients with laryngomalacia underwent nineteen procedures. The most common indications for supraglottoplasty were persistent stridor beyond 18 months of age (64.7%), difficulty feeding (47%), and failure to thrive (29.4%). The most common comorbidities were gastroesophageal reflux (88.2%) and cardiopulmonary disease (35.3%). Operative findings included shortened aryepiglottic folds in sixteen patients (94.1%), retropositioned epiglottis in sixteen (94.1%), and prolapsed arytenoid mucosa in five (29.4%). Fifteen patients (88.2%) underwent division of the aryepiglottic folds and four underwent ablation of arytenoid mucosa (23.5%). Of the seventeen patients who had followed up at the time of study conclusion, sixteen (94.1%) had symptom improvement and twelve (70.6%) had complete resolution of their symptoms.

CONCLUSIONS

Supraglottoplasty is an effective treatment for laryngomalacia. Outcomes in our patients are similar to those reported in prior literature. The findings of shortened aryepiglottic folds and a retropositioned epiglottis appear to be disproportionately represented in our cohort of patients undergoing supraglottoplasty.

Medical and Surgical Management of Congenital Laryngomalacia

Objective

To compare the growth of infants with moderate to severe laryngomalacia who underwent supraglottoplasty to the growth of those treated with medical therapy alone.

Study Design

Case-control study of patients treated between 2008 and 2013.

Setting

Tertiary care pediatric otolaryngology practice.

Subjects and Methods

Fifty-one infants newly diagnosed with moderate to severe congenital laryngomalacia. Seventeen infants underwent supraglottoplasty and 34 matched controls had medical management, which included acid suppression therapy, speech and swallowing therapy, and/or high-calorie formula. The primary outcome measure was weight percentile recorded at the second clinic visit and at the last available follow-up. The secondary outcomes were the need for primary or revision supraglottoplasty, tracheostomy or gastrostromy, or the development of or persistence of failure to thrive.

Results

There was no difference in the mean weight percentile between the surgical and nonsurgical groups at the time of last follow-up ( P = .89). The mean change in weight percentile during the study period was 32% (95% CI, 15%-48%) in the supraglottoplasty group and 31% (95% CI, 22%-40%) in the medical group ( P = .97). Five of 5 (100%) patients with failure to thrive managed surgically and 10 of 10 (100%) managed medically were above the fifth percentile at the end of the follow-up period. One (3%) patient in the medical management group required tracheostomy and gastrostomy tube placement.

Conclusions

Medical management and close observation of infants with moderate to severe congenital laryngomalacia may be a viable alternative to supraglottoplasty in appropriately selected infants.

Surgical treatment of severe laryngomalacia: a retrospective study of 11 case

Laryngomalacia is the most frequent congenital abnormality of the larynx, accounting for approximately 60-75% of congenital stridor cases. Despite its benign and self-limited aspects, 10% of cases require intervention. Currently, supraglottoplasty is considered the standard treatment of severe laryngomalacia.

Objective

To describe the experience of the authors in the surgical treatment of patients with severe laryngomalacia. Methodology: A retrospective study.

Method

The medical records of 11 consecutive cases of severe laryngomalacia who underwent surgical treatment between 2003 and 2012 were analyzed for age, gender, symptoms, associated diseases, surgical technique employed, extubation time, surgical complications, length of hospital stay and clinical outcome.

Results

Of the 11 cases of severe laryngomalacia, six patients (54.5%) were operated with the use of CO₂ laser and five patients (45.5%) were submitted to the cold technique. Only 1 patient (9.1%) required surgical reintervention. There were no cases of surgical complications. All patients had clinical improvement.

Conclusion

Supraglottoplasty proved to be effective and safe in the treatment of severe laryngomalacia.

Prevalence and risk factors for central sleep apnea in infants with laryngomalacia

OBJECTIVE

To identify the prevalence of and risk factors for central sleep apnea (CSA) in infants who are diagnosed with laryngomalacia.

STUDY DESIGN

Case series with chart review.

SETTING

Quaternary care pediatric hospital.

SUBJECTS AND METHODS

We performed a chart review in infants with laryngomalacia. All infants had diagnostic polysomnography (PSG) performed from 2003 to 2012. Infants who underwent supraglottoplasty or other upper airway surgery prior to PSG were excluded. CSA was defined as central apnea index ≥ 5. Demographic data, underlying diseases, and PSG data were reviewed and analyzed.

