Harvey's Garden

Airway malacias

2 min read

Laryngomalacia

  • Epidemiology & Risk Factors
    • Most common cause of stridor in infants.
    • Presentation typically begins at 1-2 weeks of age.
    • Peaks at 4-8 months; resolves spontaneously by 12-18 months in >90% of pts.
    • Strongly associated w/ GERD.
  • Clinical Features
    • Inspiratory stridor: Worsens w/ crying, feeding, agitation, or supine position. Improves when prone.
    • Normal phonation/cry (differentiates from vocal cord pathologies).
    • Feeding difficulties (choking, coughing, regurgitation).
    • Severe cases: Cyanosis, apnea, retractions.
  • Diagnosis
    • Initial/Screening: Often a clinical diagnosis based on classic H&P.
    • Confirmatory/Gold Standard: Flexible laryngoscopy in an awake infant.
      • Classic findings: Collapse of supraglottic structures during inspiration, shortened aryepiglottic folds, omega-shaped (Ω) epiglottis.
    • Imaging: X-rays typically not required but may show concurrent conditions (e.g., fluoroscopy/barium swallow if vascular ring suspected).
  • Differential Diagnostics
    • Tracheomalacia: Diff by expiratory stridor; intrathoracic airway collapse. Worsens w/ forced expiration (crying, coughing).
    • Vascular Ring: Diff by biphasic stridor that improves w/ neck extension. Often accompanied by dysphagia (esophageal compression).
    • Vocal Cord Paralysis: Diff by weak cry, hoarseness, biphasic stridor. Hx of difficult delivery or cardiothoracic surgery.
    • Subglottic Stenosis: Diff by biphasic stridor, Hx of prolonged intubation (acquired) or failed extubation.
  • Management
    1. First-line (Mild/Moderate): Reassurance & observation. Upright feeding.
    2. Medical: Acid suppression (PPIs/H2 blockers) if concurrent GERD is present (GERD exacerbates supraglottic swelling and collapse).
    3. Surgical (Severe): Supraglottoplasty. Indicated ONLY for severe symptoms:
      • Failure to thrive (FTT) / poor weight gain.
      • Apnea or cyanotic episodes.
      • Cor pulmonale.
  • Complications
    • Failure to thrive (2° to increased work of breathing and feeding difficulties).
    • Obstructive sleep apnea (OSA).
    • Pulmonary HTN / Cor pulmonale (rare, in severe untreated cases).
    • Aspiration.

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