Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis

OBJECTIVES

To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI).

RESULTS

100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment.

CONCLUSIONS

Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.

Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty

STUDY OBJECTIVES

Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications.

METHODS

A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography.

RESULTS

400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05).

CONCLUSIONS

In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP.

CITATION

Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

Efficacy and predictors of success on laryngomalacia surgery: experience from a tertiary pediatric care center in Brazil

OBJECTIVES

Laryngomalacia is the most common congenital cause of stridor; the natural history of the disease runs through to complete resolution by the age of two. Severe cases are characterized by cyanosis, hypoxia, apnea, furcular and/or subcostal retractions, aspirations, pulmonary hypertension, and failure to thrive and must undergo surgery. This study aimed to evaluate the success rates of supraglottoplasty in our hospital and evaluate the predictive factors for surgical success.

METHODS

Cohort study, prospectively planned. 75 patients undergoing endoscopic surgery from July 2007 to July 2016 were analyzed at the Santo Antônio Children's Hospital. The primary outcome was percentage of surgical success, defined as the absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative month (late success). The secondary outcomes were the early surgical success (absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative day).

RESULTS

39 (58.2%) were male, with an average of 4.9 months. Surgical success on the first day was 80.6% (n=54). At the end of the 1st month, surgical success was 88.6%, considering only those who completed assessment. Twenty-one (34%) presented comorbidities. Presence of comorbidities, pharyngomalacia and GERD were associated with a worse result on the 1st postoperative day, whereas, at the end of the first month, presence of comorbidities, concomitant injuries (tracheo and bronchomalacia) and pharyngomalacia were the predictive variables of surgery failure.

CONCLUSION

Supraglottoplasty has high rates of efficacy and low morbidity. The presence of comorbidities and pharyngomalacia has shown association with a worse early and late surgical outcome. Synchronous airway lesions predict a worse surgical result at the end of the first month. GERD was associated with obstructive symptomatology only in the 1st post-operative day.

LEVEL OF EVIDENCE

Level 3 of evidence, according to the "The Oxford 2011 Levels of Evidence" from Oxford Centre for Evidence-Based Medicine.

Characteristics of Patients with Laryngomalacia: A Tertiary Referral Center Experience of 106 Cases

Laryngomalacia (LM) is the most common airway congenital anomaly and the main cause of stridor in infants. Some patients with severe airway symptoms or with feeding difficulties require surgical intervention. Synchronous airway lesions (SALs) may influence the severity and course of the disease. This study aimed to determine the prevalence of various types of LM and SALs and their influence on surgical intervention decisions and feeding difficulties. Moreover, the study focused on the interrelations between SALs and the type of LM or the presence of feeding difficulties. A retrospective analysis of 106 pediatric patients revealed a significant relationship between type 2 LM and the necessity of surgical treatment. We also found a significant effect of LM type 2 on feeding difficulty. Type 1 LM is significantly more characteristic in premature children. Among different comorbidities, SALs are suspected of modification of the course and severity of LM. This study did not find a significant effect of SALs on the incidence of supraglottoplasty or feeding difficulty.

Supraglottoplasty for severe laryngomalacia can be effective and safe also in children with high-risk comorbidities - Experience from a tertiary center

OBJECTIVES

Supraglottoplasty (SGP) for severe laryngomalacia (LM) in children with medical comorbidities has been associated with high risk of surgical failure and increased need of postoperative pediatric intensive care unit (PICU) intervention, but evidence for this is ambiguous. The objective was to evaluate surgical outcome and risk of need for PICU-intervention following SGP for severe LM in comorbid patients.

METHODS

Retrospective observational study of 116 patients treated with SGP for severe LM between 2000 and 2021 at a tertial referral pediatric airway surgery center Karolinska University Hospital. Medical records were reviewed and patient data regarding surgical timing, type of SGP procedure, PICU-intervention, complications, and outcomes were recorded. Patients were defined as non-comorbid vs high-risk comorbid (HRC) based on a coexisting comorbidity for risk of surgical failure and postoperative PICU-intervention. Surgical failure was defined as need of revision surgery, tracheostomy or assisted ventilation (continuous positive airway pressure and bilevel positive airway pressure). PICU intervention was defined as need of postoperative assisted ventilation or intubation. Statistical comparisons were performed with outcome of SGP on children with LM and no comorbidities.

RESULTS

41/116 patients included had a HRC associated with an increased risk of PICU-intervention and surgical failure. 75/116 patients were defined as non-comorbid. The overall surgical success in the study population was 89.7% (104/116), 94.7% in the non HRC group vs 80.5% in the HRC-group. 5/41 HRC patients and 1/75 non-comorbid patients needed SGP revision in which 5/6 was successful. There was no significantly increased need for postoperative PICU intervention in HRC patients.

CONCLUSION

SGP for severe LM patients with high-risk comorbidities performed in a tertiary setting had an overall good result and low risk of PICU-intervention. Revision SGP was more common in HRC patients but had a good outcome. Multidisciplinary experience in perioperative care of comorbid patients may be of key importance for outcome and children with high-risk comorbidities should thus not be withheld the possible benefit of SGP without assessment at a tertiary pediatric airway center.

Disposition to pediatric intensive care unit post supraglottoplasty repair: a systematic review

BACKGROUND

Patients undergoing supraglottoplasty are often routinely admitted post-operatively to the pediatric intensive care unit (PICU) due to rare but potentially fatal complications such as airway compromise. A systematic review was performed to determine the rate of post-operative PICU-level respiratory support required by pediatric patients following supraglottoplasty, to identify risk factors for patients who may benefit from post-operative PICU admission and limit unnecessary use of intensivist resources.

REVIEW METHODS

Key search terms 'supraglottoplasty' OR 'supraglottoplasties' were queried on three databases: CINHAL, Medline and Embase. Inclusion criteria were pediatric patients under 18 years of age who underwent a supraglottoplasty procedure with either an admission to PICU or requirement for PICU-level respiratory support. Risk of bias was assessed by two independent reviewers using QUADAS-2. Findings were critically appraised by three independent reviewers and pooled proportions of criteria meeting PICU admission were calculated for meta-analysis.

RESULTS

Nine studies met inclusion criteria, totaling 922 patients. Age at time of surgery ranged from 19 days to 15.7 years with mean age of 5.65 months. A weighted pooled estimate suggested that 19% (95% CI 14-24%) of patients who underwent supraglottoplasty required PICU-admission. The included studies revealed several patient and surgical factors have been linked to postoperative respiratory issues requiring PICU admission, including: neurological disease, perioperative oxygen saturation < 95%, prolonged surgical time and age < 2 months.

CONCLUSIONS

This study found that the majority of supraglottoplasty patients do not require significant postoperative respiratory support and suggests that routine PICU admission of these patients may be avoided by careful patient selection. Given the wide heterogeneity of outcome measures, further studies are needed to determine the ideal PICU admission criteria following supraglottoplasty.

