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Laryngomalacia

Laryngomalacia is the most common cause of stridor (noisy breathing) in infants, accounting for 65-75% of all cases of stridor.  It occurs due to a collapse of structures above the vocal cords into the airway with inspiration and is indicated when there is a high-pitched noise while breathing in.  It usually presents in the first few days or weeks of life and resolves by age 12 to 20 months.  For about 90% of infants, it is self-limited and resolves on its own.  However, in about 10% of infants, it may be severe, necessitating surgery.

The cause of laryngomalacia is not exactly known but is thought to be one of two things:  a floppy larynx due to immaturity of the cartilage of the voice box, and/or gastroesophageal reflux disease, which is found in 35% to 68% of patients diagnosed with laryngomalacia.  There are no specific risk factors for this disorder, but premature infants may have more severe symptoms, which may warrant surgery.

Diagnosis

Laryngomalacia is diagnosed by history and physical exam.  There are a variety of symptoms that may be indicative of laryngomalacia, including:
 

  • Inspiratory stridor (high-pitched noise while breathing in) that is often worse with crying, laying on back, feeding
  • Cyanotic episodes (turning blue)
  • Retractions (sucking in of chest/neck with each breath)
  • Apneic episodes (stopping breathing)
  • Regurgitation
  • Coughing/choking with feeds
  • Aspiration (inhalation of food into lungs)
  • Slow feeding
  • Poor weight gain/failure to thrive

Sometimes an endoscopic exam is also needed to aid in the diagnosis of laryngomalacia. Using a small, thin, flexible scope, the physician is able to assess the voice box, looking for floppiness of the larynx and signs of reflux.

Treatment

Both medical and surgical treatment options are available for patients with laryngomalacia.  For mild cases, no treatment is indicated, as this will likely resolve on its own. For moderate cases, most infants will do well with medical treatment of reflux alone using antireflux medications, such as omeprazole or lansoprazole.  

Infants with more severe symptoms or those who do not improve despite medical treatment may require surgical intervention.  The surgery for this disorder is known as a supraglottoplasty, and it is performed using traditional surgical instruments with or without a laser. While the noisy breathing may not complete resolve, the goal of the surgery is to allow for easier feeding and breathing.  Overnight stay in the hospital following surgery is typically required to monitor for any problems with breathing following surgery.