# Laryngomalacia > Laryngomalacia for FMGE ENT: commonest congenital stridor, omega epiglottis, supraglottic collapse, natural resolution and supraglottoplasty indications. - Canonical URL: https://prepelephant.com/topics/fmge/ent/laryngomalacia-fmge - Exam / course: FMGE · Subject: ENT - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Laryngomalacia", PrepElephant, https://prepelephant.com/topics/fmge/ent/laryngomalacia-fmge ## Direct answer Laryngomalacia is the commonest congenital laryngeal anomaly and the commonest cause of stridor in a newborn, produced by dynamic collapse of the supraglottic structures on inspiration: a flaccid, omega-shaped (tubular) epiglottis, short aryepiglottic folds that tether it, and redundant arytenoid mucosa that prolapses into the airway each time the infant inhales. The stridor is inspiratory, appears within the first weeks of life, worsens with feeding, crying, agitation and the supine position, and improves in prone; between episodes the child feeds and grows normally. The diagnosis is made by awake flexible laryngoscopy showing the collapsing supraglottis, the overwhelming majority of children resolve spontaneously by 12-18 months, and the minority with feeding failure, faltering growth, cyanotic spells or cor pulmonale need acid suppression for the associated reflux and, ultimately, supraglottoplasty — division of the aryepiglottic folds and trimming of the prolapsing tissue. ## What you must remember - **Position in the hierarchy:** commonest congenital laryngeal anomaly and commonest cause of neonatal stridor; boys more often, presenting within the first weeks to months. - **Pathophysiology:** immature cartilage framework plus neuromuscular immaturity of the larynx — inspiration sucks in the soft supraglottis; the omega epiglottis, short aryepiglottic folds and bulky arytenoids are the structural triad seen on endoscopy. - **Sound signature:** inspiratory stridor (high-pitched, crowing), worse with feeding, crying, supine position and upper respiratory infections; better when prone or quiet — positional variability is the clinical clue. - **Diagnosis:** awake flexible laryngoscopy at the bedside — the diagnosis is observed dynamic collapse, which sedation can abolish; full airway evaluation follows atypical findings (roughly a tenth have a synchronous lesion such as subglottic stenosis). - **Natural history:** self-limiting maturation in the great majority, with resolution typically by 12-18 months of age — reassurance and parental education are the treatment in most cases. - **Severe disease markers:** feeding difficulty and choking, failure to thrive or crossing down weight centiles, retractions and supraclavicular indrawing, cyanosis or apparent life-threatening events, recurrent chest infections from aspiration, and eventually pulmonary hypertension or cor pulmonale. - **Reflux association:** laryngopharyngeal reflux is common and aggravates the oedema — a proton pump inhibitor trial is part of medical management in troublesome cases. - **Surgery:** supraglottoplasty (division of short aryepiglottic folds, excision of redundant arytenoid mucosa, epiglottopexy in selected anatomy) for the severe minority — highly effective, with tracheostomy now rare and reserved for failures or syndromic children with multilevel obstruction. ## Worked example: two infants, same sound, opposite plans A five-week-old term infant has noisy breathing since the second week: a crowing inspiratory sound, louder with crying or feeding, quieter asleep prone on her mother's chest. She breastfeeds vigorously and tracks the 50th centile, with normal oxygen saturation. Awake flexible laryngoscopy shows a curled, omega-shaped epiglottis folding on inspiration, short aryepiglottic folds pulling the arytenoids forward, and redundant mucosa ballooning over the glottis — the stridor's mechanics seen live. This child needs explanation and time: louder with feeds and colds, peaking around six months, fading by 12-18 months as the cartilage stiffens. The second infant, at three months, has the same sound but a different body: weight has fallen two centiles, feeds last 50 minutes with choking and sweating, suprasternal retraction is visible at rest, and one blue-lipped episode occurred during a feed. The same endoscopy confirms severe laryngomalacia with reflux oedema. Management escalates: proton pump inhibitor trial with feeding support, and when growth still falters, supraglottoplasty — division of the aryepiglottic folds with trimming of prolapsing mucosa — typically relieving obstruction within days, with tracheostomy reserved for the rare refractory or syndromic child. The noise decides nothing; growth, feeding and oxygenation decide. ## Where students slip Stridor timing trips candidates: laryngomalacia is inspiratory, glottic and subglottic lesions biphasic, tracheobronchomalacia expiratory — one word often answers the stem. Imaging is ordered first, but the diagnostic test is awake endoscopy, since sedation abolishes the dynamic collapse. A proportion of infants harbour a second airway lesion, explaining why stridor persisting beyond the expected timeline needs full evaluation. And reassurance is the answer only when feeding, growth and saturation are normal — never for the failing-to-thrive infant. ## Frequently asked questions ### What causes the stridor in laryngomalacia? Dynamic inspiratory collapse of immature supraglottic structures — an omega-shaped epiglottis, short aryepiglottic folds and redundant arytenoid mucosa — obstructing the airway with each breath. ### How is laryngomalacia diagnosed? Awake flexible fibreoptic laryngoscopy demonstrating the collapsing supraglottis during spontaneous breathing; sedation is avoided because it masks the dynamic obstruction. ### What is the natural history of laryngomalacia? Spontaneous resolution by 12-18 months of age in the great majority of infants as laryngeal cartilage and neuromuscular control mature, requiring only parental reassurance. ### Which features indicate severe laryngomalacia needing intervention? Feeding difficulty with prolonged or choking feeds, failure to thrive, cyanotic spells, significant retractions, recurrent aspiration pneumonia or evolving pulmonary hypertension. ### What operation is performed for severe laryngomalacia? Supraglottoplasty — division of the short aryepiglottic folds with excision of redundant arytenoid mucosa, sometimes with epiglottopexy — reserving tracheostomy for rare refractory or multilevel cases.