Laryngomalacia
Learn about laryngomalacia
(Floppy Voice Box).
Learn about laryngomalacia( Floppy Voice box) —the most common cause of stridor in infants. Understand symptoms, diagnosis, and treatment options, including supraglottoplasty.
What is Laryngomalacia?
(Floppy Voice box) This condition involves the floppiness of the larynx (voice box) tissues above the vocal cords, causing a partial airway obstruction. Symptoms can range from noisy breathing (stridor) to feeding difficulties, poor weight gain, choking, apnea (pauses in breathing), and cyanosis (blue spells). Diagnosis often involves a physical exam and nasopharyngolaryngoscopy. Treatment options include medical management for mild cases and supraglottoplasty surgery for more severe cases.
Introduction
- Laryngomalacia is the most common congenital cause of stridor in infants, accounting for 60-75% of neonatal stridor cases.
- It is a dynamic airway disorder characterized by inspiratory collapse of supraglottic structures, leading to airflow obstruction.
- Although most cases resolve spontaneously, some infants require intervention.
Pathophysiology & Etiology
- Anatomic factors:
Redundant arytenoid mucosa, short aryepiglottic folds, and omega-shaped epiglottis. - Neuromuscular factors:
Impaired coordination of laryngeal tone due to immature neuromuscular control. - Gastroesophageal reflux disease (GERD):
Often seen in association with laryngomalacia, though its causal role is debated.
Clinical Presentation
Mild Cases (Most Common, 80-90%)
- High-pitched inspiratory stridor that worsens with feeding, crying, or supine positioning.
- Onset typically within the first 2-4 weeks of life.
- Symptoms peak at 4-6 months and improve by 12-24 months.
Moderate to Severe Cases (10-15%)
- Feeding difficulties: Poor weight gain, choking, coughing, or aspiration.
- Airway distress: Retractions, tachypnea, hypoxia, or apnea.
- GERD association: Frequent spit-ups, Sandifer syndrome, or irritability during feeding.
Diagnosis
- Clinical history & physical exam: Stridor that worsens with agitation and improves in prone position is suggestive.
- Flexible fiberoptic laryngoscopy (FFL):
- Gold standard for diagnosis.
- Identifies supraglottic collapse during inspiration.
- Modified barium swallow (MBS) or Functional endoscopic evaluation of swallowing (FEES): If aspiration is suspected.
Management Strategies
Conservative Management (First-line for Mild Cases)
- Feeding modifications: Upright positioning, slow feeds, thickened feeds (if aspirating).
- GERD management
- Acid suppression therapy (PPIs or H2 blockers) in symptomatic infants.
- Lifestyle modifications like upright positioning after feeds.
Medical Management for Moderate Cases
- GERD therapy if suspected to contribute to symptoms.
- Oxygen support in cases with nocturnal desaturation.
- Close monitoring for feeding difficulties or worsening respiratory distress.
Surgical Intervention for Severe Cases
Indications for Supraglottoplasty:
- Failure to thrive due to feeding difficulties.
- Significant airway obstruction (retractions, hypoxia, apnea).
- Severe OSA confirmed on PSG.
- Recurrent aspiration leading to pneumonia.
Supraglottoplasty Procedure:
- Endoscopic excision of redundant arytenoid mucosa, release of short aryepiglottic folds, and possible epiglottoplasty.
- Usually performed with cold steel or CO2 laser.
- Success rate: ~90% improvement in symptoms.
Complications & Follow-Up
- Potential post-op issues:
- Aspiration (temporary in most cases).
- Supraglottic stenosis (rare).
- Need for revision surgery (~10%).
- Follow-up:
- Close monitoring of feeding and breathing.
- Repeat FFL in cases with persistent symptoms.
- PSG in cases with residual sleep-disordered breathing.
Related Links
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Tracheomalacia
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Subglottic and Tracheal Stenosis
Discover expert care for subglottic and tracheal stenosis in children.