Treatment for Laryngomalacia in Children
Supraglottoplasty is the recommended surgical intervention for children with severe laryngomalacia who present with significant symptoms such as respiratory distress, feeding difficulties, or failure to thrive. 1
Understanding Laryngomalacia
Laryngomalacia is characterized by:
- Diminished laryngeal tone resulting in supraglottic collapse, typically a congenital condition 1
- Most common cause of inspiratory stridor in infants 1
- Usually self-limiting, with most cases resolving within the first two years of life 2
- Presents with high-pitched inspiratory stridor that typically worsens with increased breathing effort and supine positioning 3
Diagnostic Approach
Diagnosis is primarily made through:
- Flexible fiberoptic laryngoscopy, which is the preferred initial diagnostic tool 1, 2
- Direct laryngoscopy and bronchoscopy may be performed when clinical symptoms suggest a synchronous airway lesion, but are not routinely required 2
- Drug-induced sleep endoscopy (DISE) is particularly useful for diagnosing sleep-dependent laryngomalacia 1
Treatment Algorithm
1. Conservative Management (for Mild to Moderate Cases)
For most children with laryngomalacia (approximately 80-85%), observation and conservative management are appropriate:
- Watchful waiting, as the condition is typically self-limiting 2, 4
- Position modifications (prone positioning often improves symptoms) 3
- Treatment of comorbidities, particularly gastroesophageal reflux disease (GERD) 1
- Empiric pharmacologic treatment of GERD is recommended as posterior laryngeal changes associated with GERD are common in these patients 1
2. Surgical Intervention (for Severe Cases)
Surgical management is necessary in approximately 15-20% of affected infants 2. Indications for surgical intervention include:
- Severe airway obstruction 1, 5
- Feeding difficulties leading to malnutrition (BMI Z-score < -2 SD) 6
- Dysphagia or symptoms of gastroesophageal reflux 6
- Oxygen desaturation (mean SaO₂ < 92%) 6
- Failure to thrive 3
- Aspiration 3
The primary surgical option is:
- Supraglottoplasty (also called epiglottoplasty or partial arytenoidectomy): Involves division of shortened aryepiglottic folds and trimming of redundant supra-arytenoidal mucosa 1, 5
- Surgical techniques include using cold steel instruments, microdebrider, or laser 1, 6
- Specific approach depends on the type of laryngomalacia:
- Type 1: Prolapse of mucosa overlying the arytenoid cartilages
- Type 2: Long, tubular epiglottis that curls on itself
- Type 3: Anterior displacement of arytenoids 2
3. Post-Surgical Management and Alternative Options
If supraglottoplasty fails or is contraindicated:
- Tracheostomy may be necessary to bypass the obstruction 1
- Non-invasive ventilation can be considered 3
- Continuous positive airway pressure (CPAP) may be beneficial for some patients 1
Outcomes and Prognosis
- Supraglottoplasty results in improvement of the airway in most patients 5
- Studies show significant improvement in symptoms, oxygenation, and nutritional status following surgical intervention 6
- At 6-month follow-up after surgery, patients typically show:
- Improved mean BMI Z-score (from -3.7 to -0.9)
- Improved mean oxygen saturation (from 89.4% to 96.7%) 6
Potential Complications of Surgery
- Airway edema (reported in up to 19% of cases) 1
- Dysphagia (can be transient or persistent) 1
- Aspiration (uncommon and primarily limited to children with neuromuscular disorders) 1
- Minor respiratory obstruction requiring oxygen supplementation 1
- Bleeding (rare and typically self-resolving) 1
- Supraglottic stenosis (rare long-term complication) 1
Careful patient selection and appropriate timing of intervention are crucial for optimizing outcomes in children with laryngomalacia requiring surgical management.