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Korean J Otorhinolaryngol-Head Neck Surg. 2026;.kjorl-hns.2025.00234

Publication date (electronic) : 2026 February 10

doi : https://doi.org/10.3342/kjorl-hns.2025.00234

Puspa Zuleika, Rohayu

Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Sriwijaya University/ Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Address for correspondence Puspa Zuleika, MD Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Sriwijaya University, Palembang, South Sumatra, Indonesia Tel +62 813-2838-4219 E-mail puspazuleika@fk.unsri.ac.id

Received 2025 April 30; Revised 2025 August 10; Accepted 2025 November 4.

Trans Abstract

Introduction

Laryngomalacia is a congenital abnormality of the larynx responsible for 70% of cases of stridor in infants [1]. Stridor is a high-pitched breathing sound that indicates an obstruction in the airway, particularly in the larynx and/or tracheobronchial region. Stridor generally worsens when the patient cries, feeds, or is in a supine position. Patients with laryngomalacia typically experience inspiratory stridor during the first few weeks of life, which often worsens and peaks in severity at 6 months of age, followed by gradual improvement of symptoms, with some patients becoming completely symptom-free by 18-24 months of age [2]. Although generally self-limiting and capable of resolving on its own, 10%-20% of laryngomalacia cases require surgical intervention [1-3].

Laryngomalacia can disrupt the coordination between suction/swallowing and respiratory functions, with patients also experiencing difficulties in feeding, failure to thrive, dysphagia, aspiration, obstructive sleep apnea (OSA), and even pulmonary hypertension in severe cases [1,2]. The actual incidence of dysphagia and aspiration in infants with laryngomalacia is unknown. Previous studies have indicated that infants with more severe laryngomalacia tend to exhibit symptoms of feeding difficulties [1]. Furthermore, there is evidence that infants with comorbid conditions such as neurological disorders or congenital heart disease tend to have a more severe form of laryngomalacia [3]. In diagnosing and evaluating the complications, a thorough clinical history and physical examination, combined with additional diagnostic tests such as Fiberoptic Endoscopic Evaluations of Swallowing (FEES), are necessary to assess swallowing function [2,3].

FEES examination is important for patients with laryngomalacia, particularly those experiencing swallowing difficulties. This procedure is performed by an ENT specialist and can be carried out at the bedside. It allows for direct anatomical assessment and evaluation of the sensory function of the pharynx, supraglottis, and glottis [4]. Thus, anatomical variations and malformations causing dysphagia can be easily detected [5,6]. This procedure can also be performed on infants who are breastfeeding and even on children who do not eat orally by observing the swallowing of colored saliva. The procedure is comfortable, safe, and provides meaningful diagnostic information [3,4,7].

This study aims to characterize FEES findings in infants with laryngomalacia at a tertiary referral hospital, focusing on clinical features, comorbidities, and swallowing abnormalities, contributing to better diagnosis and care..

Subjects and Methods

Results

A total of 21 laryngomalacia patients who underwent FEES were included. The mean age was 10.4 months (range: 2-24 months), and the majority were male (71.5%). Most patients had type I laryngomalacia (80.9%), with severe cases comprising 71.4%. Notably, 57.1% also had type II laryngomalacia, indicating that several patients presented with mixed types. Only 14.3% of patients had mild or moderate forms, while the majority were classified as severe.

Comorbidities were found in 76.2% of patients, including neurological, cardiac, and genetic conditions. Swallowing symptoms were present in 95.2%, and respiratory symptoms were reported in 52.4%. Dysphagia was noted in 57.1% of patients, while silent aspiration was observed in 14.2%. Complications were present in 71.5%, and 33.3% of the cohort had undergone tracheostomy. The same percentage had a history of intubation.

FEES findings

Across all patients, 14 abnormal swallowing events were documented during the FEES procedure. The most frequent finding was penetration (6 cases), followed by residue (4 cases), leakage (3 cases), and aspiration (1 case). The majority of abnormalities were noted with thick liquid (milk), observed in 11 of 14 abnormal findings. Rice porridge accounted for 3 findings (penetration and residue), while other consistencies such as oatmeal, wheat porridge, thin liquids, and biscuits/crackers yielded no abnormalities.

Patients with tracheostomy (n=7) demonstrated a higher proportion of abnormal FEES findings, particularly penetration and residue. Similarly, patients with severe laryngomalacia and those with comorbidities were more likely to exhibit dysphagia and silent aspiration.

Representative endoscopic images obtained during FEES are provided in the Figs. 1 and 2. These include examples of penetration with thick liquids and pharyngeal residue, demonstrating typical findings in severe laryngomalacia cases. The images support the observed trends and provide visual context for interpreting the swallowing abnormalities described.

Fig. 1.

FEES findings on case 1. Patient using nasogastric tube. A: An omega shaped epiglotis. B: Residue in vallecula (blue arrow). FEES, Fiberoptic Endoscopic Evaluation of Swallowing.

Fig. 2.

FEES findings in case 2 (first FEES). A: An omega-shaped epiglottis. Pooling of secretions was seen above the vocal cord. B: On FEES examination with milk, penetration and aspiration were seen (blue arrow). FEES, Fiberoptic Endoscopic Evaluation of Swallowing.

Discussion

This retrospective study of 21 pediatric laryngomalacia cases provides detailed insights into FEES findings and clinical characteristics. Consistent with previous reports, most patients had type I laryngomalacia and were male. Severe cases dominated our sample, which likely reflects tertiary-level referral bias, as milder cases often do not undergo endoscopic evaluation.

