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

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.

Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis

OBJECTIVES

To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI).

RESULTS

100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment.

CONCLUSIONS

Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.

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.

Efficacy and predictors of success on laryngomalacia surgery: experience from a tertiary pediatric care center in Brazil

OBJECTIVES

Laryngomalacia is the most common congenital cause of stridor; the natural history of the disease runs through to complete resolution by the age of two. Severe cases are characterized by cyanosis, hypoxia, apnea, furcular and/or subcostal retractions, aspirations, pulmonary hypertension, and failure to thrive and must undergo surgery. This study aimed to evaluate the success rates of supraglottoplasty in our hospital and evaluate the predictive factors for surgical success.

METHODS

Cohort study, prospectively planned. 75 patients undergoing endoscopic surgery from July 2007 to July 2016 were analyzed at the Santo Antônio Children's Hospital. The primary outcome was percentage of surgical success, defined as the absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative month (late success). The secondary outcomes were the early surgical success (absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative day).

RESULTS

39 (58.2%) were male, with an average of 4.9 months. Surgical success on the first day was 80.6% (n=54). At the end of the 1st month, surgical success was 88.6%, considering only those who completed assessment. Twenty-one (34%) presented comorbidities. Presence of comorbidities, pharyngomalacia and GERD were associated with a worse result on the 1st postoperative day, whereas, at the end of the first month, presence of comorbidities, concomitant injuries (tracheo and bronchomalacia) and pharyngomalacia were the predictive variables of surgery failure.

CONCLUSION

Supraglottoplasty has high rates of efficacy and low morbidity. The presence of comorbidities and pharyngomalacia has shown association with a worse early and late surgical outcome. Synchronous airway lesions predict a worse surgical result at the end of the first month. GERD was associated with obstructive symptomatology only in the 1st post-operative day.

LEVEL OF EVIDENCE

Level 3 of evidence, according to the "The Oxford 2011 Levels of Evidence" from Oxford Centre for Evidence-Based Medicine.

Supraglottoplasty for severe laryngomalacia can be effective and safe also in children with high-risk comorbidities - Experience from a tertiary center

OBJECTIVES

Supraglottoplasty (SGP) for severe laryngomalacia (LM) in children with medical comorbidities has been associated with high risk of surgical failure and increased need of postoperative pediatric intensive care unit (PICU) intervention, but evidence for this is ambiguous. The objective was to evaluate surgical outcome and risk of need for PICU-intervention following SGP for severe LM in comorbid patients.

METHODS

Retrospective observational study of 116 patients treated with SGP for severe LM between 2000 and 2021 at a tertial referral pediatric airway surgery center Karolinska University Hospital. Medical records were reviewed and patient data regarding surgical timing, type of SGP procedure, PICU-intervention, complications, and outcomes were recorded. Patients were defined as non-comorbid vs high-risk comorbid (HRC) based on a coexisting comorbidity for risk of surgical failure and postoperative PICU-intervention. Surgical failure was defined as need of revision surgery, tracheostomy or assisted ventilation (continuous positive airway pressure and bilevel positive airway pressure). PICU intervention was defined as need of postoperative assisted ventilation or intubation. Statistical comparisons were performed with outcome of SGP on children with LM and no comorbidities.

RESULTS

41/116 patients included had a HRC associated with an increased risk of PICU-intervention and surgical failure. 75/116 patients were defined as non-comorbid. The overall surgical success in the study population was 89.7% (104/116), 94.7% in the non HRC group vs 80.5% in the HRC-group. 5/41 HRC patients and 1/75 non-comorbid patients needed SGP revision in which 5/6 was successful. There was no significantly increased need for postoperative PICU intervention in HRC patients.

CONCLUSION

SGP for severe LM patients with high-risk comorbidities performed in a tertiary setting had an overall good result and low risk of PICU-intervention. Revision SGP was more common in HRC patients but had a good outcome. Multidisciplinary experience in perioperative care of comorbid patients may be of key importance for outcome and children with high-risk comorbidities should thus not be withheld the possible benefit of SGP without assessment at a tertiary pediatric airway center.

