#149: Squeaks, Squawks, and Stridor: Approach to Laryngomalacia

August 13, 2025 | By Sam Masur

Audio

Summary:

What’s that sound? It’s Dr. Eileen Raynor (Duke) walking us through laryngomalacia—why it happens, how to recognize it, who to scope, and when to supraglottoplasty your way to success. Luckily, laryngomalacia is usually just a phase, but this episode will help you and your patients breathe easier!

Laryngomalacia Pearls

1. Laryngomalacia is the most common cause of stridor in infants and typically resolves by one year of age without intervention. 
2. Gastroesophageal reflux can worsen symptoms by increasing upper airway inflammation, so reflux precautions and acid suppression can be helpful.
3. Infants with persistent feeding difficulties, growth faltering, or respiratory distress warrant referral to ENT for flexible laryngoscopy and potential surgical repair with supraglottoplasty.

Laryngomalacia Notes 

What is laryngomalacia?

Laryngomalacia is when there is excess or floppy tissue overlying the vocal cords. This tissue collapses inwards to cover the larynx during inspiration, causing obstruction and stridor. 

There are subtypes of laryngomalacia based on which structures are abnormal on laryngoscopy (e.g. floppy arytenoids, enlarged corniculate cartilages, shortened aeroepiglottic folds, omega-shaped epiglottis), but all of these structural abnormalities result in dynamic airway obstruction during inspiration. 

Pathophysiology

The pathophysiology is unknown. Infants with global hypotonia and premature infants are at increased risk, but many infants with laryngomalacia are otherwise healthy babies.

Many (but not all) infants with laryngomalacia also have gastroesophageal reflux (GER). GER can make laryngomalacia worse by causing upper airway inflammation, which worsens the upper airway obstruction. 

Special populations

Infants with Trisomy 21 may be more symptomatic. In addition to global hypotonia, they often have enlarged tongues (macroglossia) that worsen airway obstruction.

Comorbid vocal cord paralysis can also make symptoms worse. Vocal cord paralysis is most common in infants with a history of cardiac surgery, because the recurrent laryngeal nerve (which innervates the vocal cords) wraps around the aorta and can be injured during surgery. Other risk factors are Chiari malformation or prolonged endotracheal intubation.

Clinical Presentation

The most common symptom is inspiratory stridor. In a typical airway, air can flow smoothly through the open vocal cords into the pharynx, trachea, and lungs. In laryngomalacia, the excess or floppy laryngeal tissue collapses during inspiration and blocks the airflow. This introduces turbulence into the airflow, which produces a noise. 

Because the tissue only collapses and causes a partial obstruction during inspiration, infants only have inspiratory stridor (rather than biphasic or expiratory stridor).

Parents sometimes describe stridor as sounding “congested” or “snotty,” and symptoms are typically worse with feeding, agitation, or when lying flat. Inspiratory stridor may go away completely when the baby is calm.

Other symptoms:

• Feeding difficulties and/or growth faltering
• Frequent regurgitation
• Retractions
• Cyanosis
• Apnea

What else is on the differential for stridor?

Inspiratory stridor is typically caused by a supraglottic or glottic obstruction. 

• Laryngomalacia (most common)
• Vocal cord paralysis
• Laryngeal cyst
• Vallecular cyst
• Thyroglossal duct cyst
• Lingual thyroid
• Infection (croup, epiglottitis)

Biphasic stridor is typically caused by a fixed subglottic obstruction. 

• Subglottic stenosis (either congenital or acquired)
• Laryngeal web
• Subglottic cyst
• Subglottic hemangioma

Expiratory stridor is typically caused by a tracheal obstruction.

• Tracheobronchomalacia
• Vascular ring
• Complete tracheal rings
• Tracheal stenosis

Expert tip: Expiratory stridor and wheezing can overlap, and both are best heard listening with a stethoscope over the lungs.

Diagnosis

Mild laryngomalacia can be diagnosed clinically by a primary care provider. 

