Laryngomalacia: a proposed classification form

Laryngomalacia is a common cause of stridor in children. The disorder has a heterogenous presentation, from the mildest form, which resolves with maturation, to the most severe form, requiring tracheotomy. While there is a vast literature on the subject, there is neither stratification nor correlation of clinical presentation, endoscopic appearance, treatment and outcome. In order to statistically evaluate the choice of treatment based upon presentation, patients must first be classified by relevant predictors of disease severity. A form is proposed to classify the clinical presentation of laryngomalacia by recording relevant historical and anatomic factors. Historical factors are classified by (1) severity of stridor; (2) weight gain; (3) age at presentation; and (4) neurologic status, forming the mnemonic SWAN. The principal anatomic site of collapse is recorded as: (1) postero-lateral; (2) posterior; or (3) anterior. Endoscopic findings consistent with gastroesophageal reflux disease (GERD) or gross aspiration are noted. Photographic and/or video documentation is performed when possible. A pilot study was undertaken to determine the ease of use of this instrument. Ten children, four boys and six girls, were classified. Ages ranged from 1-day-old to 19 months, with a mean of 9 months. Five children were examined in the clinic and five in the operating room. The form was readily and easily applied, and allowed the heterogeneity of the disorder to be organized. Wider application of this form across institutions, with classification of patients with laryngomalacia by historical and anatomic factors, should allow the accumulation of sufficient numbers of patients to allow statistical analyses of treatment and outcome as they relate to the initial presentation of this disorder of airway dynamics.     

Laryngomalacia: a classification system and surgical treatment strategy

Laryngomalacia, the most common congenital laryngeal anomaly, is not a single disease entity but rather a variety of entities along a spectrum of underlying pathophysiologies. Based on our study of 10 children who were surgically treated for laryngomalacia in an urban tertiary care center, we have developed a system of classifying laryngomalacia on the basis of its different underlying pathophysiologic processes. Type I laryngomalacia is characterized by a foreshortened or tight aryepiglottic fold. Type 2 disease is defined by the presence of redundant soft tissue in the supraglottis. The type 3 designation applies to cases caused by other etiologies, such as underlying neuromuscular disorders. While the three types are not mutually exclusive, each should be considered as a separate disease entity with a final common clinical presentation. Each type requires a specific approach to surgical repair.     

Laryngomalacia surgery: a series from a tertiary pediatric hospital

Laryngomalacia is the condition responsible for 75% of the cases of stridor in children aged up to 30 months, in which there is supraglottic collapse during inhalation. Inspiratory stridor is a characteristic telltale. As many as 20% of the patients are severely affected and require surgery. Supraglottoplasty is the procedure of choice and the presence of comorbidities is the most relevant prognostic factor for surgery success.ObjectiveTo describe a series in a tertiary pediatric hospital, its success rates, and surgery prognostic factors.MethodThis retrospective cohort study enrolled 20 patients submitted to supraglottoplasty between July 2007 and May 2011.ResultsThirteen (65%) patients were males; mean age at the time of the procedure was 6.32 months. Endoscopic examination showed that 12 subjects had combined forms of laryngomalacia, 40% had associated pharyngomalacia, and three also had tracheomalacia. Thirteen subjects had isolated laryngomalacia and seven had gastroesophageal reflux disease. Fifteen (75%) patients underwent aryepiglottic fold resection. After the procedure, eleven patients were asymptomatic and two required tracheostomy. Presence of comorbidities was the strongest predictor of unfavorable postoperative outcome (p = 0.034).ConclusionSupraglottoplasty is a safe therapeutical procedure for select patients with laryngomalacia.     

Laryngomalacia: the role of gender and ethnicity

Introduction

The vast majority of infants in published studies regarding laryngomalacia are Caucasian. These studies suggest affected infants are likely to be male, of term pregnancies, and not of low birth weight. Our study seeks to identify possible associations among different genders and ethnicities with laryngomalacia as well as differences between our diverse population and published Caucasian-predominant studies.

Methods

Data was collected by chart review for seventy-eight children diagnosed with laryngomalacia before the age of 5, prospectively entered into a database at our academic, tertiary-care hospital from 1/16/2008 to 10/15/2010. Data was compared to expected values from the 2009 census data for the Bronx as well as published data in the literature for multiple factors, including gender, ethnicity, low birth weight, and prematurity.

Results

There were 45 male and 33 female infants in our study. Twenty-five children were African-American, 17 Hispanic, 12 multi-racial, and 4 Caucasian. Eighteen infants were premature, and 21 were of low birth weight. Twenty-eight percent of our infants had neurologic comorbidity at diagnosis and 30% received surgical treatment.

