Laryngomalacia (Pediatric)

What is laryngomalacia?

Laryngomalacia refers to the collapse of the tissues of the upper voicebox during breathing.  It occurs when the child breathes in and presents with a squeaky or hiccup type sound when the child inhales.  This sound is called inspiratory stridor.  It is the most common abnormality of the voice box present at birth, and the most common cause of noisy breathing  in newborns.  The exact cause of laryngomalacia is not known.

How is laryngomalacia diagnosed?

Laryngomalacia is diagnosed with a combination of a patient history, physical exam, and diagnostic office procedure called a flexible laryngoscopy. 

Patient History:

Patients with laryngomalacia typically present with inspiratory stridor (noisy breathing on inhalation) in the first few weeks of life.  The stridor tends to be worse with agitation, eating, or lying flat on the back.  Laryngomalacia is frequently associated with acid reflux.  Often symptoms worsen in the first few months of life, but then slowly improve and typically resolve by 12-18 months of life.

Children with laryngomalacia may have difficulty with feeding.  Severe symptoms may include poor weight gain and failing to thrive, choking with feeding, breathing pauses or blue spells while awake, breathing pauses or sleep apnea during sleep, and very hard breathing with retractions (tissue collapse in neck, chest, or belly during inhalation.)

Physical Exam:

On physical exam, the health provider may listen for the quality and intensity of the stridor.  Any signs of significant work of breathing or retractions are noted.  The pediatrician will typically follow and track the child’s weight and compare to normal weights for children the same age.  

Flexible Laryngoscopy:

Flexible laryngoscopy is an office procedure which involves passing a small scope through the nose to visualize the throat and voicebox.  The purpose of the procedure is to examine the voicebox, looking for the collapse of tissue to confirm the diagnosis of laryngomalacia.  Additionally, signs of acid reflux may also be seen during the procedure.  The scope is very narrow in size and is designed for children this age.  No anesthesia is required, and the procedure causes only mild discomfort.  The procedure takes between 1-2 minutes.  It is normal for the child to cry during the procedure, and the crying typically quickly resolves once the procedure is finished.  The child can feed immediately after the procedure.

How is laryngomalacia treated?

Most patients with laryngomalacia do not require treatment.  This applies to patients who are feeding well, gaining weight appropriately, and don’t have any of the severe symptoms of laryngomalacia. 

Often patients have some improvement in their laryngomalacia symptoms when acid reflux is treated.

Patients with severe laryngomalacia may be candidates for a surgical treatment.  Most commonly, this involves removing some of the collapsible tissue of the voice box to help open up the breathing passageway and improve the breathing.  This sometimes needs to be done more than once to achieve the desired effect.  Less commonly, a tracheostomy (tube surgically placed in the neck to help breathing) can be placed to bypass the obstruction.