The current status of corrective surgery for laryngomalacia

State-Dependent Laryngomalacia in Sleeping Children

Laryngomalacia is a common congenital laryngeal abnormality. Despite its being widely discussed in the literature, the pathophysiology is not clearly understood. Both anatomic and neuromuscular theories have been suggested to explain laryngomalacia. We report 4 cases of laryngomalacia in which the presenting signs occurred during sleep. Awake flexible nasopharyngolaryngoscopy failed to demonstrate supraglottic structure collapse. Only while the patients were breathing spontaneously under general anesthesia was laryngomalacia noted. A proposed algorithm for diagnosis and treatment is included. These 4 cases of state-dependent laryngomalacia support a neuromuscular cause for laryngomalacia.

Laryngomalacia

Laryngomalacia is the most common cause of stridor in neonates. It typically presents with inspiratory stridor and is often associated with feeding problems. Severe cases present with stridor, apnea, significant respiratory distress, and failure to thrive. Most patients are managed conservatively and can expect to see symptom resolution by 12-24 months of age. About 10% of patients require surgical treatment for their symptoms. Supraglottoplasty is the surgical technique of choice. Results of this surgery are excellent, and severe complications, such as supraglottic stenosis and aspiration, are uncommon. Supraglottoplasty is less effective in patients with significant comorbidities such as neurologic conditions and syndromes.

The effects of prematurity on incidence of aspiration following supraglottoplasty for laryngomalacia

OBJECTIVES

To determine if patients who were born premature have a higher incidence of aspiration following supraglottoplasty compared to patients born full term.

STUDY DESIGN

Retrospective study.

METHODS

Two thousand three hundred sixty (2360) patient charts from Riley Hospital for Children were reviewed retrospectively. Patients had already been treated for laryngomalacia with supraglottoplasty by Dr. Bruce Matt. Estimated weeks gestational age at birth was recorded for each patient. Prematurity was stratified as mild (32-36 weeks gestational age [WGA]), very (28-31 WGA), or extremely (<28 WGA). Patients were excluded from the study if they had suspected aspiration with chronic cough, pneumonia, chronic lung disease, or documented aspiration prior to supraglottoplasty.

RESULTS

As previously shown, 75 patients (3.2%) had aspiration following supraglottoplasty. Twenty of these patients were preterm infants at birth. The rate for aspiration following supraglottoplasty for former premature infants was statistically significant (5.9%, odds ratio = 2.3, P = .0032).

CONCLUSIONS

Children who were born premature have a higher rate of postoperative aspiration following supraglottoplasty; however, supraglottoplasty should still be considered as treatment for laryngomalacia as the rate is still relatively low (5.9%).

Speech impairment in Down syndrome: a review

PURPOSE

This review summarizes research on disorders of speech production in Down syndrome (DS) for the purposes of informing clinical services and guiding future research.

METHOD

Review of the literature was based on searches using MEDLINE, Google Scholar, PsycINFO, and HighWire Press, as well as consideration of reference lists in retrieved documents (including online sources). Search terms emphasized functions related to voice, articulation, phonology, prosody, fluency, and intelligibility.

CONCLUSIONS

The following conclusions pertain to four major areas of review: voice, speech sounds, fluency and prosody, and intelligibility. The first major area is voice. Although a number of studies have reported on vocal abnormalities in DS, major questions remain about the nature and frequency of the phonatory disorder. Results of perceptual and acoustic studies have been mixed, making it difficult to draw firm conclusions or even to identify sensitive measures for future study. The second major area is speech sounds. Articulatory and phonological studies show that speech patterns in DS are a combination of delayed development and errors not seen in typical development. Delayed (i.e., developmental) and disordered (i.e., nondevelopmental) patterns are evident by the age of about 3 years, although DS-related abnormalities possibly appear earlier, even in infant babbling. The third major area is fluency and prosody. Stuttering and/or cluttering occur in DS at rates of 10%-45%, compared with about 1% in the general population. Research also points to significant disturbances in prosody. The fourth major area is intelligibility. Studies consistently show marked limitations in this area, but only recently has the research gone beyond simple rating scales.

