UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUEA.C., CORTES AVE., LOOC MANDAUE CITY

College of Nursing

A Resource UnitOn

LARYNGOMALACIA

SUBMITTED BY:

Cornito, Monique IrishDel Rosario, Charmine

Delos Reyes, JanineDignos, Edelyn

Engasca, ParamaeEstomago, Mary Rosary

Fuentes, RoselynGasta, Jan Anthony

Inoc, CreseldaLeyson, Kerwin Dwight

Lubas, LaarniMondigo, Cathy Lou

SUBMITTED TO:

Ms. Arlene L. Galon, RNClinical Instructor

University of Cebu Lapu-Lapu and MandaueA.C. Cortes, Avenue, Looc Mandaue City

College of Nursing

Group Report

Area: Pedia Ward –Chong Hua Hospital

General Objective: After 60 minutes of lecture-discussion, the Level III students will be able to acquire basic knowledge, apply basic procedures and appreciate nursing interventions of laryngomalacia.

SPECIFIC OBJECTIVES

CONTENT METHODOLOGY TIME ALLOTMENT

RESOURCES EVALUATION

Specifically, the Level III students will be able to:

I. .state the introduction of laryngomalacia

Laryngomalacia (literally, "soft larynx") is a very common condition of infancy, in which the soft, immature cartilage of the upper larynx collapses inward during inhalation, causing airway obstruction. It can also be seen in older patients, especially those with neuromuscular conditions resulting in weakness of the muscles of the throat. However, the infantile form is much more common.

Laryngomalacia results in partial airway obstruction, most

Lecture- discussion 5 minutes

A.Materials-laptopB.Human Resources-students-Clinical InstructorC.Books:-maternal and child health nursing 5th edition, volume 1D. Electronic Resources:

http://en.wikipedia.org/wiki/Laryngomalacia

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commonly causing a characteristic high-pitched squeaking noise on inhalation (inspiratory stridor). Some infants have feeding difficulties related to this problem. Rarely, children will have significant life threatening airway obstruction. The vast majority, however, will only have stridor without other more serious symptoms.

The conventional wisdom about laryngomalacia is that the noise is more pronounced when the patient is on his or her back (with gravity making the epiglottis fall backwards). This, however, is a more common finding in older patients rather than in infants.

Laryngomalacia becomes symptomatic after the first few weeks of life, and may get louder over the first year, as the child moves air more vigorously. It generally resolves spontaneously by the second year of life. In rare cases (less than 5%), surgery is necessary. Most commonly, this involves cutting the aryepiglottic folds to let the supraglottic airway spring open. In severe cases, a temporary tracheotomy may be necessary.

II. define related terms

Stridor - is an abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, and/or trachea

Tracheomalacia - is an abnormal collapse of the tracheal walls. It may occur in an isolated lesion or can be found in combination with other lesions that

Lecture- discussion 5 minutes Mosby’s Medical Dictionary

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cause compression or damage of the airway.

Subglottic Stenosis – (SGS) is a narrowing of the subglottic airway, which is housed in the cricoid cartilage. The image below shows an intraoperative endoscopic view of a normal subglottis

Reflux Laryngitis - Inflammation of the voice box (the larynx) caused by stomach acid backing up into the esophagus. Reflux laryngitis is associated with chronic hoarseness and symptoms of esophageal irritation such as heartburn.

Vallecular cyst- a rare but generally benign lesion in the larynx, may cause stridor and even life-threatening airway obstruction in early infancy.

III. determine the causes of laryngomalacia

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. No genetic pattern is known.

Lecture- discussion 5 minutes http://www.chop.edu/service/airway-disorders/conditions-we-treat/laryngomalacia.html

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IV. identify the risk factors of laryngomalacia

Risk factors for severe laryngomalacia include:

Prematurity- Although premature infants do not necessarily have a higher incidence of laryngomalacia, they tend to develop the more severe form of this condition.

Neuromuscular disorders- As mentioned earlier, there is a higher incidence of neuromuscular disorders in

Lecture- discussion 5 minutes http://www.google.com.ph/search?q=risk+factors+of+laryngomalacia&hl=en&source=hp&aq=f&aqi=g-

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patients with laryngomalacia and the condition tends to be severe in such patients.

