|Year : 2014 | Volume
| Issue : 2 | Page : 65-67
Supraglottoplasty in a 2-month-old child with laryngomalacia
Neepa G Vellimuttam, Sanjiv Badhwar
Department of ENT and Head and Neck Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Andheri (West), Mumbai, Maharashtra, India
|Date of Acceptance||12-Nov-2014|
|Date of Web Publication||21-Jan-2015|
Neepa G Vellimuttam
F 18, Building No. 2, Moolji Nagar, Keshavnidhi CHS, S. V. Road, Borivli (West), Mumbai 400 092, Maharashtra
Source of Support: None, Conflict of Interest: None
Laryngomalacia is the most common cause of stridor in infants. It is diagnosed clinically. Treatment is not required in the majority of cases, only 10% require some surgical intervention. We present a case report of a 2-month-old child with severe laryngomalacia for whom we did supraglottoplasty and achieved good results.
Keywords: Laryngomalacia, supraglottoplasty, tracheostomy
|How to cite this article:|
Vellimuttam NG, Badhwar S. Supraglottoplasty in a 2-month-old child with laryngomalacia
. Niger J Surg Sci 2014;24:65-7
| Introduction|| |
Laryngomalacia is the commonest cause of stridor in infants. It is due to floppy structures of the supraglottic region which collapse inward during inhalation, causing a high pitched sound. It is diagnosed clinically. It becomes symptomatic usually at the age of 4-6 weeks. Most cases resolve on its own by the age of 2 years. Only 10% require surgical intervention.
| Case report|| |
A 2-month-old child presented with a history of noisy breathing since 1-month, which was worsening over last 1-week and history of difficulty in feeding since birth. On examination, patient was afebrile, irritable with heart rate of 180/min, respiratory rate 70/min, SpO 2 95% with 2 l oxygen by nasal prongs. There were severe suprasternal and subcostal retractions. On auscultation, there were bilateral crepitations and conducted sounds. In view of severe respiratory distress, patient was intubated with no. 4 endotracheal tube. Intubation was difficult as laryngeal inlet could not be visualized with poor visualization of the epiglottis.
Two-dimensional echo and computed tomography (CT) scan of chest and angiography with virtual bronchoscopy were done to rule out extrinsic compression of the trachea by vessel. CT scan of the chest showed bilateral pneumonia. Intravenous piperacillin and tazobactum alongwith ciprofloxacin were started, and child was started on nasogastric (NG) tube feeds. Child was gradually weaned off from ventilator and extubation was tried after 7 days, which was unsuccessful. Patient was taken up for examination under anesthesia that showed large, overhanging epiglottis with short aryepiglottic folds and supraglottic collapse [Figure 1]. Findings were suggestive of grade 3 laryngomalacia. Consent from parents was taken after counseling and child were taken up for surgery. CO 2 laser assisted supraglottoplasty was done where aryepiglottic folds were divided partially and overhanging epiglottis tissue was ablated. Bilateral false cords were also ablated with CO 2 laser. Tracheostomy was done and no. 3.5 tracheostomy tube was inserted. Baby was gradually weaned off from ventilator over 4 days and was kept on T piece, maintaining oxygen saturation levels of 98-99% on 2 l of oxygen. After 7 days, child was taken up for examination under anesthesia in the operation theater where healing of the operated site with mild edema was seen.
After 2 weeks, downsizing of tracheostomy to no. 3 was done followed by intermittent blocking of the tube. Since child was tolerating tracheostomy block, decannulation was done after 3 days. Child was comfortable, maintaining saturation 100% in room air. Swallowing study was done after decannulation, which showed aspiration; hence baby was discharged on NG feeds and advised to follow-up after 2 weeks. On follow-up, child was comfortable, trial of oral feeds with breast milk was conducted, which was successful. Breast feeds were gradually started and NG tube was removed after 10 days.
Examination under anaesthesia done after 4 months showed well healed laryngeal inlet with normal supraglottis and glottis area [Figure 2].
| Discussion|| |
Laryngomalacia is the most common cause of stridor in infants.  It is a dynamic condition in which the supraglottic structures collapse inward during inhalation causing airway obstruction. It is due to delay in maturation of the supporting structures of the larynx. The most widely accepted theory today suggests that the laryngomalacia is the outcome of disordered laryngeal neuromuscular tone. ,
Laryngomalacia results in partial airway obstruction leading to high pitched noise on inhalation. It leads to feeding difficulty in some infants. Rarely, it can lead to significant life-threatening airway obstruction. Stridor is worse when the infant is on his or her back because the floppy tissues fall easily over the airway in this position.
Symptoms generally become apparent during the first 2 weeks of life. Inspiratory noises typically start at age of 4-6 weeks, but can begin as late as 2-3 months. Symptoms resolve in most cases between 12 and 18 months of age. Stridor increases during feeding, crying or agitation. Baby is comfortable in the prone position. Laryngomalacia is diagnosed clinically in majority of cases. Flexible laryngoscopy or bronchoscopy usually confirms the diagnosis where the most common findings are an omega-shaped epiglottis, enlarged arytenoid cartilages prolapsing over the larynx during inspiration. Supraglottic structures appear large and lax, and collapse over glottis during inspiration. Most cases resolve with minimal or no treatment, approximately 10% require surgical intervention. 
In more than 90% of cases, treatment is conservational. Stridor generally disappears by age of 2 years. Parents are counseled and explained the condition and asked to nurse in semi-prone position. However, infants with severe retractions, cyanotic spells may require intervention. If the baby has clinically significant hypoxemia, supplementary oxygen should be administered. Published data suggests that infants with laryngomalacia and hypoxemia may readily develop pulmonary hypertension. 
Surgery is indicated in cases with severe pulmonary hypertension, failure to thrive, severe hypoxemia, corpulmonale. Surgeries for laryngomalacia include tracheostomy, supraglottoplasty.
Supraglottoplasty was originally described in 1922.  Supraglottopasty is an effective alternative to tracheostomy in carefully selected patients with severe laryngomalacia. 
Lane et al., in 1984, excised the lateral portions of the epiglottis and the corniculate cartilages to report significant improvement from laryngomalacia in a 3-month-old patient. 
Roger et al. operated 115 cases of severe laryngomalacia where endoscopic resection of aryepiglottic folds was done and concluded that endoscopic resection can be considered an effective technique for management of severe laryngomalacia. 
Marcus et al. evaluated epiglottoplasty as treatment for severe laryngomalacia. 
Toynton et al. described case series of 100 cases of severe laryngomalacia subjected to supraglottoplasty, 50% of whom were under 3 months of age. 
Though the surgery is rarely required in the treatment of laryngomalacia, the possibility of requirement of some surgical intervention should always be kept in mind. Every case has to be evaluated thoroughly before deciding the line of treatment.
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[Figure 1], [Figure 2]