Neurologic variant laryngomalacia associated with Chiari malformation and cervicomedullary compression: case reports

Two infants presented with intermittent stridor and evidence of laryngomalacia on flexible laryngoscopy. The first was a 10-month-old girl who had undergone 3 supraglottoplasty surgeries at an outside institution, without long-term resolution of symptoms. She was found during our evaluation to have a Chiari malformation. Laryngomalacia symptoms resolved after suboccipital decompression and C1 laminectomy, and the patient remained symptom-free at 6-month follow-up. The second infant was a 24-day-old boy with velocardiofacial syndrome who was found to have posterior cervicomedullary junction compression at the level of C1. He underwent C1 laminectomy for decompression of the brain stem, which resulted in immediate resolution of symptoms, and he remained symptom-free at 12-month follow-up. Neurologic abnormalities have been reported in up to 50% of infants with laryngomalacia. As such, brain stem dysfunction should be considered among the causes of laryngomalacia during evaluation, especially in patients with failure of supraglottoplasty. Both of these infants had resolution of symptoms after their neurosurgical procedures.

Acoustic characteristics of crying in infantile laryngomalacia

The purpose of this study was to add to the extant data base of acoustic cry studies by profiling the condition of laryngomalacia. We hypothesized that the acoustic characteristics of crying produced by an infant with laryngomalacia would differ compared to previously reported cry data for normal infants. An entire episode of crying was audio recorded and acoustically analyzed for the occurrence of expiratory and inspiratory cry segments, as well as the long-time average spectral (LTAS) characteristics. Results obtained for the infant were found to be considerably different from what has been previously reported for normal infants. The overall duration of the infant's crying episode was longer, with proportionately fewer expiratory phonations and more inspiratory phonations compared to normal infants. The LTAS results were reflective of aperiodic components in the glottal source spectrum. Collectively, the infant's unusual crying aspects were not limited solely to those acoustic features resulting from a prolapse of supraglottic soft tissue, and therefore provide new insight into the vocal fold vibratory behavior characterizing infantile laryngomalacia.

Laryngomalacia in a 12-year-old child after laryngeal mask use

Objective:

We present an unusual case of a 12-year-old child with state-dependent laryngomalacia presenting after anaesthesia with a laryngeal mask airway.

Method:

Current literature on state-dependent laryngomalacia and injury following laryngeal mask use is reviewed.

Results:

A child who had previously suffered with laryngomalacia as an infant presented with disturbed breathing at night and during exercise. After anaesthesia using a laryngeal mask airway, these symptoms became more pronounced. Microlaryngoscopy revealed laryngomalacic type movement of the larynx.

Conclusion:

Our case seems to support a more complex, multifactorial aetiology for laryngomalacia, including both the neurological control of the larynx as well as its structure.

Abnormal Sensorimotor Integrative Function of the Larynx in Congenital Laryngomalacia: A New Theory of Etiology

OBJECTIVES/HYPOTHESIS

Laryngomalacia is an enigmatic disease in which laryngeal tone is weak, resulting in dynamic prolapse of tissue into the larynx. Sensorimotor integrative function of the brainstem and peripheral reflexes are responsible for laryngeal tone and airway patency. The goal of this study was to elucidate the etiology of decreased laryngeal tone through evaluating the sensorimotor integrative function of the larynx. The secondary goal was to evaluate factors and medical comorbidities that contribute to the wide spectrum of symptoms and outcomes.

STUDY DESIGN

Prospective and retrospective collection of evaluative data on infants with congenital laryngomalacia at two tertiary care pediatric referral centers.

METHODS

Two hundred one infants with laryngomalacia were divided into three groups on the basis of disease severity (mild, moderate, severe). Patients were followed prospectively every 8 to 12 weeks until symptom resolution or loss to follow-up. Sensorimotor integrative function of the larynx was evaluated in 134 infants by laryngopharyngeal sensory testing (LPST) of the laryngeal adductor reflex (LAR) by delivering a duration- (50 ms) and intensity- (2.5-10 mm Hg) controlled air pulse to the aryepiglottic fold to induce the LAR. Medical records were retrospectively reviewed for medical comorbidities.

