Management of laryngomalacia

Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty

STUDY OBJECTIVES

Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications.

METHODS

A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography.

RESULTS

400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05).

CONCLUSIONS

In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP.

CITATION

Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

Tracheostomy, the Not So Definitive Airway?: Tracheostomy Morbidity in Pediatric Craniofacial Patients

BACKGROUND

Tracheostomy is the definitive treatment for airway management in severe cases of craniofacial-associated upper airway obstruction, like the Pierre-Robin sequence, but is associated with significant morbidity. The purpose of this study was to examine tracheostomy-associated morbidities and mortalities in craniofacial patients to identify opportunities to improve clinical care and patient prognosis.

METHODS

The study was a retrospective review of pediatric craniofacial patients who were tracheostomized between 2016 and 2022. Data regarding their demographics, craniofacial diagnoses, endoscopic airway anomalies, intubation grade of view classification, tracheostomy-related complications, and causes of mortality were analyzed.

RESULTS

Sixteen of the 17 tracheostomized pediatric patients had the Pierre-Robin sequence, with 5 of those patients having an additional syndromic craniofacial diagnosis. Additional airway anomalies were found in 82.4% of the patients. The mean length of hospital stay after tracheostomy was 4.08 months. Infection was the most common complication, observed in 94.1% of patients, followed by stomal granulation in 76.5% of patients. Two mortalities were observed: one following the compassionate removal of ventilator support and the other following the accidental dislodgment of the tracheostomy tube.

CONCLUSIONS

Tracheostomy-related complications were observed in all craniofacial patients in this group. Compared with the general pediatric population, tracheostomized craniofacial patients may endure longer hospital stays and greater stomal granulation rates. Mandibular distraction osteogenesis may allow for tracheostomy avoidance in these patients, and future research should focus on comparing the long-term complication rates and outcomes between tracheostomy mandibular distraction osteogenesis in this challenging patient population.

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.

Laryngeal surgery for congenital laryngomalacia: NSQIP-P analysis of complications

OBJECTIVE

To evaluate predictors of complications in children with congenital laryngomalacia who underwent laryngeal surgery.

METHODS

Multi-institutional retrospective analysis using the American College of Surgeons-NSQIP-P database (2014-2019). CPT code 31541 and ICD-10 code Q35.1 (congenital laryngomalacia) were used to select patients <18 years. Variable predictors included demographics and medical co-morbidities. Main outcomes assessed included total length of hospital stay (LOS), reintubation, reoperation and readmission.

RESULTS

1092 children were identified, 450 (41.1%) females and 642 (58.6%) males, with a mean age of 1.1 years (95% CI 1.0-1.2). Mean LOS was 3.9 days (95% CI 3.3-4.6). Sixteen (1.5%) were reintubated, 30 (2.7%) were readmitted, and 18 (1.6%) were reoperated within 30 days. Thirty-one (2.8%) were still in hospital at 30 days. Regression analysis revealed an increase in LOS for several groups; the largest effect was seen for patients with preoperative ventilator dependence, admission within the first 28 days of life, and those who were discharged to other healthcare facilities (p < .001). Preoperative co-morbidities significantly associated with a higher frequency of reintubation included ventilator dependence (p = .003), history of prematurity (p = .016) and chronic lung disease (p = .041). Children undergoing surgery in the first 28 days of life were 10.16 times as likely to return to the OR for a related reason within 30 days than older children (p = .038).

CONCLUSION

Complications were rare after laryngeal surgery with a postop diagnosis of laryngomalacia. Recognizing pertinent clinical factors can help with risk assessment and management.

Synchronous airway lesions in children with severe, progressive and atypical laryngomalacia - Experience of a UK tertiary referral centre

OBJECTIVES

Laryngomalacia is the commonest cause of stridor in the paediatric population. Whilst usually self-limiting, studies have suggested that the presence of synchronous airway lesions (SALs) might be associated with more severe clinical presentation and additional morbidity. However, evidence in the literature is scarce, contributing to controversy regarding the appropriate investigation and management of children with laryngomalacia. The aim of this study was to explore the prevalence, clinical significance and risk factors of SALs in children with severe, progressive and atypical laryngomalacia symptoms.

METHODS

Retrospective analysis of the records of all paediatric patients diagnosed with laryngomalacia in a UK tertiary referral centre, over a 2-year period, was undertaken. Data on demographics, comorbidities, management and presence of SALs were collected.