Synchronous airway lesions- These can be seen in 10-20% of patients with laryngomalacia. Tracheomalacia and subglottic stenosis have been reported to be the commonest lesions, though bronchomalacia, pharyngomalacia and an associated vallecular cyst may also occur. The presence of synchronous airway lesions potentiates GERD and also increases the risk of surgical failure.

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V. Enumerate the categories of laryngomalacia

Mild Laryngomalacia

Infants in this category have non-complicated laryngomalacia with typical noisy breathing when breathing in (inspiratory stridor) without significant airway obstructive events, feeding issues, or other symptoms associated with laryngomalacia. These infants have noisy breathing (stridor) that is annoying to the caregivers but does not cause other health care problems. These patients will usually outgrow the stridor by 12-18 months of age. Even though your child may have mild laryngomalacia, it is still important to watch for signs or symptoms of worsening laryngomalacia.

Moderate Laryngomalacia

Infants in this category have the following symptoms: Noisy breathing when breathing in (inspiratory

stridor)

Lecture discussion 5 minutes http://www.cincinnatichildrens.org/health/info/ent/diagnose/laryngomalacia.htm

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Regurgitation (vomiting or spitting up)

Airway obstruction (from floppy voice box tissue)

Feeding difficulties without poor weight gain (failure to thrive)

Clinical history of airway symptoms severe enough to warrant multiple visits to an emergency department or hospital

Gastroesophageal reflux (spitting up of acid from the stomach)

These patients also will typically outgrow the stridor by 12-18 months of age but may require treatment for gastroesophageal reflux. Even though your child may have moderate laryngomalacia, it is still important to watch for signs and symptoms of worsening laryngomalacia.

Severe Laryngomalacia

Patients in this category often require surgical intervention for treatment and to lessen the degree of symptoms. Your doctor may recommend surgery if your child has any of the following symptoms:

Life-threatening apnea

Significant cyanotic (blue) spells

Failure to thrive with feeding difficulty

Significant chest wall and neck retractions with breathing

Requires oxygen to breathe

Heart or lung problems as a result of chronic oxygen depravation

VI. List the signs and symptoms of laryngomalacia

Infants with laryngomalacia have intermittent noisy breathing when breathing in (inspiratory stridor) becomes worse with agitation, crying, excitement, feeding or position / sleeping in the supine (on the back) position. These symptoms are often present at birth and are usually apparent within the first 10 days of life. However, noisy breathing (stridor) of infantile laryngomalacia may be present in babies up to one year of age.

Symptoms will often increase or get worse over the first few months after diagnosis, usually between 4-8 months of age. Most children with laryngomalacia outgrow the noisy breathing (stridor) by 12-18 months of age.

Other symptoms that can be associated with laryngomalacia include:

Poor weight gain

Difficulty with feeding

Regurgitation of food (vomiting or spitting up)

Lecture- discussion 5 minutes http://www.cincinnatichildrens.org/health/info/ent/diagnose/laryngomalacia.htm

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Choking on food

Apnea (stops breathing)

Chest and / or neck retractions (chest and / or neck sinking in with each breath)

Turning blue (cyanosis)

Gastroesophageal reflux (spitting up of acid from the stomach)

VI. appreciate the physical assessment done associated with laryngomalacia

Upon examination, the baby is usually happy and appropriately interactive.

Mild tachypnea may be present.

Other vital signs are normal, and oxygen saturation is usually normal.

One can usually detect nasal airflow. The noise may be increased if the baby is placed supine.

The cry is normal. Hearing the baby's cry during the examination is important. An abnormal cry suggests pathology at or near the vocal cords.

The noise is purely inspiratory. The sounds may best be heard just above the sternal notch.

The rest of the examination findings are unremarkable, although another airway lesion may

Lecture- discussion 10 minutes http://emedicine.medscape.com/article/1002527

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also be present in infants with laryngomalacia.

VIII. discuss the Anatomy and physiology of larynx

The larynx is positioned in the anterior neck, slightly below the point where the pharynx divides and gives rise to the separate respiratory and digestive tracts. Because of its location, the larynx plays a critical role in normal breathing, swallowing, and speaking. Damage to the larynx or its tissues

Lecture- discussion 5 minutes http://www.google.com.ph/search?q=anatomy+and+physiology+of+larynx+&hl=en&source=hp&aq=f&aqi=&aql=f&oq=

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can result in interference with any or all of these functions.The framework of the larynx is comprised mainly of two cartilages, the upper thyroid cartilage (whose anterior prominence is oftentimes felt as the "Adam's apple"), and the lower and smaller cricoid cartilage. The epiglottis lies superiorly. This structure protects the larynx during swallowing and prevents aspiration of food.

The vocal folds lie in the center of this framework in an anterior-posterior orientation. When viewed from above the right and left folds appear as a "V"-shaped structure with the aperture between the "V" forming the entrance to the trachea. At the rear of the larynx on each side, each vocal fold is attached to a small arytenoid cartilage. Many small muscles also attach to the arytenoids. These muscles contract or relax during the various stages of breathing, swallowing, and speaking, and their action is vital to the normal function of the larynx.

Control over these muscles is provided by two branches of the vagus nerve: the recurrent laryngeal nerve and the superior laryngeal nerve. These branches are vulnerable to injury due to trauma, surgery, or other causes. If this occurs, paralysis of the vocal folds may occur. This leads to the hoarseness, aspiration, and other symptoms associated with laryngeal nerve injury.

Phonation is a complicated process in which sound is produced for speech. During phonation, the vocal folds are brought together near the center of the larynx by muscles attached to the arytenoids. As air is forced through the vocal

folds, they vibrate and produce sound. By contracting or relaxing the muscles of the arytenoids, the qualities of this sound can be altered. As the sound produced by the larynx travels through the throat and mouth, it is further modified to produce speech.

IX . trace the pathophysiology of laryngomalacia

Laryngomalacia may affect the epiglottis, the arytenoid cartilages, or both. When the epiglottis is involved, it is often elongated, and the walls fold in on themselves. The epiglottis in cross section resembles an omega, and the lesion has been referred to as an omega-shaped epiglottis. If the arytenoid cartilages are involved, they appear enlarged. In either case, the cartilage is floppy and is noted to prolapse over the larynx during inspiration. This inspiratory obstruction causes an inspiratory noise, which may be high-pitched sounds frequently heard in other causes of stridor, coarse sounds

Lecture-discussion 5 minutes http://emedicine.medscape.com/article/1002527

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resembling nasal congestion, and low-pitched stertorous noises. More severe compromise may be associated with a lower ratio of the aryepiglottic fold length to the glottic length.

A classification system has been proposed. In type 1 laryngomalacia, the aryepiglottic folds are tightened or foreshortened. Type 2 is marked by redundant soft tissue in any area of the supraglottic region. Type 3 is associated with other disorders, such as neuromuscular disease and gastroesophageal reflux.

Laryngomalacia is the most common cause of chronic inspiratory noise in infants, no matter which type of noise is heard. Infants with laryngomalacia have a higher incidence of gastroesophageal reflux, presumably a result of the more negative intrathoracic pressures necessary to overcome the inspiratory obstruction. Conversely, children with significant reflux may have pathologic changes similar to laryngomalacia, especially enlargement and swelling of the arytenoid cartilages. Some of the swelling of the arytenoid cartilages and of the epiglottis may be secondary to reflux.

Occasional inflammatory changes are observed in the larynx, which is referred to as reflux laryngitis. When the epiglottis is involved, gravity makes the noise more prominent when the baby is supine.

The exaggerated inspiratory effort increases blood return to the pulmonary vascular bed. This could account for the increased likelihood of pulmonary artery hypertension in infants with hypoxemia.

