Laryngomalacia, tracheomalacia and vocal-cord dysfunction: Case

This infant has severe laryngomalacia. Her position-dependent inspiratory stridor from three weeks of age, worse with feeding and supine posture, localises the lesion to the supraglottis; but unlike the benign majority she has crossed into severe disease, with feeding failure, cyanotic episodes and apnoea during feeds, and faltering growth from the 25th to below the 3rd centile. The clinical task is to confirm the diagnosis, exclude a second airway lesion, and plan surgical relief of the obstruction. [2]

Clinical findings

The key findings are the inspiratory stridor at rest with recession, its worsening with feeding and supine posture, the prolonged tiring feeds with coughing and back-arching, the witnessed cyanotic pauses, and the crossing of weight centiles downward. Together these define severe laryngomalacia rather than the mild disease that needs only reassurance. The normal cry is reassuring against a vocal-cord palsy, but the presence of apnoea and cyanosis is a red flag that mandates urgent airway assessment. [1]

The candidate should articulate a clear problem representation: a four-month-old with severe laryngomalacia causing feeding failure, apnoea and faltering growth, requiring airway endoscopy and surgical intervention. This single statement names the diagnosis, the severity and the plan, and signals that this child is in the small minority who need more than observation. [3]

Investigations

The diagnostic investigation is awake flexible nasolaryngoscopy, which shows the dynamic supraglottic collapse of laryngomalacia — an omega-shaped epiglottis, short aryepiglottic folds and redundant arytenoid mucosa drawn into the airway on inspiration. It is performed with the infant awake and spontaneously breathing, because the collapse is dynamic and is masked under deep anaesthesia. [1]

Because she has severe and progressive disease, she also needs a full airway endoscopy under anaesthesia — microlaryngoscopy and bronchoscopy — both to plan the supraglottoplasty and to exclude a synchronous second airway lesion, which is present in a significant minority of infants with laryngomalacia. A feeding and swallowing assessment, an evaluation for gastro-oesophageal reflux, and growth and nutrition review complete the work-up, as reflux frequently coexists and contributes to severity. [3]

Management

The management of severe laryngomalacia with feeding failure, apnoea and faltering growth is surgical. Supraglottoplasty divides the short aryepiglottic folds and trims the redundant arytenoid mucosa to relieve the inspiratory obstruction, and it resolves or greatly improves symptoms in most children. Before and around surgery she needs nutritional support to reverse the faltering growth, which may include thickened or supplemented feeds or temporary nasogastric feeding, and treatment of any contributing reflux. [1]

The candidate should recognise the small group who fail supraglottoplasty or who have significant comorbidity, and who may need revision surgery or, rarely, a tracheostomy, and the recognised surgical risks of supraglottic stenosis and aspiration, particularly with bilateral surgery or in the neurologically impaired child. A perioperative plan for airway monitoring and feeding is part of a complete answer. [3]

Progress and communication

After a successful supraglottoplasty the stridor and feeding improve, the cyanotic episodes stop, and weight gain resumes, and the child is followed to confirm catch-up growth and the resolution of symptoms. The candidate should be able to counsel the family honestly and clearly: that the noisy breathing came from a soft voice box, that in her case it became severe enough to affect feeding and growth and to cause the frightening blue episodes, that surgery is needed to relieve it, and that most children do very well afterwards. [2]

A concrete safety-net completes the communication: the family are told to return immediately if there is recurrent colour change, apnoea, worsening feeding or weight loss, and are reassured that they will have specialist airway follow-up. This behaviour-based, plain-language explanation of a severe but treatable condition is exactly the communication skill the clinical exam rewards. [1]