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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