Laryngomalacia

Laryngomalacia is caused by an immature, constricted larynx with poor structural support and/or tone. The weak and immature cartilages of the infant collapse on inspiration causing the noisy breathing characteristic of this condition. It is the most common congenital laryngeal anomaly and the most common cause of congenital stridor.

It may be associated with secondary lesions of the airway e.g. Subglottic stenosis, or tracheomalacia. It presents within weeks of birth and resolves by 18-24 months as the laryngeal tissues mature.

Differences between an adult and paediatric larynx

• Signs and symptoms (Presents within weeks of birth)
  • Intermittent high-pitched inspiratory stridor
    • May improve when prone
    • Exacerbated with feeding, crying, or when supine (due to the tongue falling back and further obstructing the airway)
  • Retractions
  • Poor weight gain
  • Failure to thrive
  • Normal voice/cry unless there is concomitant laryngopharyngeal reflux
• Differential diagnoses
  • Unilateral or bilateral vocal fold paralysis
  • Laryngeal papillomatosis
  • Subglottic hemangioma
  • Subglottic stenosis
  • Tracheomalacia or bronchomalacia
  • Vascular ring
  • Foreign body aspiration
• Investigations
  • Flexible laryngoscopy
    • Inwards collapse of the aryepiglottic folds, arytenoid cartilage, and epiglottis into the laryngeal inlet during inspiration
    • Omega shaped epiglottis
    • Short aryepiglottic folds
  If you note severe symptoms, the infant should be taken for a diagnostic laryngoscopy and bronchoscopy, with potential endoscopic intervention. A polysomnogram may be conducted to assess the presence and degree of obstructive sleep apnea.
• Indications for conservative management
  • Not in respiratory distress
  • SpO2 > 90%
  • No failure to thrive
• Indications for surgical management
  • Obstructive Sleep Apnoea
  • Failure to Thrive
  • Pulmonary Hypertension
  • Pectus excavatum
  • Hypoxemia (SpO2 <90%)
• Conservative treatment
  • Observe and reassure in mild cases: 90% resolve spontaneously by age 2 years
  • Feeding therapy – cup and spoon (typically resolves with growth)
  • Speech therapy
  • Antireflux medication: PPIs for patients with symptoms of GERD
• Surgical treatment
  • Tracheostomy
  • Supraglottoplasty to release short Aryepiglottic folds +/- remove excess mucosal tissue from the arytenoids for severe dyspnea, FTT or OSA