Abstract
Objective
The aim of this study was to describe and compare the airway findings in term and preterm infants with laryngomalacia.
Methods
A retrospective review of 130 patients diagnosed as having laryngomalacia at a tertiary referral center between July 2004 and August 2009 was conducted. Medical records were reviewed for demographic data, supraglottic and glottic airway findings, concomitant airway lesions, and the need for intervention.
Results
The mean gestational age and age at diagnosis was 36 and 15 weeks, respectively. Combined posterior and anterior supraglottic collapse was the most common finding (31%). Posterior collapse alone occurred in 25%, anterior collapse in 14%, and lateral collapse in 10%. Twelve percent of patients had all 3 sites of collapse. Forty-one percent of patients had a secondary airway lesion, with tracheomalacia being the most common. Preterm infants had significantly higher rates of reflux and more sites of collapse than did term infants ( P < .0001). Eight patients required an intervention for their symptoms.
Conclusions
Children with laryngomalacia tend to have more than 1 area of supraglottic collapse, and more than one third have a secondary lesion. All patients who required an intervention had more than 1 area of collapse, and 63% of these patients had a secondary airway lesion. Our high incidence of secondary lesions is similar to recent reports.
1
Introduction
The term laryngomalacia’ was introduced in 1942 by Chevalier Jackson. It refers to collapse of the supraglottic larynx, creating a narrow airway and turbulent airflow. Laryngomalacia is very common and accounts for 65% to 75% of stridor in infants . It may be an isolated finding or associated with other neurologic disorders such as cerebral palsy.
There are several laryngomalacia classification schemes proposed in the literature, but none of them are universal. Olney et al categorized laryngomalacia according to the area of supraglottic collapse and method of supraglottoplasty. Type 1 laryngomalacia involves prolapse of the mucosa overlying the arytenoid cartilages. In type 2, there are foreshortened aryepiglottic folds. Posterior displacement of the epiglottis is type 3. Although this classification system is useful, it fails to take into account that there may be more than 1 area of collapse. Another classification strategy proposed in the literature groups patients according to their underlying pathophysiology . In this study, type I laryngomalacia is characterized by a foreshortened aryepiglottic fold. Type 2 disease has redundant soft tissue in the supraglottis, whereas type 3 laryngomalacia is caused by other etiologies such as underlying neuromuscular disorders.
In this study, we review our experience with laryngomalacia. The goals are to identify the most common area(s) of supraglottic collapse, compare airway findings in term and preterm infants, and evaluate the incidence of secondary airway lesions in our population.
2
Materials and methods
A retrospective chart review was performed at a tertiary care center on 217 consecutive patients with a diagnosis of laryngomalacia between June 2004 and August 2009. Patients with incomplete records, an undocumented flexible fiberoptic, or direct laryngoscopy examination, or those diagnosed by airway fluoroscopy alone were excluded. This decision was based on the poor sensitivity (27%–34%) of airway fluoroscopy in diagnosing laryngomalacia when compared with airway endoscopy . A total of 130 patients met the inclusion criteria (54 were female and 76 were male). The Penn State University Institutional Review Board approved this study, and guardians gave consent during their initial office visit for the use of records for medical research.
Evaluation of each patient was dependent on their presentation. Stable patients had a flexible fiberoptic laryngoscopy, airway fluoroscopy, and a barium swallow. Those patients with abnormal fluoroscopic examinations or persistent stridor despite negative examinations underwent a direct laryngoscopy and bronchoscopy (DLB) in the operating room under general anesthesia. Patients who presented with cyanotic episodes, gray spells, and failure to thrive; intubated patients; and those with any other acute signs/symptoms underwent a DLB. During laryngoscopy, vocal fold mobility, the site of supraglottic collapse, edema, erythema, and other lesions were noted. A total of 105 patients underwent flexible fiberoptic laryngoscopy. Fifty-five patients had a DLB, and 108 patients had an airway fluoroscopy.
Patients were classified as having posterior collapse if the arytenoids themselves or the overlying mucosa obstructed the airway during inspiration. Lateral collapse included shortened aryepiglottic folds or mucosa that prolapsed medially into the airway. A retropositioned epiglottis or one that prolapsed into the airway was classified as anterior collapse. Reflux was documented if patients had a positive barium swallow, symptoms consistent with reflux, or laryngeal findings such as edema and/or erythema that could be attributed to reflux. Secondary airway lesions were documented based on fluoroscopy and/or DLB. Descriptive statistics and χ 2 analysis were completed using the Statistical Package for the Social Sciences version 17 (SPSS, Chicago, IL).
2
Materials and methods
A retrospective chart review was performed at a tertiary care center on 217 consecutive patients with a diagnosis of laryngomalacia between June 2004 and August 2009. Patients with incomplete records, an undocumented flexible fiberoptic, or direct laryngoscopy examination, or those diagnosed by airway fluoroscopy alone were excluded. This decision was based on the poor sensitivity (27%–34%) of airway fluoroscopy in diagnosing laryngomalacia when compared with airway endoscopy . A total of 130 patients met the inclusion criteria (54 were female and 76 were male). The Penn State University Institutional Review Board approved this study, and guardians gave consent during their initial office visit for the use of records for medical research.
Evaluation of each patient was dependent on their presentation. Stable patients had a flexible fiberoptic laryngoscopy, airway fluoroscopy, and a barium swallow. Those patients with abnormal fluoroscopic examinations or persistent stridor despite negative examinations underwent a direct laryngoscopy and bronchoscopy (DLB) in the operating room under general anesthesia. Patients who presented with cyanotic episodes, gray spells, and failure to thrive; intubated patients; and those with any other acute signs/symptoms underwent a DLB. During laryngoscopy, vocal fold mobility, the site of supraglottic collapse, edema, erythema, and other lesions were noted. A total of 105 patients underwent flexible fiberoptic laryngoscopy. Fifty-five patients had a DLB, and 108 patients had an airway fluoroscopy.
Patients were classified as having posterior collapse if the arytenoids themselves or the overlying mucosa obstructed the airway during inspiration. Lateral collapse included shortened aryepiglottic folds or mucosa that prolapsed medially into the airway. A retropositioned epiglottis or one that prolapsed into the airway was classified as anterior collapse. Reflux was documented if patients had a positive barium swallow, symptoms consistent with reflux, or laryngeal findings such as edema and/or erythema that could be attributed to reflux. Secondary airway lesions were documented based on fluoroscopy and/or DLB. Descriptive statistics and χ 2 analysis were completed using the Statistical Package for the Social Sciences version 17 (SPSS, Chicago, IL).
3
Results
3.1
Demographics
The mean gestational age was 36.3 weeks, with a range of 24 to 42 weeks. Thirty-eight percent of patients were preterm ( Table 1 ). The mean age at diagnosis was 3.9 months (range, 0.5–15 months). Nine patients had a history of intubation, and 6 patients had another congenital anomaly (2 had Down syndrome; 1, atrial septal defect; 1, patent ductus arteriosus; 1, cleft palate; and 1, Apert syndrome). The male/female ratio was 1.4:1.
