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TITLE: Treatment of Laryngomalacia SOURCE: Grand Rounds Presentation, UTM , !e"t# of Otolaryngology !$TE: %une &', ())' RESI!

E*T P+,SICI$*: Garrett $# +au"tman, M! -$CULT, P+,SICI$*: Matt.e/ 0# Ryan, M! SERIES E!ITORS: -rancis # 1uinn, %r#, M! and Matt.e/ 0# Ryan, M!
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/ ead and !ec" #urgery and was not intended for clinical use in its present form$ %t was prepared for the purpose of stimulating group discussion in a conference setting$ !o warranties& either e'press or implied& are made with respect to its accuracy& completeness& or timeliness$ The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion$"

Stridor is a harsh, high-pitched musical sound that results from turbulent airflow through the upper airway. Evaluation of stridor is dependent upon the clinical situation, as the underlying etiology may range from mild illness to a severe and life-threatening situation. When considering a pediatric patient, it should be noted that eighty-five percent of children under the age of 2.5 years presenting with stridor have a congenital etiology. Congenital stridor often times is not present at birth, but will typically present before the age of four months. he remaining cases are accounted for by inflammation, trauma, or foreign bodies. !ediatric stridor has a variable age of onset. he typical patient usually presents with a sudden onset of symptoms. "s a basic guideline, ac#uired stridor is more li$ely than congenital stridor to re#uire airway intervention. When assessing stridor, the location of the turbulent airflow may be determined by the respiratory phase in which the sound is noted. here are three %ones of the airway that are responsible for these sounds- supraglottic, glottic and subglottic, and intrathoracic. Supraglottic obstruction results in a high-pitched, inspiratory stridor. &bstruction of the e'trathoracic trachea, including the glottis and subglottis, is characteri%ed by biphasic stridor with an intermediate pitch. &bstruction of the intrathoracic trachea (including first and second order bronchi) results in e'piratory stridor, or whee%ing. his last area of obstruction is associated with retraction of the sternum, costal cartilage, and suprasternal tissue. he differential diagnosis of noisy breathing in children can be grouped into the anatomic location of the lesion or defect. *nderlying causes can be classified as congenital, inflammatory, neoplastic, neuromuscular, and traumatic. he following is a list of diagnoses depending on the location of the lesion or defect+ • ,ose and nasopharyn'o Congenital+ choanal atresia or stenosis, pyriform aperture stenosis, craniofacial anomalies o -nflammatory+ nasal polyps, rhinitis, retropharyngeal abscess, adenoid hypertrophy o ,eoplastic+ encephalocele, dermoid, glioma o raumatic+ foreign body &ropharyn'.hypopharyn'o Congenital+ glossoptosis.macroglossia, lingual thyroid, vallecular cyst,

foreign body racheobronchialo Congenital+ stenosis. 2ales are affected twice as often as females.• • • • craniofacial anomalies o -nflammatory+ tonsil hypertrophy.saccular cyst o -nflammatory+ epiglottitis. stenosis o -nflammatory+ laryngitis.atresia.euromuscular+ vocal cord paralysis o raumatic+ hematoma. angioneurotic edema o . thymus. asthma o .eoplastic+ mediastinal tumors. -n fact. stenosis o . stenosis Subglottic laryn'o Congenital+ stenosis. papilloma o raumatic+ foreign body /lottic laryn'o Congenital+ web.euromuscular+ hypotonia. foreign body. thyroid. he diagnosis is suspected when inspiratory stridor is auscultated and is confirmed by fle'ible nasopharyngoscopy. fracture. Chest radiographs can aid in evaluation of potential lower respiratory tract anomalies such as innominate artery compression. lymphangioma. laryngeal cleft. 1or completeness. 1urthermore. lymphangioma. bronchitis. 1luoroscopy can demonstrate the collapse of the supraglottic structures with inspiration. retropharyngeal abscess o . tracheal rings. tracheomalacia. papilloma o raumatic+ chondritis. vascular ring. foregut cysts. he stridor is most prominent when the child is in the supine position or when the child is agitated. tracheoesophageal fistula o -nflammatory+ membranous tracheitis. fracture.eoplastic+ hemangioma. and vascular rings. tracheomalacia.eoplastic+ dermoid. neurologic disease o raumatic+ foreign body Supraglottic laryn'o Congenital+ laryngomalacia. "n inspiratory film with nec$ e'tension can show medial and inferiorly displaced arytenoids and epiglottis. ypical stridor associated with laryngomalacia is low in pitch with a fluttering #uality secondary to the circumferential rimming of the supraglottic airway and aryepiglottic folds. -t is often associated with general noisy respiration.eoplastic+ hemangioma. foreign body (tracheal or esophageal) 0aryngomalacia is the most common cause of stridor in infancy. onset of symptoms typically occurs days to wee$s after birth (most commonly within the first two wee$s of life) and they will resolve at twelve to eighteen months of age without intervention. stenosis. laryngocele. 