Reasons to refer to ENT include weight faltering or respiratory issues (e.g. apnea, cyanosis, retractions).

Flexible laryngoscopy

A diagnosis of laryngomalacia is made by visualizing the collapse of laryngeal tissues during inspiration. This is typically done with a flexible laryngoscope. 

A flexible laryngoscopy is a procedure done in the ENT office that does not require sedation or anesthesia. It allows for direct visualization of supraglottic structures during inspiration and expiration (helpful video demonstration of a flexible laryngoscopy on an awake patient).

Image from Laryngomalacia and Tracheomalacia: Common Dynamic Airway Lesions

Expert tip: While flexible laryngoscopy definitively diagnoses laryngomalacia, the severity (and need for treatment) is determined by symptoms.

Treatment

Most cases of laryngomalacia resolve by 1 year of age without any treatment. As the child grows, the structures surrounding the airway grow, the laryngeal cartilage becomes stiffer, and any underlying GER improves. These changes usually lead to resolution of laryngomalacia without intervention. 

Treatment is only needed when laryngomalacia is impacting growth or respiratory status.

Non-pharmacologic treatment

Reflux precautions can help reduce GER, which can worsen laryngomalacia by causing laryngeal edema. Dr. Raynor recommends upright positioning during and after feeding, as well as side-lying or inclined sleeping.

Thickened feeds can also help reduce GER. Dr. Raynor recommends starting with thickening evening feeds, as infants are more likely to experience reflux overnight while lying down.

Pharmacologic treatment

Anti-reflux medications like H2 antagonists or proton pump inhibitors help treat underlying GER. If severe GERD is contributing, Dr. Raynor will refer to a gastroenterologist.

Surgery

Indications to consider surgery include significant impact on growth or respiratory status. There’s no specific criteria, but rather the decision to proceed with surgery is a clinical decision that accounts for the child’s age, development, comorbidities, and symptom burden.

Surgical repair of laryngomalacia is called a supraglottoplasty. The specifics of the supraglottoplasty depend on the infant’s anatomy, but relieves the upper airway obstruction by stretching or removing the tissue causing the obstruction.

Prior to surgical repair, many infants will typically undergo a bronchoscopy to evaluate for any other airway lesions that could be contributing to symptoms.

Laryngomalacia in the inpatient setting

According to Dr. Raynor, there’s no specific therapy that’s recommended for infants with laryngomalacia who are hospitalized for respiratory illnesses like croup or bronchiolitis. However, they may experience more respiratory distress and/or require a higher level of care due to the impact of inflammation on their underlying anatomy. 

Surgical repair is almost never recommended during an acute viral illness.

Dr. Raynor acknowledges that these can be challenging cases with challenging airway management. She recommends close partnership between ENT, pulmonology, the primary team, and the family. 

Expert tip: Call your peds ENT or anesthesia colleagues for backup prior to attempting intubation on a baby with known severe laryngomalacia!

Goal

Listeners will explain the pathophysiology, diagnosis, and management of laryngomalacia to improve recognition, appropriate referrals, and supportive care in both inpatient and outpatient settings.

Learning Objectives

After listening to this episode, listeners will…

1. Define laryngomalacia and explain how dynamic airway obstruction leads to inspiratory stridor.
2. Describe the clinical presentation of laryngomalacia, including common symptoms and factors that worsen stridor.
3. Differentiate laryngomalacia from other causes of stridor based on history, exam findings, and stridor timing.
4. Identify indications for ENT referral and the role of flexible laryngoscopy in diagnosis.
5. Discuss management strategies for laryngomalacia, including conservative measures, pharmacologic treatment, and surgical indications.
6. Recognize the impact of laryngomalacia in hospitalized infants and describe considerations for airway management.

Disclosures

Dr. Raynor reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Lidsky H, Raynor E, Masur S, Chiu C, Berk J. “#149: Squeaks, Squawks, and Stridor: Approach to Laryngomalacia”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 13th, 2025.