Congenital laryngomalacia: clinical approach

[Anna Moscow 10]

Hi, Stephan and all the members!

In our unit we ran across the case of congenital laryngomalacia, associated with minor brain abnormalities (cariotype 46XX).

This baby required intubation immediately after birth because of stridor, then was ventilated for 18 days. Several attempts to extubate the baby within 72 hours after birth failed. Our surgeons performed laryngotracheoscopy and the diagnosis of laryngomalacia was established. They recommended 14-day course of prednisolone 1 mg/kg/day for larynx maturation and then repeated extubation. Now baby is 1 month old, spontaneously breathing through ETT. We tried 2 attempts of extub on nCPAP mode, but severe stridor signs occurred and reintubation was needed. The questions are: 1) do steroids really maturate the laryngeal cartilages? If yes what do the indications for repeated course look like? 2) what kind of respiratory support is preferable for this baby? What are the criteria for tracheostomy? 3) If someone had such an experience, what are the possible outcomes?

Thanks for all of you.

[Stefan Johansson 553]

Well... we would call our ENT consultant and leave most decision-making to him.

I just searched PUBMED and found some nice articles. Actually, tracheomalacia was not a Mesh-term, which I found a little strange, given how common it is. I found nothing on steroids+tracheomalacia.

A qualified guess would be to that the ENT advice would be tracheostomi to get off the ventilator, and while awaiting spontaneous resolution, OR to do some kind of ENT surgery.

Please keep us posted how things develop!

Review: http://www.ncbi.nlm.nih.gov/pubmed/6847290

Laser epiglottopexy: http://www.ncbi.nlm.nih.gov/pubmed/16982974

Aortopexy: http://www.ncbi.nlm.nih.gov/pubmed/16516630

[norbertteig 18]

Hi, Stephan and all the members!

In our unit we ran across the case of congenital laryngomalacia, associated with minor brain abnormalities (cariotype 46XX).

This baby required intubation immediately after birth because of stridor, then was ventilated for 18 days. Several attempts to extubate the baby within 72 hours after birth failed. Our surgeons performed laryngotracheoscopy and the diagnosis of laryngomalacia was established. They recommended 14-day course of prednisolone 1 mg/kg/day for larynx maturation and then repeated extubation. Now baby is 1 month old, spontaneously breathing through ETT. We tried 2 attempts of extub on nCPAP mode, but severe stridor signs occurred and reintubation was needed. The questions are: 1) do steroids really maturate the laryngeal cartilages? If yes what do the indications for repeated course look like? 2) what kind of respiratory support is preferable for this baby? What are the criteria for tracheostomy? 3) If someone had such an experience, what are the possible outcomes?

Thanks for all of you.

Hi there,

In my experience (and to my knowledge) there are neither cinicial nor scientific data that would support the use of steroids in laryngomalacia.

Though all cases of laryngomalacia improve with time, the time interval is quite long (at least several months) and just waiting is no reasonable approach in patients with the most severe forms needing a tube for maintaining respiration. There are some ENT surgeons that try to stiffen the larynx by laser treatment ("trimming") and we have seen at least two patients in whom tracheostomy has been avoided by this method.

Before considering surgery, however, I would repeat the endoscopy. We have seen several newborns with a prima vista diagnosis of severe laryngomalacia who ultimately went out to have alternative diagnosis (for example vocal cord paralysis (which may be difficult to be diagnosed by an unexperienced observer) or larnygotracheal cleft). Another point ist, that laryngomalacia and tracheomalacia are two totally different entities and treatments for tracheomalacia (e.g. aortopexy) are of no value for laryngomalacia patients.

Would be nice to be informed on the further developemnt of Your patient.

______________________________________________________________________

Norbert Teig, MD

Children's Hospital

Ruhr-University Bochum, Germany

[Stefan Johansson 553]

...Another point ist, that laryngomalacia and tracheomalacia are two totally different entities and treatments for tracheomalacia (e.g. aortopexy) are of no value for laryngomalacia patients.

Norbert, you're right!

Anna, I'm sorry I did not read your post carefully enough (reading tracheomalacia instead of laryngomalacia, my fault). How are things developing?

[Anna Moscow 10]

Dear Stephan and all!

I apologise for a long silence about the clinical case of laryngomalacia. To our regret, the situation haven`t resolve yet: this baby is still intubated and spontaneously breathing through ETT. Additional examination (MRI etc) showed more severe brain abnormalities,than we suspected before, and bilateral blindness. So the prognosis seems to be poor. In Russia there`s a difficulty with performing laryngopexia on routine basis. Two days ago we transferred baby to a special clinic. As I know, they are going to perform tracheostomy.

[samridh_nagar 10]

Why don't you try Non invasive ventilation (np CPAP) instead of intubation and may be the baby outgrows the problem in some time..

Regards

Samridh

[preetha c 10]

hi all, is it possible for laryngomalacia to present on day one..