So basically, malacia means
narrowing or it’s a floppy area.
And this can happen in either
the larynx or the trachea.
It’s a common problem especially
in premature infants.
We see this all the time.
There are some genetic influences,
but the cause is basically unknown.
And it’s basically a collapse in the
airway, in the larynx, or in the trachea
due to probably mostly
poor airway motor tone.
These infants have just a hard time keeping
it stented upon when they're breathing.
So it presents with noisy breathing.
And typically depending on where
the location is primarily
will depend on what that noise is.
Stridor usually occurs for patients
who have a higher area of malacia.
In other words, in
laryngomalacia, for example,
their airway collapse is
a little bit higher up.
This means that when they breathe in,
it’s like breathing in through
the neck of a balloon.
It collapses and makes
a stridorous noise.
But when they breathe out, it will sort of
billow open and there’ll be less noise.
Or alternatively, patients
could have laryngomalacia,
but also have some
And the tracheomalacia will have more
of an exhalational component to it.
So it may be biphasic or just stridor
or if it’s all low down, just wheeze.
It will give you a clue as to the
location of the airway collapse.
The reason why it’s important to
remember the clue of the airway collapse
and where this is likely happening is
because there is a differential diagnosis.
We can’t just assume that
any baby with stridor
doesn’t have something
more substantial going on.
Patients may get superglottic webs.
These areas of tissue that are
inappropriately growing in the airway
and thus making the airway narrower
and having it harder to breathe in.
Patients may have airway hemangiomas.
This is particularly likely if you
see some also on the baby’s skin.
An airway hemangioma can
be very challenging.
It may require laser
therapy or other things.
Or we simply hope they’ll outgrow it and
gradually wait until they get bigger
because just like
hemangiomas on the legs,
these will gradually shrink
over several months.
But this can be very challenging because
they will also grow for the first few months
and so we need to watch these
children very carefully.
Another potential cause of stridor or
wheeze in an infant is a vascular ring.
There are many different
types of vascular rings
and it will take forever to list them all.
And for example, the aorta may be together
come apart and then go back together again.
And in that space in between, that
sort of like an island on a highway,
that trachea can run
through that area.
Oftentimes, the esophagus does as well.
This can lead to not only
spitting up of food,
but also a narrowing of the tracheal airway
which may happen a bit after birth as they
sort of grow into that vascular ring.
Then we could hear more
Another possibility is the patient
has a cyst or another structure
that’s pressing on that airway like a lingual
thyroid or a thyroglossal duct cyst.
And patients may have
just an area of narrowing
that’s causing the problem.
Subglottic stenosis is common in infants
who have recently been intubated.
That intubation can cause
damaging below the vocal cords
and a little stenotic area, which
can present with noisy breathing.
So for any infant with stridor, we have
to think about what might be causing it.
And so we’ll probably
do some studies to try
and get a sense of what
exactly is going on.
One thing we can do is the neck X-ray.
By looking at a neck x-ray, we can
seen an area of focal narrowing
and get a sense of where is it and
is that consistent with a mass
or is it consistent with
a general floppy airway.
If we aren’t convinced by
the neck X-ray but we don’t
have any specialist nearby who
can look in with a camera,
we might also do
What we’re doing is making
a video with x-rays
and we can see that airway collapsing
and we can make a diagnosis.
Lastly, if we’re just not
sure what’s going on,
it’s very reasonable to consult
ear, nose and throat doctors
to do direct video laryngoscopy.
They can actually look inside
and see what’s going on.
They can diagnose laryngomalacia
but they can also see the airway hemangioma
or see an area that’s compressed
by an external mass, et cetera.
So how do we support these infants.
Well, in most cases, the
treatment is entirely supportive
because as they grow,
this problem goes away.
Usually, by two or three
years of age, it’s all gone.
So we’ll provide CPAP in some severe cases.
This will help stent open
that airway of collapse
and keep them breathing
Most children do great with this.
There is a frequent
readmission in these infants
specifically with upper
respiratory tract infections.
Bronchiolitis or even
just the common cold
can tip them over the edge and make
it very hard for them to breathe.
And typically, they’ll outgrow
this by two years of age.
So that’s a brief summary of
laryngomalacia and tracheomalacia in kids.
Thanks for your time.