Introduction:
Pediatric laryngomalacia, also known as laryngeal malacia, is defined as a condition that results from a birth defect in the child’s larynx, which is known as the voice box. Stridor is caused by the soft tissues of the larynx dropping over the airway opening and partially blocking it. Stridor is called an elevated-pitched sound that is heard when the child inhales. Laryngomalacia is occasionally referred to as congenital laryngeal stridor and is the most typical cause of noisy breathing in infants. It is essential to make the diagnosis in the earlier days of infancy as it can impact multiple aspects of growth and development.
Additionally, half of the infants have noisy breathing during the initial week of life, and most develop this by two to four weeks of age. Laryngomalacia occurs rarely in older children. It is very uncommon in adults. Pediatric laryngomalacia in infants is not considered a serious condition and is manageable; such infants show normal growth and development. In such cases, pediatric laryngomalacia is seen getting resolved without surgery by the time they are 18 to 20 months old. Yet, a small ratio of babies with pediatric laryngomalacia struggle with normal functions like breathing, eating, and gaining weight. These symptoms require quick attention.
What Is Pediatric Laryngomalacia?
Pediatric laryngomalacia is a condition that is characterized by a birth defect in the voice box of an infant, which creates a rattling sound known as stridor. A stridor is defined as an abnormal, high-pitched breathing sound. It is caused by an obstruction in the throat or larynx. It is most often heard when taking in a breath. This blockage is caused by the soft tissues of the larynx descending over the airway opening and partially blocking it. Children who have narrow airways are at higher risk of airway blockage than adults. Stridor is a sign of airway blockage in younger children. It must be treated immediately to prevent the airway from becoming entirely closed. Stridor or noisy breathing is considered a crucial manifestation in identifying varying degrees of respiratory compromise.
A proper upper airway evaluation is essential for children suspected of laryngomalacia for accurate diagnosis and proper management of the condition and any underlying comorbidities. This presents a broad overview of the current diagnostic and management approaches for laryngomalacia in infants.
What Is the Etiology of Pediatric Laryngomalacia?
Many theories of laryngomalacia have been put forth by many researchers. The one that is explained based on neurologic dysfunction is one of the most expected theories, indicating that compromised laryngeal tone emerges from an abnormal integration of the laryngeal nerves. This concept is supported by a pathologic analysis that demonstrated advanced supraglottic nerve diameter in patients with severe laryngomalacia.
Another theory, such as an imbalance of demand-supply upon inhalation in infants, requires additional research. Even though researchers have not seen reflux to be a causative factor for laryngomalacia, nearly 60 to 65 % of infants were seen to be suffering from concomitant acid reflux disease. Reflux is considered to be the main factor behind the irritation and edema of the upper airway, potentially exacerbating obstruction. The loud and noisy breathing is usually worse when the infant is on their back or when crying.
What Are the Types of Pediatric Laryngomalacia?
There are certain categories or types of pediatric laryngomalacia, such as:
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Mild Laryngomalacia: Pediatric patients, especially infants in this category, have uncomplicated laryngomalacia with specific noisy breathing while breathing in without significant airway feeding issues and obstructive events for other symptoms associated with laryngomalacia. These infants have noisy breathing that is irritating to the guardians but does not cause any other healthcare problems. It is vital to keep an eye out for any signs or symptoms that the infant's laryngomalacia may be becoming worse, even if it is very minor.
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Moderate Laryngomalacia: Patients of this category have the following symptoms:
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Noise while inhaling.
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Spit up or vomit.
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Obstruction in the airway.
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Difficulty in feeding.
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Severe airway symptoms lead to emergency room visits.
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Infants with gastric reflux illness typically have a reduction in stridor and may require treatment for the condition.
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Even if the child has moderate laryngomalacia, it is still essential to look out for worsening symptoms.
3. Severe Laryngomalacia: Pediatric patients in this category need surgery to manage the symptoms. The physician may recommend surgery if the patient has any of the following symptoms:
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Apnea that is life-threatening.
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Noticeable blue spells.
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Failure to live properly because of feeding difficulty.
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Significant neck and chest wall retractions with breathing.
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Needs an oxygen supply to breathe.
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Lung or heart problems as a result of chronic oxygen deprivation.
How Is Pediatric Laryngomalacia Evaluated?
A healthcare professional may ask for details about the child's health problems and suggest tests such as nasopharyngoscopy (NPL). This test is done to view the baby's voice box. A tiny camera that looks like a strand of spaghetti with light is inserted into the lower part of the throat through the nostril to view the larynx.
If laryngomalacia is detected, then a few more tests are suggested. These include:
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X-ray of the neck.
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Airway fluoroscopy.
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Microlaryngoscopy and bronchoscopy (MLB).
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Esophagogastroduodenoscopy (EGD) and pH probe.
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Functional endoscopic evaluation of the swallow (FEES).
Nowadays, flexible fiberoptic laryngoscopy is the gold standard for diagnosing laryngomalacia due to the comfort and ability to directly assess the dynamic collapse of the supraglottic airway during awake respiration. Other diagnostic tools like direct laryngoscopy and diagnostic bronchoscopy in the operating room give the surgeon a full evaluation of the upper aerodigestive tract to the level of the mainstem bronchi. This procedure is an essential modality in patients with severe symptoms or in patients where there is a concern for synchronous airway lesions in the same infant. If necessary, direct laryngoscopy also enables surgical intervention.
In older children, a polysomnogram is useful to quantify the presence and degree of obstructive sleep apnea appearing in a patient with laryngomalacia; this is occasionally described as sleep-exclusive laryngomalacia and has fewer incidences. Diagnosis is generally done by drug-induced sleep endoscopy. These patients may benefit from surgical intervention with a supraglottoplasty to improve their apnea-hypopnea index. Airway fluoroscopy is not suggested in evaluating infant stridor as it has low sensitivity and demands increased exposure to ionizing radiation.
What Is the Treatment for Pediatric Laryngomalacia?
Almost 90 % of the cases get resolved on their own without any treatment. In severe cases of laryngomalacia, it may need medications and surgery.
Medications: A doctor may prescribe anti-reflux medications to manage gastroesophageal reflux (GERD). This treatment is important as chronic neck and chest retractions from the laryngomalacia may worsen the reflux. Acid reflux may cause swelling above the vocal cords and worsen noisy breathing.
Laryngomalacia surgery: A surgery called supraglottoplasty is the choice of treatment in severe cases. After the surgery, the child’s swallow should be reevaluated.
The treatment of the majority of patients with laryngomalacia is conservative. In mild or moderate stridor cases without any feeding difficulties, observation is advised after making a diagnosis. It is essential to monitor for proper weight gain and the development of any severe symptoms.
Positional feeding and thickened feedings can help infants with feeding difficulties. Pediatric patients with severe laryngomalacia need surgical intervention.
Conclusion:
Most infants with laryngomalacia can eat and grow normally. Yet, a small percentage of infants struggle with eating, breathing, and weight gain and their symptoms are required to be resolved rapidly. The physician will make the diagnosis, determine the category of laryngomalacia, and plan further treatment accordingly.