RESULTS

The initial LPST was higher (P < .001) in infants with moderate (6.8 mm Hg) and severe disease (7.4 mm Hg) compared with those with mild disease (4.1 mm Hg). At 1, 3, and 6 months, infants with moderate and severe disease continued to have a higher LPST compared with those with mild disease. At 9 months, the LPST decreased in all subjects (3.1-3.5 mm Hg, P = .14), which also correlated with symptom resolution. Neurologic, genetic, and cardiac diseases were more common in infants with severe disease (P < .001). Gastroesophageal reflux disease (GERD) and feeding problems more common in those with moderate and severe disease (P < .001). Apgar scores were lower in those with severe disease (P < .001). Most symptoms resolved within 12 months of presentation. Those with GERD benefited from treatment. Supraglottoplasty resulted in few complications. Multiple comorbidities (>3) influenced the need for tracheotomy.

CONCLUSIONS

Laryngeal tone and sensorimotor integrative function of the larynx is altered. The degree of alteration correlated with disease severity, indicating that factors that alter the peripheral and central reflexes of the LAR have a role in the etiology of signs and symptoms of laryngomalacia. GERD, neurologic disease, and low Apgar scores influenced disease severity and clinical course, explaining the spectrum of disease symptoms and outcomes. Sensorimotor integrative function improved as symptoms resolved.

Laryngomalacia: A Classification System and Surgical Treatment Strategy

Laryngomalacia, the most common congenital laryngeal anomaly, is not a single disease entity but rather a variety of entities along a spectrum of underlying pathophysiologies. Based on our study of 10 children who were surgically treated for laryngomalacia in an urban tertiary care center, we have developed a system of classifying laryngomalacia on the basis of its different underlying pathophysiologic processes. Type 1 laryngomalacia is characterized by a foreshortened or tight aryepiglottic fold. Type 2 disease is defined by the presence of redundant soft tissue in the supraglottis. The type 3 designation applies to cases caused by other etiologies, such as underlying neuromuscular disorders. While the three types are not mutually exclusive, each should be considered as a separate disease entity with a final common clinical presentation. Each type requires a specific approach to surgical repair.

Achados polissonográficos em crianças portadoras de laringopatias

O exame diagnóstico padrão-ouro para SAOS na infância é a polissonografia. Quando pode ser efetuado, a polissonografia separa com clareza portadores de ronco primário de pacientes com apnéia (obstrutiva, central e mista) do sono. A causa mais freqüente da SAOS na infância é a hipertrofia adenoamigdaliana. Laringomalácia é a causa mais comum de estridor na infância, porém sua fisiopatologia permanece desconhecida. Entre as teorias mais aceitas estão a imaturidade do arcabouço cartilaginoso da laringe e/ou a imaturidade neuromuscular. OBJETIVO: Nossa proposta foi descrever os achados polissonográficos de crianças portadoras de laringomalácia e outras alterações laríngeas isoladas, ou seja, sem alterações nas vias aéreas superiores. MÉTODOS: Foram selecionadas 29 crianças portadoras de alterações laríngeas exclusivas. Todas foram submetidas a exame otorrinolaringológico, nasofibrolaringoscopia e polissonografia. Foram tabulados dados relativos à idade, nasofibrolaringoscopia e polissonografia. Para análise, as crianças foram separadas em 2 grupos: portadores de laringomalácia e portadores de outras doenças laríngeas. RESULTADOS: Dentre as 18 crianças com diagnóstico de laringomalácia, 18 apresentaram eventos respiratórios do tipo central, sendo a maioria dos episódios associados à dessaturação de oxigênio e alguns à bradicardia. Nesse mesmo grupo, 3 crianças apresentaram apnéia do tipo obstrutivo. Por outro lado, as 11 crianças portadoras de outras alterações laríngeas não apresentaram predominância entre um tipo ou outro de apnéia, 4 apresentaram eventos respiratórios do tipo central, 2 do tipo obstrutivo. CONCLUSÃO: A maioria dos pacientes acometidos por laringomalácia apresentou eventos respiratórios do tipo central quando avaliados pela polissonografia. Já os pacientes com outras doenças laríngeas não apresentaram predominância entre um tipo ou outro de apnéia.

