An infant presents at birth with high-pitched inspiratory stridor that worsens when supine and improves when prone. Laryngoscopy shows retroflexion of a soft, omega-shaped epiglottis with prolapse of aryepiglottic folds on inspiration. The diagnosis and appropriate initial management are:
- A Subglottic stenosis; urgent tracheotomy followed by laryngotracheal reconstruction
- B Laryngomalacia; reassurance and positional feeds as most cases resolve spontaneously by 12-18 months; supraglottoplasty reserved for severe cases with failure to thrive ✓
- C Congenital subglottic hemangioma; propranolol therapy immediately
- D Bilateral vocal cord palsy; nasogastric feeding and long-term tracheotomy
Explanation
Laryngomalacia is the most common cause of congenital stridor, accounting for ~75% of cases. The pathognomonic features are inspiratory stridor worsening supine/during feeds, an omega-shaped epiglottis, and aryepiglottic fold prolapse on flexible laryngoscopy. It results from immaturity/hypotonia of the supraglottic structures. Over 90% resolve spontaneously by 12-18 months. Supraglottoplasty (trimming aryepiglottic folds, removing redundant arytenoid mucosa) is indicated for failure to thrive, severe apnea, or cor pulmonale. Subglottic hemangioma presents at 2-3 months and is biphasic (inspiratory + expiratory).
Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.