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European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 45–47

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Case report

Surgical treatment of a case of adult epiglottic laryngomalacia


M. Bartolomeo ∗ , A. Bigi , P. Pelliccia , M. Makeieff
Département de chirurgie cervico-faciale, centre hospitalo-universitaire Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Adult laryngomalacia is rare. It may be idiopathic or secondary to trauma or degenerative
Laryngomalacia disease.
Epiglottis Case report: A 25-year-old man presented with inspiratory dyspnea on effort of several months’ evolution.
Adult
Flexible endoscopy found epiglottic laryngomalacia, managed by CO2 laser V-shaped partial epiglottec-
Laser
tomy.
Discussion: Excessive resection of the epiglottis may lead to false passage; insufficient resection risks
being ineffective. V-shaped partial epiglottectomy minimizes risk of false passage while ensuring per-
manent respiratory airflow via the epiglottic V during epiglottic movement.
© 2014 Published by Elsevier Masson SAS.

1. Introduction laser dots to create a triangle with the base corresponding to the
free edge of the epiglottis and the apex pointing toward the valec-
Adult laryngomalacia is rare. It may be secondary to trauma, ula. The altitude of the triangle was two-thirds of the length of
surgery, neurologic lesion, degenerative disease (Parkinson’s dis- the epiglottis, and the base one-half of that of the free edge. The
ease, amyotrophic lateral sclerosis, support tissue disease such as area made available for airflow when the epiglottis was in contact
Elhers-Danlos syndrome) or idiopathic, without discernible medi- with the posterior pharyngeal wall was estimated by swinging the
cal cause [1,2]. epiglottis back manually (Fig. 2).
We report the surgical management of a case of idiopathic On histology, the epiglottic specimen was normal.
epiglottic laryngomalacia in a 25-year-old male. During the first postoperative days, the patient experienced
oropharyngeal discomfort, with an impression as of a foreign body
2. Case report on swallowing, leading to fairly frequent throat clearing, without
false passage (checked by a speech therapist).
A 25-year-old man presented with spontaneous respiratory The patient was discharged on day 2, with a prescription of
impairment on effort of several months’ evolution: laryngeal dys- corticosteroids and oral antibiotics.
pnea with stridor on moderate physical effort. At 1 month’s follow-up, the oropharyngeal discomfort was
General clinical examination, neurological examination and persistent but greatly reduced; the patient found it difficult to
cerebral CT found nothing notable. describe, with no throat clearing or false passage. The patient
Under forced inspiration, the epiglottis swung back against the could produce stridor on request, but it was no longer induced by
posterior pharyngeal wall, becoming obstructive; this was repro- physical effort. The epiglottis was slightly erythematous, with pos-
ducible, with stridor identical to that induced by physical effort. terior swing persisting but allowing airflow through the resection
CT exploration for a submucosal lesion enabled visualization of area.
this phenomenon (Fig. 1). At 4 months, weight was stable, the epiglottis was flexible
Treatment consisted in partial CO2 laser epiglottectomy under and non-erythematous (Fig. 3), stridor remained absent on effort
general anesthesia. although producible on request; swallowing was assessed on
The laser was set to fire continuously at 10 Watts. The posterior a specific swallowing-disorder quality-of-life questionnaire, the
pharyngeal wall was protected by damp cotton swabs. The first “SWAL-QOL”, as 87.7% (compared to 90% preoperatively).
step comprised producing a pattern; the epiglottis was traced by Five of the 44 questionnaire items showed pre- to postoperative
change: “Drooling”, “Having excessive saliva or phlegm”, “Having to
clear your throat”, “Choking when you take liquids”, and “It’s been
∗ Corresponding author. Tel.: +33 4 67 33 68 03. difficult for me to speak clearly”; each had worsened by 1 grade,
E-mail address: m-bartolomeo@chu-montpellier.fr (M. Bartolomeo). reducing the overall score by 2.3%.

http://dx.doi.org/10.1016/j.anorl.2013.10.004
1879-7296/© 2014 Published by Elsevier Masson SAS.
46 M. Bartolomeo et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 45–47

Fig. 3. Epiglottic aspect at 4 months. Image taken during deep inspiration, revealing
the triangular free space achieved by resection. The base of the tongue is at the
bottom and the posterior pharyngeal wall at the top.
Fig. 1. Contrast-enhanced head-and-neck CT, sagittal slice, showing epiglottal
swing on deep inspiration.
Several treatment options have been reported. Harries and Randall
described fixation to the base of the tongue, but this is complex and
3. Discussion may cause persistent oropharyngeal discomfort [4]. The most fre-
quent attitude is resection, although certain problems have been
Laryngomalacia represents supraglottic collapse on inspiration. reported: excessive resection may lead to complications such as
It is the most frequent laryngeal disorder in infants. It shows as false passage, while insufficient resection may be ineffective [4].
stridor with onset as of 10 days of life. The anatomic development To get around the difficulties of planning resection size and
of the upper aerodigestive tract usually causes symptoms to regress of postoperative complications, we performed V-shaped partial
at around 18–24 months of age [2]. epiglottectomy by CO2 laser [5,6]. This frees a permanent passage,
Secondary acquired laryngomalacia has occasionally been greatly reducing epiglottic attraction to the posterior pharyngeal
reported, with onset in both older children and in adults [2]. It wall by Venturi effect (Fig. 3).
is usually associated with trauma, surgery, neurologic lesions or The technique is simple and quick and relatively conservative,
degenerative disease such as Parkinson’s, amyotrophic lateral scle- reducing the risk of swallowing decompensation.
rosis or support tissue disease such as Elhers-Danlos syndrome Respiratory obstruction was indeed improved in the present
[1]. case, with only 2.3% reduction in SWAL-QOL score [7] at 4 months.
Usually, the epiglottis alone is involved, becoming floppy and The ability to produce stridor on request was not considered
sometimes invaginating the vocal folds [3]. Some cases, where pathological, as there was no stridor on effort; subjects free of
no medical cause can be found, are considered “idiopathic” [4,5]. oropharyngeal pathology may be able to produce stridor volun-
tarily.

4. Conclusion

Idiopathic laryngomalacia is rare in adults, and usually involves


the epiglottis. CO2 laser V-shaped partial epiglottectomy is a simple,
low-risk and effective treatment. The interest of the present case
lies in the rarity of the pathology and the simplicity of the technique
employed.

Disclosure of interest

The authors declare that they have no conflicts of interest con-


cerning this article.

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