Pathophysiology and diagnostic approach to laryngomalacia in infants

Nap polysomnography in infants with laryngomalacia as a tool to predict treatment strategy

PURPOSE

This study aimed to investigate the role of nap polysomnography (NPSG) in predicting treatment strategies for infants with moderate to severe laryngomalacia and to explore the association between obstructive sleep apnea (OSA) severity, weight gain, and laryngomalacia severity.

METHODS

A retrospective analysis was conducted on infants diagnosed with moderate to severe laryngomalacia who underwent NPSG between January 2019 and June 2023. Clinical variables, NPSG parameters, and treatment decisions were collected. Weight gain rate and its correlation with NPSG indices were assessed. Logistic regression analyses were performed to predict treatment strategies based on NPSG findings.

RESULTS

Of the 39 infants included (median age: 3.3 months), 77% exhibited OSA, with 69% having moderate to severe OSA [apnea-hypopnea index (AHI) > 5/h]. Weight gain rate correlated negatively with indices of OSA severity, including the hypopnea index (HI) and the AHI. In a multiple logistic regression analysis incorporating the severity of OSA (AHI), weight gain rate, and laryngomalacia severity, only AHI predicted the decision for surgical or non-invasive ventilation treatment (OR = 2.1, CI95 [1.6; 2.8], p ≤ 10-4). The weight gain rate was predicted (r2 = 0.28) by the AHI and the presence of retractions of auxiliary inspiratory muscles.

CONCLUSION

This study underscores the importance of NPSG in assessing infants with moderate to severe laryngomalacia. The AHI from NPSG emerged as a potential predictor for treatment decisions and weight gain rate, emphasizing its clinical relevance. These findings advocate incorporating NPSG into the diagnostic and management process for infants with laryngomalacia.

Preterm Birth, Low Birth Weight, and Medical Comorbidities Are Risk Factors for Severe Laryngomalacia in Children

Objective: To analyze the clinical characteristics and the risk factors associated with severe laryngomalacia in children. Methods: In this study, the clinical data of children (0-18 years), including gender, age at presentation, preterm delivery, low birth weight, delivery mode, feeding mode, fetal delivery, medical comorbidities, maternal gestational age at presentation, and calcium supplementation during pregnancy, diagnosed with laryngomalacia between January 2013 and January 2023 were retrospectively analyzed. The children were divided into mild-moderate and severe groups. Several risk factors were compared and analyzed between the 2 groups. The statistically significant risk factors were included in the logistic regression analysis. Results: A total of 224 children with severe laryngomalacia were enrolled in this study. The ratio of male to female patients was 1.55:1. All patients had severe laryngomalacia manifested by inspiratory laryngeal stridor. The average age of patients at symptom presentation was 2.7 (1.5-5.2) months. There were significant differences between the 2 groups in the age at presentation, premature delivery, low birth weight, medical comorbidities, and calcium supplementation during pregnancy (P < .05). Multivariate logistic regression analysis showed that premature delivery [odds ratio (OR) = 3.177, 95% confidence interval (CI): 2.329-4.334], low birth weight (OR = 3.188, 95% CI: 2.325-4.370), and medical comorbidities (OR = 1.434, 95% CI: 1.076-1.909) were independent risk factors for severe laryngomalacia (P < .05). Conclusion: Children with severe laryngomalacia exhibited persistent stridor at an earlier age at presentation. Premature delivery, low birth weight, and medical comorbidities were potential risk factors for severe laryngomalacia in children.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU

OBJECTIVE

To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties.

METHOD

A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic.

RESULTS

The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %).

CONCLUSION

Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Profiling the clinical characteristics and surgical efficacy of laryngomalacia in children

OBJECTIVE

To analyze the clinical characteristics of laryngomalacia in Chinese children and explore the surgical efficacy and factors influencing severe laryngomalacia.

METHODS

Children (0-18 years) diagnosed with laryngomalacia in our hospital from January 2016 to January 2022 were enrolled in this study. Clinical data of patients, including general conditions, clinical symptoms, grading and classification, medical comorbidities, surgical efficacy, and the risk factors influencing severe laryngomalacia were retrospectively analyzed.

RESULTS

A total of 1810 children were enrolled (male:female; 2.02:1), among which most were infants under 1 year (77.18%). Inspiratory laryngeal stridor (69.56%) was the most common symptom. Most patients had mild laryngomalacia (79.28%), with type IV laryngomalacia being the most common classification (52.27%). Congenital heart disease (37.85%) was the most common medical comorbidity. A total of 168 severe laryngomalacia cases were treated via supraglottoplasty with an effective rate of 83.93%. Notably, preterm birth (OR = 3.868, 95% CI 1.340 ~ 11.168), low birth weight (OR = 4.517, 95% CI 1.477 ~ 13.819) and medical comorbidities (OR = 7.219, 95% CI 2.534 ~ 20.564) were independent risk factors for poor prognosis (P < 0.05).