X. explain the Medical management

The diagnosis of laryngomalacia is made using a flexible telescope or fiberoptic laryngoscope.  This is a flexible tube that contains light carrying fibers that is passed through the nose and allows the doctor to view the voice box. This procedure is performed in the doctor’s office with the child awake. After a detailed examination the physician will categorize the condition as being mild, moderate, or severe. Mild symptoms and signs may be managed by periodic observation only. Moderate obstruction may require home monitoring of breathing and a more detailed assessment. Severe conditions may require a surgical procedure to relieve the obstruction and correct the functional abnormality.

Tests and Procedures

Your doctor may recommend one of the several diagnostic tests or procedures if your child is diagnosed with laryngomalacia.

Flexible Laryngoscopy

This test is required to confirm a diagnosis of laryngomalacia. This test involves placement of a lighted tube (laryngoscope) through the nose or mouth to look at the voice box. The doctor looks at the position of the tissue above the voice box to determine if it is floppy. At the same time, he / she will

Lecture-discussion 5 minutes http://www.cincinnatichildrens.org/health/info/ent/diagnose/laryngomalacia.htm

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look for any other throat / voice box problems that may contribute to the noisy breathing. If your child is seen in the Laryngomalacia Clinic at Cincinnati Children's Hospital Medical Center, the laryngoscope is connected to a television camera so that the parent or caregiver can see what the voice box looks like. While looking at the voice box, your doctor may ask you to feed your baby from a bottle to see how well your baby does with feeding, especially if there is a history of choking on food or spitting up.

Fluoroscopy

Fluoroscopy of the airway may be performed by a pediatric radiologist. The cartilages may be observed collapsing on inspiration on a lateral view of the airway.

X-rays of Neck and Chest

Some children with laryngomalacia may have an additional problem that may be contributing to the stridor. The x-rays can screen for other potential causes of noisy breathing in the upper airway, windpipe (trachea), chest and lungs. Additional studies may be recommended if these studies are abnormal.

pH Probe

There is a high association between gastroesophageal reflux (stomach acid) and laryngomalacia. All babies regurgitate and have reflux, but children with laryngomalacia may have more than other babies. Acid reflux, if it reaches the upper portion of the swallowing tube (esophagus) and voice box region, can cause additional swelling of the floppy tissue seen in

laryngomalacia.

The pH probe is a test where a small tube is placed through the nose of the baby and into the esophagus. The tube is connected to a measuring device that records the number of times acid leaves the stomach and reaches the esophagus. This test will measure the acid in two places in the esophagus, the lower esophagus just before the stomach and in the upper esophagus near the throat. Placement of the tube is usually done while taking an X-ray so that it can accurately measure acid in these two places. Your baby will need to stay in the hospital overnight for this test. Your doctor may recommend this test if he / she is concerned about the degree of acid regurgitation (vomiting or spitting up) your baby may be having.

Microlaryngoscopy and Bronchoscopy

This diagnostic test is done in the operating room under general anesthesia by the ENT surgeon. The doctor looks at the voice box (larynx) and trachea (windpipe) with telescopes. Your doctor may recommend this test if the X-ray test shows something abnormal or if your doctor has a suspicion of another airway problem in addition to laryngomalacia.

Esophagogastroduodenoscopy (EGD)

Esophagogastroduodenoscopy (EGD), also called Upper Gastrointestinal Endoscopy, is a diagnostic test done in the

operating room under general anesthesia by the gastroenterologist. The doctor looks at your child's esophagus and stomach with a lighted tube.

During an esophagogastroduodenoscopy, the doctor looks for signs of chronic inflammation from acid irritation that can occur in the stomach or the esophagus. Your doctor may recommend this if the pH probe is significantly abnormal or there is strong suspicion of significant gastroesophageal reflux based on history and clinical examination.

Surgical Treatment

There are two operations for treatment. Your doctor will most likely recommend a supraglottoplasty. The unneeded floppy tissue of the larynx is trimmed in the operating room with your child under general anesthesia. Your child will have a breathing tube in the nose through the voice box after surgery for at least one night.Your child may need to have this operation done more than once. Having the operation may not make the stridor go away completely, but it will likely be less.The other surgical option is the placement of a tracheotomy tube into the windpipe to bypass the floppy tissue of the larynx. Rarely is this operation done for laryngomalacia.

