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be made worse by surgery. Variation in practice among the current
group members remains, and the purpose of this section is to provide
a list of reasonable options based on expert opinion.
6.4.
Section 4
:
management of the difficult to feed infant with
laryngomalacia
This algorithm in
Fig. 3
outlines a guide for managing infants
who have been diagnosed with laryngomalacia and are having
difficulty with effectively and/or safely feeding. The algorithm
may be best performed in conjunction with feeding or speech
therapy services when available to guide feeding recommenda-
tions and therapy (texture modification, bottle pacing, augmenting
feeding schedule, etc.). Chest x-ray may be indicated in the infant
if there are signs of respiratory compromise. Aspiration, pooling
of secretions, and decreased supraglottic sensation may be seen
during endoscopy in the setting of uncontrolled laryngopharyn-
geal reflux or neurologic disease. Persistence of symptoms despite
maximal reflux suppression, especially in infants with hypotonia,
should prompt work-up for neurologic causes prior or concurrent
to surgical management. Neurologic disease is not a contraindica-
tion to supraglottoplasty, but the benefit of improving airway
obstruction must be weighed with the risk of worsening aspira-
tion in this scenario. Variation in practice among the current
group members remains, and the purpose of this section is to
provide a list of reasonable options based on expert opinion.
6.5.
Section 5
:
post-surgical treatment algorithm and persistent
laryngomalacia
The algorithm displayed in
Fig. 4
is intended to guide manage-
ment in infants who have undergone supraglottoplasty and is
targeted toward those who have persistent laryngomalacia despite
surgery. Time course for follow-up is variable among providers and
is dictated by the severity of persistent symptoms in the patient.
Persistent laryngopharyngeal reflux or undiagnosed eosinophilic
esophagitis may drive persistent laryngeal edema leading to con-
tinued laryngomalacia. Confirming the presence or absence of
obstructive sleep apnea may drive decision making toward surgi-
cal management vs. observation. Identifying and optimizing cardiac,
neurologic, and pulmonary co-morbidities is paramount in man-
aging the infant with persistent symptoms after supraglottoplasty,
especially before considering revision surgery. Patients with mul-
tiple severe comorbidities or multilevel airway obstruction are less
likely to succeed with supraglottoplasty alone and may require tra-
cheostomy. Again, variation in practice among the current group
members remains, and the purpose of this section is to provide a
list of reasonable options based on expert opinion.
6.6.
Section 6
:
recommendations for acid suppression therapy
Fig. 5
provides a “step-up” vs. a “step-down” regimen for man-
aging acid suppression therapy. In a “step down” regimen, therapy
Laryngomalacia
Severe Laryngomalacia
:
Apnea, cyanosis, failure to thrive, pulmonary
hypertension, cor-pulmonale
Start acid suppresion therapy and consider
feeding therapy/swallow evaluation
*see section 4
1. Laryngoscopy/bronchoscopy
2. Supraglottoplasty
*See section 5 for after care
Moderate laryngomalacia
:
Cough, choking, regurgitation, feeding
difficulty
Start acid supression therapy and consider
feeding therapy/swallow evaluation
*see section 4
Mild laryngomalacia
:
Inspiratory stridor with no other symptoms or
radiographic findings suggesting secondary
airway lesion
1 month symptom check, if stable or
improving can extend to 3-6 month symptom
check
Consider co-morbidities that
place infant at high risk to
do poorly:
1. Cardiac disease
2. Neurologic disease
3. Respiratory disease
4. Craniofacial
dysmorphism
Fig. 2.
Comprehensive care algorithm.
J. Carter et al./International Journal of Pediatric Otorhinolaryngology 86 (2016) 256–261
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