RESULTS

The study included 130 patients with laryngomalacia. Seventy-eight patients required investigation with microlaryngobronchoscopy (MLB), based on clinical presentation. SALs were identified in 22 patients (28.2%), 6 of which (7.7%) required surgical intervention. The commonest airway lesions included tracheomalacia, bronchomalacia and subglottic stenosis. A correlation between the presence of neurodevelopmental conditions in children and SALs was noted (p value < 0.05). The presence of SALs was not associated with sex, gestational age at birth or other medical comorbidities.

CONCLUSION

The results of this study allow professionals to counsel families about the utility of MLB in children with severe, progressive and atypical laryngomalacia symptoms and inform management pathways for clinicians not working in airway centres. We support the clinical practice that progressive, atypical or severe laryngomalacia symptoms should prompt consideration of an MLB, to identify potential synchronous airway lesions. Furthermore, we propose that a higher index of suspicion and more thorough investigation might be indicated in children with neurodevelopmental disorders.

Noninvasive Respiratory Support as an Alternative to Tracheostomy in Severe Laryngomalacia

OBJECTIVES/HYPOTHESIS

To analyze the role of noninvasive respiratory support (NRS) as an alternative to tracheostomy in the management of severe laryngomalacia.

STUDY DESIGN

We conducted a monocentric retrospective study in a tertiary pediatric care center.

METHODS

All children under the age of 3 years with severe laryngomalacia, treated between January 2014 and December 2019, were included. Patient demographics, medical history, nutrition, surgery, NRS, and outcome were reviewed. Predictors for NRS were analyzed.

RESULTS

One hundred and eighty-eight patients were included. Mean age was 4 ± 5 months and mean weight was 4,925 ± 1,933 g. An endoscopic bilateral supraglottoplasty was performed in 183 (97%) patients and successful in 159 (87%). NRS was initiated in 29 (15%) patients at a mean age of 3 ± 2 months (1-11 months): 15 (52%) patients were treated with NRS after surgical failure, 9 (31%) were treated with NRS initiated prior to surgery because of abnormal overnight gas exchange, and 5 (17%) were treated exclusively with NRS due to comorbidities contraindicating an endoscopic procedure. NRS was successfully performed in all patients with a mean duration of 6 ± 11 months. No patient required a tracheostomy. Univariate analysis identified the following predictors of NRS: neonatal respiratory distress (P = .003), neurological comorbidity (P < .001), associated laryngeal abnormality (P < .001), cardiac surgery (P = .039), surgical endoscopic revision (P = .007), and nutritional support (P < .001).

CONCLUSION

NRS is a safe procedure, which may avoid a tracheostomy in severe laryngomalacia, in particular, in case of endoscopic surgery failure, respiratory failure before surgery, and/or severe co-morbidity.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Laryngomalacia in the Premature Neonate

Laryngomalacia is the most common cause of stridor in newborns. Affected patients may present with noisy breathing, a classic high-pitched inspiratory stridor that worsens with feeding. While the exact etiology remains unclear, the condition is characterized by softening of the supraglottic structures, including the epiglottis, aryepiglottic folds, and arytenoid cartilages. The condition is most often self-limited and requires expectant management. However, in some infants, severe disease, including failure to thrive or respiratory distress, may require medical or even surgical intervention. When caring for premature neonates, special care is required to evaluate for synchronous airway lesions.

The maturation changes of sleep-related respiratory abnormalities in infants with laryngomalacia

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and central sleep apnea (CSA) are common in infants with laryngomalacia. The purpose of this study was to evaluate developmental changes in sleep-related breathing disorders over time in infants with laryngomalacia and understand the effect of supraglottoplasty (SGP) and nonsurgical treatment.

METHODS

This is a retrospective review of infants with laryngomalacia who had at least 2 diagnostic polysomnography studies performed from January 2000 and May 2015. We included infants who had either OSA or CSA. Comparison of sleep and respiratory parameters by age group (0-6, 6-12, and >12 months old) was performed in both SGP and non-SGP groups using a mixed-effect regression model. A log-normal mixed model was used to explore the changes in sleep and respiratory parameters with age. The time to resolution of CSA and OSA was analyzed using nonparametric survival analysis.

