Laryngomalacia is a condition of the voice box that results in noisy breathing. It occurs when the soft tissues of the voice box pull into the airway when a person inhales.

Another symptom of this condition may include the neck and chest muscles sinking during inhalation. In severe cases, a person may experience trouble breathing.

The main method of diagnosing laryngomalacia is a flexible fiberoptic laryngoscopy. This procedure allows doctors to see inside the airway and upper digestive tract.

Doctors often recommend conservative treatments, such as holding an infant upright during feeding. However, in some cases, surgery may be necessary.

This article examines the causes, symptoms, diagnosis, treatment, and outlook of laryngomalacia. It also discusses how parents and caregivers can support children with the condition and when they should seek medical attention.

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Laryngomalacia means “soft larynx.” The larynx is the area of the throat that contains the vocal cords, and some people may call it the voice box. Some infants may be born with the condition.

Laryngomalacia can cause stridor. This refers to a high-pitched, squeaky, or noisy sound that a person might experience when they inhale. It is the most typical symptom of laryngomalacia.

The severity of the condition generally tends to be mild, but it can be serious in 10–20% of cases involving infants.

Other names for this condition include congenital laryngomalacia or congenital laryngomalacia stridor.

Learn more about the larynx.

Laryngomalacia is often apparent at birth or shortly afterward. It is the most common cause of noisy breathing in infants.

Stridor is frequently worse when babies cry or when they are lying on their backs. It can also worsen with feeds.

Doctors are unsure about the incidence of this condition in the general population. Some estimate that 1 in 2,000–3,000 people have laryngomalacia. Additionally, the incidence may be higher among Black or Hispanic infants than among white infants.

Another factor that may play a role in laryngomalacia is low birth weight.

Researchers do not know the exact cause of laryngomalacia, but it may stem from immaturity and low muscle tone in the upper airway.

Weakness in the upper airways may cause the soft tissue of the larynx to pull into the airway during inhalation. This causes a temporary partial blockage during breathing, which leads to stridor.

The stridor does not occur during exhalation — when the larynx moves out of the airway — and enables it to open fully.

Additionally, experts believe there is a strong link between gastroesophageal reflux disease (GERD) and laryngomalacia. Some signs of GERD include heartburn, nausea, swallowing issues, and others.

Symptoms of include:

  • Stridor: An atypical, high-pitched sound that doctors may find when assessing someone’s breathing.
  • Sinking of the neck and chest muscles: This occurs during inhalation but is usually mild.
  • Gastroesophageal reflux: Many babies experience this, including those with laryngomalacia. It occurs when acid or food in the stomach flows backward into the esophagus, or food pipe, and into the throat. This can cause inflammation in the larynx, which worsens the stridor.

In severe cases, symptoms may include:

As laryngomalacia can affect many aspects of growth and development, it is important for a child to receive a diagnosis in early infancy.

Doctors use the following in the diagnostic process:

  • History: This includes noting surgeries that the child may have undergone as well as their feeding habits.
  • Physical exam: This focuses on the head, neck, and mouth cavity.
  • Flexible fiberoptic laryngoscopy: This procedure is the main method of diagnosis and usually takes place at a doctor’s office. It involves using a camera or mirror to allow doctors to see the airway and upper digestive tract during breathing.
  • CT dynamic airway or airway fluoroscopy: Healthcare professionals may carry out these tests if there are any concerns of additional airway issues.
  • Polysomnogram: This test shows the presence and extent of obstructive sleep apnea, which refers to frequent interruptions in breathing during sleep.

If doctors suspect that the child has another airway issue, they may use direct laryngoscopy along with another procedure called bronchoscopy.

If the doctor has any additional concerns about the child’s swallowing, they may conduct a swallow study. This test shows what happens in the esophagus and throat while a person is swallowing. Doctors may also assess a person using speech therapy.

Treatment for laryngomalacia depends on the severity of the condition.

Mild to moderate cases

Feeding and breathing issues may determine the severity of the condition.

In mild cases of laryngomalacia, where noisy breathing alone is present and there are no associated feeding problems, doctors may recommend observation rather than treatment.

In moderate cases, children may experience nosy breathing alongside issues with feeding, airway obstruction, and GERD.

However, in cases involving feeding problems, doctors may advise conservative measures, such as thickening the consistency of feed or keeping the infant in an upright position for 15–30 minutes after feeding.

Treatments include reflux medications, such as H2 blockers or protein-pump inhibitors. These aim to reduce the production of acid in the stomach.

Symptoms go away in most people, meaning surgery is often unnecessary.

Treatment of severe cases

Around 10–20% of infants with laryngomalacia may experience severe problems. They may have issues with feeding and:

  • failure to thrive or problems with weight gain
  • apnea, or breathing difficulties
  • cyanosis, or skin turning blue

These cases frequently require surgery, and when this happens, supraglottoplasty is the initial treatment of choice.

Supraglottoplasty involves removing or dividing some tissue within the larynx. This procedure occurs under general anesthesia, and infants generally tolerate it well.

Symptoms of laryngomalacia may resolve when the infant is 18 to 24 months old. In the majority of children, conservative management, such as upright feeding and close observation of breathing, are the only measures that may be necessary.

The outlook is also positive for infants who need surgery, with some studies estimating the success rate as high as 95%.

Of those who undergo surgery, some may need multiple procedures for lingering symptoms. This is more likely if the first surgery occurs in infants younger than 2 months old or in those with serious co-occurring health conditions.

The American Thoracic Society (ATS) recommends the following measures to support children with laryngomalacia:

  • keeping scheduled doctor appointments
  • monitoring the infant for signs that the condition is worsening
  • following up with the doctor for frequent weight checks
  • using feeding techniques that reduce the likelihood of gastrointestinal reflux, such as keeping the infant upright after feeding or thickening feeds
  • providing pauses and breaks during feeding to let infants catch their breath

Children should receive medical attention if they:

  • turn blue or experience pauses in breathing
  • have breathing problems, such as a sinking neck and chest for prolonged periods
  • have feeding problems, such as choking or not feeding enough
  • lose weight or do not gain enough weight

Laryngomalacia is the leading cause of stridor in infants. Although it is generally mild, it can sometimes be severe. Some other symptoms that infants may experience include the sinking of the neck and chest muscles during inhalation as well as gastroesophageal reflux.

Doctors do not know the exact cause of the condition, but it may stem from weakness in the upper airway.

While the diagnostic process involves a history and physical exam, the most important part is flexible fiberoptic laryngoscopy.

Mild to moderate cases usually need conservative or no treatment because the symptoms often resolve. Conversely, severe cases often require surgery, which is effective in most children.