By Benjamin B. Cable, MD — board-certified otolaryngologist, fellowship-trained in pediatric otolaryngology.
The short answer
- Laryngomalacia is the most common cause of noisy breathing (stridor) in infants. Soft tissue above the vocal cords collapses inward when the baby breathes in.
- Most babies with laryngomalacia feed and grow normally and outgrow it, usually by 12 to 24 months, with no surgery.
- A minority have red flags: poor weight gain, trouble feeding, pauses in breathing, or hard work of breathing. Those babies need prompt evaluation.
- When surgery is needed, the operation is called a supraglottoplasty. Dr. Cable co-authored the published classification that sorts these operations into three types.
What is laryngomalacia?
Laryngomalacia means “soft larynx.” In some newborns the tissues just above the vocal cords — the epiglottis, the arytenoids, and the folds that connect them — are floppy. When the baby breathes in, that tissue is pulled into the airway and vibrates, producing a high-pitched squeaking sound called inspiratory stridor.
Parents usually notice it in the first few weeks of life. It is typically louder when the baby is feeding, crying, excited, or lying on the back, and quieter when the baby is calm.
Will my baby outgrow it?
In most cases, yes. The noise often gets louder over the first several months as the baby breathes more forcefully, then gradually fades as the airway grows and the tissue firms up. For most children it has resolved by 12 to 24 months of age. Babies with mild laryngomalacia need observation, reassurance, and weight checks — not an operation.
What are the red flags?
These signs suggest laryngomalacia that is more than mild and should be evaluated promptly by a pediatric ENT:
- Poor weight gain or falling off the growth curve
- Choking, coughing, or turning dusky during feeds, or feeds that take a very long time
- Pauses in breathing (apnea), especially during sleep
- Visible pulling-in of the skin at the neck, between the ribs, or below the breastbone with each breath
- Bluish color around the lips
- Frequent spitting up along with worsening noisy breathing
Call 911 or go to the nearest emergency room if your baby is struggling to breathe, turns blue, or stops breathing.
How is laryngomalacia diagnosed?
The diagnosis is made in the office with a flexible laryngoscopy. A thin, flexible camera is passed through the baby’s nose while the baby is awake, so the voice box can be watched as the baby breathes. It takes a minute or two and needs no sedation. If the exam and the symptoms do not match, or if a second airway problem is suspected, a more complete airway evaluation in the operating room may be recommended. Learn more about airway and breathing problems in children.
When is surgery actually needed?
Surgery is reserved for the minority of babies whose laryngomalacia interferes with feeding, growth, or safe breathing. The operation is a supraglottoplasty: through the mouth, under general anesthesia, the surgeon trims or releases the specific tissue that is collapsing. There are no incisions on the outside of the neck.
What do supraglottoplasty types 1, 2, and 3 mean?
For years, surgeons used the single word “supraglottoplasty” for what were really several different operations, which made it hard to compare results. In 2018, Dr. Cable and colleagues at Tripler Army Medical Center reviewed 231 published articles to sort this out. Only 53 of them (1,669 patients) described the operation in enough detail to analyze; another 84 articles covering 5,731 patients did not, meaning roughly 77% of the patients in the literature could not be assessed by technique. Across the usable studies the team found eight variations of supraglottoplasty and four variations of epiglottis surgery, and consolidated them into three types:
- Type 1 — debulking of the arytenoids: removing redundant tissue over the back of the voice box that falls forward into the airway.
- Type 2 — division of the aryepiglottic folds: releasing the short, tight folds that tether the epiglottis and pull the airway closed.
- Type 3 — epiglottis surgery: addressing an epiglottis that folds or falls backward over the airway.
The point of the classification is a shared language. When surgeons report exactly which type they performed, families and physicians can see which operation works for which pattern of collapse. Many children need a combination, chosen according to what the camera shows.
Does surgery cure sleep apnea caused by laryngomalacia?
It helps, but it is often not a complete cure. In a 2016 meta-analysis on which Dr. Cable was senior author, the team searched nine databases, screened 517 studies, and found 13 that met criteria, covering 138 children aged 1 month to 12.6 years. After supraglottoplasty, both the number of breathing interruptions per hour and the lowest oxygen level during sleep improved. However, most children were not fully cured of sleep apnea. For families, that means a follow-up sleep evaluation after surgery matters, and some children need additional treatment.
When should I see a pediatric ENT?
If your baby’s breathing is noisy and you are seeing any of the red flags above, or if you simply want a clear diagnosis, an evaluation is reasonable. Dr. Cable completed a two-year pediatric otolaryngology fellowship at the University of Iowa and has taught pediatric airway endoscopy courses in the United States and abroad. Read more about his work as a pediatric airway specialist, about pediatric ENT care, or see his full publication record.
Dr. Cable sees infants and children at the Frisco office on Teel Parkway and at the McKinney office of ENT and Allergy Centers of Texas. When surgery is needed, the setting is chosen according to the child’s age and medical needs. Call (972) 984-1050.
Frequently asked questions
Is laryngomalacia dangerous?
In most babies, no. Laryngomalacia is usually mild: the breathing is noisy, but the baby feeds well, grows well, and is comfortable. A smaller group of infants have trouble feeding, gaining weight, or breathing, and those babies need closer evaluation and sometimes surgery.
Will my baby outgrow laryngomalacia?
Most do. The noisy breathing typically appears in the first weeks of life, often gets louder over the first several months, and then fades as the tissues above the vocal cords firm up, usually by 12 to 24 months of age.
How is laryngomalacia diagnosed?
A pediatric ENT passes a thin, flexible camera through the baby’s nose while the baby is awake and looks at the voice box as the baby breathes. The exam takes a minute or two in the office and does not require sedation.
What is a supraglottoplasty?
A supraglottoplasty is an operation that trims or releases the floppy tissue above the vocal cords so it stops collapsing into the airway. It is done through the mouth under general anesthesia, with no incisions on the outside of the neck.
Does supraglottoplasty cure sleep apnea in children with laryngomalacia?
It usually improves it, but often does not cure it. A 2016 meta-analysis co-authored by Dr. Cable (13 studies, 138 children) found that breathing pauses and oxygen levels during sleep improved after surgery, but most children still had some sleep apnea afterward and needed follow-up.
Where does Dr. Cable see infants with noisy breathing?
Dr. Cable evaluates infants and children at the Frisco office on Teel Parkway and at the McKinney office of ENT and Allergy Centers of Texas. Call (972) 984-1050.
References
Del Do M, Song SA, Nesbitt NB, Spaw MC, Chang ET, Liming BJ, Cable BB, Camacho M. Supraglottoplasty surgery types 1–3: a practical classification system for laryngomalacia surgery. Int J Pediatr Otorhinolaryngol. 2018;111:69–74. doi:10.1016/j.ijporl.2018.05.022 (opens in a new tab) · PubMed 29958617 (opens in a new tab).
Camacho M, Dunn B, Torre C, Sasaki J, Gonzales R, Liu SY, Chan DK, Certal V, Cable BB. Supraglottoplasty for laryngomalacia with obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope. 2016;126(5):1246–1255. doi:10.1002/lary.25827 (opens in a new tab) · PubMed 26691675 (opens in a new tab).
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This article is educational and is not a substitute for an evaluation of your child.