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Archives of the Balkan Medical Union vol. 53, no. 3, pp.

459-462
Copyright © 2018 Balkan Medical Union September 2018

MINIREVIEW

LARYNGOMALACIA IN INFANTS
Cristina M. GOANȚĂ1,2, Mihail TUȘALIU1,3  , Lavinia G. SAVA3, Vlad A. BUDU1,3
1
„Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania
2
Clinical Emergency Hospital `Sf. Pantelimon“, Bucharest, Romania
3
Institute of Phonoaudiology and Functional ENT Surgery `Prof. Dr. D. Hociotă“, Bucharest, Romania
Received 24 June 2018, Accepted 13 Aug 2018
https://doi.org/10.31688/ABMU.2018.53.3.24

Abstract Résumé

Laryngomalacia is a disease that is the most common La laryngomalacie du nourrisson


etiology causing stridor in infants and in most cas‑
es the patient presents with inspiratory stridor that La laryngomalacie est une maladie qui est la cause
worsens during feeding, crying, supine position or ag‑ la plus fréquente d’étiologie chez le nourrisson et
itation. In laryngomalacia the supraglottic structures dans la plupart des cas, le patient se présente avec un
collapse into the airway during inspiration causing stridor inspiratoire qui s’agrave pendant l’alimenta‑
airway obstruction. Typical symptoms are not present tion, les pleurs, la position couchée ou l’agitation. En
at birth, but appear within the first 4 months of life laryngomalacie, les structures supraglottiques s’effon‑
and disappear at maximum 24 months of age. The drent dans les voies respiratoires lors de l’inspiration,
most common associated symptoms are swallowing provoquant une obstruction des voies respiratoires.
dysfunctions, regurgitation, cough and sleep apnea. Généralement, les symptômes ne sont pas présents
Laryngomalacia is a self‑limiting disease with about à la naissance mais apparaissent dans les 4 premiers
20% of the patients presenting with severe disease and mois de la vie et disparaissent à l’âge de 24 mois au
they require surgical treatment. maximum. Les symptômes associés les plus courants
sont les troubles de la déglutition, la régurgitation, la
Keywords:  neonatal stridor, laryngomalacia, larynx, toux et l’apnée du sommeil. La laryngomalacie est une
glottis. maladie spontanément résolue, environ 20% des pa‑
tients présentant une maladie grave et nécessitant un
traitement chirurgical.

Mots‑clés:  stridor néonatal, laryngomalacie, larynx,


glotte.

Address for correspondence: Mihail TUȘALIU


Institute of Phonoaudiology and Functional ENT Surgery `Prof. Dr. D.
Hociotă“, Bucharest, Romania
Address: 21, Mihail Cioranu Str., Bucharest, 061344, Romania
E‑mail: mtusaliu@yahoo.com; Phone: 0040729828480
Laryngomalacia in infants – GOANȚĂ et al