2ore forceable inspiration tends to result in a louder stridor #uality due to greater prolapse and thus greater obstruction. 0aryngomalacia arises from a continued immaturity of the laryn'. lymphangioma o . . we will include radiographic findings. cysts o -nflammatory+ croup. 3adiographic studies can suggest the diagnosis of laryngomalacia. granuloma o . papilloma.eoplastic+ hemangioma. however the mainstay of diagnosis is fle'ible nasopharyngoscopy. Symptoms of laryngomalacia are often not present at birth. stenosis o .web. it is the most common congenital laryngeal anomaly. hemangioma. papilloma o raumatic+ stenosis.

-mmature neuromuscular control and movement has also been thought to impact laryngomalacia. -t is important to note that there is more than one obstructing mechanism in laryngomalacia and .595. tracheotomy was used in this setting. is short aryepiglottic folds. there is an association of gastroesophageal reflu' and laryngomalacia.1le'ible nasopharyngoscopy is best performed in an unanestheti%ed child in an upright position with a 4. hese cartilages are drawn inward during inspiration and open passively during e'piration. 2ultiple factors may contribute to the development of laryngomalacia.9:6. he re#uirement of surgical intervention in patients with laryngomalacia is rare. or a microdebrider to e'cise redundant mucosa and. ype -. "dditionally. !rior to the 45:6s.5mm nasopharyngoscope. and life threatening airway obstruction may necessitate surgical intervention. the strategy has changed to address the area of obstruction directly with a a long. his can be performed by ma$ing use of microlaryngeal an inward collapse of the aryepiglottic folds (mainly the cuneiform and corniculate cartilages). he mean ratio of patients with severe laryngomalacia was calculated to be 6. he rationale for this intervention was that a tracheotomy bypassed the area of obstruction until the supraglottic pathology spontaneously resolved. neurologic. Classic findings with fle'ible nasopharyngoscopy are a cyclical collapse of the supraglottic laryn' with inspiration. " recent article published in "pril 2665 by 7r. he specific ob8ective of the article was to compare the aryepiglottic length in pediatric patients who have severe laryngomalacia and are undergoing aryepiglottoplasty with the aryepiglottic length of a sample of control patients without laryngomalacia. ype . he study design was a prospective case-control. while the mean ratio of control patients was calculated to be 6. Short aryepiglottic folds draw the cuneiform and corniculate cartilages forward over the laryngeal inlet resulting in prolapse during inspiration. cor pulmonale. oday. Severe symptoms such as inability to feed orally. and inflammatory. SC 2anning et al. ype -. he main contributors are thought to be anatomic. hese findings will be reviewed when discussing the five types of laryngomalacia. he aryepiglottic folds are short and often times there is an omega shaped epiglottis. failure to thrive. here are five types of laryngomalacia.laryngomalacia. "lthough laryngomalacia can often ma$e visuali%ation of the vocal cords difficult. ype --. he underlying anatomic pathologies are shortening of the aryepiglottic folds and anterior collapse of the cuneiform cartilages.or cuneiform cartilages as well as releasing the shortened aryepiglottic folds and trimming the lateral edges of the epiglottis. as it is generally a self-limiting anterior. this strategy is only employed in the severely affected infant. ype . evaluated the anatomical impact on laryngomalacia. -nstead. they still must be e'amined. -t should be noted that the vocal cords are mobile in laryngomalacia. he scope should be passed through both nasal passages when e'amining the patient. his often occurs in association with ype . is posterior inspiratory displacement of the epiglottis against the posterior pharyngeal wall or inferior collapse to the vocal folds. medial collapse of the cuneiform and corniculate cartilages to occlude the laryngeal inlet during inspiration. tubular epiglottis which curls on itself and contributes to obstruction during inspiration. 2easurements were compared by creating a ratio of the aryepiglottic fold length (distance from the most anterior arytenoids cartilage to the closest posterior lateral edge of the epiglottic cartilage) to the glottic length (distance from the anterior border of the interarytenoid muscle to the anterior commissure). 3eflu' can induce posterior supraglottic edema and secondarily laryngomalacia. a carbon dio'ide laser.

