Laryngomalacia and Acid Reflux: A Systematic Review

Abstract

Objective: Laryngomalacia is widely described as having an association with acid reflux. Many otolaryngologists therefore employ empiric treatment with anti-reflux medication in this setting. This study aims to identify and appraise the evidence for this association, and to explore the potential role for treatment of reflux in the management of laryngomalacia. Method: A predefined protocol was employed to search Medline, EMBASE, the Cochrane Library, and Google Scholar. Included studies were those that explored the potential for an association between laryngomalacia and gastro-esophageal and/or laryngopharyngeal reflux. The Oxford Centre for Evidence Based Medicine (CEBM) guidelines were applied to assess study quality of evidence. Results: A total of 26 studies, representing 1295 neonates with laryngomalacia, were included. Study quality varied from CEBM 2a (n = 3 to 4 (n = 20). No randomized controlled trials were identified. While reflux definitions were diverse, overall reflux prevalence in this group was 59%. Evidence supporting an association between reflux and laryngomalacia included: the near ubiquity of acid reflux in dual-probe pH monitoring in children with laryngomalacia (3 studies); case series and reports of laryngomalacia improvement with anti-reflux therapy (5 studies); histologic evidence of reflux-related laryngeal inflammation in children with laryngomalacia (2 studies); and implication of reflux as a cofactor in laryngomalacia symptom severity (12 studies). Conclusion: The literature shows a co-existence between acid reflux and laryngomalacia, but the evidence for causal association is limited. In view of the widespread use of anti-reflux treatment in laryngomalacia, an RCT of anti-reflux medication vs placebo appears well-justified. This review provides a rational foundation for such an endeavor.