Laryngomalacia, is the most common cause of infant stridor. Early diagnosis is crucial as it can impact a child’s growth and development. Most infants get better on their own, but those with severe symptoms need surgical interventions like supraglottoplasty. Learn all about diagnosis and management of this common problem in this brief podcast episode.
Klinginsmith M, Goldman J. Laryngomalacia. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544266/
Hartl TT, Chadha NK. A systematic review of laryngomalacia and acid reflux. Otolaryngol Head Neck Surg. 2012 Oct;147(4):619-26.
Boogaard R, Huijsmans SH, Pijnenburg MW, Tiddens HA, de Jongste JC, Merkus PJ. Tracheomalacia and bronchomalacia in children: incidence and patient characteristics. Chest. 2005 Nov;128(5):3391-7.
Isaac A, Zhang H, Soon SR, Campbell S, El-Hakim H. A systematic review of the evidence on spontaneous resolution of laryngomalacia and its symptoms. Int J Pediatr Otorhinolaryngol. 2016 Apr;83:78-83.
Note: This transcript was partially completed with the use of the Descript AI
Welcome to another episode of PEMCurrents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobelewski. Your time is valuable and was mine, and that’s why I release these brief episodes, focus on a single topic, get you in, get you out, teach you something. Today, let’s talk about The most common cause of noisy breathing in newborns and infants, laryngomalacia. You’ve all seen this, or should I say you’ve all heard this, And you will hear the symptoms of stridor and noisy breathing, often positional, and it can impact growth and development.
Now I always thought it was just because airways are small and they’re floppier and therefore noisier, but All infants have small airways and all of their cartilage is soft, so there’s more to the picture. So why does this happen? Well, it could be neurologic function. You could have abnormal tone of the laryngeal nerve. You might have an imbalance of demand supply during inhalation in some infants.
And reflux isn’t a direct cause, but approximately sixty percent of infants with laryngomalacia do also have gastroesophageal acid reflux disease. And we know that reflux can irritate and swell the upper airway, potentially worsening obstructive symptoms. So the incidence is unknown, but it’s probably about one in two to three thousand infants. But it might underestimate it because lots of mild cases don’t actually present clinically, and they’re not diagnosed endoscopically. In the past, we thought there was a male predominance, But it’s equally common in female infants, and black and Hispanic infants may have a higher risk compared with white infants.
Low birth weight has also been suggested to be a contributing factor. So when you’re looking at an infant with possible laryngomalacia, You need a very detailed birth history. So were there any surgical procedures or intubations? Parents need to give you information about breathing difficulties, Especially, noisy breathing or episodes of apnea, noisy breathing that worsens with feeding or while lying down may indicate laryngomalacia. You should also ask detailed questions about feeding habits, weight gain, or if the child’s experiencing failure to thrive.
There are, of course, other causes of noisy breathing in infants that are on the differential. Unilateral vocal cord paralysis Often happens after surgery. So if the kid’s not had surgery, it’s pretty much less likely. Bilateral vocal cord paralysis, which is twice as worse, Prevents with biphasic stridor and may require tracheostomy if respiratory distress is significant. Laryngeal papillomatosis can cause a hoarse cry in upper airway obstruction, and it also appears in infancy.
Subglottic hemangiomas are fortunately rare, but they can cause Torrey Strider. Hemangiomas distributed like a beard are suggestive of this. Subglottic stenosis happens via scarring in the subglottic region due to a previous intubation. So stridor may be present in these infants, but it doesn’t typically change with position. And the child’s history would include a NICU stay and an intubation.
Tracheomalacia and bronchomalacia can coexist with a ringomalacia. Expiratory airway sounds are commonly heard in addition to the stridor, and diagnosis needs scope. We’ll talk more about those in a moment. Vascular ring is a rare cause of airway obstruction in infants, and you’d have feeding difficulties in stridor. The best way to diagnose this is through imaging like CT scans.
And finally, you should always think about foreign body aspiration Even in a child who is not eating solids yet. Remember, an older sibling could feed them something. I have seen this before. So an infant is in respiratory distress after being accompanied or the symptoms are persistent, you should always think about a foreign body, especially in the acute setting. The physical exam of a Child with possible laryngeal malaysia focuses on the airway and breathing naturally.
Make sure that the nasal passages are patent. You don’t wanna miss The oral cavity should be explored for cleft lip, cleft palate, glossoptosis, Pierre Robin sequence, or micronathia. Obviously, all of those facial and oral abnormalities can contribute to breathing and feeding difficulties. You wanna check out the neck for masses or vascular lesions. And many infants have hemangiomas, but I mentioned this before.
If you see them in a beard like distribution, worry about airway hemangiomas. So if you have an infant that has some intermittent, noisy breathing on inspiration, and sometimes it’s worse with feeding and when they lay down, you should really think about laryngomalacia. And if the infant is thriving and growing well, not having any apnea or color change, you can kinda wait it out. But if you wanna make the diagnosis definitively, you will need to have an otolaryngologist perform an awake, Flexible fiber optic laryngoscopy. That’s the primary diagnostic tool for infant stridor in general.
