Late-Onset Laryngomalacia: A Variant of Disease

• School-age children with a mean age of 6.3 years
• Presentation of respiratory pauses, gasping, loud snoring, restlessness during sleep
• Two patients with sleep-induced stridor
• Abnormal polysomnograms
• Despite prior T&A patients had persistent symptoms
• 43% with GERD
• Supra-arytenoid redundancy and prolapse during intraoperative nasopharyngoscopy and rigid microlaryngoscopy with very light sedation

Exercise-Induced LM

• Adolescents with a mean age of 15 years
• Strenuous activity induced symptoms of stridor, shortness of breath, retractions
• Relieved with rest
• Unlike exercise-induced asthma, it was unresponsive to inhaled B-agonist/Cromolyn
• 67% with GERD
• Patients underwent a treadmill test, hyperventilation study, and flexible laryngoscopy with evidence of supra-arytenoid prolapse during symptoms

Noting that late-onset LM is a clinically separate entity from the congenital form of LM that strikes very young babies, the researchers proposed that late-onset LM is made up of variants of LM, “not because it is late development of congenital disease,” they said, “but because they are late presentations of what we know LM to be.”

The team said that from an etiologic standpoint, late-onset LM logically is not due to immature laryngeal support, abnormal anatomy, or a neurologic insult, as seen in congenital and adult disease.

“We’d like to propose that these patients have a susceptible larynx at the supra-arytenoid level,” Dr. Richter said. “As the arytenoid redundance and prolapse become worse, increasing interruption of laryngeal sensitivity due to various factors such as GERD, hypoxia, and hypercarbia, as seen in these patients, contributes to an ongoing cycle. This is not a new concept. Because the larynx requires a stimulus in order to maintain a tone, via peripheral and central mechanisms, disruption of the stimulus can lead to reduced tone and subsequently supraglottic prolapse.”

Dr. Richter also noted that late-onset LM is likely exacerbated by GERD but is unlikely to resolve with time or GERD management. In these patients symptom resolution appears to require supraglottoplasty, he said.

©2007 The Triological Society