CASE REPORT

LARYNGOMALACIA

Presentator: dr. Agitha Swandaru Rastaputra

Supervisor: dr. Feri Trihandoko, Sp.T.H.T.B.K.L.

Departemen Kesehatan Telinga Hidung Tenggorok- Bedah Kepala Leher

Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan
Universitas Gadjah Mada / RSUP DR. Sardjito
Yogyakarta
2023

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 Children with Hispanic and
INTRODUCTION
African-American races have a higher
Laryngomalacia is a congenital risk than Caucasian children. Low birth
abnormality that occurs in the laryngeal weight is also thought to be a factor that
cartilages. Laryngomalacia is condition correlates with the incidence of
that results in the collapse of the laryngomalacia. (Klinginsmith, 2020).
supraglottic structures on inspiration and Various theories on the causes of
causes airway obstruction. (Klinginsmith, laryngomalacia have been proposed,
2020). This condition represents a delay in including cartilage immaturity, anatomic
the maturation of the supporting structures abnormalities and neuromuscular
of the larynx. Laryngomalacia is the most immaturity. Neuromuscular immaturity,
common cause of congenital stridor and is one of the leading theories, proposing
congenital lesions of the larynx (Lovinsky- that altered laryngeal tone results from
Desir, 2019). abnormality of the laryngeal nerves. This
The incidence of laryngomalacia in concept is supported by pathological
the general population is estimated to be studies showing increased diameter of the
around 1 in 2000 to 3000. This figure may supraglottic nerve in patients with
be an underestimation of the true number laryngomalacia.
because mild laryngomalacia is often only Other theories, such as demand-
managed clinically by pediatricians and supply imbalance during inhalation in
not diagnosed endoscopically. children, require further study. Although
(Klinginsmith, 2020). Approximately 80% researchers have not found reflux to be a
of laryngomalacia cases are mild and causative factor for laryngomalacia,
moderate cases that improve after 8-12 about 60% of children have acid reflux
months and resolution and heal after 12-24 disease. Reflux is thought to cause
months. The remaining 10-20% of cases irritation and upper airway edema, which
are life-threatening and require immediate has the potential to exacerbate the
surgery. (Thompson, 2010; Technique, obstruction (Klinginsmith, 2020).
2017).
Laryngomalacia conditions can
Although previous evidence
affect the epiglottis, the arytenoid
indicated a male predominance (58-76%),
cartilages, or both. If the epiglottis is
the new literature covering the ethnicity of
affected, it is usually elongated, and its
the wider population suggests an equal
walls fold into its walls. The epiglottis in
number of males and females (Edmonson,
cross-sectional view resembles an omega
2011).
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shape, and the lesion is referred to as observed in the larynx, which is called
“Omega-shaped epiglottis”. reflux laryngitis. If the epiglottis is
If the arytenoid cartilages are involved, gravity makes breath sounds
involved, they appear enlarged. In either more pronounced when the baby is supine.
case, the cartilage droops and prolapses Excessive inspiratory effort increases the
into the larynx on inspiration. This return of blood to the lungs. This increases
inspiratory obstruction causes a sound the likelihood of developing pulmonary
during inspiration. More severe hypertension in the child and hypoxaemia.
disturbance was associated with a lower (Lovinsky-Desir, 2019).
ratio of aryepiglottic fold length to glottic The main symptom of
length. (Lovinsky-Desir, 2019). laryngomalacia is respiratory disturbances
such as inspiratory stridor. Stridor and
A classification system has been
noisy breathing are crucial symptoms to
proposed. In type 1 laryngomalacia, the
recognize because they can indicate
aryepiglottic folds are tightened or
varying degrees of respiratory distress
foreshortened. Type 2 is marked by
(Klinginsmith, 2020).
redundant soft tissue in any area of the
Patients with laryngomalacia
supraglottic region. Type 3 is associated
usually have complaints of breath sounds
with other disorders, such as
during inspiration. Breath sounds,
neuromuscular disease and
especially during this inspiration, usually
gastroesophageal reflux. (Lovinsky-Desir,
begin at the age of the first 2 months of life.
2019).
Breath sounds can begin to appear at 4 - 6
Infants with laryngomalacia have a
weeks, but can also appear later at around
higher incidence of gastroesophageal
2 - 3 months of age (Lovinsky-Desir,
reflux, presumably the result of the more
2019).
negative intrathoracic pressure needed to
This condition rarely causes severe
counteract inspiratory obstruction.
hypoxemia or hypoventilation to interfere
Concomitantly, children with significant
with normal growth and development. In
reflux may have pathological changes
severe cases, when laryngomalacia is
similar to laryngomalacia, especially
associated with gastroesophageal reflux,
enlargement and swelling of the arytenoid
feeding disturbances such as choking or
cartilages. Some swelling of the arytenoid
gagging may occur.. (Klinginsmith, 2020).
cartilages and epiglottis may occur due to
Patients with laryngomalacia may
reflux. (Lovinsky-Desir, 2019).
experience snoring and/or difficulty
Inflammatory changes can be
breathing during sleep (Cooper, 2014).
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 Swallowing dysfunction was also found in respiration. Adequate examination provides
a significant proportion of children. Thus, the examiner with a complete view of the
sleep-disordered breathing and swallowing oropharynx, supraglottis, glottis, subglottis,
dysfunction should be considered in and hypopharynx. Infants with
children, older than 3 months, who present laryngomalacia are frequently found with
with upper airway obstruction. (Simons, shortened aryepiglottic folds that border the
