Times of India
02 June 2010
By Umesh Isalkar
Pune, India

Mangeshkar Hospital Treats Infants With Condition Called Laryngomalacia
Two–month–old Drushti suffered from noisy breathing. Her mother said the baby breathed laboriously and feeding too was difficult.

At first, all her symptoms resembled that of asthma. After she was examined by experts from the laryngology department at Deenanath Mangeshkar Hospital, Drushti was diagnosed as suffering from severe laryngomalacia, a defect of the larynx (voice box).

The department, which claims to be the only centre for treating the defect in the city, receives two to three cases of severe laryngomalacia every month.

"Laryngomalacia is the most common cause of stridor (noisy breathing) in infants and a common birth defect accounting for 50 to 75 per cent cases in the first year of life. Although most cases improve spontaneously in the first two years, in around 10–12% of cases, children have potentially life–threatening respiratory symptoms, swallowing difficulties, obstructive sleep apnea (a sleeping disorder) and even sudden death," Sachin Gandhi, head of the laryngology department of DMH, told TOI on Tuesday

Symptoms of laryngomalacia are often taken for asthma. However, it is a distinct congenital anomaly which happens due to an inward collapse of the floppy, soft upper structures of the larynx. The epiglottits, which protects the airway when the child feeds, also partially obstructs the airway during breathing. The partial obstruction is the source of noise with breathing.

"The noisy breathing is noticed soon after birth. The supine position during feeding or exertion due to crying worsens it. Positioning the baby in prone posture or holding him/her at an angle will help," said Gandhi.

"A few children who have potentially life–threatening respiratory symptoms due to the condition called severe laryngomalacia require medical or surgical interventions. In such cases, a tracheostomy was initially the only option. However, at an early age the surgery can be fatal," said Gandhi.

Tracheostomy, a surgical procedure on the neck, involves the opening of a direct airway through an incision in the windpipe.

"We opt for trans–oral laser surgery in which we correct the deformity by using laser beams. We visualise the voice box with the help of a microlaryngoscope and direct laser beams to the immature tissues of the larynx. The procedure corrects the laxity of the tissues and they stop obstructing the breathing of the child."

The hospital undertook a two–year study between June 2007 and 2009 to assess the efficacy of the trans–oral laser surgery. "We have concluded that endoscopic trans–oral laser surgery is highly effective in the management of severe laryngomalacia. The success rate has been good and the rate of incidence of disease very low," said Gandhi.

Oncosurgeon Dhananjay Kelkar, medical director of DMH, said, "Apart from larygomalacia there are many other congenital airway lesions like cyst, haemangioma (tumour of the blood vessel), vocal cord paralysis which can also be managed with the help of endoscopic laser surgery at our unit.

Anaesthetist Jitendra Kshirsagar and his team along with department of paediatrics also help carry out such surgeries. We have a specialised instrument called a high frequency jet ventilation for anaesthesia to conduct airway surgeries."

Blocking Of The Airway
Laryngomalacia is a softening of the tissues of the larynx (voice box) above the vocal cords. This softening causes the tissues to become floppy, and they may fall over the airway opening and partially block it. It is a common condition in infants

Causes
The exact cause of laryngomalacia is not known but relaxation or a lack of muscle tone in the upper airway may be a factor. It is often worse when the infant is on his or her back, because the floppy tissues can fall over the airway opening more easily in this position

When Does It Occur
Laryngomalacia symptoms are usually present at birth, and can be–come more obvious within the first few weeks of life. It is not uncommon for the noisy breathing to get worse before it improves, usually around 4 to 8 months of age. Most children outgrow laryngomalacia by 18 to 20 months of age

Symptoms

• Noisy breathing (stridor) – An audible wheeze when your baby breathes in. It is often worse when the baby is agitated, feeding, cry–ing or sleeping on the back.
• High pitched sound
• Difficulty feeding
• Poor weight gain
• Choking while feeding
• Apnea – Breathing stoppage
• Pulling in neck and check with each breath
• Aspiration – Inhalation of food into the lungs

Surgery Only If...
Surgery is the treatment of choice if the child has severe condition of laryngomalacia. Symptoms that signal the need for surgery include:

• Life–threatening apneas (breathing stops)
• Significant blue spells (turns blue around the lips while breathing noisily)
• Failure to gain weight with feeding
• Significant chest and neck retractions
• Need for extra oxygen to breathe
• Heart or lung problems related to oxygen
  

When To Seek Doctor's Help

• Has been losing or not gaining weight
• Gets tired during feeds
• Begins to choke on food
• Struggles to breathe while eating
• Constantly spits and has difficulty keeping food down