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Stridor

by Noah Lechtzin, MD, MHS

Stridor is a high-pitched, predominantly inspiratory sound. It is most commonly associated with acute disorders, such as foreign body aspiration but can be due to more chronic disorders, such as tracheomalacia.

Inspiratory stridor in croup.

Stridor

Pathophysiology

Stridor is produced by the rapid, turbulent flow of air through a narrowed or partially obstructed segment of the extrathoracic upper airway. Involved areas include the pharynx, epiglottis, larynx, and the extrathoracic trachea.

Etiology

Most causes manifest acutely, but some patients present with chronic or recurrent symptoms (see Table: Some Causes of Stridor).

Acute causes are usually infectious except for foreign body and allergy. Chronic causes are usually a congenital or acquired structural abnormality of the upper airway. Transient or intermittent stridor can result from aspiration with acute laryngospasm or from vocal cord dysfunction.

Children

The most common causes of acute stridor in children include

  • Croup

  • Foreign body aspiration

Epiglottitis has historically been a common cause of stridor in children, but its incidence has decreased since the introduction of the Haemophilus influenzae type B (HiB) vaccine. Various congenital airway disorders can manifest as recurrent stridor in neonates and infants.

Adults

Common causes in adults include

  • Vocal cord dysfunction (also called paradoxical vocal cord motion—see Vocal Cord Dysfunction)

  • Postextubation laryngeal edema

  • Vocal cord edema or paralysis

  • Laryngeal tumors

  • Allergic reactions

Vocal cord dysfunction often mimics asthma, so many patients with vocal cord dysfunction are incorrectly given drugs for asthma but do not respond. Epiglottitis may be becoming more common among adults, but adults with epiglottitis are less likely than children to have stridor.

Some Causes of Stridor

Cause

Suggestive Findings

Diagnostic Approach

Acute stridor

Allergic reaction (severe)

Sudden onset after exposure to allergen

Usually accompanied by wheezing and sometimes orofacial edema; itching

No fever or sore throat; cough rare

Clinical evaluation

Croup

Age 6–36 mo

Barking cough that is worse at night, URI symptoms, no difficulty swallowing, low-grade fever

Clinical evaluation

Sometimes anteroposterior neck x-ray showing subglottic narrowing (steeple sign)

Epiglottitis

Mainly adults, as well as children who missed HiB vaccination

Abrupt onset of high fever, sore throat, drooling, and often respiratory distress and marked anxiety

Toxic appearance

Lateral neck x-ray if the patient is stable

Examination in operating room if any signs of distress

Foreign body

Sudden onset in a toddler or young child who has no URI or constitutional symptoms

In adults, foreign body in upper airway typically apparent by history

Direct or indirect laryngoscopy or bronchoscopy

Inhalation injury (eg, due to cleaning agents or smoke inhalation)

Clinically apparent recent toxic inhalation

Clinical evaluation

Sometimes bronchoscopy

Postextubation complications (eg, laryngeal edema, laryngospasm, arytenoid dislocation)

Recent intubation and respiratory distress

Clinical evaluation

Sometimes direct laryngoscopy

Retropharyngeal abscess

Mainly in children < 4 yr

High fevers, severe throat pain, drooling, trouble swallowing, sometimes respiratory distress

Swelling that may or may not be visible in the pharynx

Lateral neck x-ray

Sometimes neck CT with contrast

Bacterial tracheitis (rare)

Barking cough that is worse at night, high fever, and respiratory distress

Toxic appearance

Neck x-rays

Sometimes direct or indirect laryngoscopy with visualization and culture of purulent tracheal secretions

Laryngospasm

Recurrent episodes, associated with gastroesophageal reflux or recent drug use or occurring after endotracheal intubation

Direct or indirect laryngoscopy

Vocal cord dysfunction

Recurrent episodes of unexplained stridor often with hoarseness, throat tightness, a choking sensation, and/or cough

Direct laryngoscopy

Chronic stridor

Congenital anomalies (numerous; laryngomalacia most common)

Usually in neonates or infants

Sometimes other congenital anomalies present

Sometimes trouble feeding or sleeping

Sometimes worse with URI

CT of neck and chest

Direct laryngoscopy

Spirometry with flow-volume loops

External compression

History of head and neck cancer or obvious mass, night sweats, and weight loss

X-ray of neck and chest

CT of neck and chest

Direct or indirect laryngoscopy

Laryngeal tumors (eg, squamous cell carcinoma, hemangiomas, small cell carcinoma)

