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BackTable / ENT / Article
Infant Laryngomalacia: Diagnosis, Clinical Management & Advanced Therapies
Olivia Reid • Jan 7, 2024 • 35 hits
Otolaryngologists Briac Thierry and Gopi Shah unravel the complexities of laryngomalacia in infants, providing information on diagnostic criteria, clinical decision making, and various treatment options.
When a patient presents with stridor, a fibroscopy must first be used to confirm laryngomalacia as the root cause, highlighting the need for meticulous evaluation. The framework provided by the International Pediatric Otolaryngology Group (IPOG) can then aid in categorizing severity based on feeding and respiratory repercussions. Severity guides the differential treatment approaches, ranging from observational follow-ups to targeted therapies like proton pump inhibitors (PPIs) and feeding strategies to section and balloon dilation techniques.
Dr. Thierry advocates for the holistic perspective, encompassing diagnostic subtleties and multi-tiered management strategies, to provide the most precise care for neonates diagnosed with laryngomalacia. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Diagnosing laryngomalacia involves fibroscopy to identify supraglottic collapses and assess vocal fold mobility, alongside investigating feeding and respiratory repercussions which weigh into the severity of the condition.
• Moderate laryngomalacia often presents with feeding difficulties, especially prolonged bottle feeding exceeding 30 minutes, giving rise to treatment strategies involving acid suppression and anti-reflux management.
• Feeding strategies for infants with laryngomalacia include thickening agents prescribed directly by the ENT specialist to manage feeding challenges.
• In the case of mild laryngomalacia, symptoms surpassing fibroscopic findings might necessitate direct laryngoscopy bronchoscopy (DLB) to explore possible secondary lesions.
• Supraglottic stenosis, often linked to a history of intubation, can be treated via section and balloon dilation techniques.
Table of Contents
(1) Laryngomalacia in Infants: Diagnostics & Clinical Decisions
(2) Clinical Management of Moderate Laryngomalacia
(3) The Role of Direct Laryngoscopy Bronchoscopy & Advanced Therapies in Mild Laryngomalacia
Laryngomalacia in Infants: Diagnostics & Clinical Decisions
The most common cause of stridor in infants, occurring in approximately 75% of cases, is laryngomalacia: the congenital softening of the tissues of the larynx. Dr. Thierry outlines the necessity of confirming the presence of laryngomalacia via fibroscopy, examining for characteristic supraglottic structure collapses, and assessing vocal fold mobility. The results of the physical examination can then be compared to the IPOG framework that allows for the categorizing of laryngomalacia severity, enabling tailored approaches based on its impact.
The differential management strategies for the patient are driven by the presence or absence of feeding and respiratory repercussions, both of which increase the severity of the laryngomalacia. Common classifications include mild, moderate, and severe, with mild necessitating follow-up by pediatricians for growth monitoring rather than immediate specialist intervention, as needed in the latter two categories.
[Dr. Gopi Shah]
Okay, so let's say this is the baby that's in your clinic, at what point do you consider observation? When do you start considering trying reflux management or when are you like, "Hey, we need to do something in the OR for this baby?"
[Dr. Briac Thierry]
There is something that we should emphasize a little bit before this, that this patient has a stridor and then you have to consider that it's just a laryngomalacia and not something else. This is very important because usually, well in the, I don't know, 75% of the cases, it would be indeed laryngomalacia. Then you've got this patient, you perform the fibroscopy, you want to see a sign of obstruction, which is corresponding to laryngomalacia, so you want to see the collapses of the supraglottis structure and you want to see also the mobility of the vocal folds. Then, and only then, you will say it's laryngomalacia and I will take care of it like laryngomalacia. Until you have all these points, you are not sure and you don't know. Well, then if it's laryngomalacia and you don't have any repercussions of the laryngomalacia, you will call it.
I think the IPOG at this point is very useful because it helps you characterize the laryngomalacia. You will have the mild, the moderate and the severe depending on the repercussions of the laryngomalacia. On the first one, you don't have anything. The patient has a stridor and it's just isolated. The baby doesn't have any repercussions on the feeding and it doesn't have any repercussions on the breathing. Okay. You can see for this kind of stridor, I don't see them after. I just tell them, "Okay, the child needs to have a follow-up by the pediatrician. I'm not the person you want to see anymore." Then you have the moderate. If you have any respiratory signs or feeding repercussions, then you will first do the medical treatment.
