Pediatric emergency medicine trisk 375

with airway obstruction at or above the level of the larynx often hyperextend the
neck and lean forward (“sniffing” position) in an effort to straighten the upper
airway and maximize air entry. Finally, response to therapies, such as nebulized
racemic epinephrine, should be noted.

FIGURE 75.2 Inspiratory (A ) and expiratory (B ) lateral neck radiographs of a child with
upper airway obstruction secondary to a granuloma (arrow ) in the upper trachea. Note
ballooning of the pharynx during inspiration (A ) and narrowing of the trachea (arrowheads )
below the level of obstruction. On expiration (B ), note the normal pharyngeal lumen and
dilation (arrowheads ) of the trachea distal to the obstruction. The “bunching up” of the
pharyngeal tissues (PT ) and the buckling of the trachea (B ) are normal findings on expiratory
films.

Emergency management of the child with stridor depends on its severity and its
likely cause. Oxygen, nebulized epinephrine, corticosteroids, laryngoscopy,
intubation, and even emergency cricothyroidotomy or tracheostomy all have
specific roles in the emergency department (ED) management of stridor,
depending on its cause (see Chapters 106 ENT Trauma and 118 ENT
Emergencies ).

Febrile Child
In the febrile child with stridor, the onset is generally acute with croup being the
most common cause. Other diagnostic possibilities to consider include bacterial
tracheitis, supraglottitis, and much less likely retropharyngeal abscess. The child
whose clinical picture is consistent with mild to moderate croup needs no further
evaluation. History and physical examination alone are the most important


diagnostic tools for croup. Radiographs are not necessary, in the evaluation of
routine clinically diagnosed croup. However, anteroposterior and lateral neck
radiographs should be obtained if the diagnosis of croup is in question or if the

child does not respond to therapy as expected. If supraglottitis is strongly
suspected, a lateral neck radiograph should only be obtained in stable and
cooperative patients. Otherwise the child should have their airway secured by the
most senior or skilled clinician prior to other interventions, in the controlled
setting of the operating room whenever possible.
Airway radiographs must be interpreted with care because they are affected by
positioning, crying, swallowing, and the phase of respiration. To properly
interpret the prevertebral space, the lateral neck radiograph must be taken with
the patient’s head extended and during inspiration. Normal tracheal buckling,
which is seen during expiration in a young child, may be misinterpreted as
tracheal mass lesion or deviation from an extrinsic mass ( Fig. 75.2 ). Abnormal
findings on a lateral neck radiograph include a swollen epiglottis or aryepiglottic
folds (supraglottis), irregular tracheal borders or stranding across the trachea
(bacterial tracheitis), and increased prevertebral width (retropharyngeal abscess) (
e-Figs. 75.1 and 75.2 ). In children, the prevertebral space should be less than
the width of the adjacent cervical vertebral body. Radiographic findings
consistent with croup are a narrowed subglottic area on anteroposterior view (the
“steeple sign”) and possibly ballooning of the hypopharynx best appreciated on
the lateral view.

Afebrile Child
In the afebrile child with acute onset of stridor, the child’s age, the duration of
symptoms, and the likelihood of foreign-body aspiration are all key elements to
consider. Emergent otolaryngologic or surgical consultation should be obtained in
a child with an evidence of airway obstruction if either aspirated foreign body or
trauma is a likely cause of stridor. Stridor from anaphylaxis follows exposure to
an allergen, and may be associated with vomiting, wheezing, facial or oral edema,
urticaria, or hypotension. Angioneurotic edema, an autosomal-dominant trait, is
characterized by rapid onset of swelling without discoloration, urticaria, or pain.
Symptoms may occur in affected patients as young as 2 years of age but usually

are not severe until adolescence. Symptoms may be precipitated by trauma,
emotional stress, or menses. Determination of the C1 -esterase inhibitor level
should be considered if angioneurotic edema is suspected. (See Chapter 85
Allergic Emergencies .)


A child with chronic stridor generally does not require an extensive evaluation
in the ED unless significant respiratory distress is present or a significant change
in the quality of the stridor is noted. The infant with chronic stridor who is
otherwise well should be referred to the primary pediatrician or to an
otolaryngologist. Once a neoplastic cause is deemed unlikely, the older child with
chronic stridor should be referred to otolaryngology for evaluation, including
nasopharyngoscopy and possible direct laryngoscopy for evaluation of the vocal
cords.
The Children’s Hospital of Philadelphia Clinical Pathways
ED Pathway for the Evaluation/Treatment of the Child With Croup
URL: />Authors: J. Piccione, MD; M. Mittal, MD; J. Seiden, MD; B. Jenssen,
MD; M. Dunn, MD; R. Hughes, PharmD; K. Cohn, MD; E. Hysinger,
MD; A. Buzi, MD; E. Walker, RT; M.F. Duff, RT; J.M Malpass, RT; S.M.
Gaines, RN
Posted: September 2014, last revised December 2016, reviewed
December 2018
ED Clinical Pathway for the Evaluation/Treatment of the Child With
a Suspected Deep Neck Space Infection
URL: />Authors: R. Abaya, MD; M. Joffe, MD; L. Vella, MD; M. Dunn, MD; S.
MacFarland, MD; M. Rizzi, MD; K. Shekdar, MD; R. Bellah, MD; J.
Lavelle, MD
Posted: February 2017, reviewed October 2019
Suggested Readings and Key References
Cherry JD. Croup. N Engl J Med 2008;358(4):384–391.

Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical
presentation, management, and outcome. J Laryngol Otol 2008;122(8):818–
823.
Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening
upper airway infections: the reemergence of bacterial tracheitis. Pediatrics


2006;118(4):1418–1421.
Ida JB, Thompson DM. Pediatric stridor. Otolaryngol Clin North Am
2014;47(5):795–819.
Tyler A, McLeod L, Beaty B, et al. Variation in inpatient croup management and
outcomes. Pediatrics 2017;139(4):e20163582.
Additional Resources Online