Laryngomalacia and its treatment

To determine 1) airway outcome of infants with laryngomalacia who do not undergo routine direct laryngoscopy (DL) and bronchoscopy (B), 2) the age at resolution of laryngomalacia, and, 3) outcome of supraglottoplasty as a function of the type of laryngomalacia and the presence of concomitant disease.

Retrospective chart review.

The records of all infants diagnosed with laryngomalacia by flexible fiberoptic laryngoscopy (FFL) between 1990 and 1998 in the Department of Otolaryngology--Head and Neck Surgery, University of Iowa (Iowa City, IA) were reviewed. The type of laryngomalacia was designated by a new classification scheme (types 1-3) based on the site of supraglottic obstruction and the type of supraglottoplasty indicated, should the patient later require surgical intervention. The log rank test was used to compare age at resolution and outcome between types of laryngomalacia and between infants with isolated laryngomalacia versus those with additional congenital abnormalities and/or severe neurological compromise.

The type of laryngomalacia was evident in 48 of the 58 charts reviewed and included type 1 (57%), type 2 (15%), type 3 (13%), or combined types (15%). Twenty percent had severe neurological compromise and/or multiple congenital anomalies. The median time to resolution of stridor in these patients was not significantly delayed when compared with infants who had isolated airway anomalies (36 and 72 wk, respectively, vs. 36 wk for isolated laryngomalacia; P<.4). Time to resolution did not correlate with the type of laryngomalacia. In 22 infants, clinical symptoms or findings suggested a synchronous airway lesion, and direct laryngoscopy and bronchoscopy were performed. In 11 infants, a second airway lesion was diagnosed (in four cases by FFL and in 7 cases by direct laryngoscopy and bronchoscopy). Complications did not arise in infants who did not undergo direct laryngoscopy and bronchoscopy. Eleven infants with severe laryngomalacia required surgical intervention. The success of supraglottoplasty did not correlate with the type of laryngomalacia or the presence of other congenital anomalies.

Routine direct laryngoscopy and bronchoscopy as part of the evaluation of laryngomalacia are not warranted. Performing these procedures should be based on clinical and physical evidence of a concomitant airway lesion. In general, laryngomalacia will resolve within the first year of life, even in children with multiple congenital anomalies and/or severe neurological compromise. The proposed classification scheme is advantageous in that it is simple and correlates the site of obstruction with the surgical procedure most likely to effect a cure, should the patient require a supraglottoplasty. Surgical management is necessary in approximately 15% to 20% of affected infants.