Microaspiration in Infants with Laryngomalacia

Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series

BACKGROUND

Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia.

METHODS

A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital.

RESULTS

13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities.

CONCLUSION

Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.

Identifying Aspiration Among Infants in Neonatal Intensive Care Units Through Occupational Therapy Feeding Evaluations

IMPORTANCE

When a neonate's sucking, swallowing, and breathing are disorganized, oropharyngeal aspiration often occurs and results in illness, developmental problems, and even death. Occupational therapists who work in the neonatal intensive care unit (NICU) need to identify neonates who are at risk for aspirating so they can provide appropriate treatment.

OBJECTIVE

To ascertain whether client factors and performance skills of infants ages 0-6 mo during occupational therapy feeding evaluations are related to results of videofluoroscopic swallowing studies (VFSSs).

DESIGN

Retrospective chart reviews.

SETTING

187-bed NICU in a nonprofit teaching hospital.

PARTICIPANTS

A purposive sample of 334 infants ages 0-6 mo, ≥33 wk gestational age at birth, admitted to a Level II, III, or IV NICU as defined by the American Academy of Pediatrics.

OUTCOMES AND MEASURES

Neonates were administered a feeding evaluation by an occupational therapist and a VFSS by a speech-language pathologist, which yielded information about client factors and performance skills.

RESULTS

Signs and symptoms of aspiration on the evaluations were significantly associated with VFSS results. Of 310 patients, 79 had silent aspiration. Of 55 infants who demonstrated no aspiration symptoms during the feeding evaluation, 45% demonstrated aspiration symptoms on the VFSS, and 55% aspirated on the VFSS but demonstrated no symptoms of aspiration.

CONCLUSIONS AND RELEVANCE

Aspiration among infants occurs inconsistently and depends on client factors, contexts, and environments. Occupational therapists are encouraged to assess an infant's feeding over several sessions to obtain a more accurate picture of the infant's feeding status.

WHAT THIS ARTICLE ADDS

This study provides information that helps occupational therapists identify infants at risk for aspiration and make optimal recommendations regarding safe feeding practices and appropriate referrals for a VFSS. Making appropriate referrals for VFSS is also important in preventing unnecessary exposure to radiation for preterm infants.

Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis

OBJECTIVE

To investigate the accuracy of clinical evaluation of swallowing in a sample of children with laryngomalacia or glossoptosis and describe the prevalence of dysphagia in each of these diseases, as well as characterize the swallow response to speech and language therapy interventions.

STUDY DESIGN

Children aged 1 month to 11 years receiving care at the Department of Otolaryngology, Hospital de Clínicas de Porto Alegre, Brazil, were evaluated in a cross-sectional design. Evaluation of swallowing was performed at two time points by two blinded speech-language pathologists, one responsible for clinical evaluation and the other for videofluoroscopic study. The protocols employed were based on the instruments proposed by DeMatteo et al. (DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol 2005;47:149-157.).

RESULTS

The study sample consisted of 29 patients: 10 patients with laryngomalacia and 19 patients with glossoptosis. The sensitivity of clinical evaluation did not exceed 50% in any of the evaluations, but specificity reached 100% in some cases, using thickened liquids. The prevalence of dysphagia was 100%, and the use of thickened liquids significantly reduced tracheal aspiration.

CONCLUSIONS

Dysphagia was highly prevalent in this sample. The sensitivity of clinical evaluation to detect laryngeal penetration and tracheal aspiration was low, as the majority of aspiration events were silent. The videofluoroscopic study is important in order to determine a safest method to feed the patient. Pediatr Pulmonol. 2017;52:41-47. © 2016 Wiley Periodicals, Inc.

Milk protein and Oil-Red-O staining of alveolar macrophages in chronic respiratory disease of infancy

