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Invited Commentary
December 27, 2018

Silent Aspiration in Laryngomalacia?Not a Hard Concept to Swallow

Author Affiliations
  • 1Division of Pediatric Otolaryngology–Head and Neck Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
  • 2Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
JAMA Otolaryngol Head Neck Surg. Published online December 27, 2018. doi:10.1001/jamaoto.2018.3764

Laryngomalacia is the most common laryngeal anomaly in infants, with a presentation of inspiratory stridor being nearly ubiquitous. In addition, young children with laryngomalacia can demonstrate feeding difficulty, dysphagia, aspiration, failure to thrive, apnea, cyanosis, and/or obstructive sleep apnea. Managing the balancing act between sucking, breathing, and swallowing is anticipated to carry additional challenge in infants with airway abnormalities, potentially leading to dysphagia, aspiration, and feeding difficulties. Somewhat unsurprisingly, infants with laryngomalacia may cough and choke during feeding, take their feeds slowly, or develop a worsening of their stridor during feeding.1 The association between laryngomalacia and feeding disorders is further strengthened by a biological gradient relationship, with more severe laryngomalacia cases shown to be more likely to have symptoms of feeding difficulty.1 In addition to dyscoordination, other proposed causes for feeding challenges in patients with laryngomalacia include decreased laryngeal sensation secondary to acid reflux and an alteration in the sensorimotor integrative function of the larynx.1 The association between acid reflux and laryngomalacia is well established, although evidence is lacking for causality or even direction of causality (ie, which is the chicken and which is the egg).2 Sensorimotor impairment in laryngomalacia is evidenced by the finding that children with laryngomalacia have higher rates of neurologic abnormalities such as hypotonia, central apneas and developmental disorders,3 and histopathologic nerve differences in their laryngeal mucosa.4

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