- 1. DEAPCIT apporach toLaryngomalacia (LM)Hamilton registrar
conference 2012 Angus Shao
2. Definition Congenital laryngeal anomaly of the newborn
characterised by flaccid laryngeal tissue and inward collapse of
the supraglottic structure leading to upper airway
obstructionJackson C, Jackson C. Diseases and injuries of the
larynx. New York: MacMillan; 1942. p.639 3. Epidemiology commonest
cause (~ 65%) of stridor in infants (17% have another intercurrent
airway lesion) may occur in older children & adults more common
in male and term baby Association with other syndromes and
neurologically-impaired (e.g. cerebral palsy) 4. Aetiology
?Cartilage immaturity?Anatomic abnormality?Neuromuscular
immaturity?Inflammatory 5. Anatomic abnormality LM is a result of
the exaggeration of an infantile larynx (Iglauer1922)May or may not
be an important factor since stridor is not seen in all infants
with omega epiglottisBelmont JR, Grundfast K.. Congenital laryngeal
stridor (laryngomalacia): etiologic factors and associated
disorders. Ann Otol Rhinol Laryngol. 1984 Sep-Oct;93(5 Pt 1):430-7.
6. Anatomic abnormality Shortening of aryepiglottic folds and
anterior collapse of cuneiform and corniculate cartilage
Prospective case-control by Manning et al created a ratio of
aryepiglottic fold length to glottic length Severe laryngomalacia =
0.380 Control = 0.535Manning SC, Inglis AF, Mouzakes J, Carron J,
Perkins JA. Laryngeal anatomic differences in pediatric patients
with severe laryngomalacia. Archives of Otolaryngology Head and
Neck Surgery. 2005 Apr; 131 (4): 340-3. 7. Neurologic immaturity
Immature neuromuscular control and movement result in neuromuscular
hypotonia LAR (laryngeal adductor reflex) Vagal mediated SLN
Receptors at aryepiglottic fold Altered laryngeal tone and
sensorimotor integrative function weak tone Dana M. Thompson.
Laryngoalacia: factors that influence disease severity and outcome
of management. Current opinion in Otolaryngology&Head and Neck
Surg. 2010, 18: 546-570. 8. inflammatory Reflux can induce
posterior supraglottic oedema and secondarily LM 65-100% of infants
with LM have GORD Not clear whether GORD is a cause or an effect of
laryngomalaciaDana M. Thompson. Laryngoalacia: factors that
influence disease severity and outcome of management. Current
opinion in Otolaryngology&Head and Neck Surg. 2010, 18:
546-570. 9. Clinical Stridor is the hallmark of congenital LM
Feeding symptoms lower pitched, inspiratory, worsens with
agitation, crying, feeding or in the supine position median time to
spontaneous resolution of stridor is 9 months of age, and 75% will
have no stridor by 18 months of age Choking, coughing, prolonged
feeding time, recurrent emesis, dysphagia, weight lossFTT,
Aspiration, Apnoea, Hypoxia, Recurrent cyanosis, Cor-pulmonale 10.
Classification Several classification systems have been proposed
with none being predominant at this time Olney DR, Greinwald Jr JH,
Smith RJ, et al: Laryngomalacia and its treatment. Laryngoscope
1999; 109:1770-1775. Chen JC, Holinger LD: Congenital laryngeal
lesions: pathology study using serial macrosections and review of
the literature. Pediatr Pathol 1994; 14:301-325. Shah UK, Wetmore
RF: Laryngomalacia: a proposed classification form. Int J Pediatr
Otorhinolaryngol 1998; 46:21-26. 11. Based on
symptomatology/flexible laryngoscopy Mild Moderate SevereBased on
mechanism of collapse Anterior: epiglottis Posterior: arytenoid
Lateral: AE fold 12. Investigation Flexible fibreoptic laryngoscopy
Age range Good for dynamic assessment May avoid needing formal
endoscopy/GA Unable to assess lower airwayMicrolaryngoscopy and
Bronchoscopy Gold standard GA required (Rigid endoscopes) Dynamic
assessment can be more difficult Allows complete structural &
dynamic view Better control of airway cf flexible endoscopy 13.
Investigation Other Adjuncts: FEES (videofluroscopy) Chest X-ray to
r/o aspiration Oesophagram Extent and degree of reflux r/o
concomitant GI disorder pH study if Nissens surgery is
necessarySleep study to document severity of apnea in severe LM and
in surgical failures 14. Treatment Observation Medical Empiric
reflux acid suppression Feeding modifications Posture
repositioningSurgicalSupraglottoplasty Epiglottopexy Tracheostomy
Thompson DM. Abnormal sensorimotor integrative function of the
larynx in congenital laryngomalacia: a new theory of etiology.
Laryngoscope 2007;117:133. Giannoni C, Sulek M, Friedman EM, et al.
Gastroesophageal reflux association with laryngomalacia:a
prospective study. Int J Pediatr Otorhinolaryngol 1998;43:1120. 15.
Surgical intervention 16. Indication Absolute Cor pulmonale Hypoxia
Apnea Recurrent cyanosis Failure to thrive Pectus excavaium Stridor
with respiratory compromise Stridor with significant retractions
Relative Aspiration Difficult-to- feed child who has failed medical
intervention Weight loss with feeding difficultyRichter GT,
Thompson DM. The surgical management of laryngomalacia. Otolaryngol
Clin North Am. 2008 Oct;41(5):837-64, vii. 17. Supraglottoplasty
18. Thank you
