Late-Onset Laryngomalacia: A Variant of Disease

SAN DIEGO—Although the most commonly seen cases of laryngomalacia (LM) are in very young children, clinicians should consider late-onset LM as a potential cause of feeding difficulties in toddlers, sleep apnea in children, and teenage exercise intolerance, according to researchers at Cincinnati Children’s Hospital Medical Center and the Mayo Clinic.

The study was presented by Gresham T. Richter, MD, a clinical fellow in pediatric otolaryngology at Cincinnati Children’s Hospital Medical Center, as part of the American Society of Pediatric Otolaryngology’s program April 28 at the Combined Otolaryngology Spring Meeting.

Dr. Richter noted that the most common form of laryngeal anomaly is the congenital form seen in two-week- to three-month-old babies. They present with respiratory and feeding difficulties, clinically tied to gastroesophageal reflux disease (GERD), and the disorder is frequently self-limited to one or two years.

Although LM is rarely seen in older children, the research team believed that late-onset LM may be obscured by related but uncommon clinical features. They noted that there have been recent case reports regarding exercise-induced LM, “state-dependent” LM, and even acquired adult LM. Because late-onset LM appears to have atypical clinical features and diagnosis is often obscured and delayed, the Cincinnati Children’s Hospital—Mayo Clinic team attempted to clarify clinical features and management approaches for late-onset LM.

Their prospective and retrospective evaluation of patients with LM between 1998 and 2005 included children who were two years of age or older when diagnosed. From 17 patients identified, three specific groups were formed based on presenting symptoms and age:

• Feeding difficulties—toddlers with a mean age of 3.3 years
• Sleep disturbances—school-age children with a mean age of 6.3 years
• Exercise intolerance—adolescents with a mean age of 15 years

According to Dr. Richter, profound arytenoid prolapse during nasopharyngeal and rigid endoscopy was discovered in all patients. Stridor was rarely present. Typical features of congenital disease, including omega-shaped epiglottis, shortened aryepiglottic folds, or retroflexed epiglottis, were not found. No patient was diagnosed with a neuromuscular disorder. And the research team noted that supraglottoplasty led to clinical cure in all patients.

Characteristics of Late-Onset LM

In looking closely at the three groups, the researchers found the following:

Feeding-Disordered LM

• Toddlers with a mean age of 3.3 years
• Cough and choke with food, variable weight loss and/or failure to thrive
• No stridor
• FEES-posterior-superior arytenoid redundancy and prolapse that worsened during feeds
• All with GERD
• Symptoms recalcitrant to medical management (such as feeding modification)

Sleep-Disordered LM