Assessment of stridor in children
- Diana R Quintero, MD
Diana R Quintero, MD
- Associate Professor
- Medical College of Wisconsin
- Khoulood Fakhoury, MD
Khoulood Fakhoury, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
Stridor describes a high-pitched, monophonic sound made when breathing that is best heard over the anterior neck. These characteristics distinguish stridor from typical wheezing due to diffuse airflow limitation (asthma or bronchiolitis), which tends to consist of multiple sounds that start and stop at different times. The term is derived from the Latin verb stridere, meaning to make a harsh noise or shrill sound, as to creak.
Stridor is caused by the oscillation of a narrowed airway, and its presence suggests significant obstruction of the large airways. The acoustics of stridor may be explained as a result of Bernoulli's Principle, which states that as the speed of a moving fluid increases, the pressure within the fluid decreases. In an application in which airflow is forced through a narrowed tube, a local area of low pressure creates a vacuum effect distal to the narrowing. The focal area of low pressure distal to a narrowed airway causes the airway walls to collapse and vibrate, generating the squeak characteristic of stridor .
A commonly encountered presenting symptom in the pediatric population, stridor is an important physical finding that requires prompt evaluation and occasionally requires emergency intervention. The pathophysiology, differential diagnosis, and clinical management of stridor will be reviewed here. Related material is found in the following topics:
- Sly PD, Collins RA. Physiological basis of respiratory signs and symptoms. Paediatr Respir Rev 2006; 7:84.
- Applied Surgical Anatomy of the Larynx and Trachea. In: Pediatric Airway Surgery, Monnier P. (Ed), Springer Berlin Heidelberg, Berlin 2011. p.7.
- Boudewyns A, Claes J, Van de Heyning P. Clinical practice: an approach to stridor in infants and children. Eur J Pediatr 2010; 169:135.
- Kussman BD, Geva T, McGowan FX. Cardiovascular causes of airway compression. Paediatr Anaesth 2004; 14:60.
- De Ugarte DA, Shapiro NL, Williams HL. Tuberculous mediastinal mass presenting with stridor in a 3-month-old child. J Pediatr Surg 2003; 38:624.
- Cevik M, Gókdemir MT, Boleken ME, et al. The characteristics and outcomes of foreign body ingestion and aspiration in children due to lodged foreign body in the aerodigestive tract. Pediatr Emerg Care 2013; 29:53.
- Kudchadkar SR, Hamrick JT, Mai CL, et al. The heat is on... thermal epiglottitis as a late presentation of airway steam injury. J Emerg Med 2014; 46:e43.
- D'Agostino J. Pediatric airway nightmares. Emerg Med Clin North Am 2010; 28:119.
- Hopkins A, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics 2006; 118:1418.
- Al-Gazi M, Quinn K. Case 1: A toddler with stridor. Paediatr Child Health 2012; 17:307.
- Shah RK, Roberson DW, Jones DT. Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends. Laryngoscope 2004; 114:557.
- Perkin R, Rothrock SG. Stridor: A review, update and current management recommendations. Pediatric Emerg Med Rep 1996; 4:29.
- Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope 2012; 122:844.
- Gavin LA, Wamboldt M, Brugman S, et al. Psychological and family characteristics of adolescents with vocal cord dysfunction. J Asthma 1998; 35:409.
- Maturo S, Hill C, Bunting G, et al. Pediatric paradoxical vocal-fold motion: presentation and natural history. Pediatrics 2011; 128:e1443.
- Licari A, Manca E, Rispoli GA, et al. Congenital vascular rings: a clinical challenge for the pediatrician. Pediatr Pulmonol 2015; 50:511.
- Ahmed I, Kureel SN, Chandra N. Stridor with recurrent chest infection. Asian Cardiovasc Thorac Ann 2011; 19:443.
- Busino RS, Quraishi HA, Cohen IT. Stridor secondary to a bronchogenic cyst in a neonate. Ear Nose Throat J 2011; 90:E8.
- Leboulanger N, Garabédian EN. Laryngo-tracheo-oesophageal clefts. Orphanet J Rare Dis 2011; 6:81.
- Rahbar R, Rouillon I, Roger G, et al. The presentation and management of laryngeal cleft: a 10-year experience. Arch Otolaryngol Head Neck Surg 2006; 132:1335.
- Pedrosa C, Ferraria N, Limbert C, Lopes L. Hypovitaminosis D and severe hypocalcaemia: the rebirth of an old disease. BMJ Case Rep 2013; 2013.
- Venkatesh C, Chhavi N, Gunasekaran D, Soundararajan P. Acute stridor and wheeze as an initial manifestation of hypocalcemia in an infant. Indian J Endocrinol Metab 2012; 16:320.
- Sittel C. Pathologies of the larynx and trachea in childhood. GMS Curr Top Otorhinolaryngol Head Neck Surg 2014; 13:Doc09.
- Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
- Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health 2011; 47:77.
- Leung AK, Cho H. Diagnosis of stridor in children. Am Fam Physician 1999; 60:2289.
- Frost HM, Robinson CC, Dominguez SR. Epidemiology and clinical presentation of parainfluenza type 4 in children: a 3-year comparative study to parainfluenza types 1-3. J Infect Dis 2014; 209:695.
- Barratt GE, Koopmann CF Jr, Coulthard SW. Retropharyngeal abscess--a ten-year experience. Laryngoscope 1984; 94:455.
- Mills JL, Spackman TJ, Borns P, et al. The usefulness of lateral neck roentgenograms in laryngotracheobronchitis. Am J Dis Child 1979; 133:1140.
- Stankiewicz JA, Bowes AK. Croup and epiglottitis: a radiologic study. Laryngoscope 1985; 95:1159.
- Diaz JH, Lockhart CH. Early diagnosis and airway management of acute epiglottitis in children. South Med J 1982; 75:399.
- Rothrock SG, Pignatiello GA, Howard RM. Radiologic diagnosis of epiglottitis: objective criteria for all ages. Ann Emerg Med 1990; 19:978.
- Steen KH, Zimmermann T. Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. Laryngoscope 1990; 100:525.
- Losek JD. Diagnostic difficulties of foreign body aspiration in children. Am J Emerg Med 1990; 8:348.
- Gilger MA. Pediatric otolaryngologic manifestations of gastroesophageal reflux disease. Curr Gastroenterol Rep 2003; 5:247.
- MayoSmith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island. N Engl J Med 1986; 314:1133.
- Mauro RD, Poole SR, Lockhart CH. Differentiation of epiglottitis from laryngotracheitis in the child with stridor. Am J Dis Child 1988; 142:679.
- - Extrathoracic obstruction
- - Intrathoracic obstruction
- Auscultatory clues
- CAUSES OF STRIDOR
- Acute onset
- Subacute onset
- CLINICAL ASSESSMENT
- Initial rapid assessment
- - Age
- - Acuity of onset
- - Associated symptoms
- - Past medical history
- Physical examination
- DIAGNOSTIC TESTING
- - Neck radiographs
- - Chest radiographs
- - Other studies
- Airway examination