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tracheostomy is done in larygomalacia.?

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Tracheostomy in Laryngomalacia

Short Answer

Tracheostomy is NOT the standard or first-line treatment for laryngomalacia. It is considered only in a small minority of the most severe, refractory cases where other interventions have failed.

What is Laryngomalacia?

Laryngomalacia (LM) is the most common cause of stridor in neonates and infants, accounting for the majority of congenital laryngeal anomalies. It results from partial or complete collapse of the supraglottic structures on inspiration.
Anatomical abnormalities:
  • Omega-shaped, floppy epiglottis that collapses posteriorly
  • Short, tight aryepiglottic folds tethering the epiglottis
  • Redundant/prolapsing arytenoid mucosa
Pathophysiology: Neuromuscular hypotonia with immature sensorimotor integration of the laryngeal adductor reflex (LAR), leading to poor laryngeal tone.
Natural history: Stridor typically appears within the first 2 weeks of life. In most (untreated) cases, the median time to resolution is 7-9 months; the vast majority resolve by 18-24 months of age.

Classification (Types)

TypeDescription
Type 1Foreshortened/tight aryepiglottic folds
Type 2Redundant supraglottic tissue
Type 3Posterior epiglottic collapse (often due to underlying neuromuscular disorder)

Management Stepwise Approach

~90% of cases are mild and require no surgery:
  1. Conservative management (mild-moderate LM)
    • Observation and parental reassurance
    • Regular documented weight checks to monitor for failure to thrive
    • Positioning (prone position improves symptoms)
    • Acid suppression (antireflux medications) - especially if GERD co-exists
  2. Surgical: Supraglottoplasty (aryepiglottoplasty) - treatment of choice for severe LM
    • Indicated in ~10-31% of cases seen by a pediatric otolaryngologist
    • Indications: severe respiratory obstruction, failure to thrive, feeding difficulties, apnea, cyanosis, risk of cor pulmonale
    • Procedure: Division of tight aryepiglottic folds + removal of redundant arytenoid mucosa using CO2 laser, laryngeal microscissors, or microdebrider
    • Key precaution: The interarytenoid mucosa bridge must be preserved to prevent scarring/stenosis
    • Success rates are high; most children obtain rapid relief; short hospital stay of 1-3 days
    • Bilateral epiglottic incision is contraindicated (risk of supraglottic stenosis)
  3. Tracheostomy - last resort only
    • Indicated only for the most severe, refractory cases where supraglottoplasty has failed or is not feasible
    • May be required in cases with: coexisting severe neurological disorder (Type 3), multiple synchronous airway lesions, bilateral vocal cord palsy coexisting with LM, severe cardiorespiratory compromise, or failure after repeated supraglottoplasties
    • Also listed as an option for severe tracheomalacia coexisting with LM

Summary Table

SeverityManagement
Mild (90%)Observation, reassurance, antireflux therapy
Severe (10-31%)Endoscopic supraglottoplasty (treatment of choice)
Extreme/refractory (very rare)Tracheostomy (last resort)

Key Exam Point

Supraglottoplasty is the surgical treatment of choice for severe laryngomalacia. Tracheostomy may be required in a very small minority of refractory or complex cases, but it is NOT the standard surgical treatment and should never be listed as a routine intervention.
  • Cummings Otolaryngology Head and Neck Surgery, Chapter 206
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 2, Chapter 30
  • K.J. Lee's Essential Otolaryngology, Chapter on Laryngomalacia
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