Abstract
Objective
Compare the incidence of endoscopic surgical treatment of patients with laryngomalacia to other aerodigestive pathology who may present with similar symptoms.
Methods
Consecutive case series with chart review of endoscopic surgical intervention in infants, aged 12 months or less, presenting with inspiratory stridor, in the absence of syndromic condition or prior history of intubation.
Results
A total of 30 patients were identified. The average age at the time of surgical intervention was 2.7 months. Endoscopic surgical management was directed at laryngomalacia (70%), vallecular cysts (23.3%), and anterior glottic webs (6.7%). All patients had nearly immediate resolution of the stridor and feeding difficulties. None required revision surgery, modified diets, or alternative means of enteric nutrition.
Conclusions
Laryngomalacia was the most commonly encountered surgical indication for stridulous newborns and infants with severe symptoms. Like most previous descriptions, patients responded well to supraglottoplasty. Vallecular cysts accounted for about one-quarter of the infants treated. Clinicians should carefully consider the presence of other airway pathology, which may mimic laryngomalacia, in non-syndromic infants without a previous history of intubation. Endoscopic surgical management may be safe and effective.
1
Introduction
Evaluation of the newborn or infant presenting with noisy breathing, dysphagia and failure to thrive starts with a detailed history and physical examination. Bedside laryngoscopy often adds a critical and integral component to the clinical assessment. Noisy breathing in infants is most often attributed to laryngomalacia. Unless there are severe symptoms, such as failure to thrive or dysphagia, most patients do well with expectant management, with only approximately less than 15% requiring surgical intervention . Those with severe symptoms are usually treated with supraglottoplasty, which has a high success rate .
However, there are several other airway pathologies that can be encountered causing symptoms that may mimic laryngomalacia, such as vallecular cysts or anterior glottic webs and should be carefully considered when evaluating these newborns and infants. Several authors have reported and described their experiences with individual pathologies but these may have overlapping symptoms that mimic each other . Our aim is to compare the incidence of endoscopic surgical treatment in patients with laryngomalacia to other aerodigestive pathology in a pediatric otolaryngology practice with who may present with similar symptoms and hope to provide a frame of reference for consideration of pathology other than laryngomalacia that can respond well to endoscopic surgery and should be considered when evaluating infants with inspiratory stridor. When the stridor is associated with severe symptoms, such as dysphagia and failure to thrive, surgical management is often indicated and usually helpful in resolving symptomatology.
2
Methods
After institutional review board (IRB) approval was obtained, the operative records of both authors were reviewed between July 1, 2009 and December 22, 2014 for infants, aged 12 months or less, who underwent endoscopic surgery for failure to thrive, stridor, and/or dysphagia. Patients were identified using current procedural terminology (CPT) codes: 31535, 31536, 31540, 31541, 31560, 31561, and 31588. Infants with ICD-9 diagnoses of dysphagia (787.2x), stridor (786.1), laryngomalacia (748.3), or failure to thrive (783.41 and 779.34) and were non-syndromic, full term (> 35 weeks gestation) without prior history of intubation were included. Infants with prior history of intubation and/or craniofacial abnormality were excluded. Microsurgical approach was surgeon dependent.
2
Methods
After institutional review board (IRB) approval was obtained, the operative records of both authors were reviewed between July 1, 2009 and December 22, 2014 for infants, aged 12 months or less, who underwent endoscopic surgery for failure to thrive, stridor, and/or dysphagia. Patients were identified using current procedural terminology (CPT) codes: 31535, 31536, 31540, 31541, 31560, 31561, and 31588. Infants with ICD-9 diagnoses of dysphagia (787.2x), stridor (786.1), laryngomalacia (748.3), or failure to thrive (783.41 and 779.34) and were non-syndromic, full term (> 35 weeks gestation) without prior history of intubation were included. Infants with prior history of intubation and/or craniofacial abnormality were excluded. Microsurgical approach was surgeon dependent.
3
Results
A total of 30 patients were identified, 13 (43.3%) boys and 17 (56.7%) girls ( Table 1 ). The average age at the time of surgical intervention was 2.7 months [range 1 week to 7 months]. Endoscopic surgical management was directed at laryngomalacia in 21 (70%) ( Fig. 1 ), vallecular cysts in 7 (23.3%) ( Fig. 2 ), and anterior glottic webs in 2 (6.7%) ( Fig. 3 ) patients. Surgical indications in cases of laryngomalacia, anterior glottic webs included significant feeding difficulties/dysphagia limiting oral intake or failure to thrive. All vallecular cysts were able to be diagnosed preoperatively on bedside, awake fiberoptic indirect laryngoscopy. All patients had nearly immediate resolution in the stridor and feeding difficulties.
| No. (%) | |
|---|---|
| Gender | |
| Females | 17 (56.7) |
| Males | 13 (43.3) |
| Endoscopic surgical procedures | |
| Supraglottoplasty | 21 (70) |
| Excision of vallecular cyst | 7 (23.3) |
| Division of anterior glottic web | 2 (6.7) |
