Laryngomalacia and Tracheomalacia

00:08 So basically, malacia means narrowing or it’s a floppy area.

00:13 And this can happen in either the larynx or the trachea.

00:17 It’s a common problem especially in premature infants.

00:21 We see this all the time.

00:23 There are some genetic influences, but the cause is basically unknown.

00:28 And it’s basically a collapse in the airway, in the larynx, or in the trachea due to probably mostly poor airway motor tone.

00:37 These infants have just a hard time keeping it stented upon when they're breathing.

00:42 So it presents with noisy breathing.

00:46 And typically depending on where the location is primarily will depend on what that noise is.

00:53 Stridor usually occurs for patients who have a higher area of malacia.

00:59 In other words, in laryngomalacia, for example, their airway collapse is a little bit higher up.

01:05 This means that when they breathe in, it’s like breathing in through the neck of a balloon.

01:11 It collapses and makes a stridorous noise.

01:14 But when they breathe out, it will sort of billow open and there’ll be less noise.

01:19 Or alternatively, patients could have laryngomalacia, but also have some tracheomalacia.

01:26 And the tracheomalacia will have more of an exhalational component to it.

01:31 So it may be biphasic or just stridor or if it’s all low down, just wheeze.

01:37 It will give you a clue as to the location of the airway collapse.

01:42 The reason why it’s important to remember the clue of the airway collapse and where this is likely happening is because there is a differential diagnosis.

01:50 We can’t just assume that any baby with stridor doesn’t have something more substantial going on.

01:57 Patients may get superglottic webs.

02:01 These areas of tissue that are inappropriately growing in the airway and thus making the airway narrower and having it harder to breathe in.

02:10 Patients may have airway hemangiomas.

02:13 This is particularly likely if you see some also on the baby’s skin.

02:18 An airway hemangioma can be very challenging.

02:20 It may require laser therapy or other things.

02:23 Or we simply hope they’ll outgrow it and gradually wait until they get bigger because just like hemangiomas on the legs, these will gradually shrink over several months.

02:33 But this can be very challenging because they will also grow for the first few months and so we need to watch these children very carefully.

02:41 Another potential cause of stridor or wheeze in an infant is a vascular ring.

02:47 There are many different types of vascular rings and it will take forever to list them all.

02:51 And for example, the aorta may be together come apart and then go back together again.

02:57 And in that space in between, that sort of like an island on a highway, that trachea can run through that area.

03:04 Oftentimes, the esophagus does as well.

03:07 This can lead to not only spitting up of food, but also a narrowing of the tracheal airway which may happen a bit after birth as they sort of grow into that vascular ring.

03:17 Then we could hear more respiratory symptoms.

03:19 Another possibility is the patient has a cyst or another structure that’s pressing on that airway like a lingual thyroid or a thyroglossal duct cyst.

03:29 And patients may have subglottic stenosis, just an area of narrowing that’s causing the problem.

03:36 Subglottic stenosis is common in infants who have recently been intubated.

03:40 That intubation can cause damaging below the vocal cords and a little stenotic area, which can present with noisy breathing.

03:49 So for any infant with stridor, we have to think about what might be causing it.

03:53 And so we’ll probably do some studies to try and get a sense of what exactly is going on.

03:59 One thing we can do is the neck X-ray.

04:01 By looking at a neck x-ray, we can seen an area of focal narrowing and get a sense of where is it and is that consistent with a mass or is it consistent with a general floppy airway.

04:12 If we aren’t convinced by the neck X-ray but we don’t have any specialist nearby who can look in with a camera, we might also do airway fluoroscopy.

04:22 What we’re doing is making a video with x-rays and we can see that airway collapsing and we can make a diagnosis.

04:28 Lastly, if we’re just not sure what’s going on, it’s very reasonable to consult ear, nose and throat doctors to do direct video laryngoscopy.

04:36 They can actually look inside and see what’s going on.

04:39 They can diagnose laryngomalacia or tracheomalacia, but they can also see the airway hemangioma or see an area that’s compressed by an external mass, et cetera.

04:51 So how do we support these infants.

04:53 Well, in most cases, the treatment is entirely supportive because as they grow, this problem goes away.

04:59 Usually, by two or three years of age, it’s all gone.

05:02 So we’ll provide CPAP in some severe cases.

05:06 This will help stent open that airway of collapse and keep them breathing comfortably.

05:10 Most children do great with this.

05:13 There is a frequent readmission in these infants specifically with upper respiratory tract infections.

05:20 Bronchiolitis or even just the common cold can tip them over the edge and make it very hard for them to breathe.

05:26 And typically, they’ll outgrow this by two years of age.

05:30 So that’s a brief summary of laryngomalacia and tracheomalacia in kids.

05:35 Thanks for your time.