Laryngomalacia overview

Also known as “floppy airway,” laryngomalacia occurs when the supraglottic structures collapse into the airway during inspiration causing temporary partial blockage of the airway. There is shortening in the distance between the arytenoids and epiglottis and an omega-shaped epiglottis. Inspiratory stridor is caused by airflow through an obstruction at the level of the vocal cords or above and is often heard in laryngomalacia. This is commonly confused with tracheomalacia in which you will hear expiratory stridor secondary to obstruction in the trachea. The exact etiology of laryngomalacia remains unknown. Stridor associated with laryngomalacia may worsen with feeding, crying/agitation, when placed in the supine position and when asleep as opposed to awake.

Recommended examination

Comprehensive Health History

• Birth history (premature, term) and any other pertinent positives
• Birth weight and current weight
• History of intubation
• Growth and development (following growth curve)
• Dietary intake (breast milk or formula)
• Frequency of feedings
• Ounces per feed and length of time to finish feeding
• Appropriate latch
• Parental report of “noisy” breathing.
• At what age was the noisy breathing noted; has it worsened; what improves it or exacerbates it
• Coughing, choking, regurgitation or breathing issues with feedings
• History of reflux, pneumonias or frequent upper respiratory illnesses
• Medications
• Immunization status

Physical Examination

Comprehensive physical exam with focus on:

• Co-morbidities/syndromes: CHARGE, Pierre’ Robin, Trisomy 21, neurologic disease, seizure disorder, hypotonia, cardiac disease, etc.
• Congenital anomalies: Examples include micrognathia, cleft lip and/or palate
• Growth and development plotted on appropriate growth curve
• Stridor: Inspiratory, expiratory, or both? Note positions or anything that may improve or exacerbate symptoms. Is it noisier when awake or asleep?
• Lung sounds: assess for upper airway congestion, especially after feeds; signs of aspiration
• Respiratory status: distress, retractions, increased work of breathing, cyanosis
• Diagnostics
• Fiber optic/flexible laryngoscopy performed by a pediatric otolaryngologist is the gold standard for diagnosis of laryngomalacia.
• Can be performed without sedation in the clinic setting. A topical anesthetic and/or nasal decongestant may be applied prior to the procedure
• Allows direct visualization of the nose, throat and anatomy at the level of the voice box and above
• Procedure: A thin tube with a fiber-optic camera (scope) is passed through the naris for direct visualization of the structures and how they move.
• This generally takes only a few minutes.
• Safe with minimal risks and is well tolerated
• Direct visualization together with associated symptoms allows the otolaryngologist to determine the severity of laryngomalacia (mild, moderate, or severe)

Treatment and management

Management depends on severity

• In the majority of infants, laryngomalacia is not dangerous and resolves spontaneously between the ages of 12 and 18 months with growth
• Surgical management is indicated for those with severe disease (feeding issues, poor weight gain/loss, breathing issues)
• Surgery: Supraglottoplasty
  • Done using micro instruments or laser to trim the folds between the epiglottis and the arytenoids
  • Usually requires a 1-night stay postoperatively

When to refer to Children’s Minnesota

Common signs and symptoms

It is imperative that the primary care provider evaluate the noisy breathing and if continued symptoms are present, referral to a specialist is appropriate.

Referral to a specialist such as the Children’s ENT and Facial Plastic Clinic is appropriate if one or more of the following criteria are met in addition to noisy breathing/stridor:

• Respiratory distress- tachypnea, retractions, tracheal tugging, apnea, blue spells (less common)
• Sleep disordered breathing
• Difficulty coordinating suck with swallow
• Feeding problems including: aspiration, regurgitation, vomiting, cough, choking and slow feeds
• Poor weight gain or weight loss (due to increased metabolic demand while trying to coordinate eating with breathing)
• Failure-to-thrive
• Prolonged stridor without other symptoms after 12 months of age

Contact us

Children’s Physician Access

• 612-343-2121
• Toll free: 866-755-2121

What to expect when working with Children’s ENT team

• Fast call backs to clinicians and families
• Coordinated appointments with other services (lab/radiology/other specialists)
• Physician calls connected right away with an ENT physician or APRN
• Letters dictated same day for primary care clinicians
• Same-day access for urgent appointments

Children’s ENT and Facial Plastic Surgery

The ENT and facial plastic surgery team includes eight pediatric otolaryngologists and four pediatric nurse practitioners. We provide services to children of all ages including those with complex medical conditions. Common conditions treated include chronic ear infections, tonsil and adenoid enlargement or infections, hearing loss, sinus disease, neck masses and voice or swallowing abnormalities. Complex conditions include airway abnormalities, congenital aural atresia, tumors of the head and neck, vascular abnormalities, thyroid and parathyroid tumors, facial weakness or paralysis, plagiocephaly, craniofacial abnormalities and craniosynostosis. Facial plastics include cleft lip and palate repair, animal bite repair, scar revision, trauma repair and ear molding. Speech and social services are provided to these patients within the department.

Our department also participates in multidisciplinary clinics throughout the Children’s Minnesota system. These include cleft palate clinic, craniosynostosis clinic, velocardiofacial clinic, vascular anomalies clinic, endocrine thyroid clinic, and prenatal and fetal clinic.

Meet the team