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WITH CEREBRALPALSY
ABSTRACT
1
Introduction
supraglottic airway with inspiration. Chevalier Jackson is credited with coining the term
laryngomalacia in 1942, but the condition was first described by Barthez an Rilliet in 1853. It
is literally meaning soft larynx, this condition refers to a dynamic prolapse of the supraglottic
structure during inspiration with endoscopic finding such as shortened aryepiglottic folds
It is the most common congenital laryngeal abnormality, accounting for over 60% of
all cases of congenital stridor. It is the most common etiology of stridor in the neonate. In
pediatric patients presenting with stridor, laryngomalacia is the cause in 45-75% of case.
Affected infants often present with inspiratory stridor within the first 10 days of life that
typically resolves spontaneously by 12-18 months of age. Laryngomalacia often present with
GERD (65-100%) and neurological disease (20-40%). Some congenital and syndromic disorder
interfere with normal respiration, feeding and even cause life- threatening episodes, and
excise the redundant tissue collapsing into the laryngeal inlet during inspiration.1,4
high morbidity and longer ICU duration. In the last 20 years, endoscopic approaches for
Case Presentation:
A 20 months old girl presented to the of Otorhinolaryngology Head and Neck Surgery
Department at Dr. Sardjito Hospital in Yogyakarta for evaluation with complain of inspiratory
stridor worsened by feeding, agitation, supine, crying, and snoring with supine position since
birth. The patients also occasionally show symptoms of dyspnea, and choking during feeding
with both liquid and solid food, and slow weight gain. The patient had history of cerebral palsy,
recurrent pneumonia, and growth retardation. The parents denied pain, bleeding and history of
injury, chronic irritation, or exposure to radiation. The family also denied the history of the same
symptom in family.
Orofaring examination showed normal pharyngeal wall, normal tonsil palatina with size
T1-T1, no mass. Anterior rhinoscopy was normal, no mass, no bleeding, no hypertrophy concha,
and no discharge. Otoscopy of both ear revealed normal ear canal and intact tympanic
membrane. Neck examination didnt show any mass, but there was retraction.
airway and aspiration. There is no mass or bleeding, and vocal fold movement looks symmetric.
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Clinical history, physical examination, and endoscopy refer to the diagnosis of
laryngomalacia type 2 with cerebral palsy, recurrent pneumonia, and growth retardation . The
management was supraglottplasty procedure via direct laryngoscopy with general anesthesia
using cold knife microlaryngosurgery method. The bleeding was handled using cotton pledge
soaked with 1/10000 adrenalin/ephinephrine The tracheostomy procedure was done first before
supraglottoplasty. During this procedure the aryepiglottic fold was cut and widened.
Two days postoperative patient was evaluated again using flexible fiberoptic
laryngoscopy. The post operative wound healing is good, and no active bleeding. Patient was
discharged home later. After 3 months post operatively, the patient has started to gain more
Figure 3
. Post operative : Flexible fiberoptic laryngoscopy view
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Discussion
Not all neonates have the same laryngeal anatomy, but all neonates potentially present
symptoms results from variable combinations of the infants specific laryngeal anatomy, poor
simple physiological variations related to changes in tone during sleep), mucosal oedema, and
increased airflow.7
the laryngeal cartilage. This theory was supported by a prospective study showing a lower
aryepiglottic fold to glottic length ratio in patients with severe laryngomalacia compared with
unaffected children, but failed to explain why some children with similar laryngeal
examinations were asymptomatic. The theory of immature and abnormally collapsible cartilage
abnormal integration of the peripheral nerves, brainstem nuclei and pathways responsible for
elicitation of normal motor responses correlating with disease severity. Additional corroboration
is provided by histologic studies showing significant size differences in the superior laryngeal
controls. Subsequent neurological and central nervous system maturation would provide a
reasonable explanation for the spontaneous resolution generally seen in the disease.8
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A presumptive clinical diagnosis of laryngomalacia can be made based on the classic
Pertinent history should include birth circumstances (including gestational age and
aggravating or temporizing factors, and feeding concerns including retarded growth, choking or
height and weight, respiratory sounds including timing in the respiratory cycle, chest
movement to determine the presence of retractions or pectus excavatum, and auscultation of the
lung fields.8
laryngoscopy alone in the vast majority of cases (88%), regardless of the experience level of
the examiner. The procedure can generally be performed on awake children in the arms of
their caregiver without the need for sedation. The flexible fiberoptic laryngoscope is passed
along the nasal floor and positioned above the larynx during several cycles of spontaneous
respiration. Topical anesthetics should be avoided when possible as they may exacerbate
The three basic abnormalities that may be present are 1) elongated, tubular epiglottis
that collaps medially, and 3) redundant mucosa overlying the arytenoid cartilages that
collaps anteriorly.1
collaps: posterolateral collaps (type A) where there is collaps of the arytenoids and the
aryepiglottic folds, complete collaps of the supraglottic structure of the larynx (type B), or
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anterior collaps (type C) where only the epiglottis collapses during inspiration. Kay and
associated with one or more of the following symptoms: dyspnoea with permanent and
weight gain.5,10,11
hypertension, cor pulmonale, severe obstructive sleep apnea. Feeding problems inludes
In the smaller group of children with laryngomalacia who fail to respond to conservative
treatment or in those with more severe respiratory or feeding difficulties upon presentation,
laryngomalacia and involves surgically modifying the supraglottis in an effort to reduce its
collaps during respiration. Supraglottoplasty includes one or more of the following procedures:
division of the aryepiglottic folds, debulking of the arytenoid mucosa and cuneiform cartilages,
making linear incisions on the lingual surface of the epiglottis, or trimming of the lateral
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edges of the epiglottis. The overarching goal of supraglottoplasty is to reduce or stabilize
laryngeal tissue, thereby preventing inspiratory collapse and airway obstruction. The
procedure is typically performed under sedation with spontaneous breathing after suspension of
the larynx.13,8,12
This procedure was first done with cold steel and was described by Zalzal et al. The
use of the carbon dioxide (CO2) laser was later introduced. Both cold-steel and laser have
been shown to have similar outcomes. Although CO2 laser supraglottoplasty was originally
thought to be more precise with less intraoperative bleeding, more recent studies have shown
assisted procedures were first described in 2005. Since coblation technology was introduced at
the beginning of the 21st century there has been little published on its use in supraglottoplasty.
A potential benefit of the coblator is a reduction in the risk of airway fires, which have been
reported with the laser. A systematic review by Preciado and Zalzal reported that therewere not
fiberoptic evaluation and intra-operative findings. The interarytenoid mucosa has been preserved
micro-debrider or CO2 laser. Similar success rates have been reported for each, therefore
Conflicts of interest
The authors declare that there is no conflict of interests regarding the publication of this paper
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References