4/18/2015
Laryngomalacia
Diagnosis & Management
Prof. Alaa Gaafar, MD
Otolaryngology – H&N Surgery Department
A l e x a n d r i a U n i v e r s i t y, E g y p t
Infantile Larynx
Adult Larynx
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Laryngomalacia
Laryngo = larynx, malacia = abnormal flaccidity.
Collapse of the supraglottic components during
inspiration:
 Epiglottis.
 Aryepiglottic
folds.
 Arytenoids.
Types
 Infantile Laryngomalacia:


Symptoms occur early in life.
Improve by the age of 2 years
 Late onset Laryngomalacia:



Children > 2 years.
Present during feeding, exercise or sleep.
Presented by snoring or OSA.
 State Dependent Laryngomalacia:



Older age group / Adults.
Occurs only during sleep.
Diagnosed by sleep endoscopy.
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Incidence
• Most common cong laryngeal anomaly (60%).
• Most common cause of chronic stridor in infants.
• More common in males.
• Associated with GERD in 75 - 80% of cases.
• Synchronous airway anomalies in 15 - 20% of cases.
• Associated with congenital anomalies in 10% of cases.
Pathophysiology
Anatomical Abnormalities
1. Omega shaped epiglottis.
2. Short AE fold:

AE/Glottic length 
 0.5 = N
 0.3 = severe LM
3. Redundant mucosa over arytenoids.
*Manning et al, Arch Otolaryngol H N Surg 2005;131(4):340-3.
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GERD & Laryngomalacia
 GERD can be invited by
laryngomalacia as a result of
increased negative intrathoracic
Laryngomalacia
pressure during inspiration.
 The presence of GERD can
aggravate laryngomalacia.
*Gastroesophageal Reflux Disease in Infants by Stuart
Morgenstein, DO (CME – online offering)
GERD
Classification of Infantile Laryngomalacia*
Primary Laryngomalacia
Secondary Laryngomalacia
 Anatomical anomalies narrow
 Reflux induce edema and
the laryngeal inlet.
narrowing of the larynx.
 Reflux 2ry to –ve ITP.
 Reflux is the inciting factor.
 Usually need surgical
 Usually respond to medical
treatment.
treatment.
*Kelly PE, et al. Operative Techniques in Otolaryngology (2005) 16, 198-202
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Clinical presentation
 Stridor:

High pitched, cyclic inspiratory stridor.

Starts few weeks after birth  increase in severity over 6-9 months 
Resolves spontaneously 18 – 24 months in 80 - 90% of cases.

Increased on supine, feeding & agitation.

Decreased on neck extension & prone position.
 Voice = normal.
 Feeding = normal (interrupted in severe cases/ ass. with reflux).
Laryngoscopy
Local or General anesthesia

No muscle relaxant.

No endotracheal tube.
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Endoscopic findings
 Omega shaped epiglottis.
 Short AE fold.
 Redundant mucosa over arytenoids.
 Signs of GERD.
 Collapse of supraglottic structure:*

Type A:
Posterolateral collapse =
AE folds & arytenoids.

Type B:
Complete collapse =
AE folds + Arytenoids + Epiglottis.

Type C:
Anterior collapse =
Epiglottis.
*Holinger & Konior, 1989.
Laryngoscopy
Type A
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Laryngoscopy
Type B
Laryngoscopy
Type C
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Treatment of Laryngomalacia
Conservative
Surgical
90%
10%
Conservative Treatment
 Assurance of parents.
 Anti reflux measures:

Type & position of feeding.

Lansoprazole = 0.5 mg/Kg once daily.

Domperidone = 1 mg/kg/day before feeding.
 Short course of CS (e.g. URTI)
 Follow up:

Monitor growth.

Respiratory distress.

Blood gases.
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Surgical Treatment
Indications:
 Severe stridor, cyanotic attacks.
 Weight loss, failure to thrive.
 Recurrent chest infection.
 Chest deformity.
 Cor pulmonale.
 Hypoxia, Hypercarbia.
Surgical Treatment
I) Tracheostomy.
Only in severe cases associated with other cong. anomalies
Side effects:

High morbidity.

Affects phonation.

Infection.

Psychic Disturbance.
II) Supraglottoplasty
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Surgical Treatment
II) Supraglottoplasty: (microscissor, laser, microdebrider)

Aryepiglottoplasty = Division of AE folds.

Trimming of epiglottis.

Vaporization of arytenoid mucosa.

Epiglottopexy.
Preoperative tips
 Do we need to do laryngobronchoscopy ?
 What type of supraglottoplasty ?
 Cold instruments or Laser ?
 Which type of Laser ?
 Unilateral or bilateral ?
 How to start ?
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Do we need to do laryngobronchoscopy ?
Synchronous Airway Lesions in 18.9 %
Clinically significant SALs in 4.7 %
SALs need intervention in 3.9 %
Mancuso et al, 1996
What type of surgery ?
LM
Type A
AE fold lysis
Type B
Epiglottoplasty
Type C
Epiglottopexy+AE
*Holinger & Konior, 1989.
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Cold instruments or Laser ?
Cold Instruments:
 No thermal trauma.
 Risk of bleeding.
Laser:
 Precise cutting.
 No bleeding.
 Thermal trauma  fibrosis.
Which type of laser ?
 CO2 laser.
 Diode
 KTP.
 Nd: YAG.
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Unilateral or Bilateral ?
Bilateral:
 Better results.
 Postoperative supraglottic stenosis (3%)
Unilateral:
 May need revision session (10%).
 No supraglottic stenosis.
How to start ?
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Supraglottoplasty – Diode Laser
Laser Supraglottoplasty
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Postoperative management
 Postop. endotracheal intubation ??

AE cutting  no need for intubation.

Epiglottoplasty  intubation for one day.
 Ward admission for 2 days.
 Postoperative antibiotic, CS and pain killer for 5 days.
 Anti-reflux measures.
Prognosis
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Prognosis
Patients without associated anomalies:
 Immediate improvement of symptoms in 70% of cases.
 Improvement of symptoms within one week in 100% of cases.
Patients with associated anomalies: Downs, CHARGE syndrome
 Delayed or failure of improvement.
Complications
Mild:
 Transient aspiration.
 Intraoperative bleeding.
 Granuloma, edema formation.
Severe:
 Supraglottic stenosis.
 Persistence of symptoms 8% (4% needs revision surgery)
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Conclusion
 Although it has a typical presentation, Laryngoscopy is the main
diagnostic tool for laryngomalacia.
 Treatment of GERD is mandatory for control of symptoms.
 Surgical treatment is indicated in minority of cases.
 Supraglottoplasty is an effective and safe procedure for relief of
symptoms of severe laryngomalacia.
Prof.. Alaa Gaafar
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