Laryngomalacia

Background

  • Common cause of inspiratory stridor in infants and children
  • Characterized by collapse of supraglottic tissue during inspiration
    • Differs from tracheomalacia in that this pathology involves soft tissue rather than tracheal cartilage
  • Etiology not well-known, possible mechanisms include redundant neck tissue, neurologic causes
  • Typically presents as early as 2 years of life, resolves by 2 years of age[1]

Clinical Features

Omega shaped epiglottis, seen in laryngomalacia.
Left, severe laryngomalacia with epiglottic collapse with inspiration; Right, tight aryepiglottic folds and redundant arytenoid mucosa with inspiration.

Differential Diagnosis

Pediatric stridor

<6mo

  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Diagnosed with flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs secondary to prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated with skin hemangiomas in beard distribution
  • Vascular ring/sling

>6mo

  • Croup
    • viral laryngotracheobronchitis
    • 6 mo - 3 yr, peaks at 2 yrs
    • Most severe on 3rd-4th day of illness
    • Steeple sign not reliable- diagnose clinically
  • Epiglottitis
    • H flu type B
      • Have higher suspicion in unvaccinated children
    • Rapid onset sore throat, fever, drooling
    • Difficult airway- call anesthesia/ ENT early
  • Bacterial tracheitis
    • Rare but causes life-threatening obstruction
    • Symptoms of croup + toxic-appearing = bacterial tracheitis
  • Foreign body (sudden onset)
    • Marked variation in quality or pattern of stridor
  • Retropharyngeal abscess
    • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Evaluation

Diagnosis

  • Confirmed with fiberoptic laryngoscopy by pediatric ENT
  • Should also evaluate for other associated anomalies (e.g., esophageal atresia)

Management

  • Mild (mild stridor with no other symptoms):
    • Frequent monitoring with PCP to ensure adequate weight gain
  • Moderate/severe:
    • Referral to ENT

Disposition

See Also

External Links

References

  1. Shah UK, Wetmore RF. Laryngomalacia: a proposed classification form. Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):21-6. doi: 10.1016/s0165-5876(98)00111-6. PMID: 10190701.