CONCLUSION

Laryngomalacia is common among infants under the age of one, and it is mostly characterized by inspiratory laryngeal stridor with various medical comorbidity. Supraglottoplasty is the first treatment choice for severe laryngomalacia cases with high success rates. However, premature delivery, low birth weight, and medical comorbidities significantly affect the efficacy of surgery.

Characteristics of Patients with Laryngomalacia: A Tertiary Referral Center Experience of 106 Cases

Laryngomalacia (LM) is the most common airway congenital anomaly and the main cause of stridor in infants. Some patients with severe airway symptoms or with feeding difficulties require surgical intervention. Synchronous airway lesions (SALs) may influence the severity and course of the disease. This study aimed to determine the prevalence of various types of LM and SALs and their influence on surgical intervention decisions and feeding difficulties. Moreover, the study focused on the interrelations between SALs and the type of LM or the presence of feeding difficulties. A retrospective analysis of 106 pediatric patients revealed a significant relationship between type 2 LM and the necessity of surgical treatment. We also found a significant effect of LM type 2 on feeding difficulty. Type 1 LM is significantly more characteristic in premature children. Among different comorbidities, SALs are suspected of modification of the course and severity of LM. This study did not find a significant effect of SALs on the incidence of supraglottoplasty or feeding difficulty.

Evaluation of vitamin D levels and biochemical markers in infants diagnosed with laryngomalacia

Background/aim

The pathology of laryngomalacia is still not clear. The aim of this study was to investigate the relationship between vitamin D levels and laryngomalacia, and to evaluate vitamin D levels according to the classification of laryngomalacia.

Materials and methods

This retrospective study was conducted in the Kahramanmaraş Sütçü İmam University Medicine Faculty's Otorhinolaryngology Clinic between June 2014 and January 2021. Laryngomalacia was classified. Laboratory tests for all patients included calcium (Ca), phosphorus (P), parathormone (PTH), blood urea nitrogen (BUN), creatinine (Cre), alanine transaminase (ALT), and 25-hydroxy vitamin D (25-OH-D).

Results

Evaluations were performed for 64 infants with laryngomalacia, including 41 male and 23 female infants with a mean age of 4.6 ± 3.0 months, and a control group of 64 healthy infants with a mean age of 4.5 ± 2.8 months. A statistically significant difference was determined between the laryngomalacia group and the control group with respect to 25-OH-D and PTH levels (p < 0.001). When data were examined according to laryngomalacia types, a statistically significant difference was determined between the groups for 25-OH-D, Ca, P, PTH, and ALT values. The 25-OH-D level was statistically significantly lower in the severe laryngomalacia group than in the mild and control groups (p < 0.001). A statistically significant difference was determined between the moderate and severe laryngomalacia groups and the control group regarding PTH levels (p < 0.001).

Conclusion

Vitamin D deficiency may have a role in the etiology of laryngomalacia, and this view is supported by the finding that there was a decrease in vitamin D levels associated with laryngomalacia classification. In addition, the reduction in PTH levels in infants with laryngomalacia may be explained by the change in Ca metabolism. It would be appropriate for further studies to investigate the response to vitamin D replacement therapy in patients with moderate and severe laryngomalacia.

Surgical Candidacy for Management of Laryngomalacia: A Proposed Scoring System

Introduction

Identifying surgical candidacy for the management of laryngomalacia is a challenge.

Objective

To develop a simple scoring system for surgical candidacy in laryngomalacia.

Methods

Eighteen years retrospective observational study of children with laryngomalacia (LM) clinically categorized into mild, moderate and severe LM and were analyzed for surgical candidacy.

Results

There were 113 children (age ranging from 5 days to 14 months), 44% being mild, 30% moderate and 26% severe LM. None in mild, 32% in moderate, and all in severe LM had surgical intervention. Presence of stridor on feeding or crying and isolated type 1 or type 2 LM on laryngoscopy were significant indicators for conservative treatment (p-< 0.0001). Moderate failure to thrive, retraction at rest/sleep, with low oxygen saturation while feeding/at rest were significantly higher in both moderate and severe groups with laryngoscopic evidence of combined type 1 and 2 in moderate LM (p < 00,001). Aspiration pneumonia, hospitalization, pectus and mean pulmonary arterial pressure of more than 25 mmHg with laryngoscopic findings of all three combined types were significantly higher in severe LM (p < 0.0001).A simple scoring system was then developed and it revealed that a score of 10 or more required surgical intervention.

Conclusion and clinical significance

A clinical scoring system is being reported for the first time in medical literature to identify 'the difficult to treat' subset within moderate laryngomalacia category simplifying decision making in its management for otolaryngologists and pediatricians as well as a referral criterion for pediatric otolaryngologists' services.

