Laryngomalacia

A labeled anatomical diagram of the vocal fold...
A labeled anatomical diagram of the vocal folds or cords. (Photo credit: Wikipedia)

Definition:
Laryngomalacia is a softening of the tissues of the larynx (voice box) above the vocal cords. This softening causes the tissues to become floppy, and they may fall over the airway opening and partially block it.

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Laryngomalacia (literally, “soft larynx”) is a very common condition of infancy, in which the soft, immature cartilage of the upper larynx collapses inward during inhalation, causing airway obstruction. It can also be seen in older patients, especially those with neuromuscular conditions resulting in weakness of the muscles of the throat. However, the infantile form is much more common.

There are several types – the mildest may cause no problems, while the most severe can be associated with other abnormalities of the respiratory tract, and with neuromuscular and gastroenterological problems.

Symptoms:
Until the larynx becomes stronger, problems can arise for several reasons:

•The soft limp tissues of the larynx can collapse as the baby breathes in. This interrupts the flow of air and causes noisy breathing, with a sound called stridor, which is a sign of obstructed air flow – in fact laryngomalacia is the commonest cause of stridor in babies. It may be worse if the baby has a respiratory infection.

•In some children, laryngomalacia can interfere with feeding. The effort required to draw air in through the obstructed airway can cause reflux of food from the stomach back up into the oesophagus or gullet.

•There may be other ear, nose and throat problems, and rarely problems with the lungs. Low oxygen levels may disrupt normal growth.

Common symptoms are :-
*Nosy breathing (stridor) – An audible wheeze when your baby breathes in. It is often worse when the baby is agitated, feeding, *crying or sleeping on the back
*High pitched sound
*Difficulty feeding
*Poor weight gain
*Choking while feeding
*Apnea — Breathing stoppage
*Pulling in neck and check with each breath
*Cyanosis — Turning blue
*Gastroesophageal reflux — Spitting, vomiting and regurgitation
*Aspiration – Inhalation of food into the lungs

Causes:
Laryngomalacia is thought to be the result of abnormally slow maturation of the tissues of the larynx, possibly because of genetic factors. This simply means that at birth the baby’s respiratory tract isn’t developed and string enough to cope with the mechanical demands of drawing breath.

Although doctors believe there’s a link between laryngomalacia and gastro-oesophageal reflu, there isn’t a single common mechanism to link these two problems, so several theories exist. In some patients with laryngomalacia, reflux may be the primary cause of their airway problems. In others, it’s an additional factor on top of neurological or anatomical abnormalities.

Reflux is common in babies less than one year old, because the muscular valve at the entrance to the stomach (which holds food in the stomach) may be weak in small infants.

Research suggests that a very large number, if not all, of babies with laryngomalacia also have reflux of gastric acid and digestive enzymes up to the pharynx (back of the throat). This may have detrimental effects on the larynx and tracheobronchial tree (air passages into the lungs). This may cause persistent swelling (oedema) of the larynx lining, which is common in children with laryngomalacia.

There’s no consensus yet about managing this link, but it makes sense to think simple treatments to control reflux could help resolve the laryngomalacia more quickly, too. More interventional treatments such as surgery, with all their inherent risks, are best avoided if possible.

Although laryngomalacia is not associated with a specific gene, there is evidence that some cases may be inherited.

Diagnosis:
Your doctor will ask you some questions about your baby’s health problems and may recommend a test called a flexible laryngoscopy (lar ring os co pee) to further evaluate your baby’s condition.

During this test, done in your doctor’s office, a tiny camera that looks like a strand of spaghetti with a light on the end is passed through your baby’s nostril and into the lower part of the throat where the larynx is. This allows your doctor to see your baby’s voicebox.

After the diagnosis — additional tests:
If laryngomalacia is diagnosed, the doctor may want to do other diagnostic tests to evaluate the extent of your child’s problems and to see whether the lower airway is affected. These tests may include:

X-ray of the neck;
A neck X-ray is done to make sure that your baby does not have other problems below the voice box (in the subglottis, trachea or chest). These are areas that the doctor cannot see during the flexible laryngoscopy.

Airway fluoroscopy;
The doctor may also order a motion picture X-ray of the trachea to make sure that there are no other problems.

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Microlaryngoscopy (my crow lar ring os co pee)and bronchoscopy (brawn cos co pee), also known as MLB
This test is done when a neck X-ray shows additional problems in the lower airway. Your child is taken to the operating room and given anesthesia. Then the doctor passes a tiny camera through your child’s mouth and down past the vocal cords (larynx) to look at the area below the vocal folds that may be contributing to the stridor (noisy breathing). The surgeon will take some pictures and will review the results with you afterward.

EGD or esophagogastroduodenoscopy pH probe
This test will be done if your child’s doctor suspects that there may be a more severe problem.

Treatment :
In almost all cases (99 percent), laryngomalacia resolves without treatment by the time your child is 18 to 20 months of age. However, if the laryngomalacia is severe, your child’s treatment may include medication or surgery.

Medication:
Your child’s GI doctor may prescribe an anti-reflux medication to help manage the gastroesophageal reflux (GERD). This is important because your child’s chronic neck and chest retractions from the laryngomalacia can worsen GERD. Also, the acid reflux can cause swelling above the vocal cords and worsen the noisy breathing.

Surgery:
Surgery is the treatment of choice if your child’s condition is severe. Symptoms that signal the need for surgery include:

*Life-threatening apneas (stoppages of breathing)

*Significant blue spells

*Failure to gain weight with feeding

*Significant chest and neck retractions

*Need for extra oxygen to breathe

*Heart or lung issues related to your child’s inability to get enough oxygen

Supraglottoplasty:
In this surgery, extra tissue above the vocal cords is trimmed in the operating room. Your child will be under general anesthesia while the surgeon does a thorough evaluation of the airway and removes the tissue. After surgery, your child will be taken to the pediatric intensive care unit (PICU) and will spend one night with a breathing tube in the nose. If there is not much swelling in this area, and if the surgeon feels it will be safe, the breathing tube will be removed the next day in the PICU. Your child will then be observed for another day to ensure that the airway is safe, and that your child is getting enough oxygen and is drinking normally.

This surgery may not completely eliminate the noisy breathing but it should help to:

*Reduce the severity of the symptoms

*Lessen the apneas (breathing stoppages)

*Reduce the extra oxygen requirements

*Improve swallowing

*Help your child gain weight.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://en.wikipedia.org/wiki/Laryngomalacia
http://www.chop.edu/service/airway-disorders/conditions-we-treat/laryngomalacia.html
http://www.bbc.co.uk/health/physical_health/conditions/laryngomalacia.shtml

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