You get a comprehensive view of the oropharynx, the supraglottis, the glottis, the subglottic area, and the hypopharynx. For infants with laryngomalacia on scope will have some specific anatomical abnormalities. They’ll have shortened aryepiglottic folds, An omega shaped epiglottis and or redundant arytenoid tissue. And again, The awake flexible fiber optic laryngoscope is the gold standard for diagnosing laryngomalacia. The Kid is awake and breathing, and that allows you to assess the dynamic collapse of the supraglatic airway during respiration.
In the child with more severe symptoms or you’re worried about tracheomalacia, direct laryngoscopy including a diagnostic bronchoscopy in the OR under general anesthesia may provide a more comprehensive look at the Airway and the upper aerodigestive tract. So you’ll scope down to the main stem bronchi in this standpoint. Sometimes you get A triple scope, which is flexible laryngoscopy, bronchoscopy, and upper endoscopy. So three endoscopists together. I don’t know if there’s a discount.
And this is important when there’s severe symptoms or you have concern about synchronous airway lesions. Direct laryngoscopy can also be a prelude to surgical intervention if you need it. Speech therapists could be particularly valuable If there’s issues with swallowing or feeding, if you’re concerned about aspiration or swallowing deficits sometimes they’ll do a modified barium swallow study. Sleep studies can be particularly helpful to look at symptoms of obstructive sleep apnea, especially in older symptomatic infants. As I’ve alluded to before, fortunately, most children resolve on their own by about twelve to eighteen months of age.
So this management is conservative, includes upright feeding, antireflux therapy, so alterations to how you Feed, burp, and position. And no study has yet shown that proton pump inhibitors improve laryngomalacia symptoms, but they’re still widely used. What’s important to remember is that the majority of infants don’t need any intervention. However, there is a small proportion of infants that do have more severe symptoms, like poor weight gain, Feeding difficulties, obstructive sleep apnea, severe breathing symptoms, they’ll need a procedure called supraglottoplasty. And so how is that done?
Well, they could use lasers or cold steel or microdebridement, and it’s really tailored to the individual patient’s anatomy. So you could divide shortened area epiglottic folds. You can remove some redundant arytenoid mucosal tissue. You could do an epiglottopexy or a combination of some of these. And you really obviously don’t wanna scar the infant’s airway or cause glottic stenosis.
Supraglottoplasty is highly effective. Ninety five percent do great and see measurable and significant improvement in their laryngomalacia symptoms. Only about five percent need some sort of provision, And a higher risk of that is seen in patients that were under two months of age when they got the initial procedure or have neurologic or cardiac comorbidities. Neurologic comorbidities have the highest rate of revision surgery. Maybe up to three out of five patients will need a trach due to ongoing airway obstruction.
Aspiration after supraglottoplasty is the main risk, but it’s rare and not significantly associated with the procedure Self. And let’s not forget the main reason that most of you have heard of larynga Malaysia. It’s because a parent was worried about it. It can be scary to have a baby who is breathing noisily. The fear in the back of your head is that the baby could stop breathing and die.
It’s real. I’ve heard it personally. Ultimately, providing reassurance, guidance, close follow-up, and helping the parent understand what they’re doing well can go a long way into making sure that you’re not missing anything else and you’re appropriately monitoring the infant with potential laryngomalacia. Refer to ENT if you’re unsure of the diagnosis or if you feel that it will benefit the patient. It may seem a little barbaric, but an awake Bedside fiber optic scope isn’t actually that big of a deal.
Alright. So here’s some summary points. The majority of patients with Laryngomalacia will outgrow it by twelve to eighteen months. Diagnosis can be suspected clinically, but awake fiber optic Flexible laryngoscopy is definitive. Severe symptoms should be monitored and include recurrent cyanosis or respiratory distress, Apnea and failure to thrive.
These need further workup, including many times direct laryngoscopy and bronchoscopy to rule out other airway abnormalities. Surgery is generally only indicated in patients with severe laryngomalacia, and it’s called Supraglottoplasty. It’s generally well tolerated to highly effective. Patients with neurologic comorbidities or congenital cardiac disease and those less than two months of age are more likely to require revision surgery for relief of ongoing symptoms. Alright.
So that’s it for this episode. Hopefully, you learned something new about laryngomalacia. If you have any other suggestions for topics, send them my way. I’ll take emails, comments on the blog, direct messages on x or Twitter, threads, Facebook, whatever channels you wanna use. My goal is to make sure that you are ready for your next ED shift with up to date information that’s evidence based and ready to deliver to patients and families.
If you have the time, leave a review on your favorite podcast site. That helps with discovery so that more people can listen and learn. And share this episode in the show with your colleagues. I’d love to hear what they think as well. For PEM currents, the pediatric emergency medicine podcast, this has been Brad Sobolewski.
See you next time.