What to Expect of Feeding Abilities and Nutritional Aspects in Achondroplasia Patients: A Narrative Review

Achondroplasia is an autosomal dominant genetic disease representing the most common form of human skeletal dysplasia: almost all individuals with achondroplasia have identifiable mutations in the fibroblast growth factor receptor type 3 (FGFR3) gene. The cardinal features of this condition and its inheritance have been well-established, but the occurrence of feeding and nutritional complications has received little prominence. In infancy, the presence of floppiness and neurological injury due to foramen magnum stenosis may impair the feeding function of a newborn with achondroplasia. Along with growth, the optimal development of feeding skills may be affected by variable interactions between midface hypoplasia, sleep apnea disturbance, and structural anomalies. Anterior open bite, prognathic mandible, retrognathic maxilla, and relative macroglossia may adversely impact masticatory and respiratory functions. Independence during mealtimes in achondroplasia is usually achieved later than peers. Early supervision of nutritional intake should proceed into adolescence and adulthood because of the increased risk of obesity and respiratory problems and their resulting sequelae. Due to the multisystem involvement, oral motor dysfunction, nutrition, and gastrointestinal issues require special attention and personalized management to facilitate optimal outcomes, especially because of the novel therapeutic options in achondroplasia, which could alter the progression of this rare disease.

Pediatric Dysphagia

Feeding difficulty is common in the pediatric population, particularly in at-risk infants, such as those born prematurely. Appropriate work-up should involve a multidisciplinary team and may commonly use modified barium swallow and flexible endoscopic evaluation of swallow, in addition to history and physical examination. Structural causes of dysphagia may involve surgical management, whereas nonstructural causes may invoke medical therapies. If symptoms do not resolve following intervention, it is important to revisit the interdisciplinary team, because dysphagia is commonly multifactorial in origin. Appropriate identification and early intervention are necessary for successful outcomes in growth and development for children.

Swallowing Outcomes Following Supraglottoplasty: A Retrospective Review

OBJECTIVES/HYPOTHESIS

Determine the incidence of short- and long-term dysphagia in pediatric patients with and without syndromes/neurodevelopmental delay following supraglottoplasty (SGP) at our institution.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of children ≤18 years old who underwent SGP from 2014 to 2019 was undertaken. Age at surgery, sex, race, insurance, underlying syndromes/neurodevelopmental delay, concurrent surgical procedures, and clinical swallowing assessments were reviewed. Logistic regression was performed to identify factors associated with postoperative feeding difficulties. Time-to-event analysis was performed to assess time to resolution of dysphagia.

RESULTS

A total of 231 patients were identified. Average age at time of SGP was 13.7 months. Of 231 patients, 88 (38.1%) had a syndrome/neurodevelopmental delay. Of these 231 patients, 112 had a preoperative videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing, of whom 53/112 (47.3%) had dysphagia. After SGP, 138/231 (59.7%) underwent clinical/instrumental swallowing assessments, of whom 95/138 (68.8%) had immediate postsurgical dysphagia. At last follow-up (1 month to 45 months), 15/95 (15.8%) had persistent dysphagia on instrumental assessment, 14/15 of whom had syndromes/neurodevelopmental delay. Time-to-event analysis revealed that for the nonsyndromic cohort, 25% had resolution of dysphagia by 4 months, 50% by 10 months, and 75% by 14 months. Cox proportional hazards regression revealed that the presence of underlying syndromes/neurodevelopmental delay was the only factor predictive of long-term postoperative dysphagia (hazard ratio of resolution 0.21 [95% confidence interval 0.096-0.48]).

CONCLUSIONS

While short-term feeding difficulties following SGP in pediatric patients are not uncommon, long-term dysphagia is rare in patients without syndromes/neurodevelopmental delay. These data can be used when counseling caregivers about the risks and benefits of SGP.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Correlation between the clinical severity of laryngomalacia and endoscopic findings

Objectives:

To correlate the clinical severity of laryngomalacia (LM) with endoscopic findings, swallowing evaluations and polysomnography in a cohort of patients .

Methods:

We conducted a retrospective analysis between 2017-2018 on a cohort of patients diagnosed with upper airway obstruction (UAO), stridor, noisy breathing or laryngomalacia. This study took place at the Pediatric Pulmonology Department, Riley Children’s Hospital, Indianapolis, United States of America.

