Severe Laryngomalacia in a 3-Month-Old Infant: A Clinical Case Report

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CLINICAL CASE REPORT

Patient Information

A male infant, approximately 3 months old, was admitted with persistent respiratory symptoms and poor weight gain. He was born preterm and small for gestational age, with a birth weight of 2.1 kg.

Clinical Presentation

The infant developed respiratory distress from the first day of life, with suprasternal, sternal/subcostal, and xiphoid retractions. He initially required non-invasive respiratory support and was later weaned to room air.

At around 45 days of life, he developed fever, cough, and cold symptoms and required hospitalization. Although the acute illness was treated, noisy breathing and recurrent respiratory retractions persisted. Because of the ongoing stridor and respiratory difficulty, he was referred for further airway evaluation.

Poor weight gain was also noted. His weight at the time of evaluation was 2.18 kg, representing only about 80 g of gain since birth.

Examination and Anthropometry

• Weight: 2.18 kg
• Length: 50 cm
• Head circumference: 34 cm
• Significant poor weight gain/failure to thrive was noted.

Flexible Bronchoscopy

Flexible bronchoscopy was performed to evaluate the cause of persistent stridor and respiratory distress.

The nasopharynx was normal. The epiglottis was floppy and had a typical omega-shaped appearance. During inspiration, the arytenoid mucosa showed dynamic prolapse into the laryngeal lumen. The vocal cords and subglottic region were normal.

The trachea, carina, and visualized right and left bronchial tree were also normal.

The findings were consistent with laryngomalacia causing dynamic upper-airway obstruction.

Diagnosis

The overall clinical and endoscopic findings were suggestive of:

• Severe laryngomalacia
• Dynamic supraglottic airway obstruction
• Failure to thrive
• History of prematurity and small-for-gestational-age birth
• Previous neonatal respiratory distress

Management

The infant required respiratory support with bubble CPAP. Enteral feeding was provided through an orogastric tube, with frequent feeds and attention to post-feed burping to support nutritional recovery.

Medical treatment included anti-reflux therapy, antimicrobial treatment, nebulization, corticosteroid therapy, and nutritional supplements as clinically indicated.

Because of the severity of the supraglottic collapse and associated failure to thrive, pediatric pulmonology and ENT teams recommended supraglottoplasty as definitive treatment.

Outcome

The caregivers were counselled regarding the severity of the airway obstruction and the potential risks of refusing further treatment, including apnea, aspiration, hypoxia, seizures, and respiratory arrest.

However, the caregivers declined continued hospitalization and the recommended surgical intervention. The infant was therefore discharged Left Against Medical Advice (LAMA).

The caregivers were advised to continue the prescribed treatment and feeding plan, monitor closely for worsening respiratory symptoms or poor feeding, and seek urgent medical attention if danger signs developed.

Discussion

Laryngomalacia is the most common cause of congenital stridor in infants. It results from dynamic collapse of the supraglottic structures during inspiration. Typical endoscopic findings include a floppy, omega-shaped epiglottis and inward collapse of the arytenoid tissues.

Many infants have mild disease that improves spontaneously. However, severe laryngomalacia can cause significant respiratory distress, feeding difficulties, and poor weight gain. In infants with severe airway obstruction or failure to thrive, supraglottoplasty may be considered to relieve the obstruction.

In this case, persistent stridor, dynamic supraglottic collapse on bronchoscopy, and marked failure to thrive indicated severe disease requiring specialist management.

References

1. Sannaboraiah SK, Ture P, Gangadharan AK, Hatyal RC. Airway challenges in an infant undergoing laser supraglottoplasty for laryngomalacia. Indian J Anaesth. 2023;67(2):230–231.

2. Pradeep S, Alexander A. Cold steel supraglottoplasty for severe laryngomalacia in infants. BMJ Case Rep. 2021;14:e242663.

3. Bhatta S, Gandhi S, Ganesuni D, Ghanpur AD. Long term follow up of severe laryngomalacia patients following CO₂ laser supraglottoplasty. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 2):2472–2476.

Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.