Stridor

Priority of stridor evaluation is based on history and clinical presentation. A child with new stridor and respiratory distress requires immediate intervention. The most common cause of chronic stridor in infants is laryngomalacia. Synchronous airway lesions need to be considered and evaluated by an otolaryngologist.

Differential Diagnosis

Nasal cavity and nasopharynx

• Congenital
  –Piriform aperture stenosis
  –Choanal atresia
  –Lacrimal duct cyst
  –Craniofacial anomaly
  –Nasopharyngeal mass (teratoma)
• Inflammatory/infectious
  –Rhinosinusitis
  –Adenoid hypertrophy

Oral cavity, oropharynx, and hypopharynx
• Congenital
  –Macroglossia
  –Glossoptosis
  –Vallecular cyst
• Inflammatory/infectious
  –Tonsillar hypertrophy
• Tumors
  –Lingual thyroid
  –Dermoid
  –Lymphovascular malformation
• Foreign body

• Congenital
  –Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
  –Saccular cyst
  –Webs
  –Clefts
  –Vocal cord paralysis

• Inflammatory/infectious
  –Epiglottitis
  –Laryngotracheitis (croup)
  –Gastroesophageal reflux
• Tumors
  –Papillomas
  –Hemangiomas
• Trauma
  –Subglottic stenosis
  –Foreign bodies
  –Laryngeal fracture
  –Caustic ingestion
  Tracheobronchial
• Congenital
  –Tracheomalacia
  –Vascular rings
  –Tracheoesophageal fistula
• Inflammatory

Workup and Diagnosis

• History
  –Duration, onset, severity, character, progression
  –Failure to thrive, feeding problems, cyanosis, apnea
  –Reflux history: Frequent spit-ups, vomiting, heartburn, chest pain, hoarseness
  –Birth, neonatal, and past medical history: Complicated labor, respiratory distress at delivery
  –Prior intubations, neurologic problems, prior episodes of croup, prior neck surgery, foreign body ingestion
  –Immunization history
• Physical exam
  –Fever, respiratory rate, heart rate, level of consciousness, cyanosis
  –Auscultation: Chest, nose, mouth, neck (phase of stridor: inspiratory, expiratory, biphasic)
  –Nose: Nasal obstruction
  –Mouth: Tonsillar hypertrophy
  –Neck: Retractions, compressive mass, thyroid
  • Studies
    –Flexible nasolaryngoscopy: Check for choanal patency, adenoid size, laryngomalacia, vocal cord mobility
    –Direct laryngoscopy and bronchoscopy (DLB): Controversial whether all children with stridor need DLB
    –MRI: Vascular compression or external mediastinal mass
    –Modified barium swallow or esophagram in children with history of swallowing difficulties

  Treatment

  • Treatment is frequently based on diagnosis from endoscopy
  • Immediate evaluation when respiratory distress is present
    –Observation, intubation, tracheostomy, FB removal
  • Acute stridor
    –Viral laryngotracheobronchitis: Steroids, racemic epinephrine, and supplemental O2
    –Bacterial tracheitis: Culture-directed antibiotic therapy, consider intubation
  • Chronic stridor of newborn
    –History, physical, and endoscopy (fiberoptic or direct) confirmation of laryngomalacia
    –Consider treatment for reflux
    –Repeat endoscopy and possible supraglottoplasty if persistent stridor and failure to thrive

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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