Results:

There were 157 patients with laryngomalacia included in the study. Patients with severe LM were significantly younger than those with mild LM (p=0.0214) and moderate LM (p=0.0220). Subjects with type I of LM were significantly older than type III (p=0.0051).When associations were tested between polysomnogram (PSG) variables and clinical severity, there were significant associations with age at PSG. The overall apnea-hypopnea index (AHI) in mild (p=0.0103) and moderate (p=0.0242) were significantly lower than the severe group. The rapid eye movement (REM) AHI was significantly lower in moderate cases than severe (p=0.0134). The end-tidal carbon dioxide (EtCO2) peak was significantly lower in mild cases than severe (p=0.0141).The total sleep time (TST) peripheral capillary oxygen saturation (SpO2) 90% occurs in both mild (p=0.0197) and moderate (p=0.0498)) were significantly lower than the severe group.

Conclusions:

The severity of the clinical manifestations of LM did not correlate with the different endoscopic types in our study. The presence of cyanosis was associated with type III LM. Rapid eye movement AHI and EtCO2 in polysomnogram were remained significantly associated with clinical severity.

Inspiratory stridor of newborns and infants admitted to a paediatric ENT outpatient clinic: diagnostic approach and therapeutic outcome

The main objective was to analyse the use of rigid laryngotracheoscopy under general anaesthesia (GA) and endoscopic surgery in the management of inspiratory stridor in patients referred to a paediatric ENT outpatient clinic. The secondary objective was to analyse the aetiological diagnoses made and their therapeutic management. This is a prospective study including all newborns and infants, corresponding to 190 patients, presenting for the first time in consultation for inspiratory stridor from January 2015 to December 2017. A consultation form was filled out after each consultation and added to a database; a management algorithm was used to determine which patients required a rigid laryngotracheoscopy. A 17.9% (n = 34) of the patients required rigid laryngotracheoscopy, of whom 12.6% (n = 24) underwent concomitant endoscopic surgery. A 65.8% (n = 125) of the patients were diagnosed with laryngomalacia, 21.1% (n = 40) with isolated posterior excess of mucosa, 9.5% (n = 18) with another diagnosis and 3.7% (n = 7) with a normal examination. The presence of comorbidity was associated (p < 0.001) with the use of rigid laryngotracheoscopy and endoscopic surgery.Conclusion: Rigid laryngotracheoscopy under GA was required in one in five to six patients. Conservative management with strict follow-up may be appropriate in a large number of patients, especially those with laryngomalacia. What is Known: • Previous research has established that laryngomalacia is the main aetiology of stridor. • Comorbidities are linked with a poor tolerance of stridor. What is new: • About one in five to six patients seen in consultation for stridor will require a trip to the operative room (and one in eight will require endoscopic surgery). • Laryngomalacia and isolated posterior excess of mucosa account for 85-90% of the patients seen in consultation for stridor.

Feasibility of Surgical Treatment for Laryngomalacia using Spontaneous Respiration Technique

Objectives.

In this study, we review our institutional experience with pediatric laryngomalacia (LM) and report our experiences of patients undergoing supraglottoplasty using the spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen (STRIVE Hi) technique.

Methods.

The medical records of 29 children with LM who visited Seoul National University Hospital between January 2017 and March 2019 were retrospectively reviewed. Surgical management was performed using the STRIVE Hi technique. Intraoperative findings and postoperative surgical outcomes, including complications and changes in symptoms and weight, were analyzed.

Results.

Of the total study population of 29 subjects, 20 (68.9%) were female. The patients were divided according to the Onley classification as follows: type I (n=13, 44.8%), II (n=10, 34.5%), and III (n=6, 20.7%). Twenty-five patients (86.2%) had comorbidities. Seventeen patients (58.6%) underwent microlaryngobronchoscopy under STRIVE Hi anesthesia. Four patients with several desaturation events required rescue oxygenation by intermittent intubation and mask bagging during the STRIVE Hi technique. However, the procedure was completed in all patients without any severe adverse effects. Overall, 15 children (51.7%) underwent supraglottoplasty, of whom 14 (93.3%) showed symptom improvement, and their postoperative weight percentile significantly increased (P=0.026). One patient required tracheostomy immediately after supraglottoplasty due to associated neurological disease.

Conclusion.

The STRIVE Hi technique is feasible for supraglottoplasty in LM patients, while type III LM patients with micrognathia or glossoptosis may have a higher risk of requiring rescue oxygenation during the STRIVE Hi technique.

Etiological profile of upper airway obstruction in infants

Background

Respiratory distress is recognized as any sign of breathing difficulty in infants. Some congenital anomalies present immediately with airway distress, while others are asymptomatic or discovered later in infancy or childhood. Our objectives are to detect different laryngeal causes of respiratory distress in infants and to measure the relative risk of some variables like age, sex, family history, and other congenital anomalies for developing laryngeal causes of respiratory distress. This observational cross-sectional study was carried out during the period from June 2017 to December 2018 at Children’s University Hospital. The study included 80 infants who presented with respiratory distress and admitted to the hospital. All patients subjected to a detailed history from their parents and full general and ENT examinations. X-ray, MSCT neck or direct laryngoscope were carried out in selected cases.

