A child presents with biphasic (inspiratory and expiratory) stridor since birth that worsens with crying but is relieved in the prone position. Flexible laryngoscopy shows omega-shaped epiglottis and collapse of the arytenoid mucosa during inspiration. The most appropriate initial management is:

• A Urgent tracheostomy
• B Systemic corticosteroids and nebulised adrenaline
• C Laryngeal dilation under general anaesthesia
• D Reassurance and prone positioning; supraglottoplasty if symptoms are severe ✓

Explanation

Laryngomalacia is the most common cause of congenital stridor and is characterised by an omega-shaped floppy epiglottis and arytenoid prolapse, with inspiratory (and sometimes biphasic) stridor that worsens with crying/feeding and improves prone. Approximately 90% of cases resolve spontaneously by 18–24 months. Supraglottoplasty (division of shortened aryepiglottic folds) is reserved for severe cases with failure to thrive, severe hypoxia, or apnoea. Tracheostomy is rarely necessary.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.