Pediatric emergency medicine trisk 374

Laryngeal papilloma
Cystic hygroma (neck)
Malignant (e.g., rhabdomyosarcoma)
Laryngospasm (hypocalcemic tetany)
Trachea and bronchi
Congenital
Vascular anomalies
Webs, cysts
Tracheal stenosis
Tracheoesophageal fistula
Neoplasm
Tracheal
Compression by adjacent structure (thyroid, thymus, esophagus)
Foreign body (tracheal or esophageal)
TABLE 75.2
COMMON CAUSES OF STRIDOR
Acute, Febrile
Croup
Tracheitis
Epiglottitis/Supraglottits
Acute, Afebrile
Foreign body
Caustic or thermal injury to airway
Spasmodic croup
Angioneurotic edema
Chronic
Laryngomalacia
Vascular anomalies
Adenotonsillar hyperplasia

Stridor With Acute Onset in the Afebrile Child

A foreign body in either the trachea or the esophagus may produce stridor. The
majority of foreign body aspirations occur in children under age 3 or in children


with developmental delays. There may be a history of choking on food or a small
object. Physical examination varies, depending on the location of the foreign
body (see Chapter 32 Foreign Body: Ingestion and Aspiration ).
Both ingestion and inhalation of caustic or thermally damaging substances may
result in injury to the airway or hypopharynx (see Chapter 104 Burns ).
Symptoms of airway compromise may be delayed for as long as 6 hours. Blind
finger sweeps have also been reported rarely to result in stridor. Other causes to
consider include spasmodic croup, anaphylaxis, angioneurotic edema, and
trauma.

Chronic Stridor
The differential diagnosis of chronic stridor varies with patient age. Stridor noted
shortly after birth is most likely caused by an anatomical defect. This type of
stridor tends to slowly worsen and is severe when the infant is crying or agitated.
Laryngomalacia is the most common cause of congenital stridor accounting for
up to 75% of chronic stridor in children younger than 1 year. Stridor associated
with laryngomalacia is positional and may be relieved by placing the child in the
prone position. It frequently disappears when the child cries. Other congenital
causes of stridor include laryngeal webs, laryngeal diverticula, vocal cord
paralysis, subglottic stenosis, tracheomalacia, and vascular anomalies such as a
double aortic arch or a vascular sling. Stridor in infants has also been reported to
be associated with gastroesophageal reflux, possibly related to associated
laryngomalacia, or acutely secondary to partial laryngospasm.


TABLE 75.3

LIFE-THREATENING CAUSES OF STRIDOR
Usually febrile
Epiglottitis/Supraglottitis
Tracheitis
Retropharyngeal abscess
Usually afebrile
Foreign body
Anaphylaxis
Angioneurotic edema
Neck trauma
Neoplasm (compressing trachea)
Thermal or caustic injury

FIGURE 75.1 Diagnostic approach to stridor.

Stridor in older children may be caused by papillomas or neoplastic processes.
Patients with papillomas generally present between 2 and 4 years of age with


complaints of hoarseness and stridor. Neoplastic processes causing tracheal
compression can also lead to stridor in the older child.
Psychogenic or functional stridor (also called vocal cord dysfunction or
paradoxical vocal cord movement) is an uncommon cause of stridor, and presents
in older children, typically adolescents. The diagnosis is three times more
common in females than males. More than 50% of patients meet diagnostic
criteria for a psychiatric disorder. This diagnosis can be challenging as many of
these patients have asthma as a comorbid condition, and may present with
apparent distress and poor aeration. Characteristically, stridor improves when the
patient is unaware that he or she is being observed, and it may clear with cough.
The diagnosis can be confirmed by nasopharyngoscopy in the symptomatic

patient when the vocal cords are noted to be adducted during inspiration.

EVALUATION AND DECISION
The first priority is to ensure that the airway is adequate by assessing the level of
consciousness, color, perfusion, air entry, breath sounds, and work of breathing,
including respiratory rate, nasal flaring, and retractions. Oxygen saturation should
be obtained, although a normal saturation does not rule out severe disease.
Conversely, a low saturation with upper airway obstruction as the only etiology of
illness is an ominous sign. If possible, the child should be allowed to assume a
position of comfort to minimize agitation and distress and maximize airway
patency. Immediate resuscitative measures should be instituted as necessary (see
Chapter 8 Airway ). The child may then be evaluated systematically. In the child
with acute onset of stridor, history should focus on associated symptoms such as
fever, duration of illness, drooling, rhinorrhea, and history of choking or trauma (
Fig. 75.1 ). Immunization status should be verified, particularly H. influenzae
vaccination. In the case of a child with chronic stridor, important historical points
include age at onset and progression of stridor, as well as ameliorating and
aggravating factors.
Physical examination should include careful inspection of the nares and
oropharynx, with particular attention to trismus, increased secretions or drooling,
visible mass, and abnormal phonation. Of note, the examination and manipulation
of the oropharynx of any child with suspected supraglottitis should be deferred
until a secure airway can be established. Quality of the voice or cry should be
noted as normal, hoarse (e.g., with croup, vocal cord paralysis, papilloma), weak
(e.g., with neuromuscular disorder), or aphonic (e.g., with laryngeal obstruction).
Regional findings such as adenopathy, neck masses, meningismus, trauma, or
bruising should also be sought. Position of comfort should be noted. Children