European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 45–47

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Case report

Surgical treatment of a case of adult epiglottic laryngomalacia

M. Bartolomeo ∗ , A. Bigi , P. Pelliccia , M. Makeieff
Département de chirurgie cervico-faciale, centre hospitalo-universitaire Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Adult laryngomalacia is rare. It may be idiopathic or secondary to trauma or degenerative
Laryngomalacia disease.
Epiglottis Case report: A 25-year-old man presented with inspiratory dyspnea on effort of several months’ evolution.
Adult
Flexible endoscopy found epiglottic laryngomalacia, managed by CO2 laser V-shaped partial epiglottec-
Laser
tomy.
Discussion: Excessive resection of the epiglottis may lead to false passage; insufficient resection risks
being ineffective. V-shaped partial epiglottectomy minimizes risk of false passage while ensuring per-
manent respiratory airflow via the epiglottic V during epiglottic movement.
© 2014 Published by Elsevier Masson SAS.

1. Introduction
Adult laryngomalacia is rare. It may be secondary to trauma,
surgery, neurologic lesion, degenerative disease (Parkinson’s dis-
ease, amyotrophic lateral sclerosis, support tissue disease such as
Elhers-Danlos syndrome) or idiopathic, without discernible medi-
cal cause [1,2].
We report the surgical management of a case of idiopathic
epiglottic laryngomalacia in a 25-year-old male.
2. Case report
A 25-year-old man presented with spontaneous respiratory
impairment on effort of several months’ evolution: laryngeal dys-
pnea with stridor on moderate physical effort.
General clinical examination, neurological examination and
cerebral CT found nothing notable.
Under forced inspiration, the epiglottis swung back against the
posterior pharyngeal wall, becoming obstructive; this was repro-
ducible, with stridor identical to that induced by physical effort.
CT exploration for a submucosal lesion enabled visualization of
this phenomenon (Fig. 1).
Treatment consisted in partial CO2 laser epiglottectomy under
general anesthesia.
The laser was set to fire continuously at 10 Watts. The posterior
pharyngeal wall was protected by damp cotton swabs. The first
step comprised producing a pattern; the epiglottis was traced by
∗ Corresponding author. Tel.: +33 4 67 33 68 03.
E-mail address: m-bartolomeo@chu-montpellier.fr (M. Bartolomeo).
laser dots to create a triangle with the base corresponding to the
free edge of the epiglottis and the apex pointing toward the valec-
ula. The altitude of the triangle was two-thirds of the length of
the epiglottis, and the base one-half of that of the free edge. The
area made available for airflow when the epiglottis was in contact
with the posterior pharyngeal wall was estimated by swinging the
epiglottis back manually (Fig. 2).
On histology, the epiglottic specimen was normal.
During the first postoperative days, the patient experienced
oropharyngeal discomfort, with an impression as of a foreign body
on swallowing, leading to fairly frequent throat clearing, without
false passage (checked by a speech therapist).
The patient was discharged on day 2, with a prescription of
corticosteroids and oral antibiotics.
At 1 month’s follow-up, the oropharyngeal discomfort was
persistent but greatly reduced; the patient found it difficult to
describe, with no throat clearing or false passage. The patient
could produce stridor on request, but it was no longer induced by
physical effort. The epiglottis was slightly erythematous, with pos-
terior swing persisting but allowing airflow through the resection
area.
At 4 months, weight was stable, the epiglottis was flexible
and non-erythematous (Fig. 3), stridor remained absent on effort
although producible on request; swallowing was assessed on
a specific swallowing-disorder quality-of-life questionnaire, the
“SWAL-QOL”, as 87.7% (compared to 90% preoperatively).
Five of the 44 questionnaire items showed pre- to postoperative
change: “Drooling”, “Having excessive saliva or phlegm”, “Having to
clear your throat”, “Choking when you take liquids”, and “It’s been
difficult for me to speak clearly”; each had worsened by 1 grade,
reducing the overall score by 2.3%.

http://dx.doi.org/10.1016/j.anorl.2013.10.004
1879-7296/© 2014 Published by Elsevier Masson SAS.
46 M. Bartolomeo et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 45–47
Fig. 1. Contrast-enhanced head-and-neck CT, sagittal slice, showing epiglottal
swing on deep inspiration.
3. Discussion
Laryngomalacia represents supraglottic collapse on inspiration.
It is the most frequent laryngeal disorder in infants. It shows as
stridor with onset as of 10 days of life. The anatomic development
of the upper aerodigestive tract usually causes symptoms to regress
at around 18–24 months of age [2].
Secondary acquired laryngomalacia has occasionally been
reported, with onset in both older children and in adults [2]. It
is usually associated with trauma, surgery, neurologic lesions or
degenerative disease such as Parkinson’s, amyotrophic lateral scle-
rosis or support tissue disease such as Elhers-Danlos syndrome
[1].
Usually, the epiglottis alone is involved, becoming floppy and
sometimes invaginating the vocal folds [3]. Some cases, where
no medical cause can be found, are considered “idiopathic” [4,5].
Fig. 2. Peroperative view after V resection. The base of the tongue is at the top and
the posterior pharyngeal wall at the bottom.
Fig. 3. Epiglottic aspect at 4 months. Image taken during deep inspiration, revealing
the triangular free space achieved by resection. The base of the tongue is at the
bottom and the posterior pharyngeal wall at the top.
Several treatment options have been reported. Harries and Randall
described fixation to the base of the tongue, but this is complex and
may cause persistent oropharyngeal discomfort [4]. The most fre-
quent attitude is resection, although certain problems have been
reported: excessive resection may lead to complications such as
false passage, while insufficient resection may be ineffective [4].
To get around the difficulties of planning resection size and
of postoperative complications, we performed V-shaped partial
epiglottectomy by CO2 laser [5,6]. This frees a permanent passage,
greatly reducing epiglottic attraction to the posterior pharyngeal
wall by Venturi effect (Fig. 3).
The technique is simple and quick and relatively conservative,
reducing the risk of swallowing decompensation.
Respiratory obstruction was indeed improved in the present
case, with only 2.3% reduction in SWAL-QOL score [7] at 4 months.
The ability to produce stridor on request was not considered
pathological, as there was no stridor on effort; subjects free of
oropharyngeal pathology may be able to produce stridor volun-
tarily.
4. Conclusion
Idiopathic laryngomalacia is rare in adults, and usually involves
the epiglottis. CO2 laser V-shaped partial epiglottectomy is a simple,
low-risk and effective treatment. The interest of the present case
lies in the rarity of the pathology and the simplicity of the technique
employed.
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
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