Discussion

Although larger studies are required, we have preliminary evidence that information learned from Caucasian-predominant studies may not apply to all patients of laryngomalacia. When ethnically diverse infants are represented, a strong association between male gender and laryngomalacia does not appear to exist. Our data suggests that premature African-American and Hispanic infants are at greater risk for laryngomalacia. In addition, African-American infants of all gestational ages may be at greater risk. Low birth weight may be a strong predictor of laryngomalacia regardless of the patient's gender or ethnicity.     

Laryngomalacia induced by exercise in a pediatric patient

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.     

Laryngomalacia: an atypical case and review of the literature

Laryngomalacia is the most common cause of stridor in newborns and infants. Patients usually present with an inspiratory stridor only, although some exhibit other anomalies. To rule out other possible pathologies, bronchoscopy is advisable. However, the authors of some recent studies have advocated the use of fiberoptic laryngoscopy as a more cost-effective and less-invasive alternative. No surgical intervention is required to treat laryngomalacia in most cases. The disease usually resolves spontaneously by the time a patient reaches the age of 24 months. In this article, we describe a case of laryngomalacia that was atypical in that the patient was 10 years old. We also review the literature in an effort to increase awareness of this condition.     

Feasibility of Surgical Treatment for Laryngomalacia Using the 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.     

Sarcoidosis: a cause for bilateral facial palsy

The facial nerve is commonly involved in neural sarcoidosis, but there is only one reported case in which bilateral facial paralysis was the sole manifestation of sarcoidosis. We report a case of sarcoidosis presenting with bilateral facial paralysis as the only sign. The pathology, clinical presentation, pathophysiology and diagnosis of sarcoidosis has been discussed.     

Palatal and middle-ear myoclonus: a cause for objective tinnitus

The cause of objective tinnitus provoked by palatal and middle-ear myoclonus may be identified by magnetic resonance imaging of the central nervous system in the Guilliain-Mollaret triangle or it may be idiopathic. The idiopathic cases are rare. From the literature, one can perceive the following unanswered questions: (1) Are palatal and middle-ear myoclonus different entities or do they usually appear together? (2) Are the clicks being produced by the palatal myoclonus (walls of the eustachian tube slapping together) or by the tensor tympani muscle contractions or by both? (3) Is stapedius muscle myoclonus important in the production of the clicks? (4) What should be the treatment for palatal and middle-ear myoclonus? We present two cases of idiopathic palatal and middle-ear myoclonus and discuss these cases in light of the literature and of some ideas of our own.     

Significance of sudden infant death (SIDS) for otorhinolaryngology

The high frequency of proven extensive infection in the upper respiratory tract, particularly the nose and pharynx, of infants with SIDS, suggests that the latter may be due to upper airway obstruction. In view of the particular vulnerability of the early infant, the widespread term "common cold" does not seem justified. The constant incidence of SIDS should stimulate study of the extension and effects of infection of the upper respiratory tract, including careful investigation, follow up and adequate therapy by otolaryngologists. Such a concept may prevent unexpected fatal complications.     

Common carotid artery dissection: a rare cause for cervical pain

Spontaneous dissections of extracranial carotid arteries occur most frequently in the internal carotid artery. In contrast, common carotid artery dissection (CCA) is a rare cause of cerebral ischaemia with only a few cases having been reported. We present the case of a 59-year-old male patient who was referred to our clinic with left cervical pain. The patient was otherwise asymptomatic. Magnetic resonance imaging (MRI) showed enhancement and double lumen in the left CCA without affecting the carotid bulb, internal carotid artery or aortic arch. We discuss the diagnostic and therapeutic management of the disease, focusing on its differentiation from other causes of cervical pain.     

Giant laryngoceles: a cause of upper airway obstruction

Laryngoceles and saccular cysts, which are abnormal dilatations of the laryngeal saccule, are uncommon. The etiology is unknown but is probably related to both congenital and acquired factors. These structures are usually asymptomatic and are incidentally discovered through radiographic studies for unrelated symptoms. We describe two patients with upper airway obstruction, one caused by a giant laryngocele and the other by a large saccular cyst. In the former patient, acute tracheotomy had to be performed. The laryngocele and saccular cyst were removed surgically, which relieved patients’ symptoms of upper airway obstruction. Received: 19 September 2000 / Accepted: 28 December 2000     

Otitic hydrocephalus of tubercular origin: a rare cause

Otitic hydrocephalus is characterized by increased intra-cranial pressure without focal signs of neurological dysfunction. It usually occurs secondary to lateral sinus thrombosis more commonly on the right side, but it can also occur without lateral sinus thrombosis. With the advent of new antibiotics there has been a spectacular decrease in the complications of otitis media. Otogenic intra-cranial hypertension, always an uncommon condition, is seen only very rarely nowadays. Tubercular otitis media still occurs in India, and due to delays in its diagnosis it usually presents with complications. We present three patients with otitic hydrocephalus of tubercular origin.