!ost-operatively. his was done with the patient in the supine position while visuali%ing the laryn' through a laryngoscope. dyspnea at rest and. ?is data included a case series of ten patients.or severe dyspnea during effort feeding difficulties height and weight growth rate stagnation sleep apnea or obstructive hypoventilation uncontrollable gastroesophageal reflu' history of intubation for obstructive dyspnea effort hypo'ia (46C higher than the normal values for the same age group) effort hypercapnia (46C higher than the normal values for the same age group) abnormal polysomnography with an increased apnea. direct laryngoscopy and bronchoscopy must be performed prior to supraglottoplasty to rule out concomitant pathology contributing to the airway obstruction. S -glauer. arytenoids. 3oger established criteria for the definition of severe laryngomalacia+ 4. ?e described a laryngoscopic approach in which redundant mucosa was e'cised from the lateral edges of the epiglottis. and apnea. aryepiglottic folds. inability to view the vocal cords with a fle'ible nasopharyngoscope during inspiration because of laryngeal inlet collapse is a clear indication for surgery. -n this paper. "ntireflu' precautions including both positioning and medication are recommended to minimi%e the raw mucosal surfaces e'posure to gastric secretions. presented epiglottoplasty as a new procedure. -n 45:5. /? @al%al et al. he direct laryngoscopy should be performed when the patient is breathing spontaneously under general anesthesia. 7r. the patients are usually left intubated over night with e'tubation the following morning. et al.when performing supraglottoplasty. he tissue to be e'cised was grasped with cup forceps and trimmed with <ellucci scissors. described a single report of the removal of the corniculate cartilages and redundant arytenoids mucosa in a child with laryngomalacia. 5. and corniculate cartilages. 7r. :. cor pulmonale. 7r. "< Seid et al. -n 45:>. 7r. =. -n 45:=. @al%al reported that Aall patients who underwent epiglottoplasty achieved complete relief from their symptoms with the e'ception of one patient in whom mucosa from the aryepiglottic folds and arytenoids area had not been ade#uately e'cised. "dditionally. 1ailure of the procedure was assigned to two children who needed tracheotomies. / 3oger. >. D. Seven patients re#uired a revision surgery. 5.obstructive hypoventilation inde' he presence of at least three of these criteria was deemed to be a formal indication for . 9. feeding difficulties. When removing tissue.B ?is indications for operating on a patient with laryngomalacia were severe stridor not resolved with time that may be associated with failure to thrive. "lso. as supraglottic stenosis can result from e'cessive tissue removal. described the use of the carbon dio'ide laser for treatment of laryngomalacia in a series of three patients. 2. *nilateral supraglottoplasty should be considered and the second side should be operated on only if symptoms do not resolve. -n 4555. "ntibiotics should be given at least five days post-operatively to prevent infection. published a retrospective study of 445 cases of resection of the aryepiglottic folds with or without a carbon dio'ide laser. 3W 0ane et al. the surgeon should be conservative. <elow is a review of the literature he original description of endoscopic removal of supraglottic tissue with a nasal snare for laryngomalacia was first described in 4522 by 7r. all potential mechanisms should be addressed. 1urther e'cision resulted in complete relief. he success rate was determined to be 5:C with an average follow-up period of thirty months.

