OVERVIEW

What is laryngomalacia?

Laryngomalacia, also known as congenital laryngeal stridor or congenital laryngeal malacia, is the most common congenital laryngeal abnormality. It refers to the abnormal collapse of supraglottic structures during inspiration, causing a stridor sound similar to "phlegm in the throat." Symptoms worsen during inhalation, low mood, fatigue, crying, agitation, feeding, or lying supine. A few infants may also experience difficulty breathing.

Laryngomalacia is common in infants, with a male-to-female ratio of 2:1. Symptoms typically appear within days to weeks after birth, most commonly at 2 weeks of age. The stridor is loudest between 4–8 months of age and gradually improves by 12–18 months.

The exact cause remains unclear, and different infants may have different underlying mechanisms. Management depends on symptom severity. For most infants with normal growth and development, laryngomalacia is not dangerous and resolves spontaneously without intervention or with conservative treatment. Severe cases affecting breathing or growth may require evaluation by an ENT specialist and even surgical intervention.

Most cases resolve with conservative treatment and do not affect development. For the rare severe cases requiring surgery, prognosis depends on disease severity, surgical approach, and the surgeon's experience.

Is laryngomalacia common?

Laryngomalacia is the most common congenital laryngeal abnormality, often appearing in the neonatal period. Acquired idiopathic laryngomalacia in adults is rare, but reports have increased in recent years due to advances in medical diagnostics.

Are laryngomalacia and congenital laryngeal malformations the same condition?

Both congenital laryngeal malformations and laryngomalacia fall under congenital laryngeal abnormalities, and there may be overlap between them.

Laryngomalacia accounts for about 50%–75% of congenital laryngeal abnormalities. Its cause is unknown, and most cases resolve spontaneously.

Congenital laryngeal malformations primarily involve structural "defects" in laryngeal formation and growth, such as laryngeal cysts, laryngeal webs, congenital subglottic stenosis, laryngeal clefts, or subglottic hemangiomas, which usually require surgical intervention.

Additionally, a very small number of laryngomalacia cases are non-congenital, termed "acquired idiopathic laryngomalacia," caused by factors such as head/neck trauma, nerve damage, or age-related bone decalcification.

SYMPTOMS

What are the common manifestations of laryngomalacia?

Laryngomalacia presents as intermittent (or persistent), low-pitched stridor during inspiration (parents often describe it as the baby having "phlegm in the throat"). Some children may also exhibit snoring.

The baby's crying and coughing sounds remain normal, without hoarseness. The stridor (phlegm-like sound in the throat) worsens during inspiration, emotional distress, fatigue, crying, excitement, feeding, or when the baby has a respiratory infection (cold).

• In mild cases, infants may only have laryngeal stridor during inspiration (worsening during crying, feeding, or lying supine, and possibly improving when prone or on their side), with no other symptoms. They feed well and grow normally. Some infants may only exhibit stridor during sleep or relaxation.
• Moderate cases involve not only laryngeal stridor during inspiration but also marked retractions, coughing, choking, acid reflux, and feeding difficulties.
• Severe cases may include apnea, cyanosis, growth retardation, pulmonary hypertension, cor pulmonale, or even fatal asphyxiation in extreme cases.

Where does laryngomalacia commonly occur?

As the name suggests, it occurs in the larynx, including the supporting cartilage, supraglottic soft tissues, epiglottis, glottis, and surrounding neuromuscular structures.

How does laryngomalacia progress?

Stridor in laryngomalacia may appear as early as the neonatal period, typically around the second week after birth, peaking in loudness at 4–8 months of age. It gradually improves, with most cases resolving by 12–18 months and the latest by 2–3 years.

In cases of acquired idiopathic laryngomalacia, spontaneous resolution is unlikely, and severe cases may require surgical intervention.

What serious complications can laryngomalacia cause?

Severe laryngomalacia may lead to chronic hypoxia, cardiomegaly, pectus excavatum, uncontrolled gastroesophageal reflux (often manifesting as spitting up, coughing, post-feeding crying, and arching), and growth retardation. More severe cases may involve intermittent apnea, episodic cyanosis, respiratory distress, heart failure, or even fatal asphyxiation in extreme cases.

CAUSES

What is the cause of laryngomalacia?

The exact cause of laryngomalacia remains unclear, but several possible mechanisms include: immature development or low tension of laryngeal cartilage structures, excessive supraglottic soft tissue, short or tight aryepiglottic folds, neuromuscular disorders, and supraglottic edema (possibly caused by gastroesophageal reflux).

Laryngeal cartilage softening causes the epiglottis to curl backward and inward during inhalation, coming into contact with the larynx. The folds of the epiglottis and the arytenoid cartilage are drawn into the larynx, obstructing the entrance and leading to breathing difficulties. Stridor occurs due to vibrations of the aryepiglottic folds.

Who is more likely to develop laryngomalacia?

Laryngomalacia primarily occurs in infants, with symptoms appearing from the neonatal period.

Is laryngomalacia hereditary?

There is no genetic predisposition, and currently, no research reports suggest hereditary factors for this condition.

DIAGNOSIS

How is laryngomalacia diagnosed?

When diagnosing laryngomalacia, doctors primarily rely on symptoms and physical examination for an initial assessment. To confirm the diagnosis, direct laryngoscopy or fiberoptic laryngoscopy may be performed.