Aspiration is a suspected cause of chronic respiratory disease in infants. We assessed the probability of aspiration by immunocytochemical staining of alveolar macrophages for milk proteins (α-lactalbumin and β-lactoglobulin) and compared these findings with the Oil-Red-O staining score. Broncho-alveolar lavage (BAL), 24-hr esophageal pH-measurement and/or gastro-esophageal scintigraphy were performed in 111 children. Seventy-nine patients were enrolled. Ten exclusively soya milk formula fed children served as a control group. Individual scores, expressed as the mean percentage of positive staining macrophages counted by three blinded authors were made. Relying on the control group, a positive score was defined as a value higher than 1%. A positive score was found in 26% (18/69). Forty-four percent (8/18) of them had positive gastro-esophageal reflux (GER) tests. In 61% (11/18) a concomitant diagnosis of laryngo-/tracheomalacia was made. A positive score was found in 48% (11/23) of patients with laryngo-/tracheomalacia, compared to 15% (7/46) in infants with normal laryngeal and tracheal anatomy. No correlation was found between the immunocytochemical staining score for milk proteins and the Oil-Red-O staining score. We conclude that assuming the 1% criterion, persistent respiratory symptoms were associated with a positive immunostaining score, suggestive for aspiration, in 26% of infants, in 48% in case of concomitant laryngo- and/or tracheomalacia and in 15% of infants with normal laryngeal and tracheal anatomy. No correlation was found between the immunocytochemical staining score for cow milk proteins and the Oil-Red-O staining score.

Non-acid gastro-oesophageal reflux in children with suspected pulmonary aspiration

BACKGROUND & AIMS

In a group of children with suspected pulmonary aspiration, we aimed to describe the type and physical characteristics of gastro-oesophageal reflux (GOR) episodes, and to determine their correlation with the lipid-laden macrophage (LLM) content in bronchoalveolar lavage (BAL).

PATIENTS AND METHODS

Twenty-one children with a diagnosis of bronchial asthma, recurrent lung consolidations and recurrent laryngotracheitis underwent 24-h multichannel intraluminal impedance and pH (MII-pH) monitoring, fibreoptic bronchoscopy and BAL. The following parameters were evaluated: total number of reflux episodes, number of acid reflux [AR; pH<4] and non-acid reflux [NAR] episodes [pH>4], height of reflux episodes, LLM content and percentage of neutrophils in the BAL.

RESULTS

The number of NAR episodes and the number of those reaching the proximal oesophagus were significantly higher in patients with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01 and p<0.01). BAL studies showed a significantly higher LLM content in children with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01). The LLM content correlated significantly with the total number of reflux episodes (r=0.73; p<0.001) and with those reaching the proximal oesophagus (r=0.67; p<0.001). Finally, the LLM content correlated with the number of NAR episodes (r=0.61; p<0.01), with those reaching the proximal oesophagus (r=0.64; p<0.01) and with the percentage of BAL neutrophils (r=0.7; p<0.01).

CONCLUSION

NAR episodes reaching the proximal oesophagus correlate with diagnostic marker for pulmonary micro-aspiration. MII-pH monitoring increases the yield in identifying types and proximal extension of reflux episodes, that discriminate between patients with and without pulmonary aspiration.

Impact of Supraglottoplasty on Aspiration in Severe Laryngomalacia

Objectives:

We examined the incidence and significance of aspiration in infants with severe laryngomalacia (LM) who undergo supraglottoplasty.

Methods:

We performed a 5-year retrospective review of a prospective database from 2 tertiary care pediatric institutions. The studied patients were 50 consecutive infants with severe LM who underwent supraglottoplasty (median age, 4.5 months) and functional endoscopic evaluation of swallowing (FEES) with or without laryngopharyngeal stimulation testing. The intervention was cold-knife microlaryngeal supraglottoplasty and reflux management. The main outcome measure was aspiration resolution.

Results:

Preoperative FEES identified laryngeal penetration in 44 infants (88%) with severe LM. Laryngeal penetration with aspiration beyond the vocal folds was noted in 36 infants (72%). Postoperative FEES (median follow-up, 3.8 months) indicated resolution of laryngeal penetration and aspiration in 36 (81.8%) and 31 (86.1%) of these patients, respectively. The 14 patients without preoperative aspiration showed no evidence of aspiration after supraglottoplasty. In patients with aspiration, the mean preoperative laryngopharyngeal stimulation test threshold was 8.45 mm Hg. This improved on average by 4.0 mm Hg after supraglottoplasty (paired t-test, p < 0.0001). Multiple medical comorbidities were present in the 5 patients who had persistent aspiration after supraglottoplasty, including congenital heart disease (all 5 patients), congenital syndromes (4 patients), neurologic disorders (2 patients), and a need for tracheostomy (2 patients).