Cerebral !alsy. he study design was a retrospective review of eighteen patients with severe laryngomalacia that had undergone unilateral carbon dio'ide laser removal of redundant supraglottic tissue. as well as long term surgical failures all had associated anomalies including "rnold-Chiari. 7r. Surgery was used for treatment of patients that had o'ygen saturation below 52C and feeding difficulties causing failure to thrive. to evaluate different carbon dio'ide laser procedures on children with various types of laryngomalacia and determine the role of associated anomalies on the outcome. 73 &lney et al. 3elief of obstructive symptoms was achieved in 5=C of the patients. 7E 3eddy et al. 7r. " retrospective review was performed in 2664 by SC oynton et al. &lney found that direct laryngoscopy and bronchoscopy as part of the routine evaluation of laryngomalacia is not warranted and should only be performed when there is clinical and physical evidence of a concomitant airway lesion. Conclusions determined by 7r. he one patient without obstructive relief had tracheomalacia secondary to previous tracheotomy for severe laryngomalacia. 7r. he median time to resolution of isolated laryngomalacia was 9D wee$s. evaluated the effectiveness of unilateral endoscopic supraglottoplasty for treatment of severe laryngomalacia in 4555. arytenoids. but children with associated neurological or anatomic anomalies will have a more complicated immediate and short term course. his finding did not vary significantly in infants with severe neurological compromise or in infants with other congenital anomalies. ?owever. " chart review was performed in 2664 by CW Senders et al. performed a retrospective review to evaluate the efficacy of unilateral supraglottoplasty compared to bilateral supraglottoplasty. !atients with slower progression of improvement were found to have a serious neurological condition. as well as a significant incidence of failure. loo$ing at one hundred patients that had endoscopic aryepiglottoplasty performed for severe laryngomalacia. 7r. Senders were that laser supraglottoplasty is a safe and effective treatment for all types of laryngomalacia. and the outcome of supraglottoplasty as a function of the type of laryngomalacia and the presence of concomitant disease. with 55C completely without stridor. Supraglottoplasty was determined to be necessary in appro'imately 45-26C of affected infants which is attributed to episodes of apnea and failure to thrive.inety-four percent of the patients had improvement of their stridor after one month. hree of the eighteen patients re#uired a contralateral supraglottoplasty. wenty-three children were included in a retrospective chart review that underwent carbon dio'ide laser vapori%ation of redundant supraglottic mucosa of the aryepiglottic fold. C?"3/E association. performed a retrospective chart review aimed at determining the airway outcome of infants with laryngomalacia who do not undergo routine direct laryngoscopy and bronchoscopy. and 3ieger syndrome.endoscopic surgery. -n 2664. and the epiglottis. !atients without associated anomalies did well. underlying neurological disease decreases the success rate of operative intervention. Seventy-two percent of patients with preoperative feeding difficulties improved their feeding. with >:C immediately resolving their respiratory symptoms and 466C resolving their respiratory symptoms within a wee$. S2 Eelly et al. and by >2 wee$s. *nfavorable immediate results. -n 4555. his study included 46D . oynton concluded that endoscopic aryepiglottoplasty is the operation of choice for severe laryngomalacia. the age at which laryngomalacia resolves. . >5C of infants were free of stridor.