Results

As regard age, 58% of cases were between 1–6 months, 28% of cases between 6 months and 1 year, and 14% between 1–2 years. Laryngeal causes of respiratory distress among infants were distributed as follow: 70% laryngomalacia, 18% subglottic stenosis, 8% laryngeal web, and 4% of cases were caused by vocal fold paralysis (VFP). The laryngeal causes of respiratory distress did not reveal any statistically significant difference among different age groups or between both genders (P = 0.257, 0.286; respectively). Also, there was no statistically significant difference between infants with positive family history and those without as regard the laryngeal causes of respiratory distress (P = .378).

Conclusion

The majority of respiratory distress cases (58%) were between 1–6 months. Bivariant analysis of variables age, sex, family history, and other congenital anomalies showed that they were not potent risk factors for developing laryngomalacia, subglottic stenosis, laryngeal web, and vocal fold paralysis. Laryngomalacia represented the commonest cause of respiratory distress (70%) followed by subglottic stenosis (18%), then laryngeal web (8%), and finally the vocal fold paralysis represented the least percentage (4%). Apart from laryngomalacia, the percentages of other causes seem to vary according to sample size and geographic area of study. So, being familiar with the common causes of respiratory distress in a given region is very essential in order not to miss a potentially life-threatening diagnosis.

Investigation of the serum vitamin D level in infants followed up with the diagnosis of laryngomalacia: a case-control study

OBJECTIVE

The possible etiological relationship of the vitamin D with laryngomalacia is unclear. The aim of the study was to demonstrate the relationship between laryngomalacia and vitamin D levels.

METHODS

Twenty-three non-syndromic babies under the age of 1 year who were diagnosed with laryngomalacia were included in the study group. Forty healthy babies were included in the control group. The detailed anamnesis was obtained and a complete systemic physical examination, a flexible endoscopic laryngeal examination, and laboratory tests [calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), parathormone (PTH), alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), creatinine (Cre), and 25-hydroxy vitamin D (25-OH D)] were performed in all patients. All laboratory tests of the groups were compared.

RESULTS

It was observed that there was no significant difference in the parameters that could affect vitamin D levels, namely type of feeding, vitamin D supplement intake, and the season when the serum sample was taken (p > 0.05). The vitamin D level was significantly lower (p = 0.003, p < 0.05) and the P and ALP levels were significantly higher (p = 0.016 and p = 0.001, respectively; p < 0.05) in the laryngomalacia group. Although the correlation between vitamin D and PTH was not statistically significant according to the Pearson correlation analysis, it was lower in the laryngomalacia group compared to the control group (p = 0.381, p > 0.05).

CONCLUSION

In this study, it was observed that the vitamin D levels were lower in infants with laryngomalacia compared to the control group. We consider that vitamin D deficiency may be a factor in the etiology of laryngomalacia with a yet-to-be-clarified etiology.

Evaluation of Aspiration in Infants With Laryngomalacia and Recurrent Respiratory and Feeding Difficulties

Importance

Laryngomalacia is the most common laryngeal anomaly and is commonly associated with stridor in children, but the recurrent respiratory and/or feeding difficulties associated with this condition may pose a threat to the well-being of the affected child.

Objective

To describe the prevalence of aspiration in pediatric patients with laryngomalacia who present with recurrent respiratory issues and/or feeding difficulty.

Design, Setting, and Participants

This retrospective review of medical records involved 142 pediatric patients. These patients received a laryngomalacia diagnosis, presented with recurrent respiratory and/or feeding difficulties, and underwent a modified barium swallow (MBS) study at a tertiary referral children's hospital from January 1, 2015, to December 31, 2015. Each patient was assessed for aspiration and swallowing discoordination. Data collection and analysis were performed from December 1, 2016, to September 30, 2017.

Main Outcomes and Measures

Demographic data, presenting symptoms, medical comorbidities, and feeding and dysphagia details were collected and analyzed. Speech-language pathologists reviewed all MBS reports to identify the presence and type of aspiration (ie, silent vs nonsilent) with different textures and consistencies of food and liquid.

Results

A total of 395 patients were diagnosed with laryngomalacia in 2015. One hundred forty-two of these patients (35.9%) presented with recurrent respiratory issues and/or feeding difficulties and were referred for MBS study for further evaluation. Ninety-two (64.8%) were male, with a median (interquartile range) age at the time of MBS study of 7.9 (3.2-20.5) months. Among these patients, 128 (90.1%) had swallowing dysfunction documented during the MBS study. Aspiration was identified in 60 patients (42.3%), and silent aspiration was documented in 59 (98.3%) of these 60 patients. Epilepsy or seizures (risk difference [RD], 11%; 95% CI, 5%-17%), laryngeal cleft (RD, 8%; 95% CI, 3%-13%), and premature birth (RD, 15%; 95% CI, 5%-25%) were statistically significantly associated with abnormal MBS findings.

