Publication: Clinical assesment of laryngomalacia and the role of laryngeal ultrasound
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Date
2022
Authors
Hasny, Nurul Syuhadah
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Abstract
Introduction: Stridor in infants is a common referral to the Department of Otorhinolaryngology (ORL) and are mostly due to laryngomalacia followed by vocal cord paralysis and subglottic stenosis. Besides stridor, they can also present with certain signs such as apnoea, cyanosis, failure to thrive, episodes of respiratory distress, obstructive sleep apnoea and feeding disturbances which also determines the severity. Flexible nasopharyngolaryngoscopy (FNPLS) is the gold standard diagnostic tool to determine the cause of stridor including laryngomalacia. Laryngeal ultrasound (LUS) is a non-invasive, painless, and well tolerated imaging option but is not routinely used to assess stridorous patients in Malaysia. Objectives: To evaluate proportion, severity, and types of laryngomalacia among stridorous infants in Hospital Universiti Sains Malaysia (HUSM) and the diagnostic role of laryngeal ultrasound (LUS) in laryngomalacia. Methods: We conducted a cross-sectional study from 2021-2022 on infants aged 12 months and below who were referred for stridor to HUSM. They were assessed clinically upon referral and via FNPLS. The following variables were collected; gestational age, birth weight, age at presentation, current weight, comorbidities, presenting signs and symptoms as well as FNPLS findings. Within one week after FNPLS, patients were seen by the radiologist for LUS, who was kept unaware of the previous findings. The severity of laryngomalacia were classified according to the presenting symptoms and physical examination. Endoscopic findings were recorded, reviewed and scored, while types of laryngomalacia were determined by Olney Classification. Results: A total of 47 patients met the criteria for the study. Congenital heart disease, syndromic child and gastroesophageal reflux (GERD) were the commonest comorbidity among them. The proportion of laryngomalacia among infants with stridor was 93.6% with the precision of 0.1 with 95% confidence. Seven of patients with laryngomalacia also had other concomitant findings such as vocal cord immobility (6) and granuloma (1). Three patients who had no laryngomalacia features were diagnosed with the following : vallecula cyst (1), left vocal cord paralysis (1) and normal findings (1). There is a significant association between Type 1 (p=0.005) and Type 3 (p=0.032) with severity (moderate-severe) of laryngomalacia. Those with combined types also show association with severity (p=0.022) where 75% infants with combined Type (1+2, 2+3, 1+2+3) had moderate-severe laryngomalacia. There was a statistically significant difference in laryngoscopic score between the different severity of laryngomalacia (p=0.012) with a median score of 1.00 for mild, 2.00 for moderate and 3.00 for severe. LUS as adjunct tool in laryngomalacia had the sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 66.7%, 97.7%, and 100% respectively. Conclusion: Laryngomalacia is consistently the most common cause of congenital stridor. FNPLS revealed that combined Type (1+2) and Type 3 laryngomalacia were associated with moderate-severe laryngomalacia. A higher laryngoscopic score suggest a more severe laryngomalacia. LUS can safely be used to screen for laryngomalacia in stridorous infants when FNPLS is not feasible.
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