Treatment Approach for Laryngomalacia in Infants
Most infants with laryngomalacia presenting with stridor and feeding difficulties should be managed conservatively with observation and acid suppression therapy, reserving supraglottoplasty for those with severe airway obstruction, failure to thrive, or life-threatening symptoms. 1
Initial Assessment and Diagnosis
Perform flexible laryngoscopy to confirm the diagnosis and rule out synchronous airway lesions, as up to 68% of infants with stridor have concomitant lower airway abnormalities requiring complete airway evaluation. 2, 3
Key clinical features to assess immediately include:
- Severity of stridor (inspiratory stridor is characteristic of laryngomalacia, worsening with crying, feeding, agitation, or supine positioning) 4, 5
- Feeding difficulties including aspiration, vomiting, or poor weight gain 6, 1
- Signs of airway obstruction such as supraclavicular, intercostal, or subcostal retractions 4, 3
- Oxygen desaturation or apnea episodes 2, 3
- Growth parameters to identify failure to thrive 5, 1
Treatment Algorithm Based on Severity
Mild-to-Moderate Disease (Majority of Cases)
Expectant management with observation is appropriate for infants with stridor alone without significant feeding-related symptoms, as laryngomalacia is typically self-limited and resolves spontaneously by 2 years of age. 5, 1
For infants with stridor plus feeding-related symptoms, initiate acid suppression therapy to treat gastroesophageal reflux/laryngopharyngeal reflux, which commonly accompanies laryngomalacia and worsens symptoms. 1
Severe Disease Requiring Surgical Intervention (Approximately 20% of Cases)
Supraglottoplasty is indicated for infants presenting with:
- Severe airway obstruction with significant respiratory distress 6, 5
- Failure to thrive despite medical management 5, 1
- Aspiration with feeding difficulties 1
- Oxygen desaturation or apnea episodes 2, 3
- Life-threatening airway obstruction 6
The surgical technique involves endoscopic excision of redundant supraglottic mucosa over the arytenoid cartilages, aryepiglottic folds, and lateral edges of the epiglottis using microlaryngeal scissors and forceps. 4
Important Clinical Considerations
Medical comorbidities predict worse symptoms and less successful surgical outcomes, so identify and optimize treatment of associated conditions. 6, 1
The presence of synchronous airway lesions increases the risk of requiring surgical intervention by 4.5-fold, making complete airway evaluation with flexible bronchoscopy essential in severe or persistent cases. 1, 2
Dynamic lesions like laryngomalacia typically cause only inspiratory stridor, whereas fixed glottic or subglottic lesions produce biphasic stridor—this distinction helps differentiate laryngomalacia from other causes of stridor such as subglottic stenosis or vocal cord paralysis. 7
Critical Pitfalls to Avoid
Never perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx. 2
Do not rely on lateral neck radiographs for diagnosis, as clinical assessment with direct laryngoscopy is more important and radiographs are often unnecessary. 2
Avoid sedation without airway expertise present if moderate-to-severe respiratory distress is present, as sedation can worsen obstruction. 3
Position infants appropriately during assessment: use a neutral head position with a roll under the shoulders to optimize airway patency in children under 2 years. 2
Surgical Outcomes
Supraglottoplasty has an excellent success rate with minimal complications and low risk of recurrence when performed for appropriate indications. 5 Most patients demonstrate significant airway improvement in the immediate postoperative period, with resolution or marked improvement of stridor, feeding difficulties, and dyspnea. 4
Rare complications include persistent disease, supraglottic stenosis, and lower respiratory tract infections, occurring most commonly in patients with multiple medical comorbidities. 6