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Stridor in the Infant Patient

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direct laryngoscopy. Assessment of the severity of laryngomalacia and vocal cord mo tion is done at this time as well, particularly if the vocal cords could not be seen on flexible endoscopy because of an obstructed view. Topical anesthesia is applied, and the rest of the airway is examined with a rigid telescope. Muscle relaxant and res piratory depressant should be avoided. 4 Thorough assessment of the hypopharynx, larynx, and tracheobronchial anatomy is performed. Instrumentation to probe the lar ynx may help identify laryngeal clefts and cricoarytenoid joint fixation. Video and photographic documentation of the procedure is mandatory for further review, future patient care, and risk management. Laryngomalacia is the most common cause of stridor in neonates and infants. 5–7 Most cases follow a relatively benign course, and most patients are managed conservatively until symptoms subside by 12 to 24 months. The incidence of severe laryngomalacia resulting in persistent stridor with failure to thrive symptoms is about 10% to 15%, prompting surgical management. 5 Pathophysiology First described by Barthez and Rilliet 8 in 1853, 3 basic abnormalities of the larynx may be present in laryngomalacia ( Fig. 2 ): Belmont and Grundfast 9 investigated the neurologic cause of laryngomalacia in 1984, and since then, many others have looked into the condition, but no single cause has been determined. Reflux has also been posited as a potential causative factor of laryngomalacia, as glottic edema may result in supraglottic prolapse. Persistent inflammation may result in injury to mucosal and submucosal nerves, leading to dimin ished laryngeal sensation and tone. 10 Clinical Presentation Patients with laryngomalacia will present with inspiratory stridor that intensifies with feeding, agitation, and supine positioning. Stridor may subside when the patient is LARYNGOMALACIA IN CHILDREN 1. Elongated epiglottis that prolapses posteriorly with inspiration 2. Short aryepiglottic folds 3. Redundant supraarytenoid mucosa that prolapses anteriorly

Fig. 2. Normal-appearing laryngeal anatomy ( A ) versus the appearance commonly seen in laryngomalacia ( B ).

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