Long term Follow Up of Severe Laryngomalacia Patients Following CO2 LASER Supraglottoplasty

Laryngomalacia is the most common cause of stridor. It is believed to be due to delayed development of the supraglottic structures. On the basis of presentation, it has been divided into 3 grades. Management is dependent upon the grades: Mild and moderate laryngomalacia are managed conservatively, while CO2 LASER supraglottoplasty is the surgical management of choice for severe disease. In this study we evaluated the outcomes of supraglottopasty in long term follow up. It was a retrospective study which included patients with severe laryngomalacia who have undergone supraglottoplasty for the dates from July 2013 to July 2018. Weight and height of the patients were taken during the follow up visit after one year and have been compared with that of the normal children of comparable age using the pediatrics growth charts. Follow up was done by telephonic conversation to evaluate the status of other symptoms associated with laryngomalacia. Total of 44 patients were included in the study, 47.7% and 52.3% females and males respectively. Weight for age, weight for height and height for age were normal in 80.9%, 80.9% and 76.1% of patients respectively after supraglottoplasty. Of the patients studied, stridor was resolved in 80.9%, early tiredness during play was resolved in 43.2%, swallowing was normal in 85.7% and there was no aspiration in 90.5%. It can be concluded that patients with severe laryngomalacia improved with respect to airway symptoms, as well as, weight and height on long term follow up after CO2 LASER supraglottoplasty. It is important to evaluate the general status of the patients as a whole to truly assess the success of the surgery in addition to the airway symptoms.

Laryngeal surgery for congenital laryngomalacia: NSQIP-P analysis of complications

OBJECTIVE

To evaluate predictors of complications in children with congenital laryngomalacia who underwent laryngeal surgery.

METHODS

Multi-institutional retrospective analysis using the American College of Surgeons-NSQIP-P database (2014-2019). CPT code 31541 and ICD-10 code Q35.1 (congenital laryngomalacia) were used to select patients <18 years. Variable predictors included demographics and medical co-morbidities. Main outcomes assessed included total length of hospital stay (LOS), reintubation, reoperation and readmission.

RESULTS

1092 children were identified, 450 (41.1%) females and 642 (58.6%) males, with a mean age of 1.1 years (95% CI 1.0-1.2). Mean LOS was 3.9 days (95% CI 3.3-4.6). Sixteen (1.5%) were reintubated, 30 (2.7%) were readmitted, and 18 (1.6%) were reoperated within 30 days. Thirty-one (2.8%) were still in hospital at 30 days. Regression analysis revealed an increase in LOS for several groups; the largest effect was seen for patients with preoperative ventilator dependence, admission within the first 28 days of life, and those who were discharged to other healthcare facilities (p < .001). Preoperative co-morbidities significantly associated with a higher frequency of reintubation included ventilator dependence (p = .003), history of prematurity (p = .016) and chronic lung disease (p = .041). Children undergoing surgery in the first 28 days of life were 10.16 times as likely to return to the OR for a related reason within 30 days than older children (p = .038).

CONCLUSION

Complications were rare after laryngeal surgery with a postop diagnosis of laryngomalacia. Recognizing pertinent clinical factors can help with risk assessment and management.

Stridor in the Infant Patient

Stridor is a high-pitched extrathoracic noise associated with turbulent airflow, commonly associated with respiratory distress in infants. Workup for stridor requires evaluation of the upper-respiratory airway, with severe distress requiring evaluation under anesthesia. The differential diagnosis of stridor depends on location of the obstruction, age of the patient, and acuity of the symptoms. The most common reason is laryngomalacia; most patients can be managed conservatively with resolution of symptoms by 2 years of age. In children who do not improve or have severe disease, supraglottoplasty is the treatment of choice, and the majority will have resolution of stridor postoperatively.

Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations

OBJECTIVE

No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database.

METHODS

Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed.

RESULTS

A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index (P = .015, OR = 0.96), structural CNS abnormality (P = .034, OR = 1.95), preoperative oxygen supplementation (P = .043, OR = 1.28), operative time (P = .019, OR = 1.84, 95% CI = 1.28-2.54), and concurrent procedure (P < .001, OR = 2.21) were all independently associated with LOS. Postoperative complications had no significantly associated variables, with an overall low incidence of readmission (5.0%), reoperation (1.7%), and reintubation (1.1%).

CONCLUSION

In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

Patterns of airway obstruction of non-acquired origin in children with and without major congenital anomalies

Major congenital anomalies are known to play a role in the management and prognosis of airway obstruction. Most studies assess acquired forms of airway obstruction. Data on congenital or otherwise non-acquired forms of airway obstruction is sparse. In this retrospective, single-institution cohort study, we sought to evaluate and compare the patterns of airway obstruction in children with and without major congenital anomalies, and to assess the impact of management and outcome, irrespective of aetiology. Fifty-five patients were included, 23 with and 32 without underlying major congenital anomalies. Multilevel airway obstruction (usually affecting the nasopharynx, oropharynx, and the trachea) was more common in children with congenital anomalies (91% vs. 41%, p < .001). Consequently, these children required more frequent and earlier surgical management, especially tracheostomy and adenotonsillar surgery.Conclusions: Major congenital anomalies are associated with multilevel airway obstruction and poor functional prognosis. A simple clinical definition considering impact of major congenital anomalies on development and growth may help guide management plans following endoscopic evaluation of the entire airway and flanked by multidisciplinary discussions. What is Known: • Children with major comorbidities display increased disease severity and more prevalent multilevel airway obstruction • Previous studies include both children with acquired and non-acquired forms of airway obstruction; therefore, the actual impact major comorbidities in children with non-acquired causes of airway obstruction remain unclear. What is New: • A total of 42% children in this study population had major comorbidities with and impact on growth and/or psychomotor development, with a higher prevalence of multilevel airway obstruction and worse rates of functional improvement/recovery. • Children with major comorbidities require tracheostomy more often and earlier than those without major comorbidities, and remain tracheostomy-dependent for a longer time.

Synchronous airway lesions in children with severe, progressive and atypical laryngomalacia - Experience of a UK tertiary referral centre

OBJECTIVES

Laryngomalacia is the commonest cause of stridor in the paediatric population. Whilst usually self-limiting, studies have suggested that the presence of synchronous airway lesions (SALs) might be associated with more severe clinical presentation and additional morbidity. However, evidence in the literature is scarce, contributing to controversy regarding the appropriate investigation and management of children with laryngomalacia. The aim of this study was to explore the prevalence, clinical significance and risk factors of SALs in children with severe, progressive and atypical laryngomalacia symptoms.

METHODS

Retrospective analysis of the records of all paediatric patients diagnosed with laryngomalacia in a UK tertiary referral centre, over a 2-year period, was undertaken. Data on demographics, comorbidities, management and presence of SALs were collected.

