Laryngomalacia with Epiglottic Prolapse Obscuring the Laryngeal Inlet

AN 8-week-old girl with congenital inspiratory stridor was listed for diagnostic laryngotracheoscopy. Flexible laryngoscopy was performed with intravenous propofol and sufentanil sedation. Spontaneous ventilation was assisted via face mask. Laryngomalacia with a retroflexed epiglottis (fig. A), epiglottic prolapse (fig. B), and a completely obstructed larynx in full inspiration (fig. C) was seen (see Supplemental Digital Content 1, https://links.lww.com/ALN/B253, which is the video from which the figure was taken).

Laryngomalacia is defined as the collapse of supraglottic structures during inspiration with resulting upper airway obstruction.¹  It is the most common cause of stridor in neonates and children. Most cases of laryngomalacia are self-limiting, rarely persist after 24 months, and do not require therapeutic intervention. Only a small number of children with severe symptomatic disease, e.g., hypoxemia, apnea, or failure to thrive, require surgical treatment.² 

Definitive diagnosis of laryngomalacia can be confirmed with flexible fiberoptic laryngoscopy. Obstruction may result from collapse of redundant arytenoid mucosa, shortened aryepiglottic folds, a retroflexed floppy epiglottis, or a combined collapse.² 

Airway management includes chin lift, jaw thrust, and continuous positive airway pressure, but difficulties with forced mask ventilation¹  are reported due to a worsening obstruction with increased pharyngeal pressures. Therefore, gentle mask ventilation avoiding high inspiratory pressure is advisable. An oropharyngeal airway may further displace the prolapsing epiglottis and is not recommended.¹  Intubation may be extremely difficult as the epiglottis might be pushed against the glottis with the tip of the laryngoscope obscuring almost completely the larynx.³  The use of a rigid bronchoscope in these cases should be considered.³