Medical Care
In more than 90% of cases, the only treatment necessary for laryngomalacia is time. The lesion gradually improves, and noises disappear by age 2 years in virtually all infants. The noise steadily increases over the first 6 months, as inspiratory airflow increases with age. Following this increase, a plateau often occurs with a subsequent gradual disappearance of the noise. In some cases, the signs and symptoms dissipate, but the pathology may persist into childhood and adulthood. In those cases, symptoms or signs may recur with exercise or sometimes with viral infections.
Children with severe retractions, cyanotic spells, and apneas during sleep may have obstructive sleep apnea associated with laryngomalacia. These children should be evaluated with a sleep study. Supraglottoplasty may be of benefit in children with severe symptoms of laryngomalacia (see below). [6] Thus, a detailed sleep history should be taken in all infants with symptoms of laryngomalacia.
Infants with laryngomalacia have a higher incidence of gastroesophageal reflux and swallowing dysfunction. [4] Thus, acid suppression and swallowing therapy have been used in children with symptoms of moderate laryngomalacia. [7]
If the baby has clinically significant hypoxemia (defined as a resting oxygen saturation < 90%), supplemental oxygen should be administered. Recent data suggest infants with laryngomalacia and hypoxemia may more readily develop pulmonary hypertension. [8] Therefore, children with hypoxemia should periodically undergo evaluation for pulmonary hypertension.
If the baby has normal cry, normal weight gain, normal development, and purely inspiratory noise that developed within the first 2 months of life, then no further workup may be necessary. Parents may be told that laryngomalacia is the most likely diagnosis, and they can be assured of its natural history.
If the picture is not obvious or if the parents are not completely reassured, diagnostic procedures include fluoroscopy and flexible laryngoscopy or bronchoscopy. Flexible bronchoscopy with the child anesthetized is more specific and sensitive than flexible bronchoscopy in a child who is awake.
Special concerns
There is a distinct group of older children (aged >2 years) with late-onset laryngomalacia, or occult laryngomalacia, who do not present with the typical congenital symptoms of noisy breathing. Children manifest symptoms during feeding, exercise, or sleep. [9] Many are identified with snoring or sleep-disordered breathing as initial symptoms and are diagnosed with laryngomalacia upon direct visualization of the airway. In late-onset laryngomalacia, supraglottoplasty may be beneficial for cases of moderate-to-severe obstructive sleep apnea associated with significant apnea-hypopnea index on sleep study. [10, 11] However, other causes for obstruction, such as adenotonsillar hypertrophy, should also be evaluated.
Surgical Care
In severe cases in which the laryngomalacia interferes with ventilation enough to impair normal eating, growth, and development, a surgical approach is possible. [12]
Approximately 10% of patients with severe congenital laryngomalacia require surgical intervention because of failure to thrive, significantly elevated carbon dioxide or hypoxemia, severe obstructive sleep apnea, pulmonary hypertension, or cor pulmonale. Operations include simple tracheotomy or supraglottoplasty in which support structures are tightened and excess tissue on the epiglottis is removed. [29] Laser epiglottopexy has been successful. [13, 14]
A meta-analysis by Farhood et al found that the Apnea-Hypopnea Index (AHI) improved by a mean of 12.5 points after supraglottoplasty for laryngomalacia with obstructive sleep apnea, however, 88% (29 of 33 children) had residual disease. [15]
Recent studies have demonstrated in severe cases of laryngomalacia that require supraglottoplasty, there is significant improvement post-operatively in overall quality of life of caregivers and infants, with a high degree of parental satisfaction, especially in parental perception of swallowing among these children. [30, 31, 32]
Consultations
If the parents require another opinion or if the lesion is clinically severe, consultation with a pediatric pulmonologist or pediatric otorhinolaryngologist may help.
Diet
No diet restrictions are necessary.
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The epiglottis is small and curled on itself (omega-shaped). Approximation of the posterior edges of the epiglottis contributes to the inspiratory obstruction. Used with permission from Oxford University Press [Benjamin B. Atlas of Paediatric Endoscopy: Upper Respiratory Tract and Oesphagus. New York, NY: Oxford University Press; 1981.]