RESULTS

The study included 130 patients with laryngomalacia. Seventy-eight patients required investigation with microlaryngobronchoscopy (MLB), based on clinical presentation. SALs were identified in 22 patients (28.2%), 6 of which (7.7%) required surgical intervention. The commonest airway lesions included tracheomalacia, bronchomalacia and subglottic stenosis. A correlation between the presence of neurodevelopmental conditions in children and SALs was noted (p value < 0.05). The presence of SALs was not associated with sex, gestational age at birth or other medical comorbidities.

CONCLUSION

The results of this study allow professionals to counsel families about the utility of MLB in children with severe, progressive and atypical laryngomalacia symptoms and inform management pathways for clinicians not working in airway centres. We support the clinical practice that progressive, atypical or severe laryngomalacia symptoms should prompt consideration of an MLB, to identify potential synchronous airway lesions. Furthermore, we propose that a higher index of suspicion and more thorough investigation might be indicated in children with neurodevelopmental disorders.

Noninvasive Respiratory Support as an Alternative to Tracheostomy in Severe Laryngomalacia

OBJECTIVES/HYPOTHESIS

To analyze the role of noninvasive respiratory support (NRS) as an alternative to tracheostomy in the management of severe laryngomalacia.

STUDY DESIGN

We conducted a monocentric retrospective study in a tertiary pediatric care center.

METHODS

All children under the age of 3 years with severe laryngomalacia, treated between January 2014 and December 2019, were included. Patient demographics, medical history, nutrition, surgery, NRS, and outcome were reviewed. Predictors for NRS were analyzed.

RESULTS

One hundred and eighty-eight patients were included. Mean age was 4 ± 5 months and mean weight was 4,925 ± 1,933 g. An endoscopic bilateral supraglottoplasty was performed in 183 (97%) patients and successful in 159 (87%). NRS was initiated in 29 (15%) patients at a mean age of 3 ± 2 months (1-11 months): 15 (52%) patients were treated with NRS after surgical failure, 9 (31%) were treated with NRS initiated prior to surgery because of abnormal overnight gas exchange, and 5 (17%) were treated exclusively with NRS due to comorbidities contraindicating an endoscopic procedure. NRS was successfully performed in all patients with a mean duration of 6 ± 11 months. No patient required a tracheostomy. Univariate analysis identified the following predictors of NRS: neonatal respiratory distress (P = .003), neurological comorbidity (P < .001), associated laryngeal abnormality (P < .001), cardiac surgery (P = .039), surgical endoscopic revision (P = .007), and nutritional support (P < .001).

CONCLUSION

NRS is a safe procedure, which may avoid a tracheostomy in severe laryngomalacia, in particular, in case of endoscopic surgery failure, respiratory failure before surgery, and/or severe co-morbidity.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Risk factors for peri-operative respiratory adverse events after supraglottoplasty

OBJECTIVE

To determine demographic and peri-operative characteristics that predict peri-operative respiratory adverse events (PRAE) requiring intensive care unit (ICU) level intervention after supraglottoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care children's hospital.

METHODS

Retrospective chart review was conducted of children with laryngomalacia who underwent supraglottoplasty between October 2014 and November 2019. PRAE were defined as any of the following events or requirements within 24 h of surgery: 1) failure to extubate, 2) reintubation, 3) positive pressure ventilation, 4) more than one dose of racemic epinephrine, or 5) greater than 4 L of oxygen via nasal cannula.

RESULTS

Fifty-one subjects were enrolled, with a median age of 4.8 months and majority (62 %) Hispanic. Twenty-one (41 %) subjects experienced PRAE. After adjusting for age and gender on multivariate analysis, children admitted preoperatively to the ICU were more likely to have PRAE than those not admitted or admitted to a floor unit (OR 40.1, 95%CI: 4.1-388.6, p = 0.001). Additionally, children with intraoperative oxygen desaturations below 90 % for greater than 1 min were more likely to have PRAE than those who did not (OR 21.3, 95%CI: 2.4-189.9, p = 0.006). Other factors significantly associated with PRAE on univariate analysis included chronic lung disease, congenital cardiac abnormality, history of intubation, supplemental oxygen requirement, gastrostomy tube dependence, intraoperative intubation and longer surgery length.

CONCLUSION

Preoperative ICU admission and intraoperative oxygen desaturations are independent risk factors for PRAE after supraglottoplasty. Results from this study can help inform decisions regarding the appropriate level of postoperative care required after supraglottoplasty.

LEVEL OF EVIDENCE

IV.

Rare Diseases of Larynx, Trachea and Thyroid

This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.

Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair

OBJECTIVES

In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies.

METHODS

A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery.

RESULTS

Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively.

CONCLUSION

Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

Feasibility of Surgical Treatment for Laryngomalacia using Spontaneous Respiration Technique

Objectives.

In this study, we review our institutional experience with pediatric laryngomalacia (LM) and report our experiences of patients undergoing supraglottoplasty using the spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen (STRIVE Hi) technique.

Methods.

The medical records of 29 children with LM who visited Seoul National University Hospital between January 2017 and March 2019 were retrospectively reviewed. Surgical management was performed using the STRIVE Hi technique. Intraoperative findings and postoperative surgical outcomes, including complications and changes in symptoms and weight, were analyzed.

Results.

Of the total study population of 29 subjects, 20 (68.9%) were female. The patients were divided according to the Onley classification as follows: type I (n=13, 44.8%), II (n=10, 34.5%), and III (n=6, 20.7%). Twenty-five patients (86.2%) had comorbidities. Seventeen patients (58.6%) underwent microlaryngobronchoscopy under STRIVE Hi anesthesia. Four patients with several desaturation events required rescue oxygenation by intermittent intubation and mask bagging during the STRIVE Hi technique. However, the procedure was completed in all patients without any severe adverse effects. Overall, 15 children (51.7%) underwent supraglottoplasty, of whom 14 (93.3%) showed symptom improvement, and their postoperative weight percentile significantly increased (P=0.026). One patient required tracheostomy immediately after supraglottoplasty due to associated neurological disease.

Conclusion.

The STRIVE Hi technique is feasible for supraglottoplasty in LM patients, while type III LM patients with micrognathia or glossoptosis may have a higher risk of requiring rescue oxygenation during the STRIVE Hi technique.

Supraglottoplasty for severe laryngomalacia. Can we predict success?

OBJECTIVES

Laryngomalacia is the dynamic collapse of supraglottic structures during inspiration, leading to a variable degree of airway obstruction. Clinical symptoms appear in the first months of life and are usually mild and resolve by the age of 12-18 months. In severe cases, surgical intervention may be considered. The goal of the study was to review the clinical outcome of pediatric patients who underwent supraglottoplasty for laryngomalacia.

