An 8-month-old infant has had noisy breathing since the first weeks of life. Stridor is biphasic, worsens during feeds, and the child has always fed slowly with occasional choking on solids. A chest radiograph is normal. Barium swallow shows a posterior indentation on the oesophagus at the level of the thoracic inlet. What is the most likely cause?
- A Congenital subglottic stenosis
- B Laryngomalacia
- C Double aortic arch vascular ring ✓
- D Tracheomalacia
Correct answer: C. Double aortic arch vascular ring
Explanation
Biphasic stridor points to a fixed extrathoracic or intrathoracic obstruction such as compression of the trachea. A double aortic arch encircles both trachea and oesophagus, producing the classic posterior oesophageal indentation on barium swallow along with feeding difficulty and dysphagia starting at weaning onto solids. Laryngomalacia produces inspiratory stridor that improves prone, congenital subglottic stenosis gives recurrent croup-like episodes, and isolated tracheomalacia does not indent the oesophagus.
Reference: Cummings Otolaryngology: Head and Neck Surgery, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.