What Is Laryngomalacia?

Laryngomalacia is a birth abnormality characterized by the softening of tissues above the voice box, resulting in noisy or high-pitched breathing called stridor and airway obstruction.

The condition usually becomes apparent shortly after birth and tends to improve as the baby grows, with most cases resolving by the age of 2 or 3 years. 

Understanding this condition more comprehensively can be helpful for parents and caregivers of infants diagnosed with laryngomalacia. The following article will discuss the causes, signs and symptoms, management and treatment, diagnosis, and FAQs related to laryngomalacia.

Overview

Laryngomalacia is a relatively common congenital condition that affects the larynx (voice box) in infants. It is characterized by the softening and floppiness of the tissues above the larynx, leading to airway obstruction and various symptoms. 

Laryngomalacia accounts for a significant proportion, around 45-75%, of all stridor cases in infants. Although most cases involve occasional noisy breathing during inhalation, some babies may struggle with feeding, inadequate weight gain, and respiratory distress. Fortunately, the majority of patients improve on their own without surgery. Still, surgery is necessary in about 10% of cases to address severe symptoms and ensure proper breathing.^1,2

Causes of laryngomalacia

The exact cause of laryngomalacia remains a subject of ongoing research. Initially, experts focused on examining structural defects as a potential cause. Still, no abnormalities were found in the cartilage or tissues of affected infants. 

However, recent studies have shed light on a possible neurologic cause. Researchers have observed changes in laryngeal sensation in children diagnosed with laryngomalacia, indicating potential nerve-related issues that impact the functioning of the larynx. In addition to neurologic factors, gastroesophageal reflux disease (GERD) has emerged as a possible contributing factor in developing laryngomalacia. It is believed that reflux episodes can lead to swelling in the vocal cords, which in turn obstructs the airway and contributes to the symptoms of laryngomalacia.^1,2

Signs and symptoms of laryngomalacia

One of the hallmark symptoms of laryngomalacia is stridor, a high-pitched or noisy breathing sound that occurs during inhalation. This occurs due to the partial collapse of the floppy tissues above the vocal cords. The stridor is often more noticeable when the baby is agitated, feeding, or lying on their back. 

Around 40% may have additional symptoms, including feeding difficulties, poor weight gain, frequent spitting up, coughing and episodes of cyanosis (bluish discolouration) during crying or feeding. About 20% of cases have severe laryngomalacia, which can cause higher-risk feeding difficulties, aspiration, apnea, and other issues. For this subset of infants, surgical intervention is frequently necessary.^1,2,3

Management and treatment for laryngomalacia

In most cases, laryngomalacia resolves independently without intervention as the baby grows and the tissues become firmer. However, there are management strategies that can help alleviate symptoms and provide support for affected infants. In cases where gastroesophageal reflux (GERD) is present, treating the reflux can often improve laryngomalacia symptoms. This may involve lifestyle modifications, such as feeding position changes and smaller, more frequent meals. In some instances, medication may be prescribed to reduce stomach acid production.^1,2

Surgical intervention may be considered for severe laryngomalacia cases that significantly impact a baby's breathing and feeding. The most common surgical procedure performed is called supraglottoplasty. This involves removing excess tissue and opening up the airway to improve breathing. Another surgery to treat laryngomalacia is epiglottopexy, which fixes the epiglottis to the tongue base. Surgical intervention is typically reserved for cases where conservative management has proven ineffective or when the baby's health and development are at risk.^1,2,3,4

Diagnosis

Healthcare providers utilize a combination of diagnostic procedures to obtain a comprehensive evaluation of the larynx, airway, and related structures to confirm the diagnosis of laryngomalacia and assess any associated conditions or contributing factors.

Diagnosis includes a thorough medical history, physical examination, and various diagnostic procedures. During the physical examination, healthcare providers listen for characteristic stridor and assess the baby's breathing patterns. One commonly performed procedure is a flexible fiberoptic laryngoscopy, where a thin, flexible tube with a camera is inserted through the nose to examine the structure and function of the larynx. This allows healthcare providers to visualize the soft tissues above the larynx and assess abnormalities. In addition to fiberoptic laryngoscopy, other diagnostic procedures may be employed. X-ray of the neck can provide valuable information about the airway, and airway fluoroscopy allows for dynamic airway assessment during breathing. Microlaryngoscopy and bronchoscopy (MLB) involve using a small endoscope to examine the larynx and the lower airways, providing a more detailed evaluation. Esophagogastroduodenoscopy (EGD) and pH probe monitoring can be utilized to assess the presence of gastroesophageal reflux disease (GERD), which may be associated with laryngomalacia. 

These tests examine the oesophagus and measure acid levels to determine if reflux contributes to the symptoms. Additionally, a functional endoscopic evaluation of the swallow (FEES) may be performed to assess swallowing function and evaluate for any potential aspiration or swallowing difficulties.^1,2,5,6,7

FAQs

How can I prevent laryngomalacia?

Laryngomalacia cannot be prevented as it is a congenital condition. Because laryngomalacia occurs during foetal development, taking good care of your overall health during pregnancy could help avoid this condition.

How common is laryngomalacia?

Infants with this syndrome are extremely common. Laryngomalacia affects more than half of all newborn babies during their first week of life, and even more develop it between two and four weeks later.

Who is at risk of laryngomalacia?

Laryngomalacia can occur in any infant, but some factors may increase the risk, such as prematurity, low birth weight, and certain medical conditions like Down’s syndrome or other chromosomal abnormalities.

When should I see a doctor?

It is advisable to consult a doctor if your baby exhibits symptoms such as persistent stridor, breathing difficulties, feeding problems, inadequate weight gain, or signs of respiratory distress. A healthcare professional can evaluate the symptoms, provide a diagnosis, and recommend appropriate management strategies to ensure your baby's well-being.

Summary

Laryngomalacia is a common condition in infants where the tissues above the larynx become soft and floppy, causing airway obstruction and various symptoms. Stridor, a noisy breathing sound, is the main symptom. While symptoms can range from mild to severe, it's important to know that they generally improve and resolve between the ages of 12 and 18 months.

The exact cause of laryngomalacia is still being studied, but researchers have identified potential neurologic factors and the role of gastroesophageal reflux disease (GERD). Understanding the intricate interactions between these factors is an active area of research, aiming to provide valuable insights into the causes of laryngomalacia. By uncovering this relationship, experts hope to enhance our understanding of the condition and improve diagnostic and treatment approaches for affected infants.