What is Laryngomalacia
Laryngomalacia is a congenital condition characterized by diminished laryngeal tone that causes collapse of supraglottic structures during inspiration, making it the most common congenital laryngeal anomaly and the leading cause of chronic stridor in infants. 1, 2
Pathophysiology
The condition results from softening and collapse of supraglottic structures—including the epiglottis, aryepiglottic folds, and arytenoid cartilages—into the airway during inspiration. 3, 4
The inspiratory collapse partially occludes the upper airway, producing the characteristic high-pitched inspiratory stridor. 3, 5
Typical anatomic features include shortened aryepiglottic folds, a retroflexed or omega-shaped epiglottis, and profound arytenoid redundancy with prolapse. 1, 6
Clinical Presentation
Stridor typically appears at birth or within the first 2 weeks of life, worsening with crying, feeding, agitation, or supine positioning, and improving in the prone position. 7, 3
The stridor is inspiratory, high-pitched, and position-dependent—a key distinguishing feature from other causes of noisy breathing. 7, 3
Mild cases present only with noisy breathing during feeding, while severe cases manifest with feeding difficulties, failure to thrive, oxygen desaturation, apnea, or cyanotic episodes. 8, 4, 5
Boys are affected more than twice as often as girls. 7
Diagnostic Evaluation
Flexible or rigid laryngoscopy is required to confirm the diagnosis, demonstrating dynamic collapse of supraglottic structures during inspiration. 7, 3
Approximately 68% of infants with stridor have synchronous airway lesions below the epiglottis, making complete airway evaluation essential in severe or persistent cases. 2, 9
Flexible bronchoscopy is indicated when diagnosis is uncertain, symptoms are severe or persistent, or when hoarseness, oxygen desaturation, apnea, or inadequate weight gain accompany the stridor. 2, 9
Disease Severity and Prognosis
Most cases are self-limited and resolve spontaneously by 18–24 months of age as the laryngeal cartilages mature and stiffen. 3, 4
Factors that predict severe disease include low APGAR scores, reduced resting oxygen saturation at presentation, presence of a secondary airway lesion, and medical comorbidities (gastroesophageal reflux, neurologic disease, congenital heart disease, genetic syndromes). 8
Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) contribute significantly to feeding symptoms and disease severity. 8
Management Algorithm
Mild to Moderate Disease
Expectant management with observation is appropriate for infants with mild stridor and no feeding difficulties or respiratory compromise. 3, 4
Acid suppression therapy improves symptoms in patients with GERD/LPR. 8
Severe Disease Requiring Intervention
Immediate referral to pediatric otolaryngology is mandatory for infants with cyanotic episodes, oxygen desaturation, severe feeding difficulties, failure to thrive, or apnea. 2
Supraglottoplasty (aryepiglottoplasty or epiglottoplasty) is the surgical treatment of choice, involving excision of redundant mucosa over the arytenoid cartilages, resection of obstructing aryepiglottic folds, and trimming of the lateral epiglottis. 7, 5
Surgical outcomes are excellent in patients without multiple medical comorbidities, with most experiencing immediate airway improvement. 8, 7
Patients with GERD/LPR plus one additional comorbidity have higher rates of revision supraglottoplasty; those with three or more comorbidities may require tracheostomy. 8
Important Clinical Pitfalls
Laryngomalacia can present later in childhood during competitive sports participation, not just in infancy—maintain a high index of suspicion in athletes with exercise-induced inspiratory stridor. 1
Do not assume laryngomalacia is an isolated lesion—the high prevalence of synchronous airway abnormalities (68%) mandates thorough airway evaluation in severe cases. 2, 9
Distinguish laryngomalacia from exercise-induced vocal cord dysfunction (VCD) in older children and adolescents, though some experts question whether these represent the same clinical syndrome. 1
In premature neonates, special vigilance is required to evaluate for synchronous airway lesions given their increased vulnerability. 4