Question

Surgical management of laryngomalacia in children failing conservative treatment.

Hint:

Supraglottoplasty is the gold standard for surgical management of severe laryngomalacia that does not improve with conservative treatment.

Answer 1

Step 1: Overview of Laryngomalacia:
Laryngomalacia is the most common cause of congenital stridor in infants. It occurs due to the softening of the tissues of the larynx, particularly the arytenoid cartilages, causing the airway to collapse inward during inhalation, leading to noisy breathing or stridor. Most cases resolve spontaneously by 18-24 months, but in severe cases or those failing conservative treatment, surgical management may be required.

Step 2: Indications for Surgery:
Surgery is indicated when conservative management (such as feeding modifications, positioning, and observation) fails to control symptoms, or when the condition causes severe breathing difficulties or failure to thrive. Surgical indications include:
1. Severe stridor affecting feeding and respiratory function.
2. Failure to gain weight and grow due to airway obstruction.
3. Signs of severe respiratory distress, such as retractions or hypoxia.
4. Recurrent episodes of apnea or cyanosis.

Step 3: Surgical Options:
1. Supraglottoplasty: This is the most commonly performed surgery for laryngomalacia. It involves the removal or modification of the redundant tissue of the supraglottic larynx, particularly the epiglottis or arytenoid cartilages, to improve airway patency. This procedure is performed under general anesthesia via an endoscopic approach.
2. Arytenoidectomy: In severe cases, partial resection of the arytenoid cartilage may be necessary to prevent airway collapse.
3. Tracheostomy: In rare, very severe cases, a tracheostomy may be required to secure the airway, especially in cases with associated complications like failure to thrive or severe apnea.