Introduction laryngomalacia, showed that the median age of pa‑


tients at diagnosis was 3 months and the big majori‑
Laryngomalacia is an anomaly of the larynx that ty of the patients (82.7%) were full‑term newborns9.
affects 50% to 70% of infants addressed to the pri‑ The main presenting symptom was stridor (92.9%)9.
mary care accusing stridor, being the most common Most patients were also diagnosed with GERD
congenital anomaly of the larynx1. Noisy breathing (69,8%), and dysphagia occurred in 50.3% of the
is a common presenting symptom among newborns patients9.
and children and laryngomalacia is the most com‑
mon cause of stridor in infants1. Methods of investigating laryngomalacia
Parents that present to the doctor are worried
because the infant has inspiratory stridor during the It is important to use a detailed history and phys‑
first few weeks of life. The stridor is usually getting
ical examination in determining a proper diagnosis.
worse over the first 6 months of age, followed by a
A detailed history is very important in establishing
gradual improvement and the symptoms usually dis‑
the correct diagnosis and is usually the main factor
appear by 24 months of age2.
Symptoms of laryngomalacia include: that leads to laryngomalacia suspicion. At admission,
‑ Inspiratory stridor –it is present from birth and is the newborn should be investigated clinically and
getting worse over the first 6 months of life. After paraclinically:
that, as the respiratory system starts to mature, the ‑ Body temperature.
stridor gets better and by month 24 of life the pa‑ ‑ Heart rate, heart sounds, oxygen saturation and
tients are symptom‑free3. blood pressure.
‑ Stridor, that is worse with agitation, crying, feeding ‑ Lengths, head circumference and thorax circumfer‑
or supine position – parents complain about the ence.
stridor getting worse during the day, each time the ‑ Respiratory rate, any physical signs of stridor, such
up‑named activities occur. After the activity is over, as intercostal, suprasternal, supraclavicular retrac‑
the stridor also goes better or even disappears. tions.
‑ Difficulty feeding – the patients that have laryn‑ ‑ Chest X‑ray – can identify a diaphragmatic paraly‑
gomalacia can also develop dysphagia, aspiration, sis, congenital pulmonary malformations, pneumo‑
apnea, reflux or obstructive sleep apnea. In patients thorax, and mediastinal masses for the differential
with severe disease, pulmonary hypertension may diagnosis with stridor.
also occur. ‑ Laboratory testing – for metabolic disorders or sep‑
Many patients with laryngomalacia also associate sis. Hypoglycemia, hypomagnesaemia may lead to
gastroesophageal reflux disease (GERD), that needs an impaired oxygen transportation to the periph‑
treatment and also is getting better as the newborn eral tissues. Hypomagnesemia may lead to hypoto‑
starts to age4. When infants swallow, they interrupt nia, depressed respiratory drive, and apnea.
breathing and so their compromised airways may not ‑ Echocardiography – most congenital heart diseas‑
coordinate well sucking, swallowing and breathing, es present with cyanosis, tachypnea, or respiratory
leading to dysphagia and aspiration that may scare distress from cardiac failure.
the parent. ‑ Routine ultrasound of the brain.
The etiology of laryngomalacia is considered to
‑ Electroencephalogram.
be multifactorial. The first one cited are anatomic
‑ Flexible endoscopy – it is typically used for diag‑
factors, like abnormal prolapse of laryngeal tissue,
nosing laryngomalacia. It provides a dynamic,
associated or not with tissue redundancy, that can
lead to supraglottic obstruction and laryngomalacia5. real‑time visualization of the upper airway, and it
Another theory, that is called the cartilaginous theo‑ can show the collapse of the supraglottic structures
ry, suggests that the immaturity of the laryngeal car‑ during inspiration, leading to inspiratory stridor
tilage contributes to the obstruction6. and airway obstruction. Other findings can be
Another cause is GERD, but its mechanism has inspiratory prolapse of the arytenoid cartilage,
not yet been established7. The neurologic mechanism shortened aryepiglottic folds or an omega shaped
(neuromuscular hypotonia and impaired neuromus‑ epiglottis10.
cular control) is cited as an important cause of laryn‑ ‑ If GERD is associated, the swallowing function
gomalacia8. should be assessed by a speech pathologist and the
A retrospective study performed over a 6 years objective methods include modified barium swal‑
period, between 1st of January 2007 and 31st of low studies and fiberoptic endoscopic evaluation of
December 2012, on 324 patients diagnosed with swallowing11.

460  /  vol. 53, no. 3


Archives of the Balkan Medical Union

Treatment of laryngomalacia Infants with laryngomalacia usually associate


swallowing dysfunction and it is important to assess
An estimated 40% of the infants presenting this function before and after treatment. Feeding
with laryngomalacia have mild symptoms and anoth‑ problems in a new born can lead to dehydration and
er 40% have moderate symptoms. They can be treat‑ low weight gain, leading to more severe health prob‑
ed conservatively and the symptoms usually resolve lems.
spontaneously by the age of 12‑24 months2. Laryngomalacia is a benign and self‑limiting dis‑
Up to 20% of the patients present with severe ease. Conservative approaches and close follow‑up are
laryngomalacia, that is not likely to cure sponta‑ adequate in most patients. In severe cases, supraglot‑
neously and needs surgical treatment12. The most toplasty shortens the length of symptomatic disease,
common surgical method used is supraglottoplasty, compared to `wait‑and‑see“ policy. Neurologic impair‑
a method that is still very controversial, because of ment is thought to influence laryngomalacia’s severi‑
the possible complications, meaning the impair‑ ty and outcome. Comorbidities are found to have an
ment of various supraglottic structures during sur‑ influence on the duration and severity of laryngoma‑
gery. Supraglottoplasty is performed by resecting lacia.
the supra‑arytenoidal redundant mucosa, incision of Since the first supraglottoplasty was described by
shortened aryepiglottic folds, epiglottopexy or a com‑ Lane et al in 1984, endoscopic supraglottoplasty with
bination of these. Epiglottopexy means de‑epithelial‑ various kinds of instruments has become an effective
ization of the vallecula and suture of the lingual side treatment for this condition16.
of the epiglottis to the base of the tongue. Indications
for supraglottoplasty are severe clinical presentation
or insufficient spontaneous resolving of symptoms
Compliance with Ethics Requirements:
during the `wait‑and‑see“ policy.
„The authors declare no conflict of interest regarding
The most common findings are: inward collapse
this article“
of arytenoids cartilages (type 1), medial displacement
„No funding for this study“
of aryepiglottic folds (type 2) and posterocaudal dis‑
placement of epiglottis against the posterior pharyn‑
geal wall (type 3).
The type of laryngomalacia determinates the
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