Laryngomalacia (Pediatr Rev 2006;27:e33)
• Floppy tissue above vocal cords that falls into airway w/ inspiration
• Collapse of supraglottic structures (arytenoid cartilages and epiglottis) w/ inspiration
• Epidemiology: Most common cause of stridor in infants (∼65–75% of all cases)
• Clinical manifestations
• Symptoms appear during the first 2 mo of life; infant usually happy/thriving
• Noises are inspiratory and may sound like nasal congestion
• Exacerbated with crying, agitation, or during an upper respiratory infection
• Prone position may diminish the stridor
• Diagnostic studies: History/physical, flexible laryngoscopy, and/or bronchoscopy
• Prognosis
• Self-limited condition, usually resolves w/o Rx by 12–18 mo of age
• In 10% of affected pts, upper airway obstruct severe enough to cause apnea or FTT; may have expiratory/biphasic stridor
• May coexist with other airway malformations
When to refer: FTT, feeding difficulty, respiratory distress/apnea/hoarseness, cyanosis, atypical clinical course/persistent stridor, sleep disturbances
Interventions: Surgery: Supraglottoplasty, tracheostomy
Tracheomalacia (Pediatr Rev 2006;27:e33)
• Weakness of the airway cartilage that results in “floppiness” of airway
• Positive intrathoracic pressure can cause intrathoracic trachea to collapse and obstruct on expiration; extrathoracic trachea may collapse on inspiration
• May be secondary to compression to mediastinal mass or vascular rings/slings
• History/exam
• Wheeze is often expiratory central, low pitched, and homophonous, possibly stridor
• Unlike the wheezing heard in asthma (which tends to be diffuse, high pitched, and musical). Unlike asthma there are no signs of hyperinflation
• Wheezing after β-agonist therapy remains unchanged or even worsens
• Better in the prone position
• Diagnosis: H&P, CXR, chest CT with contrast, airway fluoroscopy, bronchoscopy
• Prognosis: Most improve spontaneously by 6–12 mo of age if primary tracheomalacia
• Interventions
• Nasal CPAP can help maintain airway patency temporarily
• Aortopexy or tracheostomy for long-term relief of obstruction
• Treat coexisting conditions such as GERD; consider avoiding β-agonists; Atrovent
Croup (see ED section for evaluation and management of croup)
• Laryngotracheobronchitis: Inflammation & edema of subglottic larynx, trachea, bronchi
• Clinical diagnosis for acute onset of barky cough, stridor, and respiratory distress
• DDx for recurrent croup: Asthma, laryngomalacia, laryngospasm, subglottic stenosis