Surgery is the treatment of choice if your child's condition is severe. Symptoms that signal the need for surgery include:

Life-threatening apneas (stoppages of breathing)

http://www.chop.edu/service/airway-disorders/conditions-we-treat/laryngomalacia.html

Significant blue spells

Failure to gain weight with feeding

Significant chest and neck retractions

Need for extra oxygen to breathe

Heart or lung issues related to your child's inability to get enough oxygen

Supraglottoplasty

In this surgery, extra tissue above the vocal cords is trimmed in the operating room. Your child will be under general anesthesia while the surgeon does a thorough evaluation of the airway and removes the tissue. After surgery, your child will be taken to the pediatric intensive care unit (PICU) and will spend one night with a breathing tube in the nose. If there is not much swelling in this area, and if the surgeon feels it will be safe, the breathing tube will be removed the next day in the PICU. Your child will then be observed for another day to ensure that the airway is safe, and that your child is getting enough oxygen and is drinking normally.

This surgery may not completely eliminate the noisy breathing but it should help to:

Reduce the severity of the symptoms

Lessen the apneas (breathing stoppages)

Reduce the extra oxygen requirements

Improve swallowing

Help your child gain weights

Medication

Your child’s GI doctor may prescribe an anti-reflux medication to help manage the gastroesophageal reflux (GERD). This is important because your child’s chronic neck and chest retractions from the laryngomalacia can worsen GERD. Also, the acid reflux can cause swelling above the vocal cords and worsen the noisy breathing.

Possible complications

Complications are possible, especially if laryngomalacia

is severe:

Episodes of interrupted breathing (apnea).

Reflux, with stomach acid causing damage to the larynx and airway. If your child inhales the stomach contents, a form of pneumonia called “aspiration pneumonia” can occur.

Feeding problems, leading to slow growth.

XI. Understand the Nusing

Both laryngomalacia and gastro-oesophageal reflux are common in small babies and in the vast majority of cases the

Lecture-discussion 10 minutes http://www.bbc.co.uk/

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management of client’s with laryngomalacia

condition resolves with time as the child grows and matures, leaving no lasting problems. If the baby has a normal cry, normal weight gain and normal development, with just an odd noise when it breathes in, then specific treatment is not likely to be needed.

In most children the noisy stridor has gone by the age of 2. Occasionally the problem persists for longer, and very rarely into adulthood. In these case, symptoms are most likely to reappear during a respiratory infection or sometimes with exercise.

Simple treatment, especially of the reflux, is usually enough to keep on top of symptoms:

Changing the child's sleeping position. Raise the end of the cot by a few inches to let gravity help keep stomach contents down.

When children are awake, prop them in a baby chair rather than letting them lie down on the ground.

Thicken their feed with rice flour, cornflour or carob flour (but talk to your health visitor about this first).

If your baby is weaned, introduce more solids to the diet.

health/physical_health/conditions/laryngomalacia.shtml

XII. state the Prognosis of laryngomalacia

Prognosis is excellent. Most babies outgrow the condition by their second birthday, many by the first. In some cases, even though the signs and symptoms dissipate, the pathology

Lecture-discussion 5 minutes http://www.chop.edu/service/airway-

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persists. Such patients may have stridor with exercise later in life.

Go to the hospital immediately if your baby:

Stops breathing for more than 10 seconds Turns blue around the lips while breathing noisily Pulls in the neck or check without relief after being

repositioned or awakened

Call your doctor if your baby:

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

disorders/conditions-we-treat/laryngomalacia.html

BIBLIOGRAPHY

Books:

Pillitteri, Adele, Maternal and Child Health Nursing care of the childbearing and childrearing family, 5th edition, volume 1, Lippincott Williams and Wilkins.

Mosby’s Medical Dictionary

Electronic Sources:

http://www.bbc.co.

http://www.chop.edu

http://www.chop.edu/

http://www.cincinnatichildrens.org

http://emedicine.medscape.com

http://www.google.com.ph

http://en.wikipedia.org