Laryngomalacia is the most common cause of noisy breathing in infants. More than half of infants have noisy breathing during the first week of life, and most develop this by two to four weeks of age. Rarely, laryngomalacia occurs in older children, or adults, particularly those with other medical problems.

What is Laryngomalacia?

Laryngomalacia, or ‘soft larynx’, is caused by floppiness of the laryngeal tissues above the vocal cords. With breathing in, the tissues above the vocal cords fall in towards the airway and cause partial obstruction. This creates stridor, or noisy breathing due to obstruction at the level of the voice box. Typically the folds of tissue between the front and back of the voice box (aryepiglottic folds) are shortened. This causes the epiglottis to curl inward (become “omega-shaped”) and causes the tissue over the cartilage in the back of the voice box (arytenoids) to suck into the airway.

What Are the Signs and Symptoms of Laryngomalacia?

  • Harsh noisy breathing on inhaling (stridor)
  • Stridor may be louder with exertion, feeding and crying. It also may be worse when lying on the back, and quieter when sleeping or resting.
  • Stridor will typically get louder over the first several months of life, as an infant gets stronger, then to improve over the first year of life.
  • Signs of more severe laryngomalacia include difficulty feeding, increased effort in breathing, poor weight gain, pauses in the breathing or frequent spitting up.

How is Laryngomalacia Diagnosed?

Laryngomalacia can be suspected or presumptively diagnosed by taking the patient’s history and physical exam. Diagnosis can be confirmed with an in-office laryngoscopy/nasopharyngoscopy in an awake child. This allows the dynamics of the voice box to be fully evaluated. If the laryngoscopy in the office is not consistent with laryngomalacia, then further testing may be recommended.

How is Laryngomalacia Treated?

The vast majority of infants with laryngomalacia will improve without intervention. Seventy percent of infants will have resolution of stridor by 1 year of age, and 90 percent by 2 years of age. Sometimes medications are recommended to help control associated symptoms like acid reflux from the stomach (GERD), as this condition may worsen the symptoms of laryngomalacia.

For severe symptoms that are resulting in poor feeding or poor weight gain, pauses in the breathing (apnea) or turning blue (cyanosis), surgical treatment may be recommended. Surgery for this condition is called supraglottoplasty and can usually be performed through telescopes and instruments that allow access to the voice box through the mouth. Rarely, more invasive procedures might be recommended. Pediatric otolaryngologists at Nationwide Children’s have several years of additional training in specialized techniques for the treatment of laryngomalacia.

If My Child has Laryngomalacia, When Should I be Concerned?

It can be difficult for a parent or family member to discern the severity of a breathing problem when a child has laryngomalacia. If you are concerned, seek medical evaluation immediately.

In particular, signs that indicate more severe conditions include: irritability, poor feeding, pulling in of the skin at the collar bone, between the ribs, or under the ribs, flaring of the nose, increasing effort to breathe, and poor weight gain or weight loss, especially in infants.

Symptoms that should trigger emergency evaluation include: pauses in the breathing, color change of the skin (particularly if the lips, face or hands are turning blue), appearing lethargic or tired, or any other sudden change from a child’s normal breathing pattern. If any of these or other concerning signs develop, please seek immediate medical attention.