MATERIAL AND METHODS

Clinical and demographic data were retrieved from medical records of children diagnosed with laryngomalacia by laryngo-bronchoscopy between 2013 and 2019. Indications, outcome and long-term follow-up were collected from children undergoing surgery.

RESULTS

During the study period, 115 children were diagnosed with laryngomalacia. The median age at diagnosis was 3 months. Synchronous airway lesions were diagnosed in 20% of patients. Ten (8.7%) children underwent surgical treatment because of significant respiratory symptoms and/or failure to thrive. Three of them had comorbidities. All otherwise healthy children had significant respiratory and nutritional improvement after surgery while those with comorbidities had less successful outcomes.

CONCLUSION

We conclude that in severe cases of laryngomalacia, supraglottoplasty has an important role to play in management. In children with comorbidities, the surgical results may be less successful. Therefore, we recommend that the decision to operate should be individualized, ensuring full disclosure to the family regarding the probable benefit along with the limitations of surgery.

Carbon dioxide laser versus cold-steel supraglottoplasty: A comparison of post-operative outcomes

OBJECTIVE

Supraglottoplasty is the mainstay of surgical treatment for laryngomalacia, and is commonly performed via two methods: cold steel or carbon dioxide (CO₂) laser. The degree of post-operative monitoring following supraglottoplasty varies, both within and between institutions. The aim of this study was to compare the post-operative monitoring and interventions required by patients undergoing cold-steel versus CO₂ laser supraglottoplasty.

DESIGN

Retrospective cohort of pediatric patients (age < 18 years) undergoing supraglottoplasty at a tertiary care pediatric hospital. The primary exposure was the surgical instrument(s) used during supraglottoplasty. The primary outcome was prolonged intensive care unit (ICU)-stay (defined as >24 h).

RESULTS

155 cases were eligible for inclusion. Fifty-eight (37.4%) patients had a comorbid condition. Common indications for surgery included feeding difficulty (56.1%), severe respiratory distress (33.5%), and obstructive sleep apnea (25.2%). CO₂ laser was employed in 49 cases and cold-steel in 106 cases. Prolonged ICU-stay (>24 h) was observed in 14 CO₂ laser cases (28.6%) and 11 cold-steel cases (10.4%) (adjusted OR 3.42; 95% CI 1.43, 8.33). CO₂ laser cases were more likely to require post-operative intubation, non-invasive positive pressure ventilation, and nebulized racemic epinephrine. Concomitant neurological condition was associated with an increased risk of prolonged ICU-stay, while extent of surgery and age were not.

CONCLUSIONS

CO₂ laser supraglottoplasty is associated with an increased risk of prolonged ICU-stay and need for ICU-level airway intervention, compared to the cold-steel technique. While this association should not be misconstrued as a causal relationship, the current study demonstrates that specific surgical factors may influence the patient monitoring requirements following supraglottoplasty, particularly the choice of instrument and the extent of surgery.

Supraglottoplasty in Neonates under One Month of Age

OBJECTIVES

Examine outcomes of patients 1 month of age or less who received supraglottoplasty. Demonstrate the feasibility and safety of supraglottoplasty in neonates <1 month of age.

METHODS

Charts were reviewed from 2015-2017. Patients with previously identified laryngomalacia requiring surgical intervention and age 1 month or less were identified. We collected data on age, gender, surgical technique, other airway lesions, time to extubation and discharge, and comorbidities.

RESULTS

Six patients met the inclusion criteria of which four were male and two were female. Average age at time of surgery was 19.5 days. All patients had diagnosis of laryngomalacia made on flexible or direct laryngoscopy with increased work of breathing, reports of cyanotic episodes, or oxygen desaturations. All had feeding difficulties, and three had signs and history consistent with gastroesophageal reflux. Two patients underwent supraglottoplasty by CO₂ laser treatment alone, one patient received cold steel treatment alone, and the remaining three patients received cold steel with supplemental microdebrider treatment. Out of six patients, five were extubated within 5 days of their procedure. The average time to extubation was 1.8 days. The average time to discharge was 24.25 days following surgery. Two patients required revisions.

CONCLUSIONS

Supraglottoplasty in children younger than 1 month of age is rare. Despite the rare occurrence, it appears to be feasible early in life in treating laryngomalacia. Neonates with respiratory failure, apneas, and cyanosis, or difficulty feeding due to laryngomalacia should be evaluated and treated with supraglottoplasty.

Coagulation of the lateral surface of aryepiglottic folds as an alternative to aryepiglottic fold release in management of type 2 laryngomalacia

OBJECTIVE

Endoscopic supraglottoplasty is the procedure of choice in treatment of laryngomalacia with CO2 laser and cold steel being the most common instruments used with excellent results. However, bleeding, supraglottic stenosis and aspiration may occur leading to serious complications. Using coblation in management of laryngomalacia was found to be beneficial. Therefore, we conducted this study to evaluate the outcome of supraglottoplasty done by coagulation using coblation of the lateral surface of aryepiglottic folds as an alternative technique to aryepiglottic fold release in management of type 2 laryngomalacia.

METHODS

Retrospective study was conducted at Mansoura University Hospitals; Egypt from November 2017 to March 2018 included patients diagnosed with severe type 2 laryngomalacia. Supraglottoplasty was done by using coblator applied to the lateral surface of aryepiglottic folds allowing for lateral scarring thus widening the airway, preventing supraglottic collapse and avoiding re-stenosis. Outcome measures included assessment of presence or absence of the following symptoms preoperatively and postoperatively: inspiratory stridor, failure to thrive, choking and cyanosis. Preoperative and postoperative lowest oxygen saturation levels, weight-by-age percentile, and need for tracheostomy were assessed.

RESULTS

Nine patients were included in this study with a mean age of 3.78 ± 1.20 months (range 2-6 months). Overall success rate was 89%. The most significantly improved symptom was stridor (p-value 0.008). Significant improvement in lowest oxygen saturation levels (from 89.11 ± 3.06% pre-operatively to 96.44 ± 3.50% post-operatively) and weight gain (from 4288.9 ± 643.1 gm. preoperatively to 5505.55 ± 1017.4 gm. 1 month postoperatively) was achieved. No detected re-stenosis on follow up and none of our cases needed tracheostomy.

CONCLUSION

Supraglottoplasty by coagulation of the lateral surface of aryepiglottic folds using coblation is an effective and safe technique and can improve airway symptoms and weight gain in patients with type 2 laryngomalacia.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis

OBJECTIVE

To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia.

DATA SOURCES

PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase.

REVIEW METHODS

Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed.

RESULTS

A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011).

CONCLUSION

Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

Polysomnography Outcomes after Supraglottoplasty in Children with Obstructive Sleep Apnea

Objective

Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA.

Study Design

Retrospective case series.

Setting

Tertiary care medical center.

Subjects and Methods

Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery.

Results

Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery ( P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery ( P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 ( P = .04). Sleep efficiency was improved ( P = .05).

