Laryngomalacia

Laryngomalacia is a common condition in infants where soft, floppy tissue in the voice box (larynx) temporarily collapses into the airway when breathing in. This causes noisy breathing, known as stridor. Most cases are mild and resolve on their own as a baby grows, typically by 12 to 24 months of age.

What is Laryngomalacia?

Laryngomalacia is a condition where the soft tissues above a baby's vocal cords in the voice box (larynx) are weaker than usual. When the baby breathes in, these floppy tissues temporarily fall into the airway, causing a high-pitched, noisy sound called stridor. It is the most common cause of noisy breathing in infants.

This condition is often described as having a "floppy larynx." The cartilage, which is the firm but flexible tissue that gives shape to the voice box, is softer than it should be in babies with laryngomalacia. This softness causes the structures above the vocal cords to collapse inward during inhalation. While the noisy breathing can be alarming for parents, laryngomalacia is usually a harmless and temporary condition. It typically improves as the baby grows and the cartilage in their voice box becomes firmer and more mature. Most babies do not experience significant breathing problems or other health issues due to mild laryngomalacia.

Symptoms

The main symptom of laryngomalacia is noisy breathing, specifically a high-pitched sound called stridor, which is heard when a baby breathes in. This sound often becomes louder when the baby cries, feeds, is excited, or lies on their back.

Stridor is usually present from birth or develops within the first few weeks of life. The sound may change in intensity; it can become more noticeable when your baby is upset, feeding, or has an upper respiratory infection. Sometimes, the stridor might improve when your baby lies on their stomach. Most babies with laryngomalacia have mild symptoms, meaning only noisy breathing. However, some infants experience more severe symptoms, which can include difficulty feeding, slow weight gain, choking during feeds, or frequent spitting up (reflux). In the most severe cases, babies may show signs of breathing difficulty, such as the skin sucking in around their ribs or neck (retractions), pauses in breathing, or a bluish tint to their skin or lips (cyanosis).

Causes & risk factors

The exact cause of laryngomalacia is not fully understood, but it is believed to be due to the immature development of the cartilage in a baby's voice box (larynx) or problems with the nerves that control the muscles in this area. It is not considered to be an inherited or genetic condition.

The cartilage that forms the voice box is normally firm enough to keep the airway open. In babies with laryngomalacia, this cartilage is softer and more flexible than it should be, especially in the structures above the vocal cords. This immaturity causes the tissue to collapse into the airway when the baby inhales. Some theories suggest that issues with the neurological control of the larynx muscles might also play a role. This could affect the muscle tone, contributing to the floppiness of the tissue. Laryngomalacia is not linked to any specific risk factors other than being an infant, and it does not appear to run in families.

How it's diagnosed

Laryngomalacia is typically diagnosed by a doctor, often an ear, nose, and throat (ENT) specialist, using a procedure called a flexible fiberoptic laryngoscopy. During this procedure, a thin, lighted tube is gently passed through the baby's nose or mouth to directly view the voice box (larynx).

This diagnostic test allows the doctor to see the structures of the voice box in motion. They can observe how the soft tissues above the vocal cords collapse inward when the baby breathes in, confirming the presence of laryngomalacia. The procedure is usually quick and well-tolerated by infants. Before the laryngoscopy, the doctor will also perform a physical exam and ask about your baby's symptoms, including when the noisy breathing started, what makes it worse or better, and if there are any feeding difficulties or breathing problems. This information helps the doctor understand the severity of the condition.

Treatment options

Most cases of laryngomalacia are mild and do not require specific medical treatment, as the condition usually improves and resolves on its own as a child grows. For babies with severe symptoms, such as significant breathing difficulties or poor weight gain, surgery may be recommended.