Inspiratory or biphasic stridor that may progressively worsen as tumor enlarges

Direct or indirect laryngoscopy

Spirometry with flow-volume loops

Congenital tracheomalacia

Chronic symptoms

Stridor or barky cough during coughing, crying, or feeding

May worsen in the supine position

CT or MRI

Spirometry with flow-volume loops

Sometimes bronchoscopy

Bilateral vocal cord paralysis or dysfunction

Recent trauma (eg, during birth, thyroid or other neck surgery, intubation, or deep airway suctioning)

Various neurodegenerative or neuromuscular disorders present

Good voice quality but limited intensity

Direct or indirect laryngoscopy

HiB = Haemophilus influenzae type B.

Evaluation

History

History of present illness should first identify whether symptoms are acute or chronic and whether transient or intermittent. If acute, any symptoms of URI (runny nose, fever, sore throat) or allergy (itching, sneezing, facial swelling, rash, potential allergen exposure) are noted. Recent intubation or neck surgery should be clinically obvious. If chronic, the age at onset (eg, since birth, since infancy, only in adulthood) and duration are determined, as well as whether symptoms are continuous or intermittent. For intermittent symptoms, provoking or exacerbating factors (eg, position, allergen exposure, cold, anxiety, feeding, crying) are sought. Important associated symptoms in all cases include cough, pain, drooling, respiratory distress, cyanosis, and difficulty feeding.

Review of systems should seek symptoms suggesting causative disorders, including heartburn or other reflux symptoms (laryngospasm); night sweats, weight loss, and fatigue (cancer); and voice change, trouble swallowing, and recurrent aspiration (neurologic disorders).

Past medical history in children should cover perinatal history, particularly regarding need for endotracheal intubation, presence of known congenital anomalies, and vaccination history (particularly HiB). In adults, history of prior endotracheal intubation, tracheotomy, recurrent respiratory infections, and tobacco and alcohol use should be elicited.

Physical examination

The first step is to determine the presence and degree of respiratory distress by evaluating vital signs (including pulse oximetry) and doing a quick examination. Signs of severe distress include cyanosis, decreased level of consciousness, low O 2 saturation (eg,< 90%), air hunger, use of accessory inspiratory muscles, and difficulty speaking. Children with epiglottitis may sit upright with arms braced on the legs or examination table, lean forward, and hyperextend the neck with the jaw thrust forward and mouth open in an effort to enhance air exchange (tripod position). Moderate distress is indicated by tachypnea, use of accessory muscles of respiration, and intercostal retractions. If distress is severe, further examination is deferred until equipment and personnel are arranged for emergency management of the airway.

Oropharyngeal examination of a patient (particularly a child) with epiglottitis may provoke anxiety, leading to functional obstruction and loss of the airway. Thus, if epiglottitis is suspected, a tongue depressor or other instrument should not be placed in the mouth. When suspicion is low and patients are in no distress, they may undergo imaging; others should be sent to the operating room for direct laryngoscopy, which should be done by an otolaryngologist with the patient under anesthesia.

If the patient’s vital signs and airway are stable and acute epiglottitis is not suspected, the oral cavity should be thoroughly examined for pooled secretions, hypertrophic tonsils, induration, erythema, or foreign bodies. The neck is palpated for masses and tracheal deviation. Careful auscultation of the nose, oropharynx, neck, and chest may help discern the location of the stridor. Infants should be examined with special attention to craniofacial morphology (looking for signs of congenital malformations), patency of the nares, and cutaneous abnormalities.

Red flags

The following findings are of particular concern:

  • Drooling and agitation

  • Tripod position

  • Cyanosis or hypoxemia on pulse oximetry

  • Decreased level of consciousness

Interpretation of findings

The distinction between acute and chronic stridor is important. Other clinical findings are also often helpful (see Table: Some Causes of Stridor).

Acute manifestations are more likely to reflect an immediately life-threatening disorder. With these disorders, fever indicates infection. Fever plus barking cough suggests croup or, very rarely, tracheitis. Patients with croup typically have more prominent URI symptoms and less of a toxic appearance. Fever without cough, particