Common paediatric ENT viva topics
Joseph Manjaly, Peter Kullar in Advanced ENT Training, 2019
The aetiology is poorly understood; two common theories are the neurologic and cartilaginous theories. In the neurologic theory, there is sensorineuromotor dysfunction, reduced neuromuscular tone and laryngeal coordination. Gastroesophageal reflux may contribute to mucosal oedema and reduced laryngeal sensation. Increased work of breathing may in turn exacerbate reflux owing to negative intrathoracic pressure. In the cartilaginous theory, immature laryngeal cartilage offers insufficient mechanical resistance to collapse, causing collapse of the supraglottic structures on inspiration. The resulting mucosal trauma causes oedema, further worsening the stridor. This theory has not been supported by histopathology or the lack of laryngomalacia in premature babies and at birth. The commonest theory is now that laryngomalacia is a normal anatomical variant which is predisposed to collapse on inspiration until such time as the airway grows and the tissues mature.
Congenital airway malformations
Prem Puri in Newborn Surgery, 2017
Laryngomalacia is the most common congenital laryngeal anomaly and is also the most common cause of stridor in neonates.2 This symptom is usually evident soon after birth or within the first few days of life. It is generally mild but is typically exacerbated by feeding, crying, or lying in a supine position. In 50% of children, stridor worsens during the first 6 months of life. A small subset of children with severe laryngomalacia may present with a spectrum of symptoms, including apnea, cyanosis, severe retractions, and failure to thrive. Also, many patients suffer from clinically significant GER. In extremely severe cases, cor pulmonale is seen. The reported incidence of secondary airway lesions in infants with laryngomalacia varies, with some authors reporting rates as high as 50%3 and 64%.4
Congenital Disorders of the Larynx, Trachea and Bronchi
John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed in Paediatrics, The Ear, Skull Base, 2018
In severe laryngomalacia, however, there is serious respiratory obstruction with substantial sternal and intercostal recession together with feeding difficulties which may be compounded by reflux enhanced by the high negative intrathoracic pressures generated, and consequent failure to thrive. Matters are made worse if there are other factors increasing the level of cardiorespiratory embarrassment, such as congenital cyanotic heart disease. In the most severe cases, cor pulmonale may ensue and in cases of severe sternal recession a permanent pectus excavatum may develop. Therefore, in children where the stridor is severe, if there is failure to thrive or there are any atypical features (e.g. history of previous intubation, cutaneous haemangioma) that may raise the suspicion of a second, coexisting airway pathology, a microlaryngoscopy and bronchoscopy (MLB) under general anaesthesia is indicated. Optimum conditions for diagnosis require the child to be breathing spontaneously under a very light level of anaesthesia, with the beak of the laryngoscope in the vallecula; the supraglottic collapse is not seen under deep anaesthesia and will be prevented if the tip of the laryngoscope is introduced into the laryngeal vestibule.
Histopathology of laryngomalacia
Published in Acta Oto-Laryngologica, 2021
Richard Wei Chern Gan, Ali Moustafa, Kerry Turner, Lindsey Knight
A leading theory of the pathogenesis of laryngomalacia is neurological dysfunction [15]. The theory has several supporting factors including up to 20% of patients having neurological disorders [16]. Stroke, seizures, hypoxic injury and sedation can lead to laryngomalacia with resolution of symptoms observed with resolution of the neurological condition [16]. Laryngeal tone and sensorimotor integrative function have also been shown to be reduced; with the scale of reduction correlating with the severity of laryngomalacia [16]. Neurosensory dysfunction could lead to reduced neuromuscular coordination of the supraglottis [17]. Our study showed 70.5% of specimens showing signs of inflammation with at least 55.7% showing chronic inflammation. Inflammation of tissues could give rise to functional denervation and blunting of afferent reflexes [16]. However, it is important to note that the inflammation seen in the biopsies tends to be mild and the causal relationship between inflammation and denervation still lacks evidence. A study by Munson et al. [17] of the neuropathologic findings in supra-aryepiglottoplasty specimens showed nerve hypertrophy, which they suggest represents sensorineural dysfunction of the larynx.
Spectrum of upper airway pathology in children with Down syndrome in a single tertiary centre
Published in Acta Oto-Laryngologica, 2022
Mohammad Nasyatmuddin Yahya, Bee-See Goh, Fahrin Zara Mohammad Nasseri, Nor Azlin Kamal Nor, Wan Nurulhuda Wan Md Zin, Hasniah Abdul Latif
A total number of 91 patients were recruited in this study. The details of demographic and relations to UAO as shown in Table 1. There were various causes of upper airway pathology in DS children as depicted in Figure 1 and Table 2. The comorbidities of DS were shown in Table 3. This study showed laryngomalacia could occur earlier than two weeks old, which is not typical for laryngomalacia in non-syndromic children. One case was a preterm baby, while four cases were observed in term babies. Four of these cases had other pathologies associated with laryngomalacia, while one case showed only laryngomalacia was diagnosed.
The role of the pediatrician in caring for children with tracheobronchomalacia
Published in Expert Review of Respiratory Medicine, 2020
Manisha Ramphul, Andrew Bush, Anne Chang, Kostas N Prifits, Colin Wallis, Jayesh Mahendra Bhatt
Interestingly, the etymology of malacia originates from the Greek word ’malakia’, meaning soft [6]. Laryngomalacia, a congenital softening of the tissues of the larynx above the vocal cords, is commonly encountered in pediatric practice as a cause of noisy breathing and will not be reviewed in this paper.
Related Knowledge Centers
- Cartilage
- Stridor
- Tracheotomy
- Vocal Cords
- Larynx
- Epiglottis
- Laryngoscopy
- Gastroesophageal Reflux Disease