For mild cases, doctors often recommend a "watchful waiting" approach. This involves monitoring your baby's symptoms to ensure they are breathing comfortably, feeding well, and gaining weight appropriately. You might be advised to keep your baby upright for a period after feeding to help with any reflux, which can sometimes worsen symptoms. If your baby has severe laryngomalacia that causes significant breathing problems, difficulty feeding, or failure to gain weight, a surgical procedure called supraglottoplasty may be considered. During this surgery, an ENT specialist carefully trims the excess or floppy tissue in the voice box to prevent it from collapsing into the airway. Medications to treat acid reflux may also be prescribed, as reflux can irritate the sensitive tissues of the larynx and make symptoms worse.

Recovery & outlook

The outlook for children with laryngomalacia is generally excellent, as most mild cases improve and resolve completely by 12 to 24 months of age without any intervention. Even for severe cases requiring surgery, the success rate is high, leading to significant improvement in breathing and feeding.

As babies grow, the cartilage in their voice box naturally matures and becomes firmer. This strengthening of the tissue helps it maintain its shape, preventing it from collapsing into the airway. Most children will completely outgrow their noisy breathing and other symptoms. For those who undergo supraglottoplasty, the recovery period is usually short, and most babies show immediate improvement in their breathing and feeding. While some children may have mild stridor that persists for a short time after surgery, the procedure significantly reduces the severity of symptoms and improves their quality of life. Long-term complications are rare, and most children develop normally.

When to see a doctor

You should see a doctor if your baby has noisy breathing (stridor), especially if they show signs of breathing difficulty, struggle with feeding, are not gaining weight well, or have blue spells (cyanosis). Early evaluation can help determine the severity and need for intervention.

Seek immediate medical attention if your baby experiences any of the following emergency signs: severe difficulty breathing, such as rapid breathing, flaring nostrils, or the skin sucking in around their ribs or neck (retractions); pauses in breathing; a bluish tint to their lips, face, or skin (cyanosis); or if they become unusually sleepy or unresponsive. These symptoms indicate a medical emergency. Even if symptoms are not severe, it's important to consult your pediatrician if you notice persistent noisy breathing, if your baby is having trouble feeding, frequently chokes or gags, or is not gaining weight as expected. Your doctor can assess your baby's condition and refer you to an ear, nose, and throat (ENT) specialist if needed for further evaluation and diagnosis.

Frequently asked questions

Is laryngomalacia painful for my baby?

Laryngomalacia itself is not typically painful. However, severe symptoms like difficulty breathing or feeding can cause discomfort and distress for your baby. Acid reflux, which can sometimes accompany laryngomalacia, might also cause discomfort.

Can laryngomalacia affect my baby's development?

For most babies with mild laryngomalacia, development is not affected. However, if the condition is severe and leads to significant feeding difficulties, poor weight gain, or chronic breathing problems, it could indirectly impact development if not properly managed and treated.

Will my child outgrow laryngomalacia?

Yes, most children with laryngomalacia will outgrow the condition. The soft cartilage in their voice box typically strengthens and matures as they grow, and symptoms usually resolve completely by 12 to 24 months of age.

Is laryngomalacia genetic or inherited?

No, laryngomalacia is not considered a genetic or inherited condition. Its exact cause is unknown, but it's thought to be due to the immature development of the voice box cartilage or nerve control issues, rather than genetic factors.

What is supraglottoplasty?

Supraglottoplasty is a surgical procedure used to treat severe laryngomalacia. During the surgery, an ear, nose, and throat (ENT) specialist carefully trims away the excess or floppy tissue in the voice box (larynx) to prevent it from collapsing into the airway and obstructing breathing.

Can reflux make laryngomalacia worse?

Yes, acid reflux can sometimes make laryngomalacia symptoms worse. Stomach acid can irritate the already sensitive and floppy tissues of the voice box, leading to increased swelling and potentially more noticeable noisy breathing (stridor) or discomfort.

Sources

• MedlinePlus — Laryngomalacia
• Mayo Clinic — Laryngomalacia
• Cochrane Library — Laryngomalacia