4/11/2013. & approaches to management. Disclosure. No financial support

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1 Laryngomalacia: ay aaca pese presentations tato s & approaches to management Hamdy El-Hakim FRCS(Ed) FRCS(ORL) Associate Professor Pediatric Otolaryngology Division of Otolaryngology Head & Neck Surgery The Stollery Children s Hospital & The University of Alberta Hospitals Edmonton, Alberta, Canada April 2013 Disclosure No conflict of interest No financial support 1

2 Objectives Present epidemiological information on various primary presentations of laryngomalacia Discuss the overall investigative work-up of these patients Discuss the experience with supraglottoplasty and peri-operative care Classic teaching Congenital laryngeal stridor Commonest laryngeal congenital anomaly Commonest cause of stridor No or expectant treatment Supraglottoplasty for the minority Belmont JR, Grundfast K. Ann Otol Rhinol Laryngol.1984;93: Friedman EM, et al. Laryngoscope.1990;100: Holinger LD. Ann Otol.1980;89: Zalzal GH, Anon JB, Cotton RT. Ann Otol Rhinol Laryngol. 1987;96:72-6 2

3 Why are we doing this? Reports on atypical presentation Recent interests in swallowing dysfunction Sleep disordered breathing - an epidemic Richter TG, et al. Arch Otolaryngol Head Neck Surg. 2008;134(1):75-80 Hawkins DB, Clark RW. Ann Otol Rhinol Laryngol. 1987;96:81 Goldberg S, et al. Pediatric Pulmonology 2005;40: The prevalence of laryngomalacia in children presenting primarily with SDB Retrospective observational study 3.9% consecutive patients 8.2% - 75 consecutive 3 years old Persistent, late-onset, or state dependent Hitchings A et al., 2007 Richter G et al., 2008 Amin MR et al, 1997, and Smith JL et al.,

4 Research questions How common are the atypical presentation? Is the disease different? Are these children different? Are they dealt with differently? Method Cross sectional observational study Tertiary referral centre Single practice All laryngomalacia patients < 17 years old Ethics permission 4

5 Sources of data extraction Billing records Prospective surgical database Charts Stridor Sleep assessment Pulse oximetry Polysomonography History & clinical exam Awake nasolaryngoscopy (except for marginal patients) Swallowing assessment Clinical Videofluroscopy Endsocopic Evaluation (FEES) Airway endoscopy +/- Supraglottoplasty 5

6 Swallowing dysfunction History & clinical exam Awake nasolaryngoscopy (except for marginal patients) Swallowing assessment Clinical Videofluroscopy Endsocopic Evaluation (FEES) Alteration of diet Tube feeding Airway endoscopy Sleep assessment Pulse oximetry Polysomnography Sleep disordered breathing Sleep assessment Pulse oximetry Polysomonography History & clinical exam Sleep nasopharyngoscopy with / without surgery Evidence suggesting swallowing dysfunction Swallowing assessment Clinical Video fluroscopy Endoscopic evaluation (FEES) 6

7 Data collected Endoscopic diagnosis Demographics Primary complaint Absence or presence of Stridor Swallowing disorder Sleep disordered breathing Investigations Descriptive statistics Analysis of variance chi square Results 7 years 117 consecutive patients Excluded 29 - unconfirmed diagnosis 88 had flexible and / or rigid endoscopy M:F 1.9:1 7

8 Age distribution Mean 14.5±23 m range 0.2 to 96 Age at endoscopy e in months Ag Distribution of primary complaint SD: swallowing dysfunction S-SDB: snoring - sleep disordered breathing 8

9 Comparison of 3 groups Mean age (ms) M:F Supraglottoplasty SD N of 11 SDOB N of ± :1 4 (231%) 46 ± :1 6 (27%) Stridor 3.5 ± 2.8 1:1 31 (55%) N of 56 P * Ms: months, M: male, F: female. Analysis of variance. Chi square* 9

10 Types of LM 10

11 Investigative work-up Overnight pulse oximetry 11

12 Functional endoscopic evaluation of swallowing Endoscopy 12

13 Supraglottoplasty Notes on supraglottoplasty 46 patients (mean age 1.25±1.5 [ years] ]26 males). The 1ry presentation was stridor (34), 8 with SDB, and 4 with SD. T-LM correlated significantly with age (-0.9), and presentation (0.49). Presentation and SAL (P= & 0.006) 006) predicted OC. Presentation predicted T-LM (P=0.02) SAL: secondary airway lesions 13

14 Peri-operative care Proton pump inhibitors, and modification of oral feeding PICU is reserved for <3 months Severe SDB Complex babies Anterior larynx Five required revision (two had pyloric stenosis) Conclusions LM can be encountered in children who are not presenting with stridor (40%) The mean age for those presenting with sleep related symptoms is higher & the types are different Outcome of surgery is worse when there is a SAL, and if the presentation is not classical 14

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