Conclusion

Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty

OBJECTIVE

To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient.

METHODS

A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay.

RESULTS

Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2).

CONCLUSION

Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery

OBJECTIVE

The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system.

METHODS

Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system.

RESULTS

231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery.

CONCLUSION

This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Impact of Infant Supraglottoplasty on Quality of Life

Objectives The objective of the present study is to examine the impact of supraglottoplasty on the quality of life (QOL) of caregivers and infants with severe laryngomalacia and moderate laryngomalacia with feeding difficulties. Study Design Prospective cohort study. Setting Tertiary children's hospital. Subjects and Methods Thirty-nine infants who underwent supraglottoplasty were examined. The primary caregiver answered the 47-item short form of the Infant and Toddler Quality of Life Questionnaire-47 pre- and postoperatively; the subsection scores were compared. A 1-way analysis of variance was performed to analyze the effect of age and sex. A comparison was made between our cohort and a general population of healthy children. Results The average age at surgery was 4.0 months, and 53% of the patients were male. There was significant postoperative improvement in overall health, physical ability, growth and development, bodily pain, temperament, emotional impact on the caregiver, impact on caregiver's time, and family cohesion scores ( P < .05). The same subscale scores remained significantly improved postoperatively after age and sex were controlled. Preoperative QOL scores were significantly worse than those of the general population in nearly all categories. Postoperative physical ability ( P = .009) and temperament ( P = .011) QOL scores were higher than the those of the general population. Scores for growth and development ( P = .132), bodily pain ( P = .481), and family cohesion ( P = .717) were equivalent to those of the general population. Conclusion QOL was significantly improved after supraglottoplasty for infants with severe laryngomalacia and moderate laryngomalacia with feeding difficulties. After supraglottoplasty, QOL was similar to that of the general infant population in most categories.

A novel technique for unilateral supraglottoplasty

OBJECTIVES

Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty.

METHODS

Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate.

RESULTS

Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty.

CONCLUSION

Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.

Supraglottoplasty for laryngomalacia: The experience from Concepcion, Chile

OBJECTIVE

To review the clinical manifestations and outcomes of supraglottoplasty in patients with moderate to severe laryngomalacia at Guillermo Grant Benavente Hospital between January 2015 and January 2017.

METHODS

Retrospective study of patients with laryngomalacia who underwent CO2 laser supraglottoplasty at a tertiary referral center. A review of medical records of these patients was performed. Epidemiological data along with symptoms, comorbidities, morphological type of laryngomalacia, synchronous airway lesions, surgery outcomes and satisfaction of parents after the procedure were recorded. Surgical success was defined as the resolution of the criteria of severity of laryngomalacia.

RESULTS

Twenty-four patients were operated, 1 was excluded due to prior tracheostomy. Twenty-three patients were included, the median age at the time of surgery was 5.5 months. All the patients had stridor, 87% presented feeding difficulties, 34.8 % had cyanosis and 21.7% had failure to thrive. Six cases had congenital anomalies and four cases had nongenetic comorbidities. Fifteen patients (65.2%) had synchronous airway lesions. 17.4% had type I laryngomalacia and 82.6% were type 2. The postoperative average hospital stay was 1.3 days. The average follow-up was 14 months and no complications were reported. The overall success rate of surgery was 95%.

CONCLUSIONS

Patients with laryngomalacia and any symptom of severity should undergo a full airway evaluation, to rule out synchronous airway lesions, and supraglottoplasty if needed, as it has been shown to be a safe and effective technique for the management of these patients.

Comparison between selective and routine intensive care unit admission post-supraglottoplasty

OBJECTIVE

To compare major post-operative respiratory complications, post-operative disposition and duration of hospital admission before and after adopting a selective intensive care unit (ICU) admission care plan following supraglottoplasty (SGP).

METHODS

Retrospective case series set in a tertiary pediatric referral center. Eligible patients undergoing SGP between October 2003 and July 2015 were identified through a prospectively kept surgical database. Historical cohorts with routine admission to ICU and selective admission to ICU were identified based on a shift in surgeon practice. The cohorts were compared with respect to demographics, presenting features, endoscopic findings, baseline sleep and swallowing study results, major respiratory complications (including repeat or unplanned ICU admission or intubation) and length of post-operative hospital admission.

RESULTS

141 eligible patients were identified with 35 children in the routine ICU admission cohort and 106 in the selective ICU admission cohort. There were no significant differences between cohorts regarding major respiratory complications with only one patient in the selective ICU admission cohort requiring an unplanned admission to ICU (P = 1.00, Fisher's exact test). This gives a number needed to harm of 78 step-down unit admissions for 1 unplanned ICU admission. The rate of ICU admission was reduced from 71% to 26% with adoption of a selective ICU admission care plan (p < 0.01, χ²). Mean duration of post-operative hospitalization was reduced from 5.1 ± 3.5 days to 1.9 ± 2.3 days (P < 0.01, Student's t-test).

CONCLUSIONS

Selective post-operative ICU admission following SGP significantly reduces ICU utilization and may reduce length of hospital stay without compromising safety and care. This has significant cost benefit implications.

Laryngomalacia: Our Clinical Experience

Objective

The aim of this study is to analyse the clinical symptoms, follow-up and treatment properties of the laryngomalacia patients that we encountered between 2009 and 2014.

Methods

Records of 81 laryngomalacia patients who were followed up in our clinic between 2009 and 2014 were retrospectively analysed. Patients' gender, age, time of onset of the symptoms, chief complaints, other co-existing congenital laryngeal anomalies and treatment and follow-up properties were evaluated.

Results

Of the 81 patients, 48 were male and 33 were female, and the mean age was 4.9 months. The average period of follow-up was 12.1 months. The chief complaints at the time of admission were stridor (100%) and episodic cyanosis with feeding (27.16%). Symptoms of 75 patients were resolved at an average of 8.2 months with conservative treatment. Three patients underwent supraglottoplasty. Tracheotomy and posterior cordotomy was performed for a patient with co-existing vocal cord paralysis. Additional tracheotomy was necessary for a patient with pulmonary co-morbidities and for another with co-existing subglottic stenosis.

Conclusion

Laryngomalacia is the most common cause of stridor in infants. The majority of laryngomalacia patients can be managed conservatively by close follow-up. For patients in whom respiratory and feeding problems persist or growth retardation develops, surgical treatment is performed. Tracheotomy may be necessary for a small group of patients with additional diseases.

