Laryngomalacia

Laryngomalacia - Floppy Larynx Intro

• Definition: Congenital flaccidity of laryngeal tissues, leading to inward collapse during inspiration.
• Also known as "floppy larynx".
• Most common congenital laryngeal anomaly (60-75% of cases).
• Results in intermittent, partial airway obstruction.

⭐ Laryngomalacia is the most common cause of stridor in infants and newborns.

• Typically presents in the first few weeks of life.
• Stridor is usually inspiratory, worse when supine, agitated, or feeding.

Pathophysiology - Why So Wobbly?

• Immature, floppy laryngeal cartilages (epiglottis, arytenoids) leading to ↑ collapsibility.

• Redundant supraglottic soft tissues (e.g., aryepiglottic folds, arytenoid mucosa).

• Possible neuromuscular incoordination or hypotonia affecting laryngeal support.

• During inspiration, negative intrathoracic pressure causes these lax supraglottic structures to prolapse inward, obstructing the airway.

• This dynamic collapse leads to turbulent airflow and characteristic inspiratory stridor.

• Common patterns of collapse:

  • Type 1: Inward collapse of arytenoid cartilages and redundant mucosa (most common).
  • Type 2: Shortened aryepiglottic folds pulling epiglottis posteroinferiorly.
  • Type 3: Posterior and/or lateral collapse of an elongated, omega-shaped epiglottis.

⭐ Laryngomalacia is the most common congenital laryngeal anomaly and cause of stridor in infants; symptoms typically worsen with agitation, feeding, or supine positioning due to increased inspiratory effort and gravitational effects on floppy tissues.

Clinical Signs - Noisy Breather Baby

• Onset: Typically within first 2 weeks of life, often by 4-6 weeks.
• Stridor:
  • Predominantly inspiratory, high-pitched, fluttering.
  • Intermittent; worsens with supine position, agitation, feeding, URIs.
  • Improves with prone position or neck extension.
• Voice & Cry: Usually normal.
• Feeding: Generally unaffected; severe cases may show poor weight gain, choking.
• Course: Symptoms peak around ~6 months, typically resolve by 18-24 months.

⭐ Stridor in laryngomalacia is classically inspiratory and characteristically worsens in the supine position and with agitation.

Diagnosis - Scope The Larynx

• Gold Standard: Flexible Fiberoptic Laryngoscopy (FFL).
  • Performed on an awake, spontaneously breathing child.
  • Allows direct visualization of dynamic laryngeal collapse during inspiration.
• Key Findings (Inspiratory Supraglottic Collapse):
  • Type 1: Inward collapse of arytenoid cartilages/redundant mucosa.
  • Type 2: Medial collapse of short aryepiglottic folds.
  • Type 3: Posterior and inferior collapse of an omega-shaped (Ω) epiglottis.

⭐ Laryngomalacia is the most common congenital laryngeal anomaly and the primary cause of stridor in infants.

Management - Fixing The Flop

• Conservative (Most cases: 90%):
  • Observation, reassurance.
  • Positioning: Prone or upright after feeds.
  • Feeding modification: Small, frequent, thickened feeds.
• Medical:
  • Anti-reflux (PPIs, H2 blockers) if GERD suspected.
• Surgical (Severe cases: 10-20%): Aryepiglottoplasty / Supraglottoplasty.
  • Indications: Failure to thrive (FTT), severe dyspnea, cyanosis, apneas, cor pulmonale, feeding difficulties.

⭐ Supraglottoplasty is the gold standard surgical treatment for severe laryngomalacia, involving trimming of redundant aryepiglottic folds or arytenoid mucosa.

High‑Yield Points - ⚡ Biggest Takeaways

• Laryngomalacia: most common congenital laryngeal anomaly and cause of stridor in infants.
• Inspiratory stridor is characteristic, worsening with crying, feeding, supine position; improves when prone.
• Diagnosis via flexible fiberoptic laryngoscopy (FFL), showing an omega-shaped epiglottis or arytenoid prolapse.
• Typically benign and self-resolves by 18-24 months.
• Management: Observation for mild cases; supraglottoplasty for severe symptoms like failure to thrive (FTT) or apnea.
• Frequently associated with Gastroesophageal Reflux Disease (GERD).