2016). epiglottis posteriorly, an omega-shaped
A complete physical examination epiglottis, and/or redundant arytenoid tissue
of the child is necessary, with special that prolapses above the glottis. Flexible
attention to the oral cavity, nose and neck. fiberoptic laryngoscopy is currently the
Choana patency needs to be ensured, and gold standard for the diagnosis of
pyriform aperture stenosis needs to be laryngomalacia because of its convenience
ruled out. Examination of the oral cavity and ability to directly assess the presence of
for cleft lip, cleft palate, glossoptosis, abnormality or dynamic collapse of the
Pierre-Robin sequence, or micrognatia is supraglottic airway during respiration.
important because they can contribute to (Klinginsmith, 2020).
difficulty breathing and eating. Careful Management of most patients with
examination of the neck to exclude laryngomalacia is conservative. In cases
masses or vascular lesions is also with mild to moderate stridor without
necessary. Special attention needs to be feeding difficulties, observation is
paid to hemangiomas with a beard-like recommended after the diagnosis is made. It
distribution, because children are more is important to monitor weight gain and the
prone to developing hemangiomas in the development of severe symptoms.
airways. Evaluation of a patient with Positional feeding and thickening feeds can
suspected laryngomalacia requires help babies with feeding difficulties.
assessment of the supraglottic airway with Symptoms resolved in the majority of
flexible laryngoscopy in an awake child. patients by the age of 12 to 18 months
If the examiner finds severe symptoms, without the need for surgical intervention.
the doctor needs to take the child to the (Klinginsmith, 2020).
operating room for diagnostic Infants with severe retractions,
bronchoscopy (Klinginsmith, 2020). cyanotic spells, and sleep apnea may
Fiberoptic flexible laryngoscopy is develop obstructive sleep apnea associated
the primary diagnostic evaluation of infant with laryngomalacia. In these children can
stridor. This procedure allows visualization be done a sleep study. Supraglottoplasty
of the upper aerodigestive tract during may be beneficial in children with severe
4
laryngomalacia. (Powitzky, 2011). supraglottoplasty surgery, there was a
Infants with laryngomalacia have a significant post-operative increase in the
higher incidence of gastroesophageal quality of life of infants and caregivers,
reflux and swallowing and feeding with high parental satisfaction, especially
dysfunction. Acid suppression and the perception of swallowing in these
swallowing therapy can also be given to children. (Vandjelovic, 2018).
children with moderate laryngomalacia
CASE REPORT
symptoms. (Faria, 2014).
Baby boy, aged 1 year 4 months
If the infant has significant
came to the ENT clinic RSUP Dr. Sardjito
hypoxaemia (resting oxygen saturation
with the main complaint of breath sounds.
<90%), oxygen supplementation should be
The patient's parents complained of the
given. In addition, in infants with
breathing since he was 2 weeks old with a
laryngomalacia and hypoxemia,
“grok-grok” sound, which got worse as
pulmonary hypertension often occurs, so
time went on until he was treated at Dr
they need to be monitored more closely for
Sardjito General Hospital. Complaints of
this condition. (Unal, 2006).
“grok-grok” are reduced by changing the
In severe cases where
tilt position, the child looks tight, a history
laryngomalacia interferes with ventilation
of choking (+) and coughing (+) while
to the point that it interferes with eating,
feeding. Denied complaints of nose and
growth and development, an operative
ears.
approach can be considered (Ritchter,
The patient was born
2008). Approximately 10% of patients
spontaneously, at term, with a birth weight
with severe congenital laryngomalacia
of 2800 grams. The patient has no history
require surgical intervention for reasons
of cyanosis. Intake of drinking breast milk,
of failure to thrive, elevated carbon
history of frequent choking when drinking.
dioxide levels or hypoxemia, severe
On physical examination, the
obstructive sleep apnea, pulmonary
general condition was shortness of breath,
hypertension and/or cor pulmonale. The
pulse 125x/minute, respiratory rate
surgery includes a tracheostomy or
32x/minute, and temperature 36.8oC, SpO2
supraglottoplasty in which the supporting
89-92% supine position without oxygen,
structures of the larynx are tightened and
SpO2 98% with O2 1 L/minute tilt position.
excess tissue in the epiglottis is removed
Examination of the neck and
(Miller, 2018).
thoracic region found suprasternal
Based on research on cases of
retraction (-), intercostal retraction (-),
severe laryngomalacia that received
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epigastric retraction (-), and inspiratory Patients with laryngomalacia
stridor on auscultation (+), rhonchi (+), usually complain of breath sounds on
wheezing (-). Otoscopy examination inspiration starting in the first 2 months of
showed the right and left auricles of the life. Sounds usually appear at 4-6 weeks,
external auditory canal within normal but can appear later at 2-3 months of age
limits, the right and left tympanic (Lovinsky-Desir, 2019).
membranes were intact, anterior
This condition rarely causes severe
rhinoscopy examination of the cavum nasi
hypoxemia or hypoventilation to interfere
dextra and left within normal limits.
with normal growth and development. In
On flexible laryngoscopy, there
severe cases, when laryngomalacia is
was "Prolapsing Redundant Arytenoid
associated with gastroesophageal reflux,
Tissue" and with no subglottic stenosis.
feeding disturbances such as choking or
Then the patient was diagnosed with
gagging may occur. (Klinginsmith, 2020).
Laryngomalacia type 1. The patient was
planned to do conservative therapy.. On physical examination of the neck
and thoracic region, suprasternal retraction,

