Laryngomalacia

Background

Cross section of a trachea and esophagus anatomy.

Tracheal anatomy.

• 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

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.

• Inspiratory stridor (peds), especially during sleep
• Snoring
• Dysphagia
• Gastroesophageal reflux disease

Differential Diagnosis

Pediatric stridor

<6 Months Old

• 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

>6 Months Old

• 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

See Also

• Tracheomalacia