Patterns of airway obstruction of non-acquired origin in children with and without major congenital anomalies

Major congenital anomalies are known to play a role in the management and prognosis of airway obstruction. Most studies assess acquired forms of airway obstruction. Data on congenital or otherwise non-acquired forms of airway obstruction is sparse. In this retrospective, single-institution cohort study, we sought to evaluate and compare the patterns of airway obstruction in children with and without major congenital anomalies, and to assess the impact of management and outcome, irrespective of aetiology. Fifty-five patients were included, 23 with and 32 without underlying major congenital anomalies. Multilevel airway obstruction (usually affecting the nasopharynx, oropharynx, and the trachea) was more common in children with congenital anomalies (91% vs. 41%, p < .001). Consequently, these children required more frequent and earlier surgical management, especially tracheostomy and adenotonsillar surgery.Conclusions: Major congenital anomalies are associated with multilevel airway obstruction and poor functional prognosis. A simple clinical definition considering impact of major congenital anomalies on development and growth may help guide management plans following endoscopic evaluation of the entire airway and flanked by multidisciplinary discussions. What is Known: • Children with major comorbidities display increased disease severity and more prevalent multilevel airway obstruction • Previous studies include both children with acquired and non-acquired forms of airway obstruction; therefore, the actual impact major comorbidities in children with non-acquired causes of airway obstruction remain unclear. What is New: • A total of 42% children in this study population had major comorbidities with and impact on growth and/or psychomotor development, with a higher prevalence of multilevel airway obstruction and worse rates of functional improvement/recovery. • Children with major comorbidities require tracheostomy more often and earlier than those without major comorbidities, and remain tracheostomy-dependent for a longer time.

Coblation supraglottoplasty: a ten-year experience in a tertiary referral hospital

PURPOSE

The present study aims to review the outcomes of coblation supraglottoplasty performed for children with different types of laryngomalacia, and we discuss the factors affecting these outcomes.

METHODS

We retrospectively reviewed the medical records of laryngomalacia patients admitted to the Otorhinolaryngology Department, Mansoura University, from 2010 to 2020. We examined the patient's demography, symptoms, comorbidities, type of laryngomalacia, oxygen saturation, and final outcomes.

RESULTS

Our study included 235 patients; 122 patients responded to medical therapy, while 113 underwent surgical management. There is a significant relation between the types and therapy they underwent (p ≤ 0.001). Larger percentage within type I underwent medical therapy. There is a statistically significant difference between the studied groups regarding age at surgery. On pairwise comparison, patients with type II had the lowest age significantly at the surgery when compared with each other individual group (p ≤ 0.001). On multivariate regression analysis, the presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention by 17.32 and 5.803 folds, respectively.

CONCLUSIONS

Coblation supraglottoplasty is effective and safe to treat severe laryngomalacia. Different morphological types of laryngomalacia require slight surgical variations of coblation supraglottoplasty. The presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention.

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.

Supraglottoplasty in the management of laryngomalacia in children with down syndrome: A systematic review

INTRODUCTION

Children with Down syndrome (DS) who have Laryngomalacia represent a specific management challenge due to their inherent multiple levels of airway obstruction and hypotonia. Therefore, the purpose of this study is to determine the outcome of supraglottoplasty (SGP) in children with DS.

DATA SOURCE

A systematic review was performed following the PRISMA guideline. Data were collected from online medical databases- CINAHL, Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid MEDLINE in process, PubMed, and Scopus.

REVIEW METHODS

all publications that address the outcome of supraglottoplasty in children who are less than 18 years old with Down syndrome prior to December 2018 were collected. The data were collected on different phases: Screening review using search words and controlled vocabularies during the period of November-December 2018, followed by a detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles.

RESULTS

Nine articles were included in the qualitative analysis. These articles included 231 subjects, out of which 32 children with DS met the inclusion criteria. Twenty patients (62.5%) were considered successfully treated and 12/32 failed including 1/32 (3.1%) mortality in the postoperative period. The duration of follow-up was 12-102 days. All of the patients whose treatment failed had significant comorbidities.

CONCLUSION

Although the success of SPG in children with DS is less than in otherwise healthy children, it remains an option especially in patients without comorbidities. Preoperative counseling of the families and thorough assessment are necessary to determine candidacy for SPG in children with DS.

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.

One and half coblation supraglottoplasty: A novel technique for management of type II laryngomalacia

OBJECTIVES

Endoscopic supraglottoplasty is the mainstay surgical procedure in treatment of laryngomalacia. Various instruments have been used with coblation recently gaining widespread attention. Regarding the technique used, cutting the aryepiglottic folds is associated with rapid improvement but carries risk of restenosis while outer scar contracture method has delayed but established result. Therefore, this study was conducted to introduce a modified coblation supraglottoplasty technique gathering both benefits and evaluate its results and effectiveness.

METHODS

Retrospective study included patients diagnosed with type II laryngomalacia was conducted. Supraglottoplasty was done by "one and half coblation supraglottoplasty" technique which involves cutting of one aryepiglottic fold while the other one is laterally coagulated. Patients' basic and clinical data were assessed. Outcome measures included assessment of inspiratory stridor, failure to thrive, choking, cyanosis, lowest oxygen saturation levels and weight gain.