RESULTS

Fifty-four patients met the inclusion criteria. The mean age at the date PSG was performed was 3.4 ± 2.7 months. The prevalence of CSA in infants with laryngomalacia was 46.3%. Odds ratio (OR) of CSA was above 2.0 in patients with the following risk factors: underlying neurologic disease, hypotonia, or syndrome (OR = 2.5, P = .13), history of apparent life-threatening events (OR = 2.7, P = .19), premature infants (OR = 2.2, P = .33), and age less than 3 months (OR = 2.3, P = .15). However, none of the risk factors were statistically significant. Analysis of sleep architecture revealed a decrease in total sleep time (345.4 ± 70.6 minutes vs 393.5 ± 68.3 minutes, P = .02) and sleep efficiency (67.7 ± 8.9% vs 75.2 ± 9.3%, P = .004) in the CSA group.

CONCLUSION

CSA is relatively common in infants with laryngomalacia. There seems to be a higher prevalence of CSA in infants with certain risk factors, but none of the risk factors are statistically significant. The presence of CSA can lead to alteration in sleep architecture. In addition to clinical evaluation, polysomnography may be warranted for the evaluation of infants with laryngomalacia and associated complex medical conditions.

Pediatric obstructive sleep apnea syndrome

Pediatric obstructive sleep apnea syndrome (OSAS) is a common health problem diagnosed and managed by various medical specialists, including family practice physicians, pediatricians, pulmonologists, and general and pediatric otolaryngologists. If left untreated, the sequelae can be severe. Over the last decade, significant advancements have been made in the evidence-based management of pediatric OSAS. This article focuses on the current understanding of this disease, its management, and related clinical practice guidelines.

Laryngomalacia surgery: a series from a tertiary pediatric hospital

Laryngomalacia is the condition responsible for 75% of the cases of stridor in children aged up to 30 months, in which there is supraglottic collapse during inhalation. Inspiratory stridor is a characteristic telltale. As many as 20% of the patients are severely affected and require surgery. Supraglottoplasty is the procedure of choice and the presence of comorbidities is the most relevant prognostic factor for surgery success.

Objective

To describe a series in a tertiary pediatric hospital, its success rates, and surgery prognostic factors.

Method

This retrospective cohort study enrolled 20 patients submitted to supraglottoplasty between July 2007 and May 2011.

Results

Thirteen (65%) patients were males; mean age at the time of the procedure was 6.32 months. Endoscopic examination showed that 12 subjects had combined forms of laryngomalacia, 40% had associated pharyngomalacia, and three also had tracheomalacia. Thirteen subjects had isolated laryngomalacia and seven had gastroesophageal reflux disease. Fifteen (75%) patients underwent aryepiglottic fold resection. After the procedure, eleven patients were asymptomatic and two required tracheostomy. Presence of comorbidities was the strongest predictor of unfavorable postoperative outcome (p = 0.034).

Conclusion

Supraglottoplasty is a safe therapeutical procedure for select patients with laryngomalacia.

Management of laryngomalacia

Laryngomalacia is the most common laryngeal disease of infancy. It is poorly tolerated in 10% of cases, requiring assessment and management, generally surgical. Surgery often consists of supraglottoplasty, for which a large number of technical variants have been described. This surgery, performed in an appropriate setting, relieves the symptoms in the great majority of cases with low morbidity. However, few data are available concerning the objective results: preoperative and postoperative objective assessment of these infants is therefore necessary whenever possible. Noninvasive ventilation (NIV) may be indicated in some infants with comorbid conditions or failing to respond to surgical management.

Sleep Apnea in Children with Laryngomalacia

Objective

The authors study the contribution of laryngomalacia to obstructive sleep apnea syndrome (OSAS) in children older than 12 months. The clinical and polysomnographic outcomes in patients with OSAS who underwent a supraglottoplasty were also studied.

Setting

Tertiary care children’s hospital.

Study Design

A case series with chart review.

Subjects and Methods

A review of consecutive pediatric patients diagnosed with both OSAS and state-dependant laryngomalacia (SDL) between 2005 and 2008. The diagnosis of SDL was made via laryngoscopy under light general anesthesia (sleep endoscopy). All subjects underwent a supraglottoplasty.