Laser supraglottoplasty for laryngomalacia; a 14 year experience of a tertiary referral center

To review the outcomes of laser supraglottoplasty performed in children with symptomatic laryngomalacia and determine the factors influencing them. We retrospectively reviewed the medical records of patients who underwent laser supraglottoplasty for symptomatic laryngomalacia at the Lausanne University Hospital from November 2001 to November 2014. We examined the patient's demography, symptoms, comorbidities, type of laryngomalacia, synchronous airway lesions, and final outcomes. Seventy-nine patients were included in this study; median age at the time of surgery was 12.7 months. 55.7 % of the cases had comorbidities, 22.8 % of the patients were premature and synchronous airway lesions were present in 32.9 % of the cases. The different morphological types of laryngomalacia (I-III) were seen in 26.6, 62 and 11.4 % of the patients, respectively. Overall, operation specific success rate of laser supraglottoplasty was 86.1 %. Failures in 11 (13.9 %) of the 79 cases required 15 revision procedures. Success rates for patients with associated comorbidities, synchronous airway lesions, neurological disorders and prematurity were 81.8, 76.9, 69.2 and 66.7 %, respectively. Patients with type III laryngomalacia had a limited success rate (66.7 %) as compared to patients with morphological types I and II (90.5 and 87.8 %, respectively). Laser supraglottoplasty is an effective and safe treatment for symptomatic laryngomalacia. Patients with prematurity, type III LM, synchronous airway lesions and associated comorbidities are predisposed to surgical failure.

Laryngomalacia

Laryngomalacia is the most common cause of stridor in neonates. It typically presents with inspiratory stridor and is often associated with feeding problems. Severe cases present with stridor, apnea, significant respiratory distress, and failure to thrive. Most patients are managed conservatively and can expect to see symptom resolution by 12-24 months of age. About 10% of patients require surgical treatment for their symptoms. Supraglottoplasty is the surgical technique of choice. Results of this surgery are excellent, and severe complications, such as supraglottic stenosis and aspiration, are uncommon. Supraglottoplasty is less effective in patients with significant comorbidities such as neurologic conditions and syndromes.

Assessment and causes of stridor

Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").

Treatment outcome of supraglottoplasty vs. wait-and-see policy in patients with laryngomalacia

In most cases, laryngomalacia presents as a mild disease, and the symptoms resolve after wait-and-see policy. Up to 20 % of patients present with severe laryngomalacia and may require surgery (i.e. supraglottoplasty); however, the indication for surgery is not firmly established yet. The goal of this study is to determine whether supraglottoplasty results in a better outcome than wait-and-see and to investigate how different comorbidities influence outcome. A retrospective study of pediatric cases of in a tertiary referral center was performed. Photo and video documentation was available and revised in all cases. Electronic and paper charts were reviewed for the following variables: gender, sex, gestational age, birth weight, symptoms, comorbidity, date of endoscopy, severity and type of laryngomalacia, treatment modality and technique and follow-up data and a total 89 patients were included. Supraglottoplasty was found to lead to significantly faster complete improvement of laryngomalacia than wait-and-see policy (5 weeks vs. 29, p = 0.026). Synchronous airway lesions (SALs) were present in 40.4 % of patients and were associated with prolonged symptoms of laryngomalacia (38.5 weeks vs. 14.5, p = 0.043). Supraglottoplasty is safe and effective in treatment of severe laryngomalacia. SALs and comorbidities are frequently found in patients with laryngomalacia and are responsible for longer onset of complaints.

Prevalence and characteristics of tracheal cobblestoning in children

BACKGROUND

Tracheal follicular pattern or so-called tracheal cobblestoning is a poorly described entity in the literature and is depicted as a nodular or lumpy appearance of the tracheal wall mucosa suggesting tracheal irritation from factors like gastro-esophageal reflux (GERD) or pulmonary infection. The aim of the present study was to investigate the prevalence and characteristics of tracheal cobblestones in a large pediatric population.

METHODS

A large database of rigid tracheoscopies recorded in children (0-6 years of age) undergoing general anesthesia with planned tracheal intubation for elective surgical procedures was retrospectively analyzed. Tracheoscopy records were reviewed by five pediatric airway experts (authors 3-7). Data were compared using the Mann-Whitney test, chi-square or Fisher exact test as appropriate (P < 0.05).

RESULTS

A total of 971 rigid tracheoscopy records were analyzed. The median age of the patients was 3.3 years (range 0.4-6.0 yrs). Cobblestones were present in 377 out of 971 patients (38.8%) with a male to female prevalence of 254 (40.6%)/123 (35.5%). None of the children under four months of age showed the presence of cobblestones. The prevalence of cobblestones was significantly less in patients under 3 years of age compared to over 3 years (P < 0.01). There was no association between prevalence of cobblestones and GERD, current or recent respiratory infection or concomitant enlarged tonsils.

CONCLUSION

The prevalence of tracheal cobblestones in otherwise healthy children is high and is not associated with GERD or respiratory infection. The gender and age related differences are novel interesting findings that require further investigations.

Laryngomalacia and swallowing function in children

OBJECTIVES/HYPOTHESIS

1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients seen in the aerodigestive center at our institution between January 2007 and December 2012 with the diagnosis of laryngomalacia were included. Swallowing function was assessed by symptoms, clinical swallowing evaluations (CSE) performed by speech pathologists, modified barium swallow (MBS) studies, and fiberoptic endoscopic evaluations of swallowing (FEES).

RESULTS

There were 324 patients with laryngomalacia identified (41.4% female, 58.6% male). Severity of laryngomalacia was categorized in 279 patients, with 62.7% mild, 28.7% moderate, and 8.6% severe. Gastroesophageal reflux disease (GERD) was diagnosed in 69.8% of patients. Other medical comorbidities included Down syndrome (3.1%), neurological impairment (6.5%), and congenital heart disease (0.9%). Symptoms of dysphagia or feeding difficulty were present in 163/324 (50.3%), and failure to thrive was present in 31/324 patients (9.6%). At least one abnormal swallowing assessment was present in 97/120 (80.8%) patients presenting with subjective dysphagia and 43/65 (66.2%) patients without subjective dysphagia. A total of 140/185 (75.7%) patients had at least one abnormal baseline swallowing assessment. There was no significant relationship between severity of laryngomalacia and presence of abnormal swallowing function based on symptoms, CSE, MBS, or FEES. However, patients with greater severity were more likely to have failure to thrive. There was not a significant association between the presence of swallowing dysfunction or disease severity and medical comorbidities such as Down syndrome, neurological impairment, or congenital heart disease. However, GERD was more likely to be present in patients with moderate and severe laryngomalacia than in patients with mild disease.

CONCLUSIONS

Swallowing dysfunction is common in children with laryngomalacia regardless of disease severity or other medical comorbidities. Swallowing studies are frequently abnormal in laryngomalacia patients presenting both with and without subjective symptoms of dysphagia. Dysphagia assessment should be considered as part of the evaluation of infants with laryngomalacia.

LEVEL OF EVIDENCE

4.

Supraglottoplasty in Infants

Objective:

While generally well tolerated for the treatment of severe laryngomalacia, bilateral supraglottoplasty has potential complications including supraglottic stenosis and aspiration. We report a more conservative staged supraglottoplasty in infants with severe laryngomalacia.

