Laryngomalacia in a 1-Month-Old: History Taking & Clinical Examination

HISTORY TAKING

1. Presenting Complaint

• Onset of stridor: Ask when the noisy breathing was first noticed. In LM, inspiratory stridor typically appears within the first 2 weeks of life (often day 1-2 of life, or shortly after birth).
• Nature of the sound: High-pitched, fluttering inspiratory noise (sometimes described as a "squeaky" or "crowing" sound). Compared to vocal cord paralysis, it is often relatively low-pitched and lacks a musical quality.

2. Aggravating & Relieving Factors

3. Feeding History (critical in a 1-month-old)

• Does the baby tire quickly during feeds?
• How long does feeding take? (prolonged feeds >30 min are concerning)
• Does the baby need to stop and breathe during feeds?
• Any coughing, choking, or gagging during/after feeds?
• Any regurgitation or vomiting after feeds? (suggests GORD, which co-exists in the majority of LM cases)
• Breast vs. bottle fed? (bottle feeding may be better tolerated)
• Current weight and whether gaining appropriately - ask birth weight vs. current weight
• Any failure to thrive?

4. Severity Indicators - "Red Flag" Symptoms

• Cyanotic episodes or colour changes (blue/grey) during feeds or at rest
• Apnoea - pauses in breathing
• Severe chest retractions visible to parents
• Difficulty sleeping / sleep-disordered breathing
• Cardiorespiratory distress at rest (suggests severe LM requiring urgent intervention)

5. Positional History

• Does the baby breathe better in any particular position?
• Has the parent noticed improvement when baby is held upright or in prone position?

6. Birth & Antenatal History

• Gestation: Premature infants (especially Hispanic and Black infants) are at higher risk
• Birth weight, delivery method (instrumental delivery - risk of nerve injury)
• Neonatal resuscitation required? (intubation history - raises risk of subglottic stenosis as alternative diagnosis)
• NICU admission?
• Any antenatal abnormalities on scan?

7. Neurological & Developmental History

• Any known neurological diagnosis (cerebral palsy, hypotonia, Chiari malformation)? - LM may be associated with neuromuscular disorders
• Is the baby alert, fixing and following?
• Any other dysmorphic features? (syndromes such as Down's syndrome are associated)

8. Family & Social History

• Family history of airway problems
• Passive smoke exposure
• Who are the main caregivers and their level of anxiety/coping

9. Systems Review

• Any concurrent upper respiratory tract infections?
• Noisy breathing from the nose (choanal stenosis as co-existing lesion)?
• Drooling?
• Episodes of colour change?

CLINICAL EXAMINATION

General Inspection

• Overall appearance: Well vs. unwell, alert, colour (pink vs. mottled/cyanosed)
• Nutritional status: Assess for signs of failure to thrive - subcutaneous fat, muscle bulk
• Dysmorphic features: Down syndrome, Pierre Robin sequence, CHARGE syndrome (associated with LM)
• Work of breathing at rest: Is the baby comfortable or in distress?

Vital Signs

• Respiratory rate (normal in a 1-month-old: 30-60/min)
• Oxygen saturations (SpO2) - critical to assess
• Heart rate
• Weight - plot on centile chart; compare with birth weight

Respiratory Examination

Inspection

• Character of stridor: Confirm it is inspiratory (LM is purely inspiratory; biphasic stridor suggests subglottic/tracheal pathology)
• Sternal and intercostal recession: Mild recession is common in mild LM; severe recession is a red flag indicating significant obstruction
• Subcostal recession
• Suprasternal notch indrawing
• Nasal flaring
• Tracheal tug
• Abdominal breathing / paradoxical chest movement (in severe obstruction)

Auscultation

• Air entry: Equal and clear bilaterally? (unequal raises suspicion of vascular ring, mass, or other lesion)
• Listen over neck - stridor loudest over the larynx
• Any wheeze (suggests lower airway component - GOR-related / bronchomalacia)?
• Any crackles (aspiration pneumonia from feeding difficulties)?

Effect of Position

• Observe stridor in supine vs. prone - improvement in prone is characteristic of LM

Cardiovascular Examination

• Heart sounds, murmurs - exclude congenital heart disease contributing to respiratory distress
• Check femoral pulses, capillary refill time

Abdominal Examination

• Hepatomegaly (cardiac failure)?
• Signs of GORD: abdomen soft, no masses

Oropharyngeal Examination

• Inspect oral cavity for cleft palate, micrognathia (Pierre Robin)
• Tongue size (macroglossia in hypothyroidism / Beckwith-Wiedemann)

Neurological Assessment

• Tone: Hypotonia is associated with LM (neuromuscular immaturity theory)
• Primitive reflexes: suck, rooting, Moro
• Level of alertness and interaction

ENT-Specific Examination

• Nose: Patent nasal passages bilaterally (pass suction catheter or observe fogging of mirror)
• Ears: Basic otoscopy if possible

ENDOSCOPIC ASSESSMENT (Gold Standard)

"The child should be wrapped in a blanket and held firmly by a nurse or parent. The supraglottic collapse on inspiration, which is typical of laryngomalacia, is easily seen."

• Scott-Brown's Otorhinolaryngology, Vol 2

Endoscopic view of laryngomalacia showing the characteristic omega-shaped epiglottis (Scott-Brown's Otorhinolaryngology)

Progressive supraglottic obstruction on inspiration in laryngomalacia (A-D). Note the omega-shaped epiglottis collapsing into the airway. (Cummings Otolaryngology)

• Omega-shaped (curled, long) epiglottis
• Short, foreshortened aryepiglottic folds tethering the epiglottis posteriorly
• Redundant arytenoid mucosa prolapsing into the glottic airway on inspiration
• Deep interarytenoid cleft
• Normal vocal fold mobility (important to confirm - differentiates from vocal cord paralysis)

• Type 1: Foreshortened/tight aryepiglottic folds
• Type 2: Redundant supraglottic tissue
• Type 3: Posterior epiglottic collapse - associated with underlying neuromuscular disorders

ASSESSING SEVERITY - A Practical Summary

• ~90% of cases are mild and resolve spontaneously by 18-24 months without intervention
• Severe cases require supraglottoplasty (endoscopic surgical division of the aryepiglottic folds)

INVESTIGATIONS TO CONSIDER

• SpO2 monitoring (pulse oximetry)
• Weight chart / growth monitoring (serial)
• Chest X-ray if indicated (hyperinflation, aspirate, cardiac silhouette)
• Flexible nasolaryngoscopy - definitive (usually done by ENT/Paediatric otolaryngologist)
• GORD workup if clinically indicated (pH impedance study)
• Rigid microlaryngobronchoscopy under GA - if severe stridor, cyanosis, or secondary airway lesion suspected (~10-15% of LM cases have a synchronous lesion)