Videofluoroscopic evaluation of swallowing in bottle fed infants and children with laryngomalacia

Abstract

Purpose: Laryngomalacia is a congenital anomaly characterised by inward prolapse of supraglottic structures during inspiration. This study explores the impacts of laryngomalacia on swallowing biomechanics using quantitative measures from videofluoroscopic swallow studies (VFSS). Method: A retrospective clinical audit at one tertiary hospital (2012–2022) identified 877 children ascribed a diagnostic code for laryngomalacia, with 228 (26%) seen by speech language therapy and 26 (3%) receiving a videofluoroscopic swallow study (VFSS). Six VFSS were excluded due to method of fluid intake, non-compliance, study quality or coding error. The VFSS of 20 children (aged 1–23 months; 12 male) diagnosed with laryngomalacia were analysed: six with laryngomalacia in isolation; six with a co-existing chromosomal or neurological disorder, e.g., Beckwith-Wiedmann syndrome, and eight with co-existing additional anatomic abnormality, e.g., pectus excavatum or base of tongue collapse. Five children had tracheostomy insertion and 12 underwent supraglottoplasty (nine prior to their VFSS study). Studies were analysed for the presence of penetration or aspiration, pharyngeal residue, and retrograde bolus movement. Quantitative timing and displacement measures were collected and compared to previously published values indicating risk of airway violation or bolus retention in bottle fed infants. Results: Thirteen out of twenty children aspirated during VFSS (ten of whom aspirated silently). Children with laryngomalacia in isolation had significantly longer times to achieve airway closure (Airwaycl) in comparison to children with concurrent medical conditions (H = 6.810, p > .05). Longer times to achieve airway closure (Airwaycl) were correlated with increased Penetration-Aspiration Scale (PAS) scores (Max PAS Rs = 0.588, p .01). Delayed timing of airway closure in relation to bolus reaching the pharyngoesophageal segment (PES) (BP1AEcl) also correlated with increased PAS scores (Max PAS Rs = 0.648, p < .01). Total pharyngeal transit times (TPT) were longer in all groups when compared with previously published ‘at risk of aspiration’ thresholds. Pharyngeal constriction ratio (PCR) was elevated (≥ 0.1cm2 ) in two children (0 = laryngomalacia in isolation; 1 = syndromic; 1 = anatomic). Sixtyfive percent of children were referred for VFSS after surgery, with ten out of thirteen of the aspirators in the post-supraglottoplasty group. Seven children out of 20 received a follow-up VFSS, of which three VFSS assessed bottle feeding, limiting conclusions that could be drawn about change over time. Conclusions: Only a small number of children diagnosed with laryngomalacia are referred for VFSS. Of these, the majority are post-supraglottoplasty and many have multiple comorbidities alongside laryngomalacia. Aspiration, prolonged transit times and ‘at risk’ airway closure timings are common in those with laryngomalacia in isolation as well as those with other comorbidities, even after supraglottoplasty. While VFSS may not be necessary for all children with laryngomalacia, instrumental assessment should be considered, especially in those with feeding difficulty, respiratory concerns or other comorbidities.