Results

A total of 43 patients met inclusion criteria, and 36 patients had complete pre- and postoperative data available for review. The apnea-hypopnea index (AHI) score decreased following supraglottoplasty for 33 (92%; 95% confidence interval [CI], 78%-98%) of the 36 patients. The mean (SD) change in AHI score (calculated as the postoperative minus the preoperative measure) was −9.2 (11.2), representing a statistically significant reduction (95% CI, −13.0 to −5.5; P < .0001). The mean (SD) preoperative AHI was 13.3 (12.9). The minimum oxygen saturation increased following supraglottoplasty for 21 (58%; 95% CI, 41%-74%). The mean (SD) change in the minimum oxygen saturation was 3.5 (8.3), which was a statistically significant increase (95% CI, 0.7-6.3; P = .015).

Conclusion

Laryngomalacia may contribute significantly to OSAS in some children who are 12 months and older. Sleep endoscopy appears to be an effective method in the diagnosis of SDL. When present, a supraglottoplasty can be an effective procedure and may significantly improve symptoms of OSAS.

Obstructive sleep apnea in infants

Obstructive sleep apnea in infants has a distinctive pathophysiology, natural history, and treatment compared with that of older children and adults. Infants have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities; including a superiorly placed larynx, increased chest wall compliance, ventilation-perfusion mismatching, and ventilatory control instability. Congenital abnormalities of the airway, such as laryngomalacia, hemangiomas, pyriform aperture stenosis, choanal atresia, and laryngeal webs, may also have adverse effects on airway patency. Additional exacerbating factors predisposing infants toward airway collapse include neck flexion, airway secretions, gastroesophageal reflux, and sleep deprivation. Obstructive sleep apnea in infants has been associated with failure to thrive, behavioral deficits, and sudden infant death. The proper interpretation of infant polysomnography requires an understanding of normative data related to gestation and postconceptual age for apnea, arousal, and oxygenation. Direct visualization of the upper airway is an important diagnostic modality in infants with obstructive apnea. Treatment options for infant obstructive sleep apnea are predicated on the underlying etiology, including supraglottoplasty for severe laryngomalacia, mandibular distraction for micrognathia, tonsillectomy and/or adenoidectomy, choanal atresia repair, and/or treatment of gastroesophageal reflux.

Changes in sleep apnea after supraglottoplasty in infants with laryngomalacia

OBJECTIVE

To determine the clinical and polysomnography outcomes in infants with laryngomalacia undergoing supraglottoplasty.

METHODS

Infants (<1 year old) who underwent polysomnography pre- and post-supraglottoplasty at our tertiary referral center between 2003 and 2009 were reviewed retrospectively. Outcome measures included changes in stridor, sleep disordered breathing, swallowing, and polysomnography parameters before and after surgery. Pre- and postoperative distributions were compared using a Wilcoxon signed-rank test.

RESULTS

20 children met inclusion criteria. Statistically significant improvements were found in pre- to postoperative median values for apnea-hypopnea index (AHI) (median change: -6.4 points, p=0.02) and obstructive apnea index (median change: -2.9 points, p=0.01) values. Obstructive AHI, O₂ saturation nadir, and percentage of sleep spent with <90% O₂ saturation improved, although not significantly. Postoperative AHI scores correlated with improvements in stridor in 80% of patients. Stratification showed similar improvements in AHI after supraglottoplasty regardless of reflux treatment, secondary airway lesions, age at supraglottoplasty, or time lag between supraglottoplasty and postoperative polysomnography. Secondary airway lesions are the only potential confounders shown to have significantly better improvements in O₂ nadir. While the sleep study improved in patients with AHI >5, infants with AHI <5 had worse polysomnography parameter values postoperatively. Five patients had dysphagia that resolved within one month postoperatively; otherwise, supraglottoplasty resulted in no complications.

CONCLUSION

Supraglottoplasty may be an effective and safe option to improve moderate to severe obstructive sleep apnea in infants with laryngomalacia. In addition, polysomnography may be useful in infants with laryngomalacia to identify obstructive sleep apnea and/or to objectively measure outcomes after supraglottoplasty. This pilot study warrants a larger, prospective, and controlled study to validate these findings.

Late-onset laryngomalacia: a cause of pediatric obstructive sleep apnea

OBJECTIVE

To describe the presentation, diagnosis, and treatment of late-onset laryngomalacia in children with obstructive sleep apnea syndrome (OSAS).

DESIGN

Retrospective study.