Polisomnographic findings on children with laryngopathies

Polysomnography is the goldstandard exam for child OSAS. When possible, polysomnography clearly distinguishes between those with isolated primary snoring and patients with sleep apnea (obstructive, central and mixed). The most common cause of OSAS in childhood is adenotonsillar hypertrophy. Laryngomalacia is the most common cause of stridor in childhood, though its physiopathology remains unknown. Among the most prominent theories are immaturity of the cartilaginous framework of the larynx and/or neuromuscular immaturity. Objective: Our proposal was to describe polysomnographic findings in children with laryngomalacia or other isolated laryngeal alterations, that is, without other alterations in the upper airways. Methods: The sample included 29 children with exclusively laryngeal alterations. All of them underwent an otorhinolaryngological exam, nasofibrolaryngoscopy and polysomnography. Information was recorded concerning age, nasofibrolaryngoscopy and polysomnography. For analysis, the children were divided into two groups: those with laryngomalacia and those with other laryngeal diseases. Results: Among the 18 children with a diagnosis of laryngomalacia, 18 had central breathing events, knowing that the majority had showed dessaturation of oxihemoglobin and bradicardia. In this same group, 3 children had obstrutives events. On the other hand, 11 children with other laryngeal alterations showed no predominance of one type or another of apnea. Of these, 4 had central type breathing events and 2 obstructive type. Conclusion: The majority of patients with laryngomalacia showed a central type apnea. Patients with various laryngeal diseases did not present a predominant type of apnea.

Laryngeal anatomic differences in pediatric patients with severe laryngomalacia

OBJECTIVES

To compare the aryepiglottic (AE) length in pediatric patients who have severe laryngomalacia (SL) and are undergoing aryepiglottoplasty with the AE length of a convenience sample of control patients without laryngomalacia.

DESIGN

Prospective case-control study.

SETTING

A tertiary-care pediatric hospital.

RESULTS

The mean AE fold length-glottic length ratio for patients with SL (0.380) was significantly lower than the mean ratio for controls (0.535) (P = .004 in 2-sample t test with unequal variance). For patients with SL, the aryepiglottoplasy procedure resulted in an average AE length increase-glottic length ratio of 0.330. Seven of the patients with SL were also diagnosed as having an underlying neurologic condition, and 18 had a diagnosis of gastroesophageal reflux disease. Two patients with SL required a tracheotomy for treatment of persistent airway obstruction.

CONCLUSIONS

In this series, patients with SL had lower AE fold length-glottic length ratios and more frequent occurrence of neuromuscular tone abnormalities (especially gastroesophageal reflux) than controls. These 2 findings may be related in that low intrauterine tone might contribute to anatomic underdevelopment.

Endoscopic division of the ary-epiglottic folds in severe laryngomalacia

OBJECTIVE

Laryngomalacia is the commonest cause of congenital stridor. The underlying anatomical abnormality associated with this condition is a prolapse of the supraglottic tissues into the laryngeal inlet during inspiration, and may involve the epiglottis, ary-epiglottic folds and the corniculate mounds of the arytenoids. However, it has been noted that the most consistent structural abnormality seen in these cases is the shortening of the ary-epiglottic folds and marked side to side curling of the epiglottis. We describe the follow-up and outcome of 33 cases treated by the simple division of the ary-epiglottic folds.

METHOD

All case notes were reviewed with respect to indications of operation, age of operation, endoscopic findings, operative technique, complications and follow-up until resolution of symptoms.

