Aryepiglottic Fold-Predominant Supraglottitis Presenting with Paradoxical Relief of Stridor on Neck Flexion

<title>Abstract</title> <p>Background Acute supraglottitis typically presents with the classic tripod position, neck extension, leaning forward, and jaw thrust, to maximize upper airway patency. Positional worsening with neck extension and paradoxical relief with flexion is exceptionally uncommon. Case Presentation: A 26-year-old woman with type 1 diabetes mellitus presented with progressive inspiratory stridor and drooling. Stridor worsened during neck extension but improved with flexion, and the patient positioned herself accordingly based on comfort and preference. Lateral neck radiography demonstrated marked aryepiglottic fold swelling with vallecular air space obliteration and relative epiglottic sparing. She was managed with intravenous antibiotics, with complete resolution of stridor within 48 hours. Discussion Unlike the classic presentation in which neck extension improves airflow, this patient exhibited paradoxical relief with flexion. We hypothesize that predominant aryepiglottic fold edema caused dynamic airway narrowing aggravated by extension, while flexion relieved tension on these structures. This illustrates how variations in inflammation distribution may produce atypical presentations. Diabetes mellitus is a recognized risk factor for severe disease requiring airway intervention. Conclusion Clinicians should recognize that supraglottitis can present with unusual positional symptoms. Improvement with neck flexion does not exclude the diagnosis and may reflect predominant aryepiglottic fold involvement. Early recognition and prompt treatment remain essential to prevent life-threatening airway compromise.</p>