SETTING

Tertiary care children's hospital.

PATIENTS

Seventy-seven children were identified who had OSAS diagnosed by polysomnography and underwent airway endoscopy to evaluate for laryngomalacia between July 2006 and December 2008. Children with significant neurologic disease or craniofacial malformations were excluded. Seven children under 3 years of age had laryngomalacia and OSAS (Group A), 19 children 3-18 years of age had laryngomalacia and OSAS (Group B), and 51 children 3-18 years of age had OSAS but not laryngomalacia (Group C).

MAIN OUTCOME MEASURES

Comparison of pre-operative findings, intra-operative findings, interventions, and outcomes between the 3 groups.

RESULTS

Group A was consistent with previous reports of congenital laryngomalacia with respect to presentation, diagnosis, and treatment. Groups B and C had similar pre-operative findings, including a high incidence of adenotonsillar hypertrophy, and the only significant difference was the intra-operative finding of laryngomalacia in Group B. Treatments were individualized to include supraglottoplasty, adenoidectomy, tonsillectomy, adenotonsillectomy, or a combination of the above. Of the 52 patients who returned in follow-up, 44 noted improvement, but this was rarely confirmed by polysomnogram.

CONCLUSIONS

Late-onset laryngomalacia may act alone or in concert with additional dynamic or fixed lesions to cause pediatric OSAS. Although there is no specific pre-operative indicator to diagnose late-onset laryngomalacia, it can be readily identified intra-operatively and effectively treated with supraglottoplasty, with or without concurrent adenotonsillectomy.

Age-related changes in the hyoepiglottic ligament: functional implications based on histopathologic study

PURPOSE

The study aimed to identify age-related changes in the hyoepiglottic ligament associated with function of the epiglottis during swallowing and respiration.

MATERIALS AND METHODS

Normal postmortem laryngeal tissue samples were obtained at autopsy from 20 individuals with no history of laryngeal disease. The subjects were divided into 2 groups: those aged 81-91 years (elderly group, n = 11) and those aged 31-48 years (non-elderly group, n = 9). Specimens were subjected to Elastica van Gieson and hematoxylin-eosin staining, and characteristics of the hyoepiglottic ligament were compared between groups.

RESULTS

The hyoepiglottic ligament extended from the epiglottis to both lingual muscles and the hyoid bone (pars lingualis and pars hyoideus). The numbers of muscle fibers (P < .001), collagenous fibers (P < .01), and elastic fibers (P < .001) were significantly decreased in the elderly group in comparison to those in the non-elderly group.

CONCLUSION

Age-related changes in the hyoepiglottic ligament appear to be associated with aspiration, obstructive sleep apnea syndrome, and acquired laryngomalacia in the elderly.

A case of Michelin tire baby syndrome with a thickened epiglottis

Multiple circumferential skin folds have been reported as part of the Michelin tire baby syndrome (MTBS). There has been a wide spectrum of associated clinical findings reported in children with MTBS. We report a case of MTBS associated with a thickened epiglottis.

Polysomnography outcomes following transoral CO2 laser microsurgery in pediatric patients with laryngomalacia

OBJECTIVE

Laryngomalacia is the most common cause of stridor in newborns and infants. The aim of the contribution was to present objectified data of the outcome of transoral CO(2) laser microsurgery in patients with laryngomalacia utilizing polysomnography (PSG).

PATIENTS AND METHODS

This retrospective study comprised 21 patients who were diagnosed to suffer from laryngomalacia. Diagnosis was confirmed by pharyngo-laryngoscopy under spontaneous breathing. If there was evidence for laryngomalacia a transoral CO(2) lasersurgical intervention and/or epiglottopexy was performed in the same session. 8 patients, on whom the following should be focused, received pre- and postoperative PSG which was performed for efficiency control of the applied treatment.

RESULTS

All 21 patients underwent invasive treatment for laryngomalacia (lasersurgical division of the aryepiglottic folds: n=13; epiglottopexy: n=5; combined procedure: n=3). All patients were successfully extubated after surgery. In 20/21 cases breathing improved clearly after one single intervention. Stridor disappeared completely in the further course of the disease. In the 8 patients who received pre- and postinterventional PSG, lasersurgical interventions were performed. Statistical analysis of pre- and postoperative PSG revealed that MOAI/h (mixed obstructive apnea index/hour) improved significantly (p=0.016, Wilcoxon-Signed-Rank Test). Also desaturation/hour improved in the postoperative course (p=0.11).

