Laryngomalacia
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Laryngomalacia ("Soft Larynx") is the most common cause of stridor in newborns and infants (60-70%).
It involves the collapse of immature supraglottic structures (arytenoids and epiglottis) into the airway during inspiration, creating a characteristic sound.
Clinical Scenario: The Noisy Eater
A 6-week-old infant is referred for 'noisy breathing'. The mother says he 'squeaks' when he breathes in, especially when he gets excited or feeds. He is gaining weight well and sleeps peacefully. There is no cyanosis.
Key Teaching Points
- This is the specific history of Laryngomalacia.
- Symptoms typically appear at 2 weeks, peak at 6 months, and resolve by 12-24 months.
- The **Inspiratory Stridor** is key. (Expiratory = Tracheomalacia/Asthma; Biphasic = Subglottic Stenosis).
- If the child is gaining weight, conservative management is appropriate.
Image Integration Plan
| Image Type | Source | Status |
|---|---|---|
| Management Algorithm | AI-generated | PENDING |
| Pathophysiology (Supraglottic Collapse) | AI-generated | PENDING |
| Laryngoscopy (Omega Epiglottis) | Web Source | PENDING |
[!NOTE] Image Generation Status: Diagrams illustrating the Bernoulli effect on the floppy epiglottis are queued.
Clinical Severity Grading
- Mild: Auditory stridor only. No recession.
- Moderate: Stridor + Retractions (subcostal/sternal) + Feeding issues.
- Severe: ALTE (Apparent Life Threatening Event), Cyanosis, Failure to Thrive.
- Prevalence: Very common.
- Sex: Male:Female = 2:1.
- Associations: Down Syndrome, Neuromuscular disorders, GORD (Gastro-oesophageal Reflux Disease).
- Anatomical Defect:
- Short Aryepiglottic Folds (tether the epiglottis).
- Redundant/Floppy arytenoid mucosa.
- Omega-shaped (Ω) Epiglottis curled in on itself.
- Mechanism:
- During inspiration, negative pressure is generated in the trachea.
- The floppy supraglottic structures are sucked inwards (Bernoulli principle), obstructing the airflow.
- This vibration causes high-pitched stridor.
The Noise
Feeding Difficulties (The Red Flag)
GORD Interaction
- Observation:
- Note stridor type (Inspiratory?).
- Work of breathing: Suprasternal/Subcostal recession.
- Pectus Excavatum: Chronic obstruction can cause a sunken chest.
- Positioning: Does stridor improve when baby is held upright or placed prone?
- Growth Chart: Essential. Is weight tracking the centiles?
- Flexible Nasendoscopy (Awake):
- Gold Diagnostic Standard. Performed in clinic by ENT.
- Visualises the dynamic collapse of arytenoids ("prolapse") and omega epiglottis.
- Excludes other causes (e.g., vocal cord palsy, haemangioma).
- Microlaryngoscopy & Bronchoscopy (MLB):
- Performed under General Anaesthetic.
- Only if diagnosis unclear or surgery planned.
- To rule out synchronous lesions (e.g., Subglottic Stenosis) which occur in 10-15%.
- Sleep Study: If severe apnoea suspected.
A. Conservative (90% of cases)
- Reassurance: "It will get worse before it gets better" (peaks at 6 months).
- Monitoring: Weight checks.
- Anti-Reflux Medication: Gaviscon Infant / Omeprazole. Treating GORD often significantly improves the stridor.
B. Surgical (Supraglottoplasty)
Indications (Severe Disease - 10%):
- Failure to Thrive (weight loss).
- Severe Apnoea / Cyanosis.
- Cor Pulmonale.
- Severe chest deformity (Pectus).
Procedure:
- Supraglottoplasty: Endoscopic trimming of the short aryepiglottic folds. This releases the epiglottis, allowing it to spring open.
- Success: >90% symptom resolution.
C. Tracheostomy
- Reserved for extremely rare cases where supraglottoplasty fails or there are severe comorbidities (e.g., neurological CP).
- Aspiration Pneumonia.
- Failure to Thrive.
- Sudden Death (extremely rare, usually associated with reflux/aspiration).
- Self-limiting: Resolves spontaneously by 12–24 months as the cartilages stiffen ("harden up") and the airway grows.
- Long term: Usually no sequelae.
- ENT UK Guidelines: Management of Stridor in Children.
- International Consensus: Supraglottoplasty indications.
What is Laryngomalacia? It means "Soft Voice Box". The cartilage in your baby's larynx is floppy and immature.
Why is he noisy? When he breathes in, the floppy tissue gets sucked into the airway, vibrating and making a squeaking noise (stridor). It sounds scary, but the airway doesn't block completely.
Is it dangerous? In 9 out of 10 babies, it is harmless. It sounds worse when they are excited or feeding. As long as your baby is growing and gaining weight, they are getting enough air.
Will it go away? Yes. It usually gets louder until about 6 months old, then slowly disappears by age 1 or 2 as the voice box becomes firmer.
What should I watch for?
- Blue spells: Lips turning blue.
- Weight loss: If he is too tired to finish feeds.
- Pauses: Stopping breathing for 10+ seconds. If these happen, we may need a small operation to trim the floppy tissue.
- Thorne MC, Garetz SL. Laryngomalacia: Review and Summary of Current Clinical Practice in 2015. Paediatr Respir Rev. 2016.
- Ayari S, et al. Supraglottoplasty for severe laryngomalacia: predictive factors for success. Int J Pediatr Otorhinolaryngol. 2013.
- Landry AM, Thompson DM. Laryngomalacia: disease presentation, diagnosis, and management. Ann Otol Rhinol Laryngol. 2012.