DISCUSSION epigastric retraction, and inspiratory stridor

were found on auscultation. Otoscopy
In the anamnesis, data was obtained
examination showed the right and left
for a male baby, aged 1 year and 4 months,
auricles of the external auditory canal
with the main complaint of breath sounds
within normal limits, the right and left
since the age of 2 weeks with a "grok-
tympanic membranes were intact, anterior
grok" sound, getting worse with time.
rhinoscopy examination of the cavum nasi
Complaints are reduced by changing the
dextra and left within normal limits, on
tilt position, there is also history of
examination of the oropharynx within
choking and coughing while feeding.
normal limits.
Denied complaints of nose and ears.
A complete physical examination of
The main symptom of the infant/child should be performed, with
laryngomalacia is respiratory special attention to the oral cavity, nose and
disturbances such as inspiratory stridor. neck. Choana patency needs to be ensured,
Stridor and noisy breathing are crucial and piriform aperture stenosis needs to be
symptoms to recognize because they can ruled out. Examination of the oral cavity for
indicate varying degrees of respiratory cleft lip, cleft palate, glossoptosis, Pierre-
distress. (Klinginsmith, 2020). Robin sequence, or micrognatia is
important because they can contribute to
6
difficulty breathing and eating. Careful supraglottic airway collapse during
examination of the neck to exclude masses sustained respiration. (Klinginsmith, 2020)
or vascular lesions is also necessary.
The patient was diagnosed with
Special attention needs to be paid to
Laryngomalacia type 1. The proposed
hemangiomas with a beard-like
classification system is: type 1, the
distribution, because children are more
aryepiglottic folds are tightened or
prone to developing hemangiomas in the
shortened; type 2 is characterized by soft
airways. Evaluation of a patient with
tissue in the supraglottic region; type 3 is
suspected laryngomalacia requires
associated with other disorders, such as
assessment of the supraglottic airway with
neuromuscular disease and
flexible laryngoscopy in an awake child. If
gastroesophageal reflux (Lovinsky-Desir,
the examiner finds severe symptoms, the
2019).
doctor needs to take the child to the
operating room for diagnostic The patient is planned for