Conclusions:

Laryngeal penetration and aspiration improve after cold-knife supraglottoplasty. Supraglottoplasty does not cause aspiration in patients who do not have preoperative aspiration. Supraglottoplasty may not improve aspiration in patients with multiple medical comorbidities.

General anesthesia for a patient with deletion 6q syndrome in addition to laryngomalacia undergoing dental treatment

Chromosome 6 deletions are very rare (1,2), and deletion 6q syndrome is clinically characterized by mental and/or neuromotor retardation and microcephaly (3). Other alterations frequently observed are decreased biparietal diameter, hypertelorism, hypotelorism, absent eyebrows, prominent eyes with ptosis, receding chin, dysmorphic ears, large extremities, prominent nasal bridge, long philtrum, epicthus, strabismus, and micrognathia (3-5). Laryngomalacia is the most common congenital laryngeal anomaly and the most frequent cause of stridor in infants (6-11). We report the case of a 14-year-old male patient with both deletion 6q syndrome and laryngomalacia, who we treated for multiple dental caries. He had a medical history of tracheotomy at age 11 years for laryngomalacia, and has suffered from epileptic attacks and aspiration pneumonia over the last 2 and 6 years, respectively. Since he was mentally retarded and in a poor respiratory state, dental treatment under general anesthesia was scheduled in our hospital. General anesthesia was induced and maintained using 30% nitrous oxide and 1-3% sevoflurane in oxygen through the tracheotomy tube. Pre- and intraoperative endotracheal suction improved the condition of both lungs markedly and the procedures were uneventful and completed in 2 h and 58 min.

Diagnosis of airway malacia by virtual bronchoscopy

The study was aimed to identify the role of virtual bronchoscopy in detection of airway malacia in children. In a pre-experimental study over 3 years (from Nov. 2003 to Oct. 2006), 35 consecutive patients were presented to Tabriz Children's Hospital with clinical manifestations of airway malacia, examined by the technique of virtual bronchoscopy. Thirty five patients including 23 males and 12 females with the mean age of 3.7 +/- 1.6 months were studied. The presence of airway malacia and its location and severity were determined by virtual bronchoscopy in all studied cases; that revealed: laryngomalacia, bronchomalacia, tracheomalacia, laryngotracheomalacia and laryngobronchomalacia in 42.8, 25.7, 20, 8.6 and 2.9% of patients, respectively. Virtual bronchoscopy is a non-invasive, accurate and rapid imaging technique with an excellent validity for diagnosis of airway malacia and stenosis, therefore it can replace conventional bronchoscopy.

Lower airway inflammation in infants with cystic fibrosis detected by newborn screening

Controversy exists over whether the lower airway inflammation that characterizes cystic fibrosis (CF) is initiated primarily by the genetic defect. To determine if inflammation precedes infection, we examined bronchoalveolar lavage (BAL) fluid cytology, cytokines (interleukin (IL)-1beta, IL-4, IL-5, IL-6, IL-8, IL-10, and tumor necrosis factor-alpha), and free neutrophil elastase activity from 70 CF (aged 1.5-71 months) children detected by newborn screening and 19 (aged 2.0-48 months) controls with chronic stridor. CF subjects were selected and categorized as pristine (13 aged </= 6 months, lacking prior respiratory symptoms and exposure to antibiotics, and without respiratory pathogens on BAL), infected (42 with viruses or >/= 10(5) colony-forming units/ml of pathogenic bacteria in BAL), and uninfected (15 aged > 6 months, asymptomatic, not taking antibiotics at bronchoscopy, and free of pathogens in their BAL). To further resolve if inflammation develops without infection, inflammatory mediators in paired annual BAL samples from 38 CF subjects were measured, and results were grouped according to whether BAL showed persistence (n = 6), acquisition (n = 8), clearance (n = 13), or absence (n = 11) of infection. While pristine, uninfected, and control subjects had similar BAL profiles, infected patients showed elevated inflammatory indices, including increased IL-10 (P < 0.001). Pristine subjects had the fewest signs of inflammation. Analysis of BAL pairs found differences between the four infection groups for changes in neutrophil percentages, IL-8 (P < 0.001), and free neutrophil elastase (P = 0.009). Infection was associated with elevated inflammatory mediators in BAL fluid. In contrast, minimal or reduced signs of inflammation accompanied absence of eradication of infection from BAL fluid. We conclude that in CF, infection initiates and sustains airway inflammation.