Diagnosis of Laryngomalacia by Fiberoptic Endoscopy: Clinical Scoring

The laryngoscopy performed using the WT was performed with the infant held awake in a sitting position by a parent. Topical anesthesia (lidocaine 1% and phenylephrine 0.25%) was applied to the nose, and FFL was performed to the level of the vocal cords. In the DAT, each infant received anesthesia with IV propofol. A dose of 2.5 mg/kg was injected slowly over 15 min as small boluses of 0.5 to 1.0 mL/kg. Additional boluses were added as needed. To prevent pain on injection, 0.3 mL of a 1% lidocaine solution was slowly injected prior to the injection of diluted propofol. All infants received 100% oxygen by a nonrebreathing mask during propofol loading and then a continuous flow of 2 to 3 L/min of 100% oxygen administered directly to the hypophar-ynx by an 8F feeding tube. The procedures were performed by a pediatric pulmonologist (Y.S.) in the pediatric ICU with the assistance of the pediatric ICU resident and a registered nurse. Oxygen saturation, respirations, BP (automatically every 2 min), and ECG were continuously monitored. The endoscopies were performed using a bronchoscope (model FB-10V or FB-8V; Pentax; Tokyo, Japan) with a distal outside diameter of 3.5 or 2.8 mm, respectively. Initially, only the upper airways were investigated looking for the cause of the stridor. Only when this stage was complete, was a 1% solution of lidocaine applied to the glottis and the bronchoscope advanced to visualize the trachea. All endoscopies were recorded on videotape. The study was approved by the institutional review board of our hospital.
The degree of upper airway obstruction and stridor in each infant was assessed separately by the two investigators who performed the endoscopies using a clinical scoring system based on (1) history and (2) physical examination (Table 1). This scoring system is a modification of the scoring system for patients with croup as applied to laryngomalacia and its chronic nature. more
In order to compare the WT with the DAT, the videotapes of all procedures were reviewed by each of the three investigators (ie, Y.S., J.B.A., and A.D.). New videotapes were specifically prepared for this assessment by copying the 84 video clips of each laryngoscopy session (42 for each technique). A total of 31 clips were copied twice (WT, 15 clips; DAT, 16 clips) for the assessment of each investigator’s accuracy (repeatability) and the interobserver variability of the evaluation.

Table 1—Laryngomalacia Clinical Scoring System

Scoring System Score 0 Score 1 Score 2 Score 3 Score 4
History (maximal score, 10)
Clinical features
Does baby have noisy breathing? No Mild Severe
Is the noise persistent or intermittent? Intermittent Persistent
Worsening during feeding or agitation? No Yes
Have you noticed cessation of breathing during sleep? No Yes
Have you noticed cyanosis/cyanotic episodes? No Yes
Has the baby difficult breathing? No During sleep During feeding All the time
Does baby spit up? No Yes
Physical examination (maximal score, 4)
Clinical finding
Stridor occurring only during agitation or crying Yes
Stridor at rest but no respiratory distress Yes
Stridor with distress, chest retractions, or nasal flaring Yes
Severe stridor as in score 3 but with cyanosis Yes

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