RESULTS

Surgical outcomes could only be ascertained in only 32 patients. Twenty-two cases (68.7%) showed complete resolution of stridor and associated complications of laryngomalacia. In the remaining ten cases who could be followed up (31.2%), seven patients (21.8%) showed partial resolution with no further surgery required, two patients (6.2%) required additional excision of redundant mucosa as second procedure, one patient (3%) with associated cleft lip/palate and tracheomalacia had to undergo a tracheostomy. There was improvement in feeding after surgery in all the 12 patients (100%) who had had pre-operative feeding difficulties. All the four patients with cyanosis pre-operatively were cured, but one of the two patients with apnoeic episodes pre-operatively continued to have apnoeic spells despite resolution of their laryngomalacia.

CONCLUSION

Simple endoscopic excision of the ary-epiglottic folds is a quick, reliable, highly effective procedure with very few complications. We recommend its use as the first line option in the management of severe laryngomalacia, with more extensive methods reserved for the very occasional case of primary failure.

Laser partial epiglottidectomy as a treatment for obstructive sleep apnea and laryngomalacia

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

Laryngeal motion during exercise

OBJECTIVE

To compare laryngoscopically observed changes in the larynx during exercise in persons with exercise-induced laryngomalacia (EIL) with changes in asymptomatic control subjects.

STUDY DESIGN

Clinical study using a standardized exercise protocol.

METHODS

Subjects exercised on an incremental ergometer: videotaped recordings of the larynx were obtained through the entire exercise; pulmonary function tests were completed before and/or immediately after the exercise.

RESULTS

Laryngeal lumen size decreases during exercise in subjects with EIL.

CONCLUSION

Subjects with EIL had a significant decrease in laryngeal lumen size during exercise compared with asymptomatic control subjects.

State-dependent laryngomalacia

We have observed 5 infants who demonstrate normal breathing when awake, but develop stridor while asleep. Flexible laryngoscopy in the awake state reveals either a normal larynx or redundancy of the aryepiglottic folds or arytenoid soft tissue without prolapse into the laryngeal inlet. When these children are sedated, however, the classic signs of laryngomalacia appear. Wet inspiratory stridor with concomitant supraglottic prolapse can be demonstrated by flexible videolaryngoscopy in this state. As these findings vary with level of consciousness, we have dubbed this condition "state-dependent" laryngomalacia. We believe the appearance and disappearance of classic laryngomalacia with changes in level of consciousness adds credence to the neurogenic theory of laryngomalacia.

Pediatric exercise-induced laryngomalacia

Laryngomalacia is a well-recognized cause of airway obstruction and inspiratory stridor in infants. As children grow and become more active, laryngomalacia may manifest in different, unexpected ways. Otherwise healthy athletes may generate enough inspiratory force to draw the aryepiglottic folds into the endolarynx, causing a subtotal glottic obstruction. This problem may be overlooked or attributed to asthma, lack of fitness, or functional abnormalities. The purpose of this report is to review the prevalence, diagnosis, and treatment of exercise-induced laryngomalacia (EIL) in children and young adults. To study the incidence and diagnosis of this disorder, we examined 10 healthy volunteers. Fiberoptic laryngoscopy was used to videotape each subject's larynx during active exercise on a stationary bicycle. All volunteers demonstrated altered laryngeal dynamics with exercise, and 1 of the 10 volunteers developed laryngomalacia. Anatomically, it appears that the aryepiglottic fold serves as the critical point of obstruction. When symptomatic, laryngomalacia may be treated with supraglottoplasty. We have had experience with 2 EIL patients in the last 12 months who have undergone carbon dioxide laser microlaryngoscopy. Both patients benefited significantly from surgery. We conclude that EIL is underdiagnosed but responds well to treatment.

Bifid epiglottis: a case report

Bifid epiglottis is a rare congenital laryngeal anomaly, usually associated with multiple congenital anomalies which include digital anomalies and hypothalamic pituitary dysfunction manifesting as growth retardation. A case is presented of a 2-year-old child with this picture in whom the bifid epiglottis prolapsed over the laryngeal inlet to cause inspiratory airway obstruction. Corrective surgery was not successful and eventually a partial epiglottectomy was required.