What is the treatment for an infant with laryngomalacia?

Treatment of Laryngomalacia in Infants

Most infants with laryngomalacia require only observation and reassurance, as the condition typically self-resolves by 12-24 months of age, but those with severe symptoms including respiratory distress, feeding difficulties, or failure to thrive require supraglottoplasty. 1

Initial Diagnostic Evaluation

• Flexible fiberoptic laryngoscopy is the preferred initial diagnostic tool to confirm laryngomalacia and characterize the pattern of supraglottic collapse 1
• Routine direct laryngoscopy and bronchoscopy are not warranted unless clinical evidence suggests a synchronous airway lesion, as up to 68% of infants with stridor have concomitant abnormalities below the epiglottis 2, 3
• Consider complete airway evaluation with bronchoscopy if the infant presents with severe or persistent stridor, associated hoarseness, oxygen desaturation, or apnea 2

Conservative Management Algorithm

For mild to moderate laryngomalacia without severe symptoms:

• Expectant management with observation is appropriate, as laryngomalacia resolves within the first year of life in most cases, even in children with multiple congenital anomalies or severe neurological compromise 3
• Empiric pharmacologic treatment of gastroesophageal reflux disease (GERD) is recommended, as posterior laryngeal changes associated with GERD are common in these patients 1
• Acid suppression therapy should be initiated even without formal GERD diagnosis, given the high prevalence of reflux-related laryngeal changes 1

Indications for Surgical Intervention

Supraglottoplasty is indicated when infants present with:

• Significant respiratory distress with retractions or hypoxia 1
• Feeding difficulties with aspiration or failure to thrive 1, 4
• Severe airway obstruction despite medical management 4

Approximately 15-20% of infants with laryngomalacia require surgical intervention 3

Surgical Technique and Outcomes

• Supraglottoplasty involves endoscopic excision of redundant supraglottic tissue including the aryepiglottic folds and lateral edges of the epiglottis 5, 6
• The procedure relieves symptoms in the great majority of cases with low morbidity 7
• Success of supraglottoplasty does not correlate with the type of laryngomalacia or presence of other congenital anomalies, making it effective across patient populations 3

Important Surgical Complications to Anticipate

• Airway edema occurs in up to 19% of cases and requires close postoperative monitoring 1
• Dysphagia can be transient or persistent following supraglottoplasty 1
• Aspiration is uncommon and primarily limited to children with neuromuscular disorders 1
• Most patients demonstrate significant airway improvement in the immediate postoperative period 6

Rescue Therapy for Surgical Failures

• Noninvasive ventilation (NIV) may be indicated in infants with comorbid conditions or those failing to respond to surgical management 7
• Tracheotomy remains an option for the rare cases where supraglottoplasty fails, though this has largely been replaced by supraglottoplasty as first-line surgical treatment 5

Critical Clinical Pitfall

Do not assume isolated laryngomalacia based on flexible laryngoscopy alone in severe cases. The presence of synchronous airway lesions is common, and failure to identify these can lead to persistent symptoms despite appropriate treatment of the laryngomalacia 2, 3