[Dr. Gopi Shah]
For the babies that are mild, if I'm seeing them under three months of age, I used to see them in follow-up because I thought laryngomalacia could get a little worse between three to six months or the other reason is because I would worry maybe I need to check their weight in a couple of weeks or if something changes, so I always did. Am I being too cautious?
[Dr. Briac Thierry]
I think that you may not be the specialist that they want to see. You just need to check the weight and the growth. Maybe this is not your work.
[Dr. Gopi Shah]
You're right because, well, at that next visit, I'm not re-scoping. You know what I mean? If they look good, sound good, it's a counseling session. It's just "Oh," and a pat on the back, "Good job, parents."
[Dr. Briac Thierry]
Exactly.
[Dr. Gopi Shah]
Yes. That's interesting. Yes, you're right. What's it for? That's interesting. Yes.
[Dr. Briac Thierry]
Exactly. I don't see them after. If something happens, well, of course, they will--
[Dr. Gopi Shah]
They're going to call you.
[Dr. Briac Thierry]
Exactly. I don't do a systematic consultation after the first one if I don't see any gravity sign.
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Clinical Management of Moderate Laryngomalacia
When classifying an infant’s laryngomalacia as moderate, the primary marker is feeding difficulties. Apart from the persistent stridor, infants might exhibit feeding challenges, such as prolonged bottle feeding exceeding the 30-minute threshold. To address these issues, feeding strategies, including acid suppression and anti-reflux management, can be employed. Dr. Thierry suggests the use of a proton pump inhibitor at the lowest effective dose to mitigate some of the symptoms experienced by this patient population, while advocating for a brief duration of treatment due to the potential long-term risks associated with prolonged medication usage. Because of this, it is important for infants with moderate laryngomalacia to receive regular consultations to reevaluate the necessity of ongoing PPI treatment. Furthermore, the physiological increase in respiratory demand in neonates often warrants closer follow-up within the first weeks post-birth to monitor potential decompensation.
[Dr. Gopi Shah]
We'll first define. Tell me a little bit about moderate, what puts them in that category versus mild or severe?
[Dr. Briac Thierry]
They'll have feeding difficulties. I think this is the first and maybe they will have some-- The stridor, it can be permanent. Well, they don't have apnea during the day. They will have the stridor. I think the most important is the feeding difficulties, but they grow. They don't have gross repercussions because of the feeding difficulties. It's just that bottle feeding takes more than 30 minutes. I think 30 minutes is a threshold that you can have in mind. It's quite simple. I will perform feeding strategies, acid suppression, and anti-reflux management and that's all.
I will see them in consultation two or three weeks after to see if it's still okay. There is something that we didn't talk about, is the physiology of the breathing of the neonates. In the end of the first months, they increase the volume of air that they need. They can have a decompensation of the laryngomalacia or any obstruction, to speak the truth, at this point. I may have a more intense follow-up if I see them in the first week. I will see them after this physiology increase of a respiration need.
[Dr. Gopi Shah]
That makes sense. I'm glad you made that point. In terms of the moderate laryngomalacia babies, do you prescribe a H2 blocker or a PPI? Do you have a preference?
[Dr. Briac Thierry]
Yes, I have a preference. I use a PPI and just the slightest dose needed, so one milligram per kilo. Also, I keep in mind that I don't want to keep this treatment for years. This is very important because it has been proven that if you take this kind of medication for years, then you will have an increased risk of inflammatory disease in adulthood. It's important to keep this quite short. Maybe weeks, maybe months, but I always have a consultation to stop the PPI.
[Dr. Gopi Shah]
Four to six weeks or how long do you keep them on it for, you think?
[Dr. Briac Thierry]
Well, it depends. Yes, probably, I don't know, maybe three months. We don't have any proof of this, so it's difficult to be reasonable, but well, there is something which is important. You don't want to keep this forever.
[Dr. Gopi Shah]
When you say it's time to stop the PPI, do you taper it, do you wean it down or can they just stop it?
[Dr. Briac Thierry]
No, I just stop it.
