Experience Summary

Laryngo-tracheo-bronchoscopy (LTB) is a critical diagnostic and sometimes therapeutic procedure in the evaluation of paediatric airway disorders. In this 360-degree video, observe the team performing an LTB on a 3-year-old patient with signs of laryngomalacia.

CLINICAL CONTEXT

In the context of suspected laryngomalacia—a common congenital abnormality of the larynx—LTB plays a vital role in confirming the diagnosis, assessing severity, and excluding coexisting airway pathologies. Laryngomalacia typically presents in infants within the first few weeks of life with inspiratory stridor, which may worsen with feeding, agitation, or when supine.

The clinical decision to proceed with LTB is usually based on concerning features such as severe stridor, feeding difficulties, apnoeic episodes, failure to thrive, or signs of airway obstruction that go beyond the expected mild course of laryngomalacia. While flexible nasendoscopy at the bedside can suggest the diagnosis, formal LTB under general anaesthesia allows a more detailed, dynamic assessment of the entire airway—including the supraglottis, glottis, subglottis, trachea, and bronchi—during respiration.

The procedure is particularly important because laryngomalacia can be associated with other airway anomalies such as tracheomalacia, subglottic stenosis, or vocal cord paresis. LTB can distinguish between isolated laryngomalacia and more complex airway compromise, which directly impacts management decisions, including the need for supraglottoplasty or other surgical interventions.

Anaesthetic considerations are paramount. Children with laryngomalacia may have difficult airways and a tendency for dynamic airway collapse under sedation or anaesthesia. The anaesthetic plan often involves maintaining spontaneous ventilation to preserve airway tone and facilitate dynamic observation of supraglottic structures. Skilled anaesthetic and ENT teams must be prepared for potential airway obstruction, desaturation, or the need for emergent airway intervention.

Intraoperative findings in laryngomalacia may include an omega-shaped epiglottis, shortened aryepiglottic folds, redundant arytenoid mucosa, or prolapse of supraglottic tissues into the airway during inspiration. The severity of these findings helps guide further treatment.

Preoperative planning must include a multidisciplinary team brief to clarify roles, confirm equipment availability, and plan for airway emergencies. Parents should be counselled regarding the risks of general anaesthesia, potential need for postoperative observation, and possible interventions based on findings.

LEARNING OBJECTIVES

1. Understand the procedural steps for LTB
2. Understand the equipment required for LTB
3. Understand the steps for assessing the airway in an LTB