A noteworthy proportion (57.1%) showed overlapping features of type I and II, reinforcing the concept that laryngomalacia can present as a spectrum. Our findings align with Pokhare [l8] and Bredun, et al. [9], who also reported mixed-type presentations.

The high incidence of comorbidities (76.2%) is consistent with literature showing associations between laryngomalacia and conditions such as Down syndrome, GERD, and neurologic disorders [10-12]. These comorbidities contribute to symptom severity and swallowing dysfunction. However, our study lacked sufficient power to analyze statistical correlations between comorbidity subtypes and FEES outcomes.

In this study, 52.4% of patients with laryngomalacia exhibited respiratory symptoms, with inspiratory stridor being the most common, exacerbated by eating, agitation, supine position, and crying. Stridor often improves or disappears during sleep in mild to moderate cases. Respiratory issues such as OSA, tachypnea, dyspnea, respiratory distress, or hypoxemia occurred in 5%-20% of children, and in severe cases, pulmonary hypertension and cor pulmonale may develop without proper treatment [13]. While infants with stridor and no significant feeding-related symptoms can be monitored without surgery, supraglottic airway obstruction from laryngomalacia can increase respiratory effort and energy demands, potentially leading to poor weight gain or even muscle atrophy when combined with feeding difficulties [3,14].

The study also found that 95.25% of patients experienced swallowing issues, with 49% showing symptoms like regurgitation or aspiration, though no clear relationship between these conditions has been established. Previous studies suggest that swallowing problems in laryngomalacia patients may be linked to comorbid conditions such as neurological disorders or respiratory reflux diseases [2,12]. Silent aspiration, where food or liquid enters the airway without triggering a cough reflex, was observed in three patients, which is common in around 40% of swallowing dysfunction cases and can lead to serious respiratory conditions like aspiration pneumonia. The study also found that 57.14% of cases had dysphagia, with similar findings in other studies, although the prevalence of swallowing difficulties is often underestimated due to silent aspiration. The relationship between laryngomalacia and dysphagia is not well-understood but may involve mechanical obstruction during swallowing, increased subglottic negative pressure, and disturbances in the suck-swallow-breath sequence, as well as impaired laryngeal protection reflexes and reduced supraglottic mucosal sensitivity. Gastroesophageal reflux further exacerbates dysphagia by damaging the mucosa and decreasing laryngeal reflex sensitivity [13,15].

Penetration and residue were the most common findings on FEES. These abnormalities were predominantly observed with thick liquid (milk), highlighting the importance of evaluating consistency-specific swallowing function in infants. The solitary aspiration event observed also occurred with thick liquids. These results are consistent with Ha [1] and Simons, et al. [2], who also found thick liquids to be the most problematic consistency in infants with laryngomalacia. Richter and Thompson [16] reported 88% penetration and 72% aspiration in severe laryngomalacia patients who underwent supraglottoplasty, with 82% of patients with penetration and 86% with aspiration experiencing resolution post-surgery.

Laryngeal penetration occurs when food enters the larynx but does not pass the true vocal cords, and when deep laryngeal penetration occurs, 85% lead to aspiration. Residue is associated with oral phase changes and delayed swallowing reflex initiation. Clinical swallowing assessments should be conducted on all patients with laryngomalacia, even without subjective dysphagia symptoms [4,12,15]. These findings highlight the importance of conducting swallowing function assessments for all laryngomalacia patients, regardless of whether they show dysphagia symptoms.

Importantly, patients with tracheostomy and severe grades exhibited a higher rate of penetration and residue. Although formal statistical testing was not feasible due to the small sample, this trend suggests that FEES can aid in identifying high-risk subgroups who may benefit from modified feeding strategies or further intervention.

The presence of silent aspiration in 14.2% supports earlier recommendations for routine instrumental swallowing assessments, even in patients who lack overt symptoms. Our data confirms the diagnostic value of FEES in uncovering clinically silent but significant swallowing issues.

Intra- and inter-rater reliability were maintained through double reading and consensus discussions, helping to mitigate subjectivity.

Limitations include the retrospective nature of the study, small sample size, and the absence of standardized scoring for FEES. Nevertheless, the results underscore the need for early swallowing assessment in laryngomalacia patients, especially those with comorbidities or respiratory compromise.

In summary, this study reinforces that FEES is an essential tool in the multidisciplinary management of pediatric laryngomalacia. Future research should include larger, prospective cohorts with structured FEES scoring and detailed comorbidity analysis.

In conclusion, this study highlights that swallowing dysfunction is common in pediatric patients with laryngomalacia, particularly those with severe disease, comorbidities, or a history of tracheostomy. Penetration and residue were the most frequent abnormalities observed on FEES, predominantly with thick liquid consistencies such as milk. Silent aspiration was also present in a subset of patients, reinforcing the need for instrumental evaluation even in the absence of overt symptoms.

Our findings support the routine use of FEES as a safe and effective diagnostic tool in evaluating feeding and swallowing in infants with laryngomalacia. It enables early detection of aspiration risks and guides personalized management, especially in high-risk subgroups. Despite the limitations of retrospective design and small sample size, the study underscores the clinical relevance of FEES in the multidisciplinary care of this population. Future prospective studies with standardized scoring systems are warranted to further validate the role of FEES and establish clear protocols for early intervention in laryngomalacia-related dysphagia.

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