OUR PROMISE TO YOU MEET THE TEAM • Fast call backs to CHILDREN’S EDUCATION BRIEF clinicians and families

• Coordinated appointments with other services (lab/radiology/ other specialists) LARYNGOMALACIA Barbara Malone, MD, Heidi Gruenhagen, Luke Jakubowski, MD Kristin Kemper, • Physician calls connected Medical Director APRN, CNP APRN, CNP How to diagnose and treat laryngomalacia right away with an ENT physician or APRN

• Letters dictated same day for primary care clinicians

• Same-day access for urgent appointments Timothy Lander, MD Abby Meyer, MD Frank Rimell, MD Brianne Roby, MD

CHILDREN’S PHYSICIAN ACCESS

24/7 assistance James Sidman, MD Robert Tibesar, MD Tiffanie Woods, • referrals APRN, CNP • consultations • admissions

612-343-2121 CHILDREN’S ENT AND FACIAL PLASTIC SURGERY 866-755-2121 The ENT and facial plastic surgery team includes eight pediatric otolaryngologists and four pediatric nurse practitioners. We provide services to children of all ages including those with complex medical conditions. Common conditions treated include Laryngomalacia is the most common cause of noisy breathing in infants. Most cases are mild chronic ear infections, tonsil and adenoid enlargement or infections, hearing loss, and will resolve spontaneously without treatment by 12-18 months of age, but there are times THREE LOCATIONS sinus disease, masses and voice or swallowing abnormalities. Complex conditions include airway abnormalities, congenital aural atresia, tumors of the head and neck, when symptoms warrant further evaluation. Primary care providers are one of the first to see Children’s St. Paul vascular abnormalities, thyroid and parathyroid tumors, facial weakness or paralysis, 345 North Smith Avenue, Suite 302 the infant in the newborn period and therefore may be the first to detect the noisy breathing plagiocephaly, craniofacial abnormalities and craniosynostosis. Facial plastics include St. Paul, MN 55102 () associated with laryngomalacia. cleft lip and palate repair, animal bite repair, scar revision, trauma repair and ear Children’s Minneapolis molding. Speech and social services are provided to these patients within the department. 2530 Chicago Avenue South, Suite 70 Minneapolis, MN 55404 Our department also participates in multidisciplinary clinics throughout the Children’s Minnesota system. These include cleft palate clinic, craniosynostosis clinic, Children's Minnetonka THIS BRIEF: 5950 Clearwater Drive, Suite 510 velocardiofacial clinic, vascular anomalies clinic, endocrine thyroid clinic, and prenatal Minnetonka, MN 55343 and fetal clinic. • Reviews laryngomalacia common signs and symptoms • Shares key evaluation and examination criteria • Recommends treatment and management tips childrensMN.org • Identifies when to refer to an otolaryngologist

childrensMN.org

M0829 2/17 Physical Examination TREATMENT/MANAGEMENT LARYNGOMALACIA Comprehensive physical exam with focus on: Management depends on severity • Co-morbidities/syndromes: CHARGE, Pierre’ Robin, Trisomy • In the majority of infants, laryngomalacia is not dangerous and Also known as “floppy 21, neurologic disease, seizure disorder, hypotonia, cardiac resolves spontaneously between the ages of 12 and 18 months airway” occurs when the disease etc. with growth supraglottic structures • Congenital anomalies: Examples include micrognathia, cleft lip • Surgical management is indicated for those with severe disease collapse into the airway and/or palate (feeding issues, poor weight gain/loss, breathing issues) during inspiration causing • Growth and development plotted on appropriate growth curve • Surgery: Supraglottoplasty temporary partial blockage • Stridor: Inspiratory, expiratory, or both? Note positions or > Done using micro instruments or laser to trim the folds of the airway. There is anything that may improve or exacerbate symptoms. Is it between the and the arytenoids shortening in the distance noisier when awake or asleep? > Usually requires a 1-night stay postoperatively between the arytenoids and • sounds: assess for upper airway congestion, especially epiglottis and an omega- after feeds; signs of aspiration WHEN TO REFER TO THE CHILDREN’S ENT AND shaped epiglottis. Inspiratory • Respiratory status: distress, retractions, increased work of FACIAL PLASTIC SURGERY CLINIC stridor is caused by airflow breathing, cyanosis Common signs and symptoms through an obstruction at Diagnostics the level of the Because laryngomalacia may not be present at birth and becomes or above and is often heard Fiberoptic/flexible performed by a pediatric more prominent in the first few weeks to months of life, it is otolayngologist is the gold standard for diagnosis of in laryngomalacia. This is imperative that the primary care provider evaluate the noisy laryngomalacia. breathing and if continued symptoms are present, referral to a commonly confused with • Can be performed without sedation in the clinic setting. A specialist is appropriate. in which topical anesthetic and/or nasal decongestant may be applied Referral to a specialist such as the Children’s ENT and Facial you will hear expiratory prior to the procedure Plastic Clinic is appropriate if one or more of the following criteria stridor secondary to • Allows direct visualization of the nose, throat and anatomy at are met in addition to noisy breathing/stridor: obstruction in the . the level of the voice box and above • Respiratory distress- tachypnea, retractions, tracheal The exact etiology of • Procedure: A thin tube with a fiber-optic camera (scope) tugging, apnea, blue spells (less common) laryngomalcia remains is passed through the naris for direct visualization of the • Sleep disordered breathing unknown. Stridor associated structures and how they move. with laryngomalacia may • This generally takes only a few minutes. • Difficulty coordinating suck with swallow worsen with feeding, crying/ • Safe with minimal risks and is well tolerated • Feeding problems including: aspiration, regurgitation, agitation, when placed in the Barbara Malone, MD vomiting, cough, choking and slow feeds supine position and when • Direct visualization together with associated symptoms allows the otolaryngologist to determine the severity of asleep as opposed to awake. • Poor weight gain or weight loss (due to increased metabolic RECOMMENDED EXAMINATION laryngomalacia (mild, moderate, or severe) demand while trying to coordinate eating with breathing) Comprehensive Health History • Failure-to-thrive • Prolonged stridor without other symptoms after 12 months Laryngomalacia is the • Birth history (premature, term) and any other pertinent positives of age cause of stridor in • Birth weight and current weight • History of intubation • Growth and development (following growth curve) At the time of 45-75% • Dietary intake (breast milk or formula) LARYNGOMALACIA PRESENTATION of infants presenting • Frequency of feedings with noisy breathing • Ounces per feed and length of time to finish feeding 40% of infants have mild • Appropriate latch laryngomalacia, • Parental report of “noisy” breathing. • At what age was the noisy breathing noted; has it worsened; what improves it or 40% of infants have moderate exacerbates it laryngomalacia and • Coughing, choking, regurgitation or breathing issues with feedings 20% of infants have severe • History of reflux, or frequent upper respiratory illnesses laryngomalacia. • Medications

(Landry and Thompson, 2012) • Immunization status Tiffanie Woods, APRN, CNP (Landry and Thompson, 2012)