bronchoscopy. (Klinginsmith, 2020). conservative therapy

On flexible laryngoscopy, there was The management of most patients

"Prolapsing Redundant Arytenoid Tissue" with laryngomalacia is conservative. In
and no subglottic stenosis. cases with mild to moderate stridor without
Fiberoptic flexible laryngoscopy is feeding difficulties, observation is
the primary diagnostic evaluation of infant recommended after the diagnosis is made.
stridor. This procedure allows visualization It is important to monitor weight gain and
of the upper aerodigestive tract during the development of severe symptoms.
respiration. Adequate examination Positional feeding and thickening feeds can
provides the examiner with a complete help babies with feeding difficulties.
view of the oropharynx, supraglottis, Symptoms subside in the majority of
glottis, subglottis, and hypopharynx. patients between the ages of 12 and 18
Infants with laryngomalacia are frequently months without the need for surgical
found with shortened aryepiglottic folds intervention (Klinginsmith, 2020). Infants
that border the epiglottis posteriorly, an with severe retractions, cyanotic spells, and
omega-shaped epiglottis, and/or redundant sleep apnea may develop obstructive sleep
arytenoid tissue that prolapses above the apnea associated with laryngomalacia. In
glottis. Fiberoptic flexible laryngoscopy is these children can be done a sleep study.
now the gold standard for the diagnosis of Supraglottoplasty may be beneficial in
laryngomalacia because of its convenience children with severe laryngomalacia
and ability to directly assess dynamic
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(Powitzky, 2011). A meta-analysis by Farhood et al
found that the Apnea-Hypopnea Index
Infants with laryngomalacia have a
(AHI) increased by 12.5 points after
higher incidence of gastroesophageal
supraglottoplasty for laryngomalacia with
reflux and swallowing dysfunction, eating
obstructive sleep apnea, but 88% (29 of 33
acid suppression therapy and swallowing
children) had residual disease. (Farhood,
therapy can also be given to children with
2015).
moderate laryngomalacia symptoms.
(Faria, 2014).

If the infant has significant KESIMPULAN

hypoxaemia (defined as resting oxygen
A boy aged 1 year and 4 months
saturation <90%), oxygen
came to ENT Clinic in Dr. Sardjito with
supplementation should be given. In
complaints of “grok-grok” breath sound
addition, in infants with laryngomalacia
since 2 weeks of birth. From the anamnesis,
and hypoxemia, pulmonary hypertension
physical examination, and supporting
often occurs, so they need to be monitored
examinations, the patient was diagnosed
more closely for this condition. (Unal,
with Laryngomalacia Type 1. and planned
2006).
for conservative therapy
In severe cases where
laryngomalacia interferes with ventilation
to the point that it interferes with eating,
growth and development, an operative
approach can be considered (Ritchter,
2008). Approximately 10% of patients
with severe congenital laryngomalacia
require surgical intervention due to failure
to thrive, elevated carbon dioxide levels or
hypoxemia, severe obstructive sleep
apnea, pulmonary hypertension or cor
pulmonale. The surgery includes a
tracheostomy or supraglottoplasty in
which the supporting structures of the
larynx are tightened and excess tissue in
the epiglottis is removed (Miller, 2018).

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