Methods:

A retrospective review was performed of our patients who underwent staged supraglottoplasty from June 2007 to June 2012. Fifteen infants were identified and scored based on stridor, retractions, oxygen saturation, and feeding quality. Outcomes were compared with those reported in the literature for conventional bilateral supraglottoplasty.

Results:

Seventy-three percent had significant improvement or resolution of stridor following the first stage of surgery and 100% in those undergoing a second stage. Twelve patients (80%) had mild to no retractions following one procedure and 100% had resolution after a second surgery. All 6 patients with recurrent preoperative desaturations had resolution after the first stage of surgery. Of the 11 infants who had preoperative moderate-severe feeding problems, 9 of them (82%) had resolution after one surgery and the remaining 2 had resolution after a second surgery. There were no complications in any of the patients.

Conclusions:

Staged supraglottoplasty appears to be an effective, low-risk method to treat severe laryngomalacia. A second procedure was only required in 40% of patients.

Management of laryngomalacia in children with congenital syndrome: the role of supraglottoplasty

BACKGROUND/IMPORTANCE

Supraglottoplasty is the surgical procedure of choice for severe laryngomalacia and has shown to be successful in most cases; however, patients with medical comorbidities present a higher rate of failure. To date, the best management of laryngomalacia in children with congenital syndrome remains unclear.

PURPOSE

To study the outcome of supraglottoplasty in children with severe laryngomalacia, and to analyze the management and outcome in infants with a congenital syndrome.

METHODS

Retrospective medical records review from January 2003 to October 2012 of all patients who underwent laser supraglottoplasty for severe laryngomalacia at the University Children's Hospital Zurich, Switzerland.

RESULTS

Thirty-one patients were included; median age at time of surgery was 3.5 months. Three patients (10%) had a genetically proven congenital syndrome with associated neurologic anomalies. Overall success rate was 87%. Failures were observed in four (13%) of 31 cases; including all three patients presenting a congenital syndrome.

CONCLUSIONS

Supraglottoplasty is an effective and safe treatment for laryngomalacia in otherwise healthy children. Signs of a possible underlying predominant neurologic origin and discrepancy between the clinical presentation and the endoscopic findings have to be taken into account, as in children with congenital syndrome with neurologic anomalies the risk of failure is higher.

Pathologies of the larynx and trachea in childhood

Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented. Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglottoplasty summarizes all different techniques used for it's repair using an endoscopic approach. Glottic stenosis is rare in children. Usually a compromise between voice preservation and airway restoration has to be sought. Type of reconstruction and timing are varying considerably in individual cases, endoscopic approaches should be preferred. Subglottic stenosis remains the largest group in paediatric airway pathology, with cicatrial stenosis being predominant. Today, cricotracheal resection is the most successful treatment option, followed by the classical laryngotracheal reconstruction with autologous cartilage. In early infancy subglottic stenosis is particularly demanding. Endoscopic treatment is possible in selected patients, but open reconstruction is superior in more severe cases. Tracheostomy is not a safe airway in early infancy, it's indication should be strict. Foreign body aspiration needs to be managed according to a clear algorhythm. Recurrent respiratory papillomatosis should be treated with emphasis on function preservation. The role of adjuvant medication remains unclear. Infectious diseases can be managed conservatively by a pediatrician in the majority of cases.

Synchronous airway lesions in children: an analysis of characteristics and comorbidities

OBJECTIVES

To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy.

METHODS

Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial).

RESULTS

Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06-9.41; OR 3.0, 95% CI 1.05-8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84-6.52; OR 2.0, 95% CI 0.76-5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention.

CONCLUSIONS

The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Characteristics of patients undergoing supraglottoplasty for laryngomalacia

OBJECTIVE

To examine the characteristics of patients undergoing supraglottoplasty for the treatment of laryngomalacia and to better understand the features of laryngomalacia that may predispose patients to the need for supraglottoplasty.

METHODS

Review of patients who underwent supraglottoplasty for laryngomalacia at our academic tertiary care children's hospital between 2005 and 2012 examining demographic information, medical comorbidities, symptoms, indications for surgery, operative findings and procedure, site of laryngeal obstruction, operative techniques, and surgical success rates.

RESULTS

Seventeen patients with laryngomalacia underwent nineteen procedures. The most common indications for supraglottoplasty were persistent stridor beyond 18 months of age (64.7%), difficulty feeding (47%), and failure to thrive (29.4%). The most common comorbidities were gastroesophageal reflux (88.2%) and cardiopulmonary disease (35.3%). Operative findings included shortened aryepiglottic folds in sixteen patients (94.1%), retropositioned epiglottis in sixteen (94.1%), and prolapsed arytenoid mucosa in five (29.4%). Fifteen patients (88.2%) underwent division of the aryepiglottic folds and four underwent ablation of arytenoid mucosa (23.5%). Of the seventeen patients who had followed up at the time of study conclusion, sixteen (94.1%) had symptom improvement and twelve (70.6%) had complete resolution of their symptoms.

CONCLUSIONS

Supraglottoplasty is an effective treatment for laryngomalacia. Outcomes in our patients are similar to those reported in prior literature. The findings of shortened aryepiglottic folds and a retropositioned epiglottis appear to be disproportionately represented in our cohort of patients undergoing supraglottoplasty.

Surgical treatment of severe laryngomalacia: a retrospective study of 11 case

Laryngomalacia is the most frequent congenital abnormality of the larynx, accounting for approximately 60-75% of congenital stridor cases. Despite its benign and self-limited aspects, 10% of cases require intervention. Currently, supraglottoplasty is considered the standard treatment of severe laryngomalacia.

Objective

To describe the experience of the authors in the surgical treatment of patients with severe laryngomalacia. Methodology: A retrospective study.

Method

The medical records of 11 consecutive cases of severe laryngomalacia who underwent surgical treatment between 2003 and 2012 were analyzed for age, gender, symptoms, associated diseases, surgical technique employed, extubation time, surgical complications, length of hospital stay and clinical outcome.

Results

Of the 11 cases of severe laryngomalacia, six patients (54.5%) were operated with the use of CO₂ laser and five patients (45.5%) were submitted to the cold technique. Only 1 patient (9.1%) required surgical reintervention. There were no cases of surgical complications. All patients had clinical improvement.

Conclusion

Supraglottoplasty proved to be effective and safe in the treatment of severe laryngomalacia.

Prevalence and risk factors for central sleep apnea in infants with laryngomalacia

OBJECTIVE

To identify the prevalence of and risk factors for central sleep apnea (CSA) in infants who are diagnosed with laryngomalacia.

STUDY DESIGN

Case series with chart review.

SETTING

Quaternary care pediatric hospital.

