Can laryngomalacia (softening of the tissues of the larynx) cause sleep apnea in a 2-year-old?

Laryngomalacia as a Cause of Sleep Apnea in Two-Year-Olds

Yes, laryngomalacia can definitely cause sleep apnea in a two-year-old child, and this condition requires appropriate evaluation and management to prevent morbidity and mortality associated with sleep-disordered breathing. 1

Understanding Laryngomalacia and Sleep Apnea

Laryngomalacia is the most common congenital laryngeal anomaly and the most frequent cause of persistent stridor in children 1. While typically presenting with inspiratory stridor in infancy, laryngomalacia can manifest differently:

• Classic laryngomalacia: Presents with stridor when the infant is awake and agitated
• Sleep-dependent (occult) laryngomalacia: Symptoms worsen during sleep 2

Mechanism of Airway Obstruction

In laryngomalacia, the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoid cartilages) are abnormally soft and collapse inward during inspiration, causing:

• Inspiratory collapse of redundant supra-arytenoidal mucosa (type 1 laryngomalacia) 1
• Narrowing of the airway during sleep when muscle tone decreases
• Progressive obstruction leading to obstructive sleep apnea (OSA)

Diagnosis of Sleep Apnea Related to Laryngomalacia

Sleep-dependent laryngomalacia is increasingly recognized as a cause of persistent OSA 1. Diagnostic evaluation should include:

1. Sleep study (polysomnography): To document the presence and severity of OSA

   • Measures apnea-hypopnea index (AHI)
   • Evaluates oxygen desaturation
   • Assesses sleep fragmentation

2. Flexible endoscopy:

   • Preferably during sleep or under light sedation (sleep endoscopy) 3
   • Allows visualization of dynamic airway collapse during inspiration
   • Can identify other concomitant airway abnormalities (present in up to 68% of cases) 1

Treatment Options

For a two-year-old with laryngomalacia causing sleep apnea, treatment options include:

Surgical Management

Supraglottoplasty is the most effective intervention for sleep-dependent laryngomalacia causing OSA 1:

• Involves division of shortened aryepiglottic folds and trimming of redundant supra-arytenoidal mucosa
• Can be performed using cold steel instruments, microdebrider, or laser
• Studies show significant improvement in:
  • Apnea-hypopnea index (AHI) reduction from 13.3 to 4.1 events/hour 3
  • Improved oxygen saturation during sleep 1, 3
  • Resolution of snoring in up to 86% of children 1

Non-Surgical Options

• Continuous Positive Airway Pressure (CPAP): May be considered in cases where surgery is contraindicated 4
• Watchful waiting: Only appropriate for very mild cases without significant sleep disruption or oxygen desaturation

Prognosis and Follow-up

• Most children show improvement in OSA symptoms following supraglottoplasty 3
• Both OSA and central sleep apnea tend to improve with age in children with laryngomalacia 5
• Children with neurological disorders, congenital anomalies, or genetic syndromes may take longer to resolve OSA 5

Important Considerations and Pitfalls

1. Don't miss concomitant airway abnormalities: Up to 68% of children with laryngomalacia may have additional airway abnormalities below the epiglottis 1

2. Age-specific presentations: While laryngomalacia typically presents in infancy, late-onset or persistent forms can occur in older children 6

3. Potential complications of supraglottoplasty:

   • Respiratory distress
   • Postoperative bleeding
   • Feeding difficulties
   • Aspiration (particularly in children with neuromuscular disorders)
   • Supraglottic stenosis (rare) 1

4. Importance of polysomnography: Sleep studies are crucial for diagnosis and treatment planning, as the presence of OSA may change the severity classification and treatment decisions in over 50% of cases 4

In summary, laryngomalacia is a significant cause of obstructive sleep apnea in two-year-old children, requiring proper diagnosis through sleep studies and endoscopy, with supraglottoplasty being the most effective treatment option for improving respiratory parameters and quality of life.