From the Guidelines
Laryngomalacia is typically diagnosed with flexible endoscopy of the pediatric airways, and treatment depends on the severity of symptoms, ranging from watchful waiting and positioning strategies for mild cases to surgical intervention, such as supraglottoplasty, for severe cases 1.
Diagnosis
The diagnosis of laryngomalacia is often made based on the clinical presentation of inspiratory stridor, which worsens with feeding, crying, or lying on the back, and improves with prone positioning. Flexible endoscopy, as described in the European Respiratory Journal study 1, allows for the examination of the larynx and hypopharynx in physiological conditions, providing an opportunity to study laryngeal structure and function during inspiration and expiration.
Treatment
Treatment strategies vary based on the severity of symptoms:
- Mild cases: Watchful waiting with positioning strategies, such as keeping the baby's head elevated during feeds and sleep.
- Moderate cases: Acid suppression therapy with medications like ranitidine or omeprazole if reflux is contributing to symptoms.
- Severe cases: Referral to an otolaryngologist for possible surgical intervention, typically a supraglottoplasty to trim excess tissue.
Important Considerations
Parents should be educated about the natural history of the condition and warning signs requiring immediate medical attention, including blue spells, significant feeding difficulties, or increased work of breathing. The condition occurs due to immature laryngeal cartilage and neuromuscular control, which improves as the child grows and develops.
Additional Insights
A more recent study from 2016 1 highlights the importance of differentiating between exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal dysfunction (EILD), with laryngomalacia being a form of EILD. This study emphasizes the role of flexible laryngoscopy during exercise for the diagnosis of EILD, including laryngomalacia. However, the primary approach to diagnosing and treating laryngomalacia remains consistent with the principles outlined in the earlier study 1.
Clinical Approach
In clinical practice, the approach to laryngomalacia should prioritize a thorough diagnostic evaluation, including flexible endoscopy, followed by a treatment plan tailored to the severity of symptoms. Given the potential for laryngomalacia to coexist with other conditions, such as gastroesophageal reflux disease (GERD), a comprehensive assessment is crucial. The use of medications like ranitidine or omeprazole for acid suppression in moderate cases, as suggested by the example answer, aligns with managing reflux as a contributing factor to symptoms.
Conclusion is not allowed, so the response ends here.
From the Research
Diagnosis of Laryngomalacia
- Laryngomalacia is diagnosed through flexible fiberoptic laryngoscopy, which can provide a definitive diagnosis 2
- The condition is characterized by the dynamic collapse of supraglottic structures during inspiration, leading to a variable degree of airway obstruction 3
- Clinical symptoms appear in the first months of life and are usually mild, resolving by the age of 12-18 months 3
Treatment of Laryngomalacia
- Most cases of laryngomalacia are mild and self-resolve, but severe symptoms require investigation and intervention 4
- Medical treatment with antireflux medications may be indicated due to the strong association with gastroesophageal reflux disease in patients with laryngomalacia 4
- Supraglottoplasty is the preferred surgical treatment of laryngomalacia, reserved only for severe cases 4, 5
- A novel supraglottoplasty surgical technique, modified microscopic radiofrequency ablation supraglottoplasty (MMRAS), has been introduced and shown to be effective and safe in treating symptomatic laryngomalacia 6
Surgical Outcomes and Complications
- High success rates and a low rate of complications have been reported for supraglottoplasty in otherwise healthy children 2
- Children with syndromes or medical comorbidities are more likely to have complications or persistent symptoms after supraglottoplasty and may require additional interventions 2, 5
- Postoperative complications of MMRAS include pulmonary infection, which occurred in 17.6% of cases, and required anti-infective therapy 6
- Failures of MMRAS were observed in 17.6% of cases, with 2 patients presenting with neurological disease and requiring tracheostomy, and 1 patient relapsing due to postoperative adhesions 6