Laryngomalacia, or floppy larynx, is commonly seen in newborns and presents anywhere from birth to 2 months as a sharp inspiratory stridor which is worse when feeding, sleeping or distressed.
The diagnosis of laryngomalacia can be made on clinical history and examination alone. Other than the characteristic inspiratory stridor, worsening with feeding, sleeping or distress, there may be mild associated increased work of breathing and/or aphonia.
More invasive investigations are generally reserved for those with associated symptoms (harsh cough, failure to thrive, aspiration or significant feed difficulties, obstructive symptoms or apnoea).
Other congenital airway abnormalities generally present with other features:
- tracheomalacia - inspiratory stridor and harsh cough
- bronchomalacia - no stridor, central low pitched wheeze
- laryngeal web - mild to severe stridor, generally from birth, sometimes with weak cry
- tracheo-esophageal fistula or cleft - excess secretions, choking, cyanosis, cough with feeds
- vascular ring - vomiting, brassy cough, worse with crying, feeding or neck flexion
- Laryngomalacia is generally a benign, self-limiting condition that does not require further investigation or management.
- Infants with associated symptoms require further investigation (harsh cough, failure to thrive, aspiration or significant feed difficulties, obstructive symptoms or apnoea)
- Children with a past history of laryngomalacia can then have episodes of mild stridor with infections or stress - this does not equate to a diagnosis of croup.
No routine investigations are required for uncomplicated laryngomalacia. For those infants with associated symptoms (see Diagnosis above), referral to ENT or respiratory services for laryngoscopy +/- bronchoscopy is reasonable.
Layngomalacia is benign and self-limiting, generally stopping some time between 4-18 months of age. Children with a past history of laryngomalacia can then have episodes of mild stridor with infections or stress - this does not equate to a diagnosis of croup.
- Referral to paediatric outpatient services is not required for uncomplicated laryngomalacia, this can be safely managed in the general practice setting.
- Referral to paediatric outpatient services is reasonable for infants with associated symptoms (see Diagnosis above) to exclude other causes and consider ENT/respiratory referral.
- Referral to ENT services for laryngoscopy is appropriate for laryngomalacia with associated symptoms (see Diagnosis above).