o complications including . 7enoyelle concluded that supraglottoplasty failed only in patients that had laryngomalacia and additional congenital anomalies. edema or webG and supraglottic stenosis. .or failure to thriveG need for additional treatmentG presence of granuloma. edema or web) occurred in 9. 7r. -n 2662. /? @al%al et al.o patients undergoing unilateral supraglottoplasty developed supraglottic stenosis.=C of patients. sleep apnea. F" Werner et al.patients. isolated posterior displacement of the epiglottis was addressed by 7r. &ne patient re#uired a tracheotomy. he techni#ue involved initially dividing the aryepiglottic fold with microlaryngeal scissors. Subse#uently. his year (2665). .= of which were solely epiglottope'y and 2 of which were combined epiglottope'y with transaction of the aryepiglottic folds. he procedure was performed transorally with a carbon dio'ide laser. "ll si' children demonstrated significant airway improvement without any further stridor. while 22C showed partial resolution of stridor with no further surgical intervention re#uired. ?e reported on a series of five patients that had been diagnosed with sever laryngomalacia and underwent a microdebrider-assisted supraglottoplasty. minor complications (granuloma. psychomotor retardation. miscellaneous). it was removed with the microdebrider. -f redundant supra-arytenoid mucosa was identified. -t was also noted that deglutition was not affected by this procedure. 462 of which had isolated laryngomalacia and 9= of which had additional congenital anomalies (!ierre 3obin. 3eddy recommended that unilateral supraglottoplasty is a reasonable initial surgical management of pediatric patients with severe laryngomalacia. 7 0o$e et al. he failures and complications of supraglottoplasty were analy%ed in 2669 by 7r. 1ailure or only partial improvement of symptoms was only seen in patients with additional congenital anomalies (:.55 patients undergoing bilateral supraglottoplasty and => patients undergoing unilateral supraglottoplasty as the initial surgery. 1ifteen percent of the patients that had unilateral supraglottoplasty performed needed an additional contralateral procedure performed for resolution of symptoms. 7r. Si' patients underwent epiglottope'y. and. performed a retrospective review in 2664 that e'amined the outcome of 92 cases of severe laryngomalacia that underwent a simple division of the aryepiglottic folds. Si' percent re#uired one additional procedure which included more e'tensive e'cision of redundant mucosa. 7r. -t was concluded that endoscopic e'cision of the aryepiglottic folds is highly effective and should be the first-line treatment for severe laryngomalacia. 7own syndrome.>C of patients and supraglottic stenosis occurred in =. 1 7enoyelle et al. Surgical success was defined as the resolution of clinically significant laryngomalacia and was reported to approach 5DC in this study.=C of patients. by performing an epiglottope'y for the treatment of severe laryngomalacia. C?"3/E association. the folds are resected with the microdebrider with tissue removal e'tended anteriorly to the lateral edge of the epiglottis and posteriorly to the arytenoids cartilage. wo patients (9C) that underwent bilateral supraglottoplasty initially developed supraglottic stenosis.:C). he need for revision surgery was =. he study design was a retrospective review that included 49D patients. presented a new approach to supraglottoplasty by ma$ing use of the microdebrider. "ppro'imately D5C showed complete resolution of stridor and associated complications of laryngomalacia. 7r. &utcome measures included persistence of dyspnea. "ll five patients had resolution of their stridor postoperatively. he complication rate was found to be similar between isolated laryngomalacia and patients that had laryngomalacia with additional congenital anomalies.

it must be decided if there are associated congenital anomalies that could impact the success of the surgery. 1urthermore. laryngomalacia tops the differential diagnosis. -t is established that the ma8ority of symptoms of laryngomalacia resolve without intervention by the ages of twelve to eighteen months. When evaluating an infant that presents with stridor. he otolaryngologist must decide if the associated symptoms 8ustify operative intervention. .supraglottic stenosis have been identified and no revision surgeries have been performed. -f surgical intervention is pursued. all potential mechanisms contributing to laryngomalacia should be addressed.

