What are the treatment options for an infant diagnosed 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 feeding difficulties, failure to thrive, or respiratory distress require supraglottoplasty. 1

Initial Management Strategy

Mild Disease (Observation Only)

• Infants presenting with isolated inspiratory stridor without feeding problems can be managed expectantly without intervention. 2
• The median time to resolution is approximately 36 weeks (9 months), even in children with multiple congenital anomalies or severe neurological compromise. 3
• Stridor typically worsens with crying, feeding, and supine positioning, but improves when prone. 4

Moderate Disease (Medical Management)

• Infants with stridor plus feeding-related symptoms should receive empiric acid suppression therapy for gastroesophageal reflux disease (GERD). 1
• GERD treatment is recommended because posterior laryngeal changes associated with reflux are common in laryngomalacia patients. 1
• Acid suppression therapy provides symptom improvement in patients with gastroesophageal or laryngopharyngeal reflux. 2

Indications for Surgical Intervention

Supraglottoplasty is indicated when infants present with:

• Significant respiratory distress or airway obstruction 1
• Feeding difficulties with aspiration 1, 2
• Failure to thrive 1, 2
• Hypoxia or oxygen desaturation 5, 4
• Apneic episodes 5

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

Diagnostic Workup Before Surgery

Essential Diagnostic Steps

• Flexible fiberoptic laryngoscopy is the preferred initial diagnostic tool to confirm laryngomalacia and assess the type of supraglottic collapse. 1
• Drug-induced sleep endoscopy (DISE) is particularly useful for diagnosing sleep-dependent laryngomalacia. 1

When to Perform Complete Airway Evaluation

• Direct laryngoscopy and bronchoscopy should be performed only when clinical evidence suggests a synchronous airway lesion, not routinely. 3
• Up to 68% of infants with laryngomalacia may have concomitant abnormalities below the epiglottis. 5
• The presence of an additional level of airway obstruction increases the risk of requiring surgical intervention by 4.5-fold. 2
• Indications for complete airway evaluation include: persistent/unexplained wheezing unresponsive to bronchodilators, localized monophonic wheeze, or clinical suspicion of tracheomalacia or other lower airway pathology. 5

Surgical Technique and Outcomes

Supraglottoplasty Procedure

• The procedure involves excision of redundant mucosa over the arytenoid cartilages, resection of obstructing aryepiglottic folds, and trimming lateral edges of the epiglottis using microlaryngeal instruments. 6
• Surgery can be performed with general anesthesia, with or without intubation. 6
• The success of supraglottoplasty does not correlate with the type of laryngomalacia or presence of other congenital anomalies. 3

Expected Outcomes

• The great majority of cases experience symptom relief with low morbidity. 7
• Most patients demonstrate significant airway improvement in the immediate postoperative period. 6

Potential Complications

• Airway edema occurs in up to 19% of cases and may require brief postoperative ventilation. 1, 6
• Dysphagia can be transient or persistent following supraglottoplasty. 1
• Aspiration is uncommon and primarily limited to children with neuromuscular disorders. 1

Salvage Options for Failed Surgery

Non-Invasive Ventilation

• Continuous positive airway pressure (CPAP) may be used in infants failing to respond to surgical management or those with comorbid tracheomalacia. 8, 7

Tracheostomy

• Tracheostomy should be considered only when other means of correcting obstruction have failed, as it may delay speech development and increases need for specialized care and monitoring. 8
• This is typically reserved for cases with multiple failed interventions or severe comorbid conditions. 7

Important Clinical Caveats

• The presence of medical comorbidities predicts worse symptoms and outcomes. 2
• Boys are affected over twice as often as girls. 6
• Routine direct laryngoscopy and bronchoscopy are not warranted unless clinical findings suggest synchronous airway lesions. 3
• Airway endoscopy should be performed in any child with severe or persistent symptoms, hoarseness, oxygen desaturation, or apnea. 5