Conclusions and Relevance

Swallowing dysfunction and aspiration were commonly found in pediatric patients with laryngomalacia and recurrent feeding and/or respiratory issues; these children should undergo an MBS study for dysphagia and silent aspiration.

RETRACTED: The role of laryngeal ultrasound in diagnosis of infant laryngomalacia

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Authors and the Editor-in-Chief. After a thorough investigation, the Editor-in-Chief has concluded that details in the origin of data and permissions integral to the article’s acceptance in the journal necessitate a retraction. A single hospital was mentioned in the article but this was not where the data was collected. Reviewers would have assumed that informed consent was received and properly reviewed by this institution, as it was not otherwise specified. Several oversights within the article that were brought forward by the Authors make it clear that the article that was accepted had misrepresentation of key data. While the Authors presented some differences of opinion about how these concerns about the key data originated, it is clear that when the manuscript was accepted that Reviewers and Editors would not have had knowledge of these difficulties, and this may have created a different review process and outcome for this manuscript. One of the Authors has requested an ability to provide additional information to address the concerns. However, the Editor-in-Chief has decided that this would not follow the process for accepted manuscripts or address some of the concerns presented and, therefore, has settled on the retraction of the manuscript as the final decision regarding this paper.

Congenital laryngomalacia: Is it an inflammatory disease? The role of vitamin D

OBJECTIVES/HYPOTHESIS

Laryngomalacia is the most common cause of stridor in infants. The exact pathophysiology is still not well understood. Our objective was to investigate whether laryngomalacia is an inflammatory disease, focusing on the possible role of vitamin D.

STUDY DESIGN

Case-control study.

METHODS

Sixty Egyptian infants and 60 mothers were included in this study. They were divided into four equal groups (n = 30 for each): infants with laryngomalacia (LM-infants), control infants (C-infants), mothers of the infants with laryngomalacia (LM-mothers), and mothers of the control infants (C-mothers). Laryngoscopy was performed and serum 25-hydroxyvitamin D (25[OH]-vitamin-D) and interleukin 6 (IL-6) were estimated.

RESULTS

Significant increase of serum IL-6 associated with a significant decrease in serum 25(OH)-vitamin D was observed in the LM-infants compared to the C-infants (P < .001 for both). LM-mothers had significantly lower 25(OH)-vitamin D status compared to C-mothers (P < .001).

CONCLUSIONS

Deficiency of 25(OH)-vitamin D in LM-infants may result in dysregulation of the immune responses with elevation of a proinflammatory cytokine (IL-6). Laryngomalacia could be an inflammatory disease due to 25(OH)-vitamin D deficiency as evidenced by the high level of IL-6. This finding may open the door to the appropriate prevention, diagnosis, and treatment, especially for moderate to severe laryngomalacia.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:448-453, 2020.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Supraglottoplasty in children with laryngomalacia: A review and parents' appraisal

PURPOSE

To assess the parents' perspective concerning the children's clinical picture before and after supraglottoplasty for the treatment of laryngomalacia (LM).

MATERIALS AND METHODS

Retrospective study in 110 children diagnosed with LM followed at the Pediatric Otorhinolaryngology outpatient clinics of S. João Hospital Center, between 2008 and 2016. Children who underwent supraglottoplasty were reviewed in terms of demographics, symptoms, comorbidities, treatment and follow-up. Parents were interviewed and filled out a structured questionnaire designed to evaluate their perception of the child's clinical picture and their degree of comfort before and after surgery.

RESULTS

Thirty-one children (28,2%) underwent supraglottoplasty at a median age of 6 months-old. Twelve patients had one or more medical comorbidities. Stridor was present in all children on the pre-operative period and resolved in 92,3% of the cases after supraglottoplasty; shortness of breath persisted in 3,8% in contrast to the previous 57,7%; and feeding difficulties remained in 15,4% children against the 65,4% before the procedure. Failure in thriving was also a pre-operative complaint, that recovered as reported by parents in all children after supraglottoplasty. No surgical complications were reported, and the median hospital stay was two days. In a 0 to 10 points scale, the median level of the parents' comfort with their child's clinical picture before supraglottoplasty was one point which was significantly worse than the mean level of ten points after surgery (p < 0.001).

CONCLUSIONS

In severe cases, LM can have a strong negative impact on family dynamics and functioning. In selected cases, supraglottoplasty can be a safe and effective treatment option which is associated with a high degree of parental satisfaction.

