Laryngomalacia Workup: Laboratory Studies, Imaging Studies

Laboratory Studies

Oxygen saturation should be monitored in patients with laryngomalacia.

Imaging Studies

Fluoroscopy

• Fluoroscopy of the airway may be performed by a pediatric radiologist.
• The cartilages may be observed collapsing on inspiration on a lateral view of the airway.

Laryngoscopy and bronchoscopy

• These studies are the best studies used to confirm the diagnosis. However, in an infant with typical inspiratory noises (worse when supine) who have a normal cry and normal growth and development, clinical diagnosis is not unreasonable.
• A pediatric pulmonologist or pediatric otorhinolaryngologist may perform flexible laryngoscopy or bronchoscopy. Bronchoscopy under anesthesia has been shown to be more sensitive and specific than bronchoscopy in infants who are awake.
• Direct visualization of the airway reveals an omega-shaped epiglottis that prolapses over the larynx during inspiration.
• Enlarged arytenoid cartilages that prolapse over the larynx during inspiration may also be present.

Treatment & Management

Stephanie Lovinsky-Desir, MD Assistant Professor in Pediatric Pulmonology, Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons

Stephanie Lovinsky-Desir, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society

Coauthor(s)

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Girish D Sharma, MD FCCP, FAAP, Professor of Pediatrics, Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Medical College; Senior Attending, Department of Pediatrics, Rush University Medical Center

Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, Royal College of Physicians of Ireland, American College of Chest Physicians, American Thoracic Society

References

1. Edmondson NE, Bent JP 3rd, Chan C. Laryngomalacia: the role of gender and ethnicity. Int J Pediatr Otorhinolaryngol. 2011 Dec. 75(12):1562-4. [Medline].
2. Dickson JM, Richter GT, Meinzen-Derr J, Rutter MJ, Thompson DM. Secondary airway lesions in infants with laryngomalacia. Ann Otol Rhinol Laryngol. 2009 Jan. 118(1):37-43. [Medline].
3. Cooper T, Benoit M, Erickson B, El-Hakim H. Primary Presentations of Laryngomalacia. JAMA Otolaryngol Head Neck Surg. 2014 May 8. [Medline].
4. Boggs W. Laryngomalacia Commonly Presents With Snoring or Swallowing Dysfunction. Reuters Health Information. Available at http://www.medscape.com/viewarticle/825146. May 15, 2014; Accessed: June 16, 2015.
5. [Guideline] Institute for Clinical Systems Improvement (ICSI). Preventive services for children and adolescents. 2008 Oct. [Full Text].
6. Powitzky R, Stoner J, Fisher T, Digoy GP. Changes in sleep apnea after supraglottoplasty in infants with laryngomalacia. Int J Pediatr Otorhinolaryngol. 2011 Oct. 75(10):1234-9. [Medline].
7. Unal E, Oran B, Baysal T, et al. Pulmonary arterial pressure in infants with laryngomalacia. Int J Pediatr Otorhinolaryngol. 2006 Dec. 70(12):2067-71. [Medline].
8. Richter GT, Rutter MJ, deAlarcon A, Orvidas LJ, Thompson DM. Late-onset laryngomalacia: a variant of disease. Arch Otolaryngol Head Neck Surg. 2008 Jan. 134(1):75-80. [Medline].
9. Revell SM, Clark WD. Late-onset laryngomalacia: a cause of pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2011 Feb. 75(2):231-8. [Medline].
10. Chan DK, Truong MT, Koltai PJ. Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome. Arch Otolaryngol Head Neck Surg. 2012 Jan. 138(1):50-4. [Medline].
11. Richter GT, Thompson DM. The surgical management of laryngomalacia. Otolaryngol Clin North Am. 2008 Oct. 41(5):837-64, vii. [Medline].
12. Whymark AD, Clement WA, Kubba H, Geddes NK. Laser epiglottopexy for laryngomalacia: 10 years' experience in the west of Scotland. Arch Otolaryngol Head Neck Surg. 2006 Sep. 132(9):978-82. [Medline].
13. Erickson B, Cooper T, El-Hakim H. Factors Associated With the Morphological Type of Laryngomalacia and Prognostic Value for Surgical Outcomes. JAMA Otolaryngol Head Neck Surg. 2014 Sep 4. [Medline].
14. Bertrand P, Navarro H, Caussade S, et al. Airway anomalies in children with Down syndrome: endoscopic findings. Pediatr Pulmonol. 2003 Aug. 36(2):137-41. [Medline].
15. Cotton RT, Richardson MA. Congenital laryngeal anomalies. Otolaryngol Clin North Am. 1981 Feb. 14(1):203-18. [Medline].
16. Denoyelle F, Mondain M, Gresillon N, et al. Failures and complications of supraglottoplasty in children. Arch Otolaryngol Head Neck Surg. 2003 Oct. 129(10):1077-80; discussion 1080. [Medline].
17. Fauroux B, Pigeot J, Polkey MI, et al. Chronic stridor caused by laryngomalacia in children: work of breathing and effects of noninvasive ventilatory assistance. Am J Respir Crit Care Med. 2001 Nov 15. 164(10 Pt 1):1874-8. [Medline]. [Full Text].
18. Gessler EM, Simko EJ, Greinwald JH. Adult laryngomalacia: an uncommon clinical entity. Am J Otolaryngol. 2002 Nov-Dec. 23(6):386-9. [Medline].
19. Kay DJ, Goldsmith AJ. Laryngomalacia: a classification system and surgical treatment strategy. Ear Nose Throat J. 2006 May. 85(5):328-31, 336. [Medline].
20. Mancuso RF, Choi SS, Zalzal GH, Grundfast KM. Laryngomalacia. The search for the second lesion. Arch Otolaryngol Head Neck Surg. 1996 Mar. 122(3):302-6. [Medline].
21. Manning SC, Inglis AF, Mouzakes J, Carron J, Perkins JA. Laryngeal anatomic differences in pediatric patients with severe laryngomalacia. Arch Otolaryngol Head Neck Surg. 2005 Apr. 131(4):340-3. [Medline].
22. Midulla F, Guidi R, Tancredi G, et al. Microaspiration in infants with laryngomalacia. Laryngoscope. 2004 Sep. 114(9):1592-6. [Medline].
23. Sivan Y, Ben-Ari J, Soferman R, DeRowe A. Diagnosis of laryngomalacia by fiberoptic endoscopy: awake compared with anesthesia-aided technique. Chest. 2006 Nov. 130(5):1412-8. [Medline].
24. Smith JL, Sweeney DM, Smallman B, Mortelliti A. State-dependent laryngomalacia in sleeping children. Ann Otol Rhinol Laryngol. 2005 Feb. 114(2):111-4. [Medline].
25. Thompson DM. Abnormal sensorimotor integrative function of the larynx in congenital laryngomalacia: a new theory of etiology. Laryngoscope. 2007 Jun. 117(6 Pt 2 Suppl 114):1-33. [Medline].

Laryngomalacia: The epiglottis is small and curled on itself (omega-shaped). Approximation of the posterior edges of the epiglottis contributes to the inspiratory obstruction. (From B Benjamin, Atlas of Paediatric Endoscopy, Oxford University Press, NY, 1981, with permission.)