RESULTS

Seventeen patients were included in this study with a mean age of 3.71 ± 1.1 months. Significant statistical improvement was reached regarding stridor, failure to thrive and cyanosis. Also, minimal oxygen saturation and weight gain were significantly improved. None of the cases needed tracheostomy and no major postoperative complications occurred.

CONCLUSION

We conclude that "one and half coblation supraglottoplasty" is an effective and safe treatment for type II laryngomalacia with satisfactory outcomes.

LEVEL OF EVIDENCE

IV.

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.

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

INTRODUCTION

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

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

Epiglottopexy by external puncture for epiglottic prolapse in severe laryngomalacia. A novel technique

INTRODUCTION

Laryngomalacia (LM) is the first cause of stridor in infants. 10 to 20% of patients with LM may require surgery due to the development of severe symptoms. Supraglottoplasty is the most commonly performed surgery for severe LM. However, it is insufficient for the rostrocaudal displacement of the epiglottis against the posterior pharyngeal wall.

CASE SUMMARY

We report a case of a 2-month-old infant with severe laryngomalacia with a remarkable collapse of the epiglottis towards the glottis with secondary obstruction of the airway, alteration in swallowing and failure to thrive. The patient was treated satisfactorily through epiglottopexy by an external puncture. During a follow-up of 2 years, the patient has been asymptomatic, without any adverse event.

DISCUSSION

Glottic obstruction from posterior epiglottic collapse is the most severe type of laryngomalacia, generating severe respiratory symptoms and failure to thrive. Epiglottopexy by external puncture is a new technique, certainly affordable since it does not require special instruments and it can be performed in medical centers through suspension laryngoscopy. It can be achieved alone or in combination with traditional supraglottoplasty.

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.

Topical Lidocaine Does Not Exaggerate Laryngomalacia in Infants During Flexible Bronchoscopy Under Propofol Anesthesia

BACKGROUND

Topical lidocaine has been found to result in overestimation of the severity of laryngomalacia in infants undergoing flexible bronchoscopy under conscious sedation with midazolam and nalbuphine. This effect has never been confirmed and may depend on the level of sedation and the drugs used. We assessed the effect of topical lidocaine on laryngomalacia in infants undergoing flexible bronchoscopy under general anesthesia with propofol.

METHODS

Thirteen infants with congenital stridor referred to diagnostic flexible video-bronchoscopy were studied under propofol anesthesia before and 3 minutes after topical lidocaine administration to the larynx at a dose of 3 mg/kg body weight. Laryngomalacia was scored using 60 seconds video recordings of the larynx before and after lidocaine administration in random order by 2 independent blinded observers using the previously described arytenoid score (AS), epiglottis score (ES), and the total score (TS=AS+ES).

RESULTS

No significant differences in AS, ES, and laryngomalacia score were found between the prelidocaine and postlidocaine assessments by the 2 raters. The intraclass correlation coefficients were 0.995 (95% confidence interval, 0.986-0.998) and 0.975 (0.930-0.991) and 0.989 (0.971-996) for AS, ES, and TS, respectively.

CONCLUSIONS

The assessment of laryngomalacia is not affected by topical lidocaine under propofol anesthesia. The lidocaine effect on laryngomalacia may vary depending on the medication regime used and the depth of procedural sedation.

Laryngomalacia: Our Clinical Experience

Objective

The aim of this study is to analyse the clinical symptoms, follow-up and treatment properties of the laryngomalacia patients that we encountered between 2009 and 2014.

Methods

Records of 81 laryngomalacia patients who were followed up in our clinic between 2009 and 2014 were retrospectively analysed. Patients' gender, age, time of onset of the symptoms, chief complaints, other co-existing congenital laryngeal anomalies and treatment and follow-up properties were evaluated.

Results

Of the 81 patients, 48 were male and 33 were female, and the mean age was 4.9 months. The average period of follow-up was 12.1 months. The chief complaints at the time of admission were stridor (100%) and episodic cyanosis with feeding (27.16%). Symptoms of 75 patients were resolved at an average of 8.2 months with conservative treatment. Three patients underwent supraglottoplasty. Tracheotomy and posterior cordotomy was performed for a patient with co-existing vocal cord paralysis. Additional tracheotomy was necessary for a patient with pulmonary co-morbidities and for another with co-existing subglottic stenosis.

Conclusion

Laryngomalacia is the most common cause of stridor in infants. The majority of laryngomalacia patients can be managed conservatively by close follow-up. For patients in whom respiratory and feeding problems persist or growth retardation develops, surgical treatment is performed. Tracheotomy may be necessary for a small group of patients with additional diseases.

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.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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