CONCLUSION

The presented concept describes an effective and reliable approach for diagnostics and treatment for laryngomalacia. To objectify the success of supraglottoplaty in patients suffering from severe laryngomalacia a pre- and postoperative PSG seems to be useful and advisable. The present results of PSG demonstrate that children with laryngomalacia to benefit from lasersurgical division of the aryepiglottic folds and/or epiglottopexy. This fact is supported by the postoperative improved clinical aspect.

Objective assessment of supraglottoplasty outcomes using polysomnography

OBJECTIVE

Supraglottoplasty is well documented as an effective procedure in the management of moderate to severe laryngomalacia. Traditionally assessed outcomes in the treatment of laryngomalacia include: reduced stridor, improved feeding and a resumption of weight-gain. Previous authors have documented the use of polysomnography in assessing the severity of paediatric laryngeal abnormalities. The aim of the current study was to objectively assess the efficacy of supraglottoplasty for laryngomalacia by comparing data from pre- and post-operative polysomnography.

METHODS

A retrospective review was performed of patients undergoing supraglottoplasty for laryngomalacia at a tertiary referral paediatric hospital over a 35-month period. Patients were required to have undergone full overnight polysomnography both before and after supraglottoplasty. Pre- and post-operative polysomnographic results were compared and the statistical significance between mean values was determined.

RESULTS

From a total of 46 patients, 10 were suitable for inclusion into the study. Mean age at first presentation was 2 months and 19 days (range 30-134 days). The surgical procedure performed was bilateral division of aryepiglottic folds alone in 1 patient (1/10), bilateral division of aryepiglottic folds and bilateral trimming of arytenoid mucosa in 5 patients (5/10) and bilateral aryepiglottic fold division, bilateral arytenoid mucosal trimming and epiglottic trimming or epiglottopexy in 4 patients (4/10). Statistically significant improvements occurred in mean values for Total Sleep Time (TST) (P=0.049), Lowest Oxygen Saturation Levels (SpO2 nadir) (P=0.006), Obstructive Apnoea Hypopnoea Index (OAHI) (P=0.009) and Respiratory Disturbance Index (RDI) (P=0.002), following supraglottoplasty. An improvement in mean Transcutaneous Carbon Dioxide (TcCO2) value occurred, but did not achieve statistical significance (57.1 vs. 52.8) (P=0.259). The mean age at which post-operative polysomnography confirmed a reversal of abnormal respiratory parameters following surgery was 5 months and 18 days.

CONCLUSIONS

Polysomnography is an effective method for objectively assessing the efficacy of supraglottoplasty for laryngomalacia. Supraglottoplasty effectively reverses the abnormal respiratory parameters occurring in moderate to severe laryngomalacia.

Supraglottoplasty for laryngomalacia with obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To determine if supraglottoplasty (SGP) is effective in reversing abnormal respiratory parameters in children with laryngomalacia and obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective case series at a tertiary referral children's hospital.

METHODS

Ten patients with laryngomalacia and OSA as documented by polysomnography underwent SGP between 2005 and 2007. Data collected included age, findings on flexible and rigid endoscopy, type of procedure performed, and postoperative course. The postoperative polysomnographies were reviewed to identify changes in obstructive apnea index, obstructive apnea/hypopnea index, respiratory disturbance index, and low arterial oxygen saturation (O2 nadir) after SGP.

RESULTS

All 10 patients were successfully extubated after SGP. There were no peri- or postoperative complications, and no patient required a subsequent airway procedure. Each patient had a postoperative nocturnal polysomnography performed after SGP at 11 weeks (range 2-29 weeks). Caregivers reported mild improvement (10%), significant improvement (70%), and complete resolution (20%) of stridor and nocturnal snoring at a follow-up visit 4 weeks after discharge. Marked improvements were observed in obstructive apnea index, obstructive apnea/hypopnea index, respiratory disturbance index and O2 nadir, all of which were statistically significant (P < .05).

CONCLUSIONS

Polysomnography should be considered in the initial evaluation of infants with moderate laryngomalacia to rule out OSA. SGP is an effective treatment for infants with laryngomalacia and OSA. The significant benefits of the procedure outweigh thelow morbidity. Improvement after surgery was reliably confirmed by polysomnography in this study.