Laryngomalacia

Definition /diagnostic criteria Laryngomalacia is the most common congenital laryngeal anomaly, characterised by excessive collapsibility of the supraglottic structures of the larynx during inspiration, leading to airway obstruction. It is typically diagnosed based on clinical features, notably inspiratory stridor that typically presents within the first few weeks of life.

Epidemiology Laryngomalacia accounts for approximately 70% of laryngeal anomalies in infants and is seen more commonly in males. Most cases are benign and self-limiting, resolving by 18-24 months of age.

Diagnosis
Clinical features: The hallmark of laryngomalacia is inspiratory stridor that usually manifests within the first two months post-birth. This stridor is characteristically worsened by crying, feeding, or lying on the back and improves when the child is prone or asleep.

Other associated symptoms may include feeding difficulties, cough, and cyanotic episodes.

Investigations: Definitive diagnosis is established through laryngoscopy, which reveals omega-shaped epiglottis, short aryepiglottic folds, and prolapse of the arytenoid mucosa. These structural abnormalities lead to dynamic airway collapse during inspiration. However, laryngoscopy is typically reserved for cases where symptoms are severe, atypical, or when there is a failure to thrive.

Treatment The management of laryngomalacia is primarily conservative, as most cases resolve spontaneously. Education and reassurance of parents are essential. For infants with feeding difficulties, techniques like upright feeding and thickened feeds can be beneficial. Pharmacological intervention is not typically indicated.

In severe cases, where there is failure to thrive, significant oxygen desaturations, or severe respiratory distress, surgical intervention may be required. Supraglottoplasty, a procedure to trim the supraglottic tissues to prevent airway collapse, is the surgical treatment of choice. However, this is only considered in approximately 10% of cases.

Prognosis The prognosis for infants with laryngomalacia is generally excellent. The condition often resolves spontaneously by 18-24 months as the laryngeal structures mature and stiffen. In severe cases that require surgical intervention, outcomes are usually positive with significant improvement in airway symptoms post-surgery.