RESULTS

A total of 102 infants were included; 57 had only OSA and 45 had both CSA and OSA. There were significant decreases in apnea-hypopnea index, obstructive index, central apnea index, and arousal index with increasing age in both SGP and non-SGP groups. The mean age at resolution of CSA (central apnea index < 5) was 7.60 months old for SGP and 12.57 months old for non-SGP (P < .05). There were no significant differences in the mean age at resolution of OSA (obstructive index < 1; 35.18 [SGP] vs 41.55 months [non-SGP]; P = .60) between SGP and non-SGP groups. Infants with neurologic disease, congenital anomalies, or genetic syndromes required significantly more time to resolve OSA (28.12 [normal] vs 53.13 [neurological] vs 59.53 months [congenital anomalies and genetic]; P < .01).

CONCLUSIONS

Both OSA and CSA improve in infants with laryngomalacia with increasing age regardless of SGP. The mechanism underlying these changes may involve airway growth and maturation of respiratory control. Time to resolution of OSA is affected by the presence of neurologic diseases, congenital anomalies, and genetic syndromes. Further studies are needed to confirm these findings and to evaluate long-term outcomes in this population.

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.

Efficacy and toxicities of low-temperature plasma radiofrequency ablation for the treatment of laryngomalacia in neonates and infants: a prospective randomized controlled trial

Background

Laryngomalacia is the most common cause of stridor in neonates and infants, and supraglottoplasty is the mainstay of surgical treatment. Although low-temperature plasma radiofrequency ablation (LTP-RFA) using coblation technology has been used for treating laryngomalacia, it is still lack of high-quality clinical evidence. Therefore, we conduct this prospective randomized study to clearly define the role of LTP-RFA for the treatment of laryngomalacia in neonates and infants.

Methods

Between Jan 2017 and Dec 2019, a total of 89 children with laryngomalacia were included for analysis. All patients were initially stratified according to the severity of laryngomalacia. Patients with severe laryngomalacia were randomly assigned to receive LTP-RFA or traditionally surgical supraglottoplasty, while patients with moderate laryngomalacia were assigned to LTP-RFA or observation. The primary end point was the efficacy and toxicities of LTP-RFA by assessing the changes of clinical score and visual analogue scale (VAS) symptom score. The total score was the combination of clinical score with VAS score.

Results

Of the 89 children, 40 children presented with severe laryngomalacia, and the remaining 49 children were diagnosed as moderate laryngomalacia. The median age was 68 days (range, 19 to 337 days). For children with severe laryngomalacia, our results showed that LTP-RFA treatment significantly reduced the operative time (5.55±1.66 vs. 18.7±5.31 min, P<0.001), length of hospital stay (6.71±1.15 vs. 7.95±1.55 days, P=0.008) and the amount of intraoperative hemorrhage (1.71±1.79 vs. 4.90±1.82, P<0.001) when compared to traditionally surgical supraglottoplasty, while the treatment efficacy was comparable between LTP-RFA and traditionally surgical supraglottoplasty in terms of changed total score (P=0.322), changed clinical score (P=0.135) and changed VAS symptom score (P=0.559). Additionally, for children with moderate laryngomalacia, LTP-RFA treatment significantly improved the symptom evaluated by total score (P<0.001), clinical score (P<0.001) and VAS symptom score (P<0.001) in comparison with the observation group. Post-operative pneumonia was observed in 10 patients. No surgical related death was reported.

Conclusions

The present study indicated that LTP-RFA was an effective treatment option for both severe and moderate laryngomalacia in neonates and infants with a low intraoperative complication. Long-term outcomes of LTP-RFA for laryngomalacia would be reported in further studies.

Prevalence of Laryngomalacia among Young Children Presenting with Stridor in a Tertiary Care Hospital

Introduction:

Laryngomalacia is one of the most common causes of stridor in young children. It can be a serious concern to both parents and caregivers. The main objective of this study is to find the prevalence of laryngomalacia among young children presenting with stridor in a tertiary care hospital in central Nepal.

Methods:

A descriptive cross-sectional study was carried out form 1st December 2017 to 1st May 2020 in children less than two years of age in a tertiary care hospital. Ethical approval was taken from the Institutional Review Committee of the hospital (reference number: 2020/23). Convenient sampling was done. Detailed demography, clinical examination, and video laryngoscopy findings were evaluated to find the prevalence of laryngomalacia among all children with stridor. Data were analyzed by using Statistical Package for the Social Sciences version 20. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.

