What is laryngomalacia?

From the Guidelines

Laryngomalacia is a congenital condition characterized by the collapse of the soft tissues of the larynx during breathing, leading to noisy breathing known as stridor, and is the most common cause of persistent stridor in children. This condition typically affects infants and is caused by the underdevelopment of the laryngeal cartilage at birth, making it susceptible to collapse during breathing 1. The characteristic sound of laryngomalacia is usually a high-pitched, squeaky noise that worsens during feeding, crying, or lying on the back, and improves when the child is calm or in certain positions like face-down or with the neck extended.

Key Characteristics of Laryngomalacia

• Most common congenital laryngeal anomaly
• Most frequent cause of persistent stridor in children
• Caused by underdevelopment of the laryngeal cartilage at birth
• Characterized by collapse of the soft tissues of the larynx during breathing

Diagnosis and Management

According to the most recent study 1, laryngomalacia can be diagnosed through flexible endoscopy, and sleep-dependent laryngomalacia is preferentially diagnosed by drug-induced sleep endoscopy (DISE). Management of laryngomalacia typically involves positioning techniques to manage symptoms, and in more severe cases, surgical intervention called supraglottoplasty may be recommended to trim excess tissue.

Surgical Intervention

Supraglottoplasty is a surgical procedure that involves division of shortened aryepiglottic folds and trimming of redundant supra-arytenoidal mucosa, and is performed under general anesthesia 1. This procedure has been shown to improve PSG parameters and reduce the severity of obstructive sleep apnea (OSA) in children with persistent OSA.

Importance of Multidisciplinary Approach

A collaborative approach to airway endoscopy by a multidisciplinary team is recommended, as endoscopic techniques complement each other and facilitate identification of different airway pathologies 1. Flexible laryngoscopy should be performed in an awake child to identify upper airway pathology, while direct or rigid laryngobronchoscopy can be used to identify glottic/subglottic pathology and tracheal/bronchial pathology.

From the Research

Definition of Laryngomalacia

• Laryngomalacia is a condition characterized by the weakening of the larynx, resulting in a collapse of the laryngeal cartilages, especially the epiglottis, into the airway 2.
• This partial occlusion of the upper airway during inspiration causes inspiratory stridor, which is often associated with a high-pitched sound 2.
• The exact etiology of the condition is not known, but it is a well-known cause of noisy breathing in neonates and infants 2.

Clinical Presentation

• The common presentation of laryngomalacia is a neonate with flushing and high-pitched inspiratory stridor that is usually noticed before 14 days of age 2.
• The stridor worsens with breathing and supine positioning and improves in a prone position 2.
• Less commonly, it can present with hypoxia, feeding problems, aspiration, and failure to thrive 2.

Diagnosis and Treatment

• The condition is diagnosed with laryngoscopy, and the treatment varies with presentation and severity 2.
• Neonates with uncomplicated disease can be treated expectantly, while those presenting with feeding problems and gastroesophageal reflux will require acid suppression 2.
• Severe complications like aspiration, severe airway obstruction, and hypoxia will require surgical treatment, including supraglottoplasty 2.
• Supraglottoplasty is an effective method to treat severe laryngomalacia, especially in patients with severe laryngomalacia that is uncomplicated by neurological conditions or multiple medical problems 3.

Surgical Management

• Surgical correction of the abnormal tissue represents an acceptable alternative to tracheostomy in severe cases of laryngomalacia 4.
• Supraglottoplasty, also referred to as epiglottoplasty or partial arytenoidectomy, is a surgical procedure that can improve the airway in patients with severe laryngomalacia 5.
• The success of supraglottoplasty does not correlate with the type of laryngomalacia or the presence of other congenital anomalies 6.