What tests are needed for laryngomalacia?

For infants with mild inspiratory stridor, an experienced pediatrician or ENT specialist may make a clinical diagnosis directly without further testing.

Patients with severe or progressive symptoms, apnea, cyanosis, or growth retardation require evaluation by an ENT specialist and may undergo direct laryngoscopy or fiberoptic laryngoscopy.

What conditions can laryngomalacia be confused with? How to differentiate them?

Besides laryngomalacia, other conditions can also cause inspiratory stridor, such as laryngeal disorders (congenital laryngeal cysts, laryngeal hemangiomas, subglottic stenosis, vocal cord paralysis, etc.), tracheal abnormalities (congenital tracheal webs, tracheal stenosis, tracheomalacia or malformation, neck tumors, enlarged lymph nodes, or thymus compressing the trachea or bronchi), or micrognathia.

In addition to clinical symptoms and physical examination, doctors may perform endoscopic examinations or other relevant tests, such as X-rays or CT scans, based on the specific situation.

TREATMENT

Which department should I visit for laryngomalacia?

Pediatrics or otolaryngology (ENT).

Can laryngomalacia heal on its own?

Most children with mild laryngomalacia improve spontaneously by 12–18 months of age, and no later than 2–3 years. However, severe congenital laryngomalacia may require medication or surgical treatment. Acquired idiopathic laryngomalacia typically does not resolve on its own, and severe cases may need surgery.

How is laryngomalacia treated?

Mild congenital laryngomalacia usually requires no specific treatment and resolves on its own.

For moderate or severe cases with gastroesophageal reflux, acid-suppressing medications may be prescribed under the guidance of an experienced pediatrician, with regular follow-ups due to potential risks for infants.

Surgery may be recommended for severe or life-threatening cases.

Can expectorants be used for the "phlegm-like sound" in laryngomalacia? Will not treating it lead to pneumonia?

The "phlegm-like sound" is not actual phlegm but caused by laryngeal abnormalities, which do not affect the lungs. Expectorants are ineffective for laryngomalacia and are not recommended. Not treating this "phlegm" will not cause pneumonia.

Does laryngomalacia require hospitalization?

Mild cases need neither medication nor hospitalization—regular outpatient follow-ups suffice. Severe cases require hospitalization for prompt symptomatic management or surgery.

What are the common risks of surgical treatment for laryngomalacia?

Possible complications include surgical scar formation, adhesion of the epiglottis to the tongue base, chronic aspiration, and dysphonia.

How long is the recovery period after surgery for laryngomalacia?

Recovery time varies depending on the extent of surgery. Procedures like epiglottoplasty or laryngoplasty typically require 1–2 weeks of hospitalization, with full recovery taking about 3 months.

Can laryngomalacia be completely cured?

This depends on symptom severity, surgical approach, and the surgeon’s expertise.

Non-surgical cases can resolve spontaneously. Most surgical patients experience symptom relief, though a few may require reoperation—e.g., due to insufficient tissue removal or supraglottic stenosis.

DIET & LIFESTYLE

What should patients with laryngomalacia pay attention to in their diet?

For infants with mild congenital laryngomalacia, no special dietary precautions are needed—normal feeding is sufficient. However, care should be taken to avoid choking on milk, and burping and upright holding after feeding are recommended.

For moderate to severe cases, small, frequent meals are advised. If gastroesophageal reflux is suspected, under a doctor's guidance, consider increasing food thickness (except for premature or overweight infants), avoiding cow's milk-based diets, and breastfeeding mothers may try eliminating allergens (e.g., avoiding milk and eggs for at least 2 weeks). Burp and hold the baby upright (e.g., over the shoulder) for 20–30 minutes after each feeding.

What should laryngomalacia patients pay attention to in daily life? How to care for a baby with laryngomalacia?

• Although some infants may experience symptom relief in the prone position, to reduce the risk of sudden infant death syndrome (SIDS), babies under 12 months should sleep on their backs. Exceptions include severe gastroesophageal reflux cases (e.g., neurologically impaired infants or those at high risk of aspiration), where prone positioning may be advised under medical supervision with constant monitoring.
• Avoid exposure to tobacco smoke.
• Prevent colds and illnesses. Family members should wash hands after returning home, and sick individuals should isolate, wear masks, and practice hand hygiene. Vaccinations are encouraged for disease prevention.
• Ensure adequate vitamin D intake: 400 IU daily before age 1, and 600 IU daily after (per AAP guidelines; Chinese guidelines recommend 400 IU daily).

What should be noted after laryngomalacia surgery? How to provide postoperative care?

• Follow the doctor’s instructions for temporary fasting, then start with small amounts of food, gradually increasing to train epiglottis function and prevent choking.
• For infants, nasogastric tube feeding is typically recommended for about 3 months post-surgery. Avoid excessive crying, shouting, or vigorous activity to allow throat rest.
• Family members should practice hand hygiene to prevent infections like colds.

PREVENTION

Can laryngomalacia be prevented?

There are currently no effective methods to prevent this condition.

How to prevent recurrence of laryngomalacia?

Provide attentive care and reduce the occurrence of gastroesophageal reflux (refer to dietary and lifestyle precautions for laryngomalacia).

How can patients with laryngomalacia prevent complications?

Patients with moderate to severe symptoms should seek medical attention promptly and undergo surgery if indications are met.