Laryngomalacia is a common congenital laryngeal abnormality. Despite its being widely discussed in the literature, the pathophysiology is not clearly understood. Both anatomic and neuromuscular theories have been suggested to explain laryngomalacia. We report 4 cases of laryngomalacia in which the presenting signs occurred during sleep. Awake flexible nasopharyngolaryngoscopy failed to demonstrate supraglottic structure collapse. Only while the patients were breathing spontaneously under general anesthesia was laryngomalacia noted. A proposed algorithm for diagnosis and treatment is included. These 4 cases of state-dependent laryngomalacia support a neuromuscular cause for laryngomalacia.
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