The Role of Direct Laryngoscopy Bronchoscopy & Advanced Therapies in Mild Laryngomalacia
When infants presenting with stridor as a result of laryngomalacia do not experience great feeding or respiratory difficulties, the classification of the laryngomalacia is most often deemed mild. However, in some cases, the patient’s symptoms will surpass the scope findings, leading to suspicions of secondary lesions or alternative etiologies. Dr. Thierry explains the use of the direct laryngoscopy bronchoscopy to aid in the further exploration of the affected regions in these particular cases.
Oftentimes, there is the presence of supraglottic stenosis which may trace back to a history of intubation, facilitating relatively straightforward diagnosis and intervention through section and balloon dilation techniques. This is done through the judicious use of glucocorticoid injections for soft and inflammatory lesions, followed by post-procedural care involving nebulized corticoids, epinephrine, and proton pump inhibitors. Dr. Thierry concludes by emphasizing the need for a clinical follow up in these infants, rather than an endoscopic procedural follow-up, due to the importance of vigilant observation for subsequent interventions based on the infant's evolving condition.
[Dr. Gopi Shah]
Usually, unless you're super young, which is not common, but I think it's very similar, where usually without a tube, and hopefully by the end of the case we can send them they're breathing spontaneously and they're doing okay. We're going to switch gears for a second. Let's say the laryngomalacia is very mild. Let's say actually when you size the airway, let's say there's some supraglottic stenosis, tell me what you do in that situation.
[Dr. Briac Thierry]
If the laryngomalacia is mild, I will say that I won't perform a DLB.
[Dr. Gopi Shah]
That you won't?
[Dr. Briac Thierry]
Yes. In case of a mild laryngomalacia.
[Dr. Gopi Shah]
Oh, meaning symptomatically they have more symptoms than what your scope looks like, and you feel like, okay, there's a secondary lesion or hey, there might be something else going on. They're symptomatic, but your exam some-- That happens a lot too.
[Dr. Briac Thierry]
This is very important. If you're looking at a child with a stridor and then you perform a fibroscopy and you don't find anything, then there is something and you need to perform a DLB. This is very important because if you're not, well, it means that you didn't understand that something is happening, so you will perform the DLB. If I found a supraglottic stenosis, it means, well, usually, that the patient has a medical history, and quite often, a story of intubation. You can perform, well, the diagnosis quite easy, and you can per-- I do like section and dilation with balloons.
[Dr. Briac Thierry]
Your section meaning do you like to use a cold knife and cut the scar?
[Dr. Briac Thierry]
Yes, if it's completely inflammatory, you don't need to perform any section because it won't help.
[Dr. Gopi Shah]
Because it's still soft.
[Dr. Briac Thierry]
Because it's still soft and because there's plenty of inflammation, well, it won't help. You can have some dilation, you can put some glucocorticoid into the inflammatory region, and then, well, I've got tips about this. If I see an inflammatory region in the supraglottic area, I will inject some glucocorticoid into the lesion and then I will have some dilatation so that the glucocorticoid that you've put into the inflammatory agent, will spread all over. Then probably, I will have the patient intubated for a few days and we will have the extubation in the IQ and then see how it's going.
[Dr. Gopi Shah]
In terms of the steroid injection, is that just for the hard scarred supraglottic stenosis or do you also use the steroid injection for the ones that are soft and inflammatory?
[Dr. Briac Thierry]
No, most of the time, we only use it for the inflammatory. Well, not when it's fibrosis and because it's not useful anymore.
[Dr. Gopi Shah]
Yes. What's your routine post-op recommendations or orders? Are these babies on IV steroids, reflux medicine? What do you usually do?
[Dr. Briac Thierry]
Yes, exactly. If I perform a treatment during a DLB, they will have some nebulized corticoid and nebulized epinephrine for the first 12 hours. They also will have some PPI, and that's all.
[Dr. Gopi Shah]
Then do you routinely take these babies back for another look in 7 to 10 days? How do you decide what your follow-up evaluation is?
[Dr. Briac Thierry]
It's clinical. I don't perform it systematically. I don't schedule another endoscopy, but I look at the child, and if it's okay, I won't go to the OR. If it's not, definitely will perform a DLB, but it would be in an emergency setting, not a systematic one.
[Dr. Gopi Shah]
So depending on how they're doing?
[Dr. Briac Thierry]
Yes.
Podcast Contributors
Dr. Briac Thierry
Dr. Briac Thierry is an ENT surgeon with APHP in Paris, France.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 7). Ep. 141 – Stridor in Newborns: Evaluation & Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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