Pediatric emergency medicine trisk 1496 1496

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