SUBJECTS AND METHODS

We performed a chart review in infants with laryngomalacia. All infants had diagnostic polysomnography (PSG) performed from 2003 to 2012. Infants who underwent supraglottoplasty or other upper airway surgery prior to PSG were excluded. CSA was defined as central apnea index ≥ 5. Demographic data, underlying diseases, and PSG data were reviewed and analyzed.

RESULTS

Fifty-four patients met the inclusion criteria. The mean age at the date PSG was performed was 3.4 ± 2.7 months. The prevalence of CSA in infants with laryngomalacia was 46.3%. Odds ratio (OR) of CSA was above 2.0 in patients with the following risk factors: underlying neurologic disease, hypotonia, or syndrome (OR = 2.5, P = .13), history of apparent life-threatening events (OR = 2.7, P = .19), premature infants (OR = 2.2, P = .33), and age less than 3 months (OR = 2.3, P = .15). However, none of the risk factors were statistically significant. Analysis of sleep architecture revealed a decrease in total sleep time (345.4 ± 70.6 minutes vs 393.5 ± 68.3 minutes, P = .02) and sleep efficiency (67.7 ± 8.9% vs 75.2 ± 9.3%, P = .004) in the CSA group.

CONCLUSION

CSA is relatively common in infants with laryngomalacia. There seems to be a higher prevalence of CSA in infants with certain risk factors, but none of the risk factors are statistically significant. The presence of CSA can lead to alteration in sleep architecture. In addition to clinical evaluation, polysomnography may be warranted for the evaluation of infants with laryngomalacia and associated complex medical conditions.

Supraglottoplasty in Premature Infants with Laryngomalacia

Purpose

Prematurity is thought to be to be an independent risk factor for supraglottoplasty (SGP) failure. The purpose of this study was to compare the outcomes of supraglottoplasty in premature infants with congenital laryngomalacia (LM) with that of term infants.

Study Design

Case series with chart review.

Setting

Tertiary-care pediatric institution.

Methods

Analysis was performed on 325 consecutive patients undergoing SGP between 2004 and 2012. Patients older than 12 months age or with syndrome, neurologic, or cardiac comorbidities were excluded. Resolution of airway symptoms after SGP was considered successful while revision SGP and tracheostomy were considered failures. The rates of secondary airway lesions (SAL), dysphagia, and gastrostomy tube (GT) placement were also compared.

Results

A total of 176 infants (136 term, 40 preterm) were identified. SGP was successful in 92.7% term and 90% preterm infants with no significant difference ( P = .5865). Incidence of revision SGP and tracheostomy was similar among the groups. The outcomes of SGP were the same in all groups stratified by age. Incidence of SAL was significantly higher in preterm (72.5%) compared to term infants (34.6%, P = .0002). Dysphagia rates in the follow-up were higher in preterm (32.5%) versus term infants (6.6%, P < .001). The rate of GT insertion was significantly greater ( P = .003) in preterm (27.5%) than term infants (6.6%). The preoperative dysphagia, persistent dysphagia, and GT in follow-up was significantly higher when gestation age <32 weeks (25%, P = .0168).

Conclusion

Supraglottoplasty outcomes in term and preterm infants were similar irrespective of gestation age. Higher rates of dysphagia in follow-up are seen when gestation age <32 weeks.

Laryngomalacia

Laryngomalacia is the most common cause of stridor in infants. Stridor results from upper airway obstruction caused by collapse of supraglottic tissue into the airway. Most cases of laryngomalacia are mild and self-resolve, but severe symptoms require investigation and intervention. There is a strong association with gastroesophageal reflux disease in patients with laryngomalacia, and thus medical treatment with antireflux medications may be indicated. Supraglottoplasty is the preferred surgical treatment of laryngomalacia, reserved only for severe cases. Proper identification of those patients who require medical and surgical intervention is key to providing treatment with successful outcomes.

Success of supraglottoplasty for severe laryngomalacia: the experience from Northeastern Ontario, Canada

OBJECTIVES

To review the outcomes of supraglottoplasty performed in children with severe laryngomalacia at a pediatric university teaching hospital and to determine if these outcomes are influenced by gender, age at time of supraglottoplasty, or medical comorbidities.

METHODS

Retrospective chart review of children who underwent supraglottoplasty for severe laryngomalacia between 2001 and 2010 at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Statistical significance was obtained using 2-tailed Fisher's exact test. The outcome measures were resolution of laryngomalacia symptoms or persistence of laryngomalacia symptoms with or without additional surgery.

RESULTS

Among 26 post-primary supraglottoplasty patients, 46.2% had resolution and 53.8% had persistence, including 19.2% with partial improvement and 34.6% requiring revision supraglottoplasty and/or tracheostomy. Resolution was present in 35.7% of males and 58.3% of females (p = 0.43); in 33.3% of all patients ≤2 months old and 52.9% of all patients >2 months old (p = 0.43); and in 50.0% of non-comorbid patients ≤2 months old and 80.0% of non-comorbid patients >2 months old (p = 0.52). 71.4% of persistence cases were found in comorbid patients. 83.3% of comorbid patients had persistence, compared to 28.6% of non-comorbid patients (p=0.008). Of the 3 patients with overlapping comorbid categories, 2 required at least 2 revision supraglottoplasties and ultimately required a tracheostomy.

CONCLUSIONS

Persistence of laryngomalacia symptoms post-primary supraglottoplasty was not associated with gender or age at time of surgery, and was more commonly found in children with comorbidities. Patients with coexisting medical conditions appear to require more aggressive surgical management, beyond one revision supraglottoplasty.

Multilevel airway obstruction including rare tongue base mass presenting as severe croup in an infant

Laryngomalacia is the most common cause of neonatal stridor, accounting for up to 60% of cases [1]. Less common causes of neonatal stridor include subglottic or tracheal stenosis, or congenital masses of the upper airway. Neonates with an identified congenital etiology of symptomatic upper airway obstruction often have synchronous airway lesions leading to multilevel airway obstruction. These infants deserve an endoscopic evaluation to better diagnose and manage respiratory distress. Here we present a rare case of an infant initially diagnosed with croup, but ultimately found to have multilevel airway obstruction including severe laryngomalacia and an obstructing tongue base mass.

[Laryngomalacia. When does surgery make sense?]

The most common cause of stridor in newborns is instability of the upper larynx, called laryngomalacia. In approximately 10% of children normal development is impaired. The diagnostics and therapy must follow a clear plan that is also comprehensible to the parents. The obstruction should be localized endoscopically, the anatomical characteristics determined, and the surgical possibilities evaluated. Additional pathological changes of the upper airway (e.g., vocal fold paresis) need to be excluded. Surgery for laryngomalacia, called supraglottoplasty, allows reduction of excess mucus, transectioning of aryepiglottic folds that are too short, and in some cases epiglottic fixation to the base of the tongue. In extreme cases tracheotomy is unavoidable. Surgery is only recommended for severe cases; when carried out correctly according to the medical indications, the success rate is over 90%.