Laryngomalacia: causes, symptoms, diagnosis, treatment

Laryngomalacia is a developmental defect of the larynx in which the tissues of the vestibule prolapse into its lumen during inspiration, due to their abnormal compliance or as a result of neuromuscular insufficiency of the larynx.

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What causes laryngomalacia?

There are two causes of laryngomalacia - genetically determined laryngomalacia and acquired laryngomalacia. The first cause, according to McKusick's hypothesis, is due to the autosomal dominant nature of inheritance, the second is a consequence of the impact on the fetus in the prenatal period of unfavorable factors, various neuromyogenic dysfunctions of the stomach and esophagus (gastroesophageal reflux), etc. As noted by A. Yu. Petrunichev (2004), a number of authors consider laryngomalacia in adults as a result of an increase in the air flow passing through the larynx in athletes during extreme physical exertion or as a result of a violation of the innervation of the corresponding muscular apparatus of the larynx.

Symptoms of Laryngomalacia

The most common symptoms of laryngomalacia are inspiratory stridor and all manifestations associated with it. Other symptoms of this disease include dyspnea, especially during physical exertion, hypodynamia of the child, developmental delays, choking, sleep apnea, complications with the lungs and heart, and even sudden infant death syndrome. Laryngomalacia is often combined with laryngeal congenital stridor.

Usually, due to age-related development of the larynx, as a result of which its cartilaginous skeleton is compacted, the muscular, ligamentous and fibrous apparatus of the larynx is strengthened, the signs of laryngomalacia disappear by the 2nd-3rd year of the child's life. Early diagnostics and the implementation of appropriate treatment and rehabilitation measures contribute to this. However, in their absence, the restoration of the laryngeal structures can be delayed for quite a long time. In this case, there is a lag in the child's physical development, frequent colds that increase the symptoms of laryngomalacia, disorders of the external respiratory function and other anomalies associated with this condition, which ultimately leads to a "narrowing" of a person's normal lifestyle and acquires not only medical but also social significance.

According to the works of E.A. Tsvetkov and A.Yu. Petrunichev, the clinical and pathogenetic characteristics of laryngomalacia can be determined by the following postulates:

1. signs of laryngomalacia include not only the well-known laryngeal symptoms, but also gastroesophageal reflux and funnel-shaped deformation of the child's chest;
2. macrostructural abnormalities of the larynx in laryngomalacia can persist in older children and even in adults, causing a negative impact on the functions of the larynx and the body as a whole;
3. in the development of some cases of laryngomacelluar malacia, dysplastic processes in connective tissue play a certain role;
4. At least 25% of cases of laryngomalacia are familial forms, which indicates the hereditary nature of this disease.

Thanks to the research of A. Yu. Petrunichev, conducted under the supervision of E. A. Tsvetkov, we have the opportunity to present some unique data obtained by these authors concerning the dynamics of morphofunctional compensation of laryngomalacia. All examined patients were divided into 5 groups.

• The first group: an increase in the vertical size of the sphenoid cartilages, combined with thinning of the aryepiglottic folds.
• The second group: the aryepiglottic folds are thinned in the upper parts and are attached high to the epiglottis. In this group, a variant is noted in which the aryepiglottic folds are also thinned and look like cup-shaped "sails" that are pulled from the middle to the lateral walls of the pharynx (2).
• Third group: the epiglottis is folded and pulled back by short aryepiglottic folds.
• The fourth group: the epiglottis has a normal shape, but during phonation it freely deviates forward, lying on the root of the tongue. Its stem protrudes significantly into the lumen of the larynx, and the aryepiglottic folds are spread out along its lateral surfaces.
• Fifth group: excess tissue of the posterior parts of the vestibule of the larynx.

Diagnosis of laryngomalacia

Diagnosis of laryngomalacia involves a systematic approach to this problem, developed by A.Yu.Petrunichev (2004). The method proposed by the author has universal significance, since it can be used to diagnose not only laryngomalacia, but also other laryngeal malformations. This method includes:

1. recording complaints, collecting data on the child's medical history and life, most often obtained from the child's parents; when collecting the medical history, the fact of possible inheritance of the disease is also taken into account;
2. performing endofibrolaryngoscopy of a child through the nose;
3. X-ray of the neck (larynx) in lateral projection;
4. performing direct support laryngoscopy under anesthesia (for special indications);
5. conducting a general physical examination of the child;
6. collection of anamnesis of life and, if necessary, physical examination of parents and other close relatives of the child to establish the fact of inheritance of the disease.

A.Yu.Petrunichev proposes formulating the diagnosis of laryngomalacia in accordance with the classification of criteria he developed (2004):

1. by form - mild and severe laryngomalacia;
2. by clinical period (stage) - compensation, subcompensation and decompensation;
3. according to the clinical course - typical and atypical (severe, asymptomatic, protracted).

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Treatment of laryngomalacia

Treatment of laryngomalacia is basically the same as for congenital stridor. In case of pronounced anatomical changes that significantly disrupt the respiratory and voice-forming function of the larynx, appropriate surgical intervention is indicated, aimed at strengthening the walls of the laryngeal vestibule.

What is the prognosis for laryngomalacia?

Laryngomalacia has a favorable prognosis, however, in severe forms, especially in protracted ones, it may be questionable in terms of both severe respiratory complications and full vocal function.