neuromuscular disorders, subglottic stenosis, or vascular rings Laryngomalacia or tracheomalacia may simulate respiratory distress, with noisy respirations originating in the upper airway, but oxygen saturation and chest radiographs are normal Clinicians should also look for signs and symptoms of GERD, which are commonly associated with laryngomalacia The reflux of gastric content causes swelling of the vocal cords but it is also thought that laryngomalacia causes increases in negative intrathoracic pressure in an attempt to overcome the laryngeal obstruction, and this incites gastric contents to reflux In moderate to severe cases, diagnosis can be confirmed by flexible fiberoptic nasolaryngoscopy performed at the bedside by an ear, nose, and throat (ENT) surgeon ( Fig 96.35 ) ENT consultation for fiberoptic laryngoscopy is also recommended for mild cases with progressive symptoms or other associated symptoms Occasionally, the ENT surgeon will request a modified barium swallow or rigid bronchoscopy to rule out secondary comorbidities in cases where stridor is out of proportion to the degree of laryngomalacia seen on flexible laryngoscopy or in the presence of aspiration suspicious for posterior laryngeal cleft or tracheosophageal fistula Management is mainly conservative (watchful waiting) as infants will outgrow the condition Control of reflux with positioning after feeds and acid suppression therapy may be helpful Surgery (supraglottoplasty) is rarely required and is only indicated for cases with severe obstruction, hypoxic episodes, pulmonary hypertension, and failure to thrive