Laryngomalacia Treatment & Management
- Author: Stephanie Lovinsky-Desir, MD; Chief Editor: Denise Serebrisky, MD more...
In more than 90% of cases, the only treatment necessary for laryngomalacia is time. The lesion gradually improves, and noises disappear by age 2 years in virtually all infants. The noise steadily increases over the first 6 months, as inspiratory airflow increases with age. Following this increase, a plateau often occurs with a subsequent gradual disappearance of the noise. In some cases, the signs and symptoms dissipate, but the pathology may persist into childhood and adulthood. In those cases, symptoms or signs may recur with exercise or sometimes with viral infections.
Children with severe retractions, cyanotic spells, and apneas during sleep may have obstructive sleep apnea associated with laryngomalacia. These children should be evaluated with a sleep study. Supraglottoplasty may be of benefit in children with severe symptoms of laryngomalacia (see below). Thus, a detailed sleep history should be taken in all infants with symptoms of laryngomalacia.
If the baby has clinically significant hypoxemia (defined as a resting oxygen saturation < 90%), supplemental oxygen should be administered. Recent data suggest infants with laryngomalacia and hypoxemia may more readily develop pulmonary hypertension. Therefore, children with hypoxemia should periodically undergo evaluation for pulmonary hypertension.
If the baby has normal cry, normal weight gain, normal development, and purely inspiratory noise that developed within the first 2 months of life, then no further workup may be necessary. Parents may be told that laryngomalacia is the most likely diagnosis, and they can be assured of its natural history.
If the picture is not obvious or if the parents are not completely reassured, diagnostic procedures include fluoroscopy and flexible laryngoscopy or bronchoscopy. Flexible bronchoscopy with the child anesthetized is more specific and sensitive than flexible bronchoscopy in a child who is awake.
There is a distinct group of older children (aged >2 years) with late-onset laryngomalacia, or occult laryngomalacia, who do not present with the typical congenital symptoms of noisy breathing. Children manifest symptoms during feeding, exercise, or sleep. Many are identified with snoring or sleep-disordered breathing as initial symptoms and are diagnosed with laryngomalacia upon direct visualization of the airway. In late-onset laryngomalacia, supraglottoplasty may be beneficial for cases of moderate-to-severe obstructive sleep apnea associated with significant apnea-hypopnea index on sleep study.[8, 9] However, other causes for obstruction, such as adenotonsillar hypertrophy, should also be evaluated.
In severe cases in which the laryngomalacia interferes with ventilation enough to impair normal eating, growth, and development, a surgical approach is possible.
Approximately 10% of patients with severe congenital laryngomalacia require surgical intervention because of failure to thrive, significantly elevated carbon dioxide or hypoxemia, severe obstructive sleep apnea, pulmonary hypertension, or cor pulmonale. Operations include simple tracheotomy or supraglottoplasty in which support structures are tightened and excess tissue on the epiglottis is removed. Laser epiglottopexy has been successful.[11, 12]
If the parents require another opinion or if the lesion is clinically severe, consultation with a pediatric pulmonologist or pediatric otorhinolaryngologist may help.
No diet restrictions are necessary.
No activity restrictions are necessary.
Edmondson NE, Bent JP 3rd, Chan C. Laryngomalacia: the role of gender and ethnicity. Int J Pediatr Otorhinolaryngol. 2011 Dec. 75(12):1562-4. [Medline].
Dickson JM, Richter GT, Meinzen-Derr J, Rutter MJ, Thompson DM. Secondary airway lesions in infants with laryngomalacia. Ann Otol Rhinol Laryngol. 2009 Jan. 118(1):37-43. [Medline].
Cooper T, Benoit M, Erickson B, El-Hakim H. Primary Presentations of Laryngomalacia. JAMA Otolaryngol Head Neck Surg. 2014 May 8. [Medline].
Boggs W. Laryngomalacia Commonly Presents With Snoring or Swallowing Dysfunction. Reuters Health Information. Available at http://www.medscape.com/viewarticle/825146. May 15, 2014; Accessed: June 16, 2015.
Powitzky R, Stoner J, Fisher T, Digoy GP. Changes in sleep apnea after supraglottoplasty in infants with laryngomalacia. Int J Pediatr Otorhinolaryngol. 2011 Oct. 75(10):1234-9. [Medline].
