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1 Background The word "stridor" is derived from the Latin word "stridulus," which means creaking, whistling or grating. Stridor is a harsh, vibratory sound of variable pitch caused by partial obstruction of the respiratory passages that results in turbulent airflow through the airway. Although stridor may be the result of a relatively benign process, it may also be the first sign of a serious and even life-threatening disorder. Stridor is a distressing symptom to its victims and their parents, and presents a diagnostic challenge to physicians. As such, stridor demands immediate attention and thorough evaluation to uncover the precise underlying cause. Stridor is a sign of upper airway obstruction. It sounds high pitch resulting from turbulent air flow in the upper airway. In children, laryngomalacia is the most common cause of chronic stridor, while croup is the most common cause of acute stridor. Generally, an inspiratory stridor suggests airway obstruction above the glottis while an expiratory stridor is indicative of obstruction in the lower trachea. A biphasic stridor suggests a glottic or subglottic lesion. Laryngeal lesions often result in voice changes. A child with extrinsic airway obstruction usually hyperextends the neck. The airway should be established immediately in children with severe respiratory distress. Treatment of stridor should be directed at the underlying cause. Stridor is indicative of a potential medical emergency and should always command attention. Wherever possible, attempts should be made to immediately establish the cause of the stridor (e.g., foreign body, vocal cord edema, tracheal compression by tumor, functional laryngeal dyskinesia, etc.) That examination requires visualization of the airway to control the airway. 1.2 Etiology and Clinical Manifestation 1.2.1 Causes of stridor in children These may be acute or chronic and the presentation and causes are considered below.
tracheoesophageal fistula Croup Tracheal lesion Epiglottitis. subglottic hemangioma Laryngomalacia. macroglossia. micrognathi Viral or spasmodic croup Tracheoesophageal fistula. foreign body aspiration Foreign body aspiration. retropharyngeal or peritonsillar abscess Laryngeal anomaly or neuromuscular disorder Supraglottic lesion Croup. foreign body in esophagus. laryngeal web and vascular ring Laryngomalacia Croup. infections such as croup and epiglottitis Structural lesion such as laryngomalacia. laryngeal web or larynogotracheal stenosis Laryngomalacia. tracheomalacia. vocal cord paralysis Adenoidal or tonsillar hypertrophy . vascular compression Croup. congenital lesions such as choanal atresia. bacterial tracheitis Foreign body aspiration. neurologic disorder.Historical data Possib le etiolog y Age of onset Birth 4 to 6 weeks 1 to 4 years Chronicity Acute onset Long duration Precipitating factors Worsening with straining or crying Worsening in a supine position Worsening at night Worsening with feeding Antecedent upper respiratory tract infection Choking Associated symptoms Barking cough Brassy cough Drooling Weak cry Muffled cry Hoarseness Snoring Vocal cord paralysis. epiglottitis. tracheomalacia.
Abscesses: . Barking.Dysphagia Past health Endotracheal intubation Birth trauma. cardiac problem Atopy Family history Down syndrome Hypothyroidism Psycosocial history Psychosocial stress Supraglottic lesion Vocal cord paralysis. spasmodic croup Down syndrome Hypothyroidism Psychogenic stridor 1. Preceded by choking or coughing. Usually age 6 months to 2 years. Inhaled foreign body: • • Common especially in children aged 1 to 2 years. seal-like cough. laryngotracheal stenosis Vocal cord paralysis Angioneurotic edema.1 Acute stridor in children Croup or laryngotracheobronchitis: • • • The most common acute stridor in children.2. Tracheitis: • • • Uncommon cause. perinatal asphyxia. Bacterial infection following a viral infection in toddlers. low fever and worse at night.1. Usually occurs under age 3 years.
sore throat. difficulty swallowing and hyperextension of the neck. Epiglottitis: • • Usually occurs between ages 2 and 7 years. Accompanied by other symptoms of an allergic Usually within 30 minutes of exposure to an allergen. and crying and feeding. The stridor is often exacerbated by the prone position. A medical emergency with high fever. drooling and dysphagia accompanying the acute stridor. . Anaphylaxis: • • • Hoarseness and inspiratory stridor.• • • • • May be retropharyngeal (under age 6 years). Present with high fever and difficulty swallowing. Vocal cord dysfunction: • • • This is the next most common cause of infant stridor.2.1. Retropharyngeal abscesses present with pain on Peritonsillar abscess presents with trismus. Or peritonsillar (usually in adolescents). The stridor is biphasic and associated with a weak cry. with swallowing and difficulty with speaking. It occurs in neonates and early infancy. 1. reaction.2 Chronic stridor in children Laryngomalacia: • • • This is the most common cause of stridor. Unilateral vocal cord palsy is most common and can be secondary to birth trauma or intrathoracic surgery.
laryngeal cysts. commonly. These may be and other disorders produce stridor. It causes inspiratory stridor but this can be biphasic and and cricoid rings. Subglottic stenosis: • • • This may be congenital with narrowing of the subglottis It can be acquired after prolonged intubation. or papillomas (vertical transmission of human papillomavirus). catheter. exercise-induced laryngomalacia Laryngeal tumours may cause stridor. more It is the most common cause of expiratory stridor. Bilateral may present with apnoea or cyanosis during It can be diagnosed by an inability to pass a nasal Most common congenital anomaly of the nose in feeding. haemangiomas (rare). Laryngeal dyskinesia. Tracheal stenosis: • Congenital tracheal stenosis is usually caused by . Laryngeal disorders: • • • Congenital laryngeal webs can cause biphasic stridor. misdiagnosed as asthma.• It usually resolves in the first 2 years of life. Tracheomalacia: • • This is caused either by external compression or. • • • Unilateral may be asymptomatic. by a defective tracheal cartilage Choanal atresia: • infants.
tracheal rings and presents with persistent stridor and a prolonged expiratory phase. . • Other congenital causes of tracheal stenosis include external compression from aortic arch abnormalities.