Differential diagnosis and management of adult-onset laryngomalacia
Introduction
Adult-onset laryngomalacia is an incompletely understood and perhaps underdiagnosed clinical entity. The term laryngomalacia is most frequently used in reference to pediatric patients; however, this condition can affect adults in the absence of congenital anomaly.
During normal breathing, the epiglottis tilts anteriorly to enable airflow into the larynx; in contrast, the supraglottic larynx in a patient with laryngomalacia collapses on inspiration. This collapse decreases airway diameter and can cause stridor and dyspnea. The differential diagnosis for an adult presenting with stridor and dyspnea is broad, encompassing conditions such as paradoxical vocal fold motion, laryngeal stenosis, asthma, and the less commonly reported adult-onset laryngomalacia. This study aims to assemble and analyze the reported cases of adult laryngomalacia in an effort to improve understanding of the clinical presentation, contributing factors, and treatment outcomes. A case report of adult-onset laryngomalacia is also presented.
Section snippets
Methods
PubMed and Google Scholar searches were conducted with the terms ‘laryngomalacia’, ‘adult laryngomalacia’, ‘acquired laryngomalacia’, ‘idiopathic laryngomalacia’, ‘laryngeal obstruction’, ‘floppy epiglottis’, ‘floppy epiglottis’, and ‘epiglottis prolapse’. Case reports or articles describing presentation and management of laryngomalacia in persons aged 18 or above were included. No restrictions were applied to study design, date of publication, or language. Articles were screened for the
Case report
A thirty-six-year-old female presented to laryngology clinic with 2–3 weeks of variable dyspnea, inspiratory stridor and throat irritation worsened by inspiring or laying supine. Flexible laryngoscopy demonstrated anteromedial prolapse of arytenoid cartilages and aryepiglottic folds during inspiration (Fig. 1). Initial trial of respiratory retraining therapy did not improve symptoms. CO2 laser supraglottoplasty was then performed with symptom resolution. Six years after initial surgery, the
Patient demographics
Forty-one cases of adult laryngomalacia in 21 reports (26M:14F; median 42 years old) were identified for review [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]]. Most common symptoms at presentation were inspiratory stridor (n = 26) and dyspnea (n = 11); other associated symptoms included dysphonia (n = 3), throat irritation or cough (n = 2), and dysphagia (n = 2). Symptom onset coincided with extubation in four patients and decannulation
Discussion
The diagnosis of adult-onset laryngomalacia requires first consideration in the differential diagnosis and differentiation from similar pathologic states. Awake fiberoptic laryngoscopy is the gold standard for diagnosis and identifies the direction of supraglottic collapse, which guides surgical management. The etiology of laryngomalacia does not always dictate the direction of supraglottic collapse, but the majority of patients with post-operative (71.4%) and neurologic (64.3%) laryngomalacia
Conclusion
Adult laryngomalacia is a rare diagnosis comprising a wide spectrum of disease. Although the diagnosis is frequently overlooked within the adult population, association with neurologic injury, surgery, exercise, comorbidity, or age should encourage consideration. Adult patients more commonly require surgical intervention than pediatric patients. Surgery is based on the direction of supraglottic collapse, where partial epiglottidectomy and supraglottoplasty are effective interventions.
Declaration of competing interest
None.
References (21)
- et al.
A case of floppy epiglottis in adult: a simple surgical remedy
Auris Nasus Larynx
(2007) - et al.
Adult laryngomalacia: an uncommon clinical entity
Am J Otolaryngol
(2002) - et al.
Diagnosing aerodynamic supraglottic collapse with rest and exercise flexible laryngoscopy
J Voice Off J Voice Found
(2012) - et al.
Acquired laryngomalacia: resolution after neurologic recovery
Otolaryngol
(1995) - et al.
Acquired airway obstruction caused by hypertrophic mucosa of the arytenoids and aryepiglottic folds
Am J Otolaryngol
(1996) - et al.
Acquired laryngomalacia as a cause of obstructive sleep apnea
Chest
(1994) - et al.
Surgical treatment of a case of adult epiglottic laryngomalacia
Eur Ann Otorhinolaryngol Head Neck Dis
(2015) - et al.
Age-related changes in the hyoepiglottic ligament: functional implications based on histopathologic study
Am J Otolaryngol
(2010) - et al.
Repetitive postoperative extubation failure and cardiac arrest due to laryngomalacia after general anesthesia in an elderly patient: a case report
J Anesth
(2017) - et al.
Acquired idiopathic laryngomalacia treated by laser aryepiglottoplasty
J Laryngol Otol
(2002)