Unal E, Oran B, Baysal T, et al. Pulmonary arterial pressure in infants with laryngomalacia. Int J Pediatr Otorhinolaryngol. 2006 Dec. 70(12):2067-71. [Medline].
Richter GT, Rutter MJ, deAlarcon A, Orvidas LJ, Thompson DM. Late-onset laryngomalacia: a variant of disease. Arch Otolaryngol Head Neck Surg. 2008 Jan. 134(1):75-80. [Medline].
Revell SM, Clark WD. Late-onset laryngomalacia: a cause of pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2011 Feb. 75(2):231-8. [Medline].
Chan DK, Truong MT, Koltai PJ. Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome. Arch Otolaryngol Head Neck Surg. 2012 Jan. 138(1):50-4. [Medline].
Richter GT, Thompson DM. The surgical management of laryngomalacia. Otolaryngol Clin North Am. 2008 Oct. 41(5):837-64, vii. [Medline].
Whymark AD, Clement WA, Kubba H, Geddes NK. Laser epiglottopexy for laryngomalacia: 10 years' experience in the west of Scotland. Arch Otolaryngol Head Neck Surg. 2006 Sep. 132(9):978-82. [Medline].
Erickson B, Cooper T, El-Hakim H. Factors Associated With the Morphological Type of Laryngomalacia and Prognostic Value for Surgical Outcomes. JAMA Otolaryngol Head Neck Surg. 2014 Sep 4. [Medline].
[Guideline] Institute for Clinical Systems Improvement (ICSI). Preventive services for children and adolescents. 2008 Oct. [Full Text].
Bertrand P, Navarro H, Caussade S, et al. Airway anomalies in children with Down syndrome: endoscopic findings. Pediatr Pulmonol. 2003 Aug. 36(2):137-41. [Medline].
Cotton RT, Richardson MA. Congenital laryngeal anomalies. Otolaryngol Clin North Am. 1981 Feb. 14(1):203-18. [Medline].
Denoyelle F, Mondain M, Gresillon N, et al. Failures and complications of supraglottoplasty in children. Arch Otolaryngol Head Neck Surg. 2003 Oct. 129(10):1077-80; discussion 1080. [Medline].
Fauroux B, Pigeot J, Polkey MI, et al. Chronic stridor caused by laryngomalacia in children: work of breathing and effects of noninvasive ventilatory assistance. Am J Respir Crit Care Med. 2001 Nov 15. 164(10 Pt 1):1874-8. [Medline]. [Full Text].
Gessler EM, Simko EJ, Greinwald JH. Adult laryngomalacia: an uncommon clinical entity. Am J Otolaryngol. 2002 Nov-Dec. 23(6):386-9. [Medline].
Kay DJ, Goldsmith AJ. Laryngomalacia: a classification system and surgical treatment strategy. Ear Nose Throat J. 2006 May. 85(5):328-31, 336. [Medline].
Mancuso RF, Choi SS, Zalzal GH, Grundfast KM. Laryngomalacia. The search for the second lesion. Arch Otolaryngol Head Neck Surg. 1996 Mar. 122(3):302-6. [Medline].
Manning SC, Inglis AF, Mouzakes J, Carron J, Perkins JA. Laryngeal anatomic differences in pediatric patients with severe laryngomalacia. Arch Otolaryngol Head Neck Surg. 2005 Apr. 131(4):340-3. [Medline].
Midulla F, Guidi R, Tancredi G, et al. Microaspiration in infants with laryngomalacia. Laryngoscope. 2004 Sep. 114(9):1592-6. [Medline].
Sivan Y, Ben-Ari J, Soferman R, DeRowe A. Diagnosis of laryngomalacia by fiberoptic endoscopy: awake compared with anesthesia-aided technique. Chest. 2006 Nov. 130(5):1412-8. [Medline].
Smith JL, Sweeney DM, Smallman B, Mortelliti A. State-dependent laryngomalacia in sleeping children. Ann Otol Rhinol Laryngol. 2005 Feb. 114(2):111-4. [Medline].
Thompson DM. Abnormal sensorimotor integrative function of the larynx in congenital laryngomalacia: a new theory of etiology. Laryngoscope. 2007 Jun. 117(6 Pt 2 Suppl 114):1-33. [Medline].