unknown_mediumLaryngomalacia is the most frequent cause of stridor or noisy breathing in infants. It occurs as a result of a floppy portion of the larynx (voice box) that has not yet developed the strength to provide rigid support of the airway. During inspiration, negative pressure is created through the larynx, which results in a collapse of these structures into the airway and a narrower breathing passage. The partial obstruction is the source of the noise with breathing.

The hallmark sign includes a high pitched or squeaky intermittent sound noted mostly on inspiration. It is usually more prominent when the infant is lying on his/her back, crying, feeding, excited or has a cold. This is usually first noticed in the first few weeks of life. It may worsen over the first few months and become louder. This is because as the baby grows, the inspiratory force is greater, which causes greater collapse of the laryngeal structures into the airway. This is usually at it’s worst at 3-6 months and then gradually improves as the rigidity of the cartilage improves. Most children are symptom free by 12 months.

It is usually a self-limited condition, but it can be associated with gastroesophageal reflux, neuromotor disease, and obstructive apnea.  Infants with severe laryngomalacia may require supraglottic surgery to prevent the consequences of neonatal upper airway obstruction.

Holinger described several patterns of inspiratory supraglottic collapse, one or more of which are found in each infant with laryngomalacia: inward aryepiglottic fold collapse (type 1), tubular epiglottic shape (type 2), anterior-medial collapse of the arytenoids (type 3), posterior epiglottic displacement (type 4), short aryepiglottic folds (type 5), and an acutely angled epiglottis at the petiole (type 6).

The mainstay of surgical treatment has been resection of the aryepiglottic fold.[1,3] Resection of a portion of the aryepiglottic fold has been shown to be effective,[6] but simple incision of the aryepiglottic fold improved almost 90% of children with severe laryngomalacia in one series.[7]The need to lengthen the aryepiglottic fold is highlighted by Manning and colleagues,[8] who found lower aryepiglottic fold length-glottic length ratios in children requiring surgery for laryngomalacia when compared with controls.

Supraglottoplasty has been performed with “cold” microsurgical instruments and the CO2 laser.[9]Supraglottic stenosis and interarytenoid adhesion have been described as complications, scarring that has a much poorer prognosis than laryngomalacia itself. Kelly and Gray used unilateral supraglottoplasty as a means of reducing the potential for such complications, although staged surgery on the second side was required in 3 of their 18 patients.[10] Conservative, precise tissue division or removal seems prudent.

Todd Files — Laryngomalacia

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