4555 . 45:5G 46+$ Surgery. 2665 "prG 494 (=)+ 9=6-9. 45:=G 446+ 5=D-54. @al%al /?. "rchives of &tolaryngology ?ead and . Senders CW. 0aryngeal anatomic differences in pediatric patients with severe laryngomalacia. 2669 &ctG425 (46)+ 46>>-:6. 0indley E. Weider 7F. 2ancuso 31. 4555+ =5>-564. 2ou%a$es F. -nternational Fournal of !ediatric &torhinolaryngology. !ractical !ediatric &tolaryngology. Carron F. 4522G 92+ 5D-55. 2att <?. "rchives of &tolaryngology ?ead and . 2ondain 2. "ryepiglottoplasty for laryngomalacia+ 466 consecutive . "rchives of &tolaryngology ?ead and . 2664 FunG 42> (D)+ D5=-5. 0aryngomalacia+ he search for the second lesion. . 0aser division of the aryepiglottic folds for severe laryngomalacia. 2664 Ful 96G D6 (4)+ 55D9. "rchives of &tolaryngology ?ead and . -glauer S. *nilateral$ Surgery. 2anning SC. 455D 2arG 422 (9)+ 962-D. !er$ins F". bilateral supraglottoplasty for severe laryngomalacia in children. with report of a$ Surgery. !anarese ". 3oger /. -nternational Fournal of !ediatric &torhinolaryngology. 3oger /.. Cotton 3 . Seid "<. /arabedian E. !ierro "$ Surgery. 2669 FanG D> (4)+ 44-=. riglia F2. 0ane 3W. 2664+ 562-9. 0aryngoscope. oynton SC. 0o$e 7. 1ailures and complications of supraglottoplasty in children. 4555 &ctG465+ 4444->.Bibliography <ailey <F. <auman . Epiglottidectomy for the relief of congenital laryngeal stridor. 0aryngoscope. Choi SS. <ull !7. Saunders$ Surgery H &tolaryngology 9rd Edition. Endoscopic division of the ary-epiglottic folds in severe laryngomalacia. Chaudre 1. 7enoyelle 1. /hosh S. "rchives of &tolaryngology ?ead and . ?adfield !F. Severe laryngomalacia+ surgical indications and results in 445 patients. /rundfast E2. /arabedian E.avarrete E/. Steinem$ Surgery. <ailey C2. he effect of aryepiglottoplasty for laryngomalacia on gastro-oesophageal reflu'. !ar$ S2. &lney 73. /ugeheim S.2. 0aryngoscope. Eearns 2F.ovG 465 (44)+ 4>>6-5. /reinwald F? Fr. -nternational Fournal of !ediatric &torhinolaryngology. 0aryngomalacia+ a review and case report of surgical treatment with resolution of pectus e'cavatum.. "lbert 72. /resillon . -nglis "1. 0aser supraglottoplasty for laryngomalacia+ are specific anatomical defects more influential than associated anomalies on outcomeI -nternational Fournal of !ediatric &torhinolaryngology. 3eddy 7E. <ailey C2. 7enoyelle 1. Smith 3F. ?ead and . 0aryngomalacia and its treatment. 2arin-!adella 2. 2664 2arG 5> (9)+ 295-==.

Cotton 3 . -ndian Fournal of !ediatrics. @al%al /?. 2665 2arG D5 (9)+ 965-5. 3hinology.en$ata$arthi$eyan C. "non F<. . and 0aryngology. Collins W&. Endoscopic correction of severe laryngomalacia.cases. @al%al /?. 0ippert <2. 45:>G 5D+ >2-D. Werner F". -nternational Fournal of !ediatric &torhinolaryngology. Fournal of 0aryngology and &tology. 1ol% <F. "n$ermann . "nnals of &tology. 2665 1ebG >2 (2)+ 4D5-:. Epiglottope'y for the treatment of severe laryngomalacia. Seyberth ?. 7unne "". 2664 FanG 445 (4)+ 95-:. 0odha 3. Epiglottoplasty for the treatment of laryngomalacia. 2icrodebrider-assisted supraglottoplasty. European "rchive of &torhinolaryngology. 2662 &ctG 255+ =55-D=. ha$ar ". .