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Pediatric Laryngomalacia

Laryngomalacia is the most common congenital laryngeal anomaly and the most common cause of stridor during breathing in infants, accounting for approximately 75% of infants with stridor. Stridor is a medical term that means "noisy breathing." The stridor caused by laryngomalacia is a high-pitched sound that is most noticeable while breathing in or inhaling.

When the upper part of the larynx (or “voicebox”) becomes floppy or soft, it is called laryngomalacia. Reduced laryngeal tone results in constriction of air while the child is breathing in, producing a high pitch squeaking or peeping sound. The underdeveloped cartilage shrinks inward during inhalation, blocking the airway and causing the child to make a noisy sound. In most cases, the sound is slight and increases with the crying or during breastfeeding. If the infant has an upper respiratory infection, the stridor will worsen.


Laryngomalacia is classified as mild, moderate, or severe. The majority of infants born with laryngomalacia have mild or moderate forms.

Mild laryngomalacia


Mild Laryngomalacia is characterized by noisy breathing but no other illnesses.  Whereas babies with moderate laryngomalacia frequently have difficulty coordinating their feeding and breathing, necessitating frequent feeding breaks.


Severe laryngomalacia

Severe laryngomalacia can include  having difficult feeding which result in  weight gain difficulties as well as apnea and cyanotic diseases.  In 90% of cases, the condition improves with the infant's growth and disappears by the age of 18 months without any surgical intervention. Surgery is recommended in chronic cases where laryngeal softening interferes with breathing and affects food intake, growth, and development.


Causes of laryngomalacia

Other than the fact that the child is born with it, there is no known reason for this thinning of the laryngeal cartilage. Laryngomalacia has a multifactorial etiology, with anatomic, inflammatory, and neurologic factors all playing a role. According to many studies, laryngomalacia is caused primarily by neuromuscular dysfunction. 


Symptoms of Laryngomalacia

Patients usually present with inspiratory stridor in the first few weeks of life, which worsens during the first 6 months of life, peaks in severity about 6 months of age, and then gradually improves, with most patients symptom-free by 18 to 24 months.  In children with laryngomalacia, swallowing problems are very common. Some babies have feeding difficulties such as coughing, choking, gagging, regurgitation, emesis, and slow and/or inefficient feeding because of disruption of the swallow-breathe sequence and airway protection. In certain situations, the feeding problem is so severe that the infant is unable to eat by mouth.


Gastroesophageal reflux disease and laryngomalacia

In 65–100% of infants with laryngomalacia, gastroesophageal reflux is reported. Gastroesophageal reflux disease (GERD) is a well-known comorbidity of laryngomalacia, and many patients with laryngomalacia have reflux symptoms and are treated for it, despite the fact that a clear causal mechanism has yet to be established.

The airway obstruction of laryngomalacia generates negative intrathoracic pressure, which promotes gastric acid reflux onto the laryngopharyngeal tissues leading to laryngopharyngeal reflux. Infants with stridor and feeding-related symptoms offten benefit from acid suppression treatment.


How to diagnose a flexible larynx: 

Physical examination of the infant, as well as a detailed medical history, is often sufficient to confirm the diagnosis, especially if the infant is in good health and does not have any problems with breastfeeding. Flexible fiberoptic laryngoscopy confirms the diagnosis of laryngomalacia in which supraglottic structures collapsed during inspiration, resulting in inspiratory stridor and airway obstruction.

It's essential to test patients with laryngomalacia swallowing function before and after treatment. Swallowing studies are often abnormal in patients with laryngomalacia present either with or without dysphagia or feeding difficulties.


Possible complications

Laryngeal penetration and aspiration are more common in children with laryngomalacia, according to research. Aspiration can exacerbate established respiratory problems and worsen the growth-slowing feature of laryngomalacia. Supraglottoplasty may be required in patients who have symptoms of aspiration, worsening stridor, failure to thrive, and complications caused by airway obstruction and hypoxia. Moderate-severe laryngomalacia can result in sleeping difficulties and pauses in the breathing (apneic spells).  

If you would like to speak with a therapist regarding the diagnosis and treatment of laryngomalacia, please schedule a consultation here.

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