Predictors for routine admission to paediatric intensive care for post-supraglottoplasty laryngomalacia patients

Objectives:

Supraglottoplasty for the treatment of laryngomalacia has little current evidence regarding post-operative care. Our study aimed to: (1) retrospectively assess what proportion of patients required paediatric intensive care unit level of care; (2) identify pre-operative predictive factors common to these cases; and (3) report patient outcomes at six weeks’ follow up.

Methods:

A 10-year retrospective case series analysis was conducted of all patients diagnosed with laryngomalacia and subsequently treated with supraglottoplasty. Paediatric intensive care unit level of care was defined as the need for intubation or tracheostomy, positive pressure ventilation, multiple doses of nebulised adrenaline, and oxygen dependency beyond 12 hours.

Results:

Forty-two patients (19 males, 23 females) were identified; 28.5 per cent of cases met our criteria for paediatric intensive care unit level of care. A low pre-operative oxygen saturation was the only significant risk factor that predicted a future need for paediatric intensive care unit level of care (p = 0.0008).

Conclusion:

This is the first study published in the UK to suggest the importance of pre-operative oxygen saturation as a predictor of a future need for paediatric intensive care unit level of care.

Utility of polysomnography in determination of laryngomalacia severity

OBJECTIVE

To examine the efficacy of polysomnography in determining the severity of laryngomalacia in pediatric patients.

METHODS

Prospective cohort study. Pediatric patients referred to our pediatric otolaryngology department with a polysomnogram already performed for a presumptive diagnosis of laryngomalacia were enrolled in the study. Patients with concurrent airway lesions or neuromuscular disorders were excluded. Patients underwent history, physical exam, and flexible fiberoptic laryngoscopy. These results were used to calculate a total laryngomalacia severity score.

RESULTS

25 pediatric patients (n = 25) with an average age of 3.9 months at time of initial evaluation met criteria for enrollment in our study. 100% of patients had obstructive sleep apnea by definition. 80% of these patients underwent supraglottoplasty. The average AHI of those who underwent surgery (57.26) was not significantly different in those who underwent surgery vs. those that did not (55.43) (p = 0.41). In comparison, the average laryngomalacia severity score based from history, physical exam and flexible laryngoscopy was significantly greater in the patients that required supraglottoplasty (11.16) vs. those who did not (5.33) (p = 0.03). In addition a higher laryngomalacia severity score was not correlated with a higher AHI (p = 0.81, r = 0.08, CI: -0.5197 to 0.6235).

CONCLUSION

In our cohort, polysomnography was not useful in determining the severity of laryngomalacia, did not correlate with the clinical evaluation, and alone was not predictive of the patients that would require surgical intervention. History, physical exam, and endoscopic findings remain reliable predictors of disease severity and need for operative intervention.

Types of laryngomalacia in children: interrelationship between clinical course and comorbid conditions

The aim of this study was to: (1) find out whether laryngomalacia (LM) types are related to clinical course; (2) which patients with LM are at higher risk of other airway malacia [tracheomalacia (TM) and/or bronchomalacia (BM)]; and (3) evaluate the prevalence of LM in our region. Patients with established LM diagnosis and complete clinical and endoscopy records were enrolled. They were classified into different LM types according to classification based on the side of supraglottic obstruction. One hundred ten children were included. The most common LM appearance was type I—58 children, followed by combine types (I + II and I + III)—38. The other airway malacia were found in 47 patients: TM in 31, BM in 10, and TM with BM in 6. Other comorbidities (cardiac, neurological, and genetic disorders) were identified in 30 children. Patients with combine types of LM differ from those with single type of LM in terms of prematurity (13 vs 31 %, p = 0.04) and higher weight on the examination day (p = 0.006). Patients with other airway malacia differ from children with isolated LM in terms of prematurity (40 vs 13 %, p = 0.008), comorbidities (38 vs 19 %, p = 0.024), and lower weight on the examination day (p = 0.014). The prevalence of clinically relevant LM was one in 2600–3100 newborns. Clinical course of LM cannot be anticipated on the basis of solely endoscopic evaluation of the larynx. Comorbidities and prematurity increase the risk of other airway malacia. The prevalence of LM is relatively high in the middle-south part of Poland.

Congenital laryngomalacia is related to exercise-induced laryngeal obstruction in adolescence

OBJECTIVES

Congenital laryngomalacia (CLM) is the major cause of stridor in infants. Most cases are expected to resolve before 2 years of age, but long-term respiratory prospects are poorly described. We aimed to investigate if CLM was associated with altered laryngeal structure or function in later life.

METHODS

Twenty of 23 (87%) infants hospitalised at Haukeland University Hospital during 1990-2000 for CLM without comorbidities and matched controls were assessed at mean age 13 years. Past and current respiratory morbidity was recorded in a questionnaire, and spirometry performed according to standard quality criteria. Laryngoscopy was performed at rest and continuously throughout a maximal treadmill exercise test (continuous laryngoscopy exercise test (CLE-test)), and scored and classified in a blinded fashion according to preset criteria.

