Management of Severe Laryngomalacia in a 6-Week-Old Infant
This infant requires urgent referral to ENT for flexible bronchoscopy and likely surgical intervention given the presence of severe symptoms including failure to thrive (below 3rd percentile), apneic episodes, and positional stridor. 1, 2
Why ENT Referral is Mandatory
Airway endoscopy should be performed in any child with severe or persistent symptoms, if associated with hoarseness or if it leads to oxygen desaturation or apnoea. 1 This infant meets multiple criteria for urgent evaluation:
- Failure to thrive (below 3rd percentile for weight) - this is the most contributive element indicating severe disease 3
- Apneic episodes - a clear indication for immediate endoscopic evaluation 1, 2
- Abnormal breathing sounds with positional variation - classic for laryngomalacia but requires confirmation 2, 3
Why Other Options Are Inappropriate
Reassurance is Dangerous Here
While laryngomalacia is typically self-limited and resolves by 18 months in most cases 4, 5, up to 20% of infants present with life-threatening disease necessitating surgical management 4. This infant's failure to thrive and apneic episodes place them in the severe category requiring intervention, not observation 3, 6.
Bronchodilators Have No Role
Bronchodilators are ineffective for structural airway obstruction like laryngomalacia 1. The European Respiratory Society guidelines specifically note that persistent/unexplained wheezing that does not respond to bronchodilator therapy warrants flexible bronchoscopy, not continued bronchodilator trials 1.
Chest X-Ray is Not the Next Step
While radiographic studies may eventually be part of the workup, flexible bronchoscopy is the diagnostic procedure of choice as it allows examination of the larynx and hypopharynx in physiological conditions while stridor is audible 1. Chest X-ray would not visualize the supraglottic collapse that defines laryngomalacia 3.
What ENT Will Do
The ENT specialist will perform flexible laryngoscopy to confirm the diagnosis and assess severity 1, 3. This examination allows visualization of laryngeal structure and function during inspiration and expiration 1.
Importantly, abnormalities below the epiglottis are found in up to 68% of cases, so both upper and lower airways should be inspected 1. This is critical as concomitant abnormalities are common and may affect management 1.
Likely Surgical Intervention
Given this infant's severe presentation with failure to thrive and apneic episodes, surgical correction via supraglottoplasty (aryepiglottoplasty or epiglottoplasty) will likely be required 4, 7, 6, 5. This endoscopic procedure involves excision of redundant mucosa over the arytenoid cartilages, aryepiglottic folds, and lateral edges of the epiglottis 7, 5.
Surgery relieves symptoms in the great majority of cases with low morbidity 6, and most patients demonstrate significant airway improvement in the immediate postoperative period 7.
Critical Pitfall to Avoid
Do not delay referral based on the infant's age. While stridor may not develop until 2 weeks of age and typically worsens before improving 7, 3, the presence of severe symptoms (failure to thrive, apnea) at 6 weeks mandates immediate evaluation rather than watchful waiting 1, 3.