Results:

Out of 430 participants who presented with stridor, the laryngomalacia was found in 234 (66%) (58.7-74.07) cases at a 95% confidence interval. The male: female ratio was 1.7:1. Most children, 192 (67.6%), presented with a milder form of laryngomalacia. The most common type was a mixed type of laryngomalaciain 159 (56%). Sleep-disordered breathing was seen in 113 (39.79%) of children diagnosed with laryngomalacia.

Conclusions:

Our study concluded that laryngomalacia was the most common cause of stridor in children less than two years of age. However, in most cases, the problem is not serious and a regular follow-up with weight monitoring is warranted.

The clinical safety and efficacy of flexible bronchoscopy in a neonatal intensive care unit

Flexible bronchoscopy (FB), developed in the 1960s, is widely used in the clinical practice of pediatrics and has demonstrated fundamental value in clinical diagnoses and treatment. However, as an invasive procedure, the use of FB is limited due to concerns regarding the tolerance of the procedure and the possible complications in neonatal units. Thus, the present study aimed to investigate the clinical safety and efficacy of flexible bronchoscopy (FB) in a neonatal intensive care unit (NICU). Neonates (n=54) who received FB in the NICU of Shanghai Children's Hospital between January 2012 and December 2016 were enrolled as the experimental group and another 54 neonates who required nebulization and tracheal secretion suction treatments were the control group. Indicators including blood gas, complete blood count, C-reactive protein (CRP), X-ray, patient breathing rate, temperature and blood pressure were monitored prior to and following the procedure. No significant differences in sex, gestational age, birth weight or postnatal age were observed between the experimental group and the control group (P>0.05). Among the 54 FB patients, several cases with side effect were identified, including 18 (33.3%) with respiratory tract stenosis, nine (16.7%) with malacia and stenosis and six (11.1%) with esophagotracheal fistula. Among the 54 members of the control group, 44 neonates (81.4%) were discharged with improved condition, five (9.3%) succumbed and five patients (9.3%) abandoned the treatment and left the hospital. Bronchoalveolar lavage demonstrated consistent results with respiratory secretion culture or tracheal tube culture. In comparison between the experimental and the control groups, no significant difference in pH, partial pressure of carbon dioxide (PCO₂), partial pressure of oxygen (PO₂) and HCO₃ ^- was observed, while there were no statistical differences in the values of pH, PCO₂ and HCO₃ ^- (P>0.05). However, PO₂ was significantly increased, and CRP was significantly reduced, following FB procedure compared with prior to FB (P<0.05). No pneumothorax, shock, other severe complications, fever or diffused pneumonia were observed during or after FB. The data from the present study demonstrated that FB is a safe and effective strategy for the diagnosis and differentiation of neonatal respiratory diseases in NICU.

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.

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.

Supraglottoplasty in neonates and infants: A radiofrequency ablation approach

BACKGROUND

Supraglottoplasty is the mainstay of surgical treatment for laryngomalacia. A novel supraglottoplasty surgical technique is needed to achieve better efficacy. The purpose of this study was to introduce modified microscopic radiofrequency ablation supraglottoplasty (MMRAS) for the treatment of congenital laryngomalacia and to evaluate the outcome and effectiveness of this novel approach.

METHODS

Seventeen children with severe laryngomalacia who underwent MMRAS were studied retrospectively. Supraglottoplasty of type III laryngomalacia was different from classical method. All the patients were kept intubated for 5 days after surgery to achieve a better epiglottal position and to avoid reconglutination of aryepiglottic folds. The patients' demographic information, symptoms, comorbidities, type of laryngomalacia, synchronous airway lesions and final outcomes were examined.

RESULTS

The median age at the time of surgery was 3.36 months (3 months 10 days). Operative indications included feeding difficulties, noisy breathing or respiratory distress (or both), and sleep-related symptoms. The MMRAS success rate was 82.4%. Most patients were extubated successfully on postoperative day 5. The major postoperative complication was pulmonary infection which occurred in 3 cases (17.6%) and required anti-infective therapy. No perioperative deaths and no long-term complications occurred. Failures were observed in 3 (17.6%) of 17 cases, 2 patients presented with a neurological disease and required tracheostomy, 1 patient relapsed because of postoperative adhesions and later underwent revision supraglottoplasty.

CONCLUSIONS

From these results, we conclude that MMRAS is an effective and safe treatment for symptomatic laryngomalacia and has the potential to provide better breathing, feeding, and sleeping outcomes in children with severe laryngomalacia. Postoperative intubation for 5 days may result in better therapeutic outcomes. Multicenter cooperative studies of comparison between MMRAS and conventional approaches would lend further evidence-based support for this surgical method.

Supraglottoplasty for laryngomalacia: The experience from Concepcion, Chile

OBJECTIVE

To review the clinical manifestations and outcomes of supraglottoplasty in patients with moderate to severe laryngomalacia at Guillermo Grant Benavente Hospital between January 2015 and January 2017.

METHODS

Retrospective study of patients with laryngomalacia who underwent CO2 laser supraglottoplasty at a tertiary referral center. A review of medical records of these patients was performed. Epidemiological data along with symptoms, comorbidities, morphological type of laryngomalacia, synchronous airway lesions, surgery outcomes and satisfaction of parents after the procedure were recorded. Surgical success was defined as the resolution of the criteria of severity of laryngomalacia.

RESULTS

Twenty-four patients were operated, 1 was excluded due to prior tracheostomy. Twenty-three patients were included, the median age at the time of surgery was 5.5 months. All the patients had stridor, 87% presented feeding difficulties, 34.8 % had cyanosis and 21.7% had failure to thrive. Six cases had congenital anomalies and four cases had nongenetic comorbidities. Fifteen patients (65.2%) had synchronous airway lesions. 17.4% had type I laryngomalacia and 82.6% were type 2. The postoperative average hospital stay was 1.3 days. The average follow-up was 14 months and no complications were reported. The overall success rate of surgery was 95%.

CONCLUSIONS

Patients with laryngomalacia and any symptom of severity should undergo a full airway evaluation, to rule out synchronous airway lesions, and supraglottoplasty if needed, as it has been shown to be a safe and effective technique for the management of these patients.

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.

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.

Laser supraglottoplasty for laryngomalacia; a 14 year experience of a tertiary referral center

To review the outcomes of laser supraglottoplasty performed in children with symptomatic laryngomalacia and determine the factors influencing them. We retrospectively reviewed the medical records of patients who underwent laser supraglottoplasty for symptomatic laryngomalacia at the Lausanne University Hospital from November 2001 to November 2014. We examined the patient's demography, symptoms, comorbidities, type of laryngomalacia, synchronous airway lesions, and final outcomes. Seventy-nine patients were included in this study; median age at the time of surgery was 12.7 months. 55.7 % of the cases had comorbidities, 22.8 % of the patients were premature and synchronous airway lesions were present in 32.9 % of the cases. The different morphological types of laryngomalacia (I-III) were seen in 26.6, 62 and 11.4 % of the patients, respectively. Overall, operation specific success rate of laser supraglottoplasty was 86.1 %. Failures in 11 (13.9 %) of the 79 cases required 15 revision procedures. Success rates for patients with associated comorbidities, synchronous airway lesions, neurological disorders and prematurity were 81.8, 76.9, 69.2 and 66.7 %, respectively. Patients with type III laryngomalacia had a limited success rate (66.7 %) as compared to patients with morphological types I and II (90.5 and 87.8 %, respectively). Laser supraglottoplasty is an effective and safe treatment for symptomatic laryngomalacia. Patients with prematurity, type III LM, synchronous airway lesions and associated comorbidities are predisposed to surgical failure.

A systematic review of the evidence on spontaneous resolution of laryngomalacia and its symptoms

INTRODUCTION AND OBJECTIVES

Laryngomalacia (LM) is the most common cause of congenital stridor. Tradition holds that the majority of patients resolve spontaneously by 12-18 months of age. The objective of this study was to systematically review the literature on the spontaneous resolution of LM and/or its presenting symptoms, in otherwise healthy infants.

METHODS

Data sources included Medline/PubMed, EMBASE, Scopus, CINAHL, Proquest, Cochrane database, Cochrane Methodology Register, Web of Science Conference Proceedings Citation Index, and ACP Journal Club. Study inclusion criteria included participants with an endoscopic diagnosis of LM, and symptoms of stridor, swallowing dysfunction, and/or snoring/sleep-disordered breathing, that documented subjective or objective resolution endpoints. Surgical series, case reports, and narrative reviews were excluded. Studies with insufficient follow-up (<3 months), and patients with comorbidities without subgroup analysis were excluded. Two independent reviewers extracted follow-up duration, rate of retention, time to resolution of LM, and method of documentation of resolution.

RESULTS

Of the 1146 articles identified, three met inclusion/exclusion criteria (n=411 patients). All were retrospective and used stridor resolution as the only endpoint. Resolution rate was 89%, with time to resolution ranging from 4 to 42 months. Level of evidence was low, and studies suffered from lack of follow-up, and no objective endpoints. Meta-analysis was not possible.

CONCLUSIONS

Endoscopic evidence of the natural history of laryngomalacia and its resolution is lacking. Low level of evidence supports that stridor and respiratory distress resolve, but the range of the time to resolution and rate of resolution is wide. Other clinical manifestations have not been studied. Prospective longitudinal trials are required to better understand the natural history.

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.

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.

Supraglottoplasty for sleep endoscopy diagnosed sleep dependent laryngomalacia

OBJECTIVES

To evaluate the polysomnographic outcomes of supraglottoplasty (SGP) performed for sleep endoscopy diagnosed sleep dependent laryngomalacia as treatment for obstructive sleep apnea syndrome (OSAS).

METHODS

Nine subjects aged 6-55 months underwent supraglottoplasty for sleep dependent laryngomalacia. All subjects underwent both pre- and post-procedural polysomnograms.

RESULTS

Supraglottoplasty for sleep dependent laryngomalacia resulted in improvement of OSAS as measured by collective improvements in 8 different primary polysomnogram parameters: apnea-hypopnea index (AHI), minimum (nadir) and mean oxygen saturation, mean and maximum carbon dioxide, total sleep time, sleep efficiency, arousal index, as well as improvement in weight for length percentiles. Subjects had a significant 80% decrease in percentage change in AHI (p<0.005), with decrease in mean AHI from 23.4 to 4.8 following supraglottoplasty. Seven of 9 subjects demonstrated improvement in nadir saturations, 6 of 9 subjects had improvement in sleep efficiency, and 7 of 8 subjects under 4 years of age had improvement in weight for length percentile.

CONCLUSIONS

Supraglottoplasty for sleep dependent laryngomalacia is an effective treatment of OSAS, and can be readily diagnosed using sleep endoscopy. Further investigation is warranted to increase awareness and outcomes related to sleep dependent laryngomalacia.

Laryngeal schwannoma treated with a CO2 laser: A case report

Laryngeal schwannoma is a rare benign tumor of the larynx, with a high recurrence rate. The present study reports the case of a 36-year-old male patient with a two-week history of hoarseness. Electronic laryngoscopy revealed that there was a submucosal mass at the level of the right supraglottic area. A computed tomography scan of the larynx showed an 8×11-mm expansile mass in the right supraglottic area. Histopathological examination diagnosed a schwannoma of the larynx. The tumor was removed by CO₂ laser through an endoscopic transoral approach. One year later, the patient remained symptom-free and direct examination of the larynx showed no signs of recurrence. The aim of the present study is to highlight this rare disease and its management options to the otolaryngological community.

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.

[Management of stridor]

Pediatric stridor is usually due to benign laryngomalacia. This pathology of unknown origin usually heals spontaneously during the first 18 months of life. Mild laryngomalacia is characterized by normal weight growth, the absence of sleep apneas and of associated swallowing or neurological disorders. Medical treatment is sufficient to release symptoms. Severe clinical forms are more rare, representing about 10 % of cases. They require an endoscopic evaluation of the upper airway under general anesthesia, as well as an endoscopic suppraglottoplasty. Non-invasive ventilation is an interesting additional tool in case of surgical failures or in some infants with comorbid conditions.

Thyroglossal duct cyst accompanied by laryngomalacia and pulmonary sequestration

A 2-month-old full-term female infant developed nasal stridor, which progressed to respiratory distress and poor sucking ability. Direct pharyngoscopy showed laryngomalacia and a midline cystic mass in the lingual region. The mass pressed on the epiglottis, causing dyspnea. Computed tomography incidentally revealed extralobar pulmonary sequestration. Direct deroofing of the lingual cyst and plication of the epiglottis were performed at 3 months of age, and the patient recovered from the respiratory distress. Histopathology of the cystic mass showed a thyroglossal duct cyst. Thoracoscopic resection of the pulmonary sequestration was then done at 17 months of age. Thyroglossal duct cysts in the lingual region may cause destabilization of the epiglottis and laryngomalacia, resulting in acquired respiratory obstruction. The combination of thyroglossal duct cyst, laryngomalacia, and pulmonary sequestration is rare; therefore, reports must be accumulated in order to explore the embryological origins of such cases.