RESULTS

In the CLM group, laryngeal anatomy supporting CLM in infancy was described at rest in nine (45%) adolescents. Eleven (55%) reported breathing difficulties in relation to exercise, of whom 7 had similarities to CLM at rest and 10 had supraglottic obstruction during CLE-test. Overall, 6/20 had symptoms during exercise and similarities to CLM at rest and obstruction during CLE-test. In the control group, one adolescent reported breathing difficulty during exercise and two had laryngeal obstruction during CLE-test. The two groups differed significantly from each other regarding laryngoscopy scores, obtained at rest and during exercise (p=0.001 or less).

CONCLUSIONS

CLM had left footprints that increased the risk of later exercise-induced symptoms and laryngeal obstruction. The findings underline the heterogeneity of childhood respiratory disease and the importance of considering early life factors.

The changing face of the paediatric microlaryngobronchoscopy (MLB): A two year prospective study

BACKGROUND

Changes in the management and survival of paediatric patients with airway complaints combined with improving survival rates of premature babies have resulted in a different patient population for the paediatric airway surgeon than that previously described in the literature.

OBJECTIVES

To examine the presentation, diagnosis, clinical course and outcomes for patients undergoing microlaryngobronchoscopy (MLB).

STUDY DESIGN

2 year prospective longitudinal study.

STUDY POPULATION

210 microlaryngobronchoscopy examinations were performed on a total of 102 patients. Mean age at initial examination was 29.4 months with a male preponderance (68%).

RESULTS

72 (71%) patients had other documented medical co-morbidities with 30 children having no previous medical history. Of the 102 patients the primary diagnoses were: Subglottic Stenosis (29.4%), Laryngomalacia (20.6%), Laryngeal Cleft (16.7%), Normal Anatomy (11.8%) and Vocal Cord pathology (5.9%). The average rate of diagnoses per patient for the whole cohort was 1.57. Of those patients with a diagnosis on examination, 40 had a solitary diagnosis whilst 50 patients (55.5%) were found to have multiple diagnoses, equating to 2.35 diagnoses per patient. Children with a history of prematurity accounted for 18.6% of our cohort with a 100% rate of laryngo-tracheal pathology on examination and an average number of diagnoses per child of 2.21.

CONCLUSION

Our cohort illustrates the varied population served by today's paediatric airway surgeon alongside common diagnoses and co-pathologies affecting our patients.

Newborn respiratory distress: airway abnormalities

Respiratory distress is a common symptom in the newborn. Surfactant deficiency in the preterm infant and meconium aspiration and transient tachypnea in the term newborn are among the most common causes of respiratory distress, but primary airway abnormalities can also present with respiratory distress in the newborn. Delay in diagnosis of airway abnormality can be life threatening. Radiologists are among the first to be consulted in the evaluation of a neonate with respiratory distress, and knowledge of the spectrum of airway anomalies is essential for making the correct diagnosis. This article describes airway abnormalities that can present as respiratory distress in a neonate.

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.

Airway malacia in children with achondroplasia

This study was undertaken to assess the frequency of airway malacia in infants and young children with achondroplasia, a population well known to be at risk for a variety of respiratory problems. We also wished to evaluate what, if any, contribution airway malacia makes to the complex respiratory issues that may be present in those with achondroplasia. Retrospective chart review of all infants and young children with achondroplasia who were assessed through the Midwest Regional Bone Dysplasia Clinics from 1985 through 2012 (n = 236) was completed. Records of comprehensive clinical examinations, polysomnographic assessments, and airway visualization were reviewed and abstracted using a data collection form. Analyses were completed comparing the group with and those without evidence for airway malacia. Thirteen of 236 patients (5.5%) were found to have airway malacia. Most of those affected had lower airway involvement (9/13). The presence of airway malacia was correlated with an increased occurrence of obstructive sleep apnea as well as need for oxygen supplementation, airway surgeries and tracheostomy placement. Although estimates of the frequency of airway malacia in the general population are limited, its frequency in children with achondroplasia appears to be much higher than any published general population estimate. The presence of airway malacia appears to confound other breathing abnormalities in this population and results in the need for more invasive airway treatments.

Laryngomalacia presenting as recurrent croup in an infant

Laryngomalacia is a common disease of infancy which can present with atypical symptoms and at an atypical age, causing the diagnosis to often be overlooked. We report a case of a male patient who was diagnosed with laryngomalacia at the age of three months. The patient's inspiratory stridor resolved within a year, but he went on to develop atypical croup. The patient was later diagnosed with severe laryngomalacia which complicated his “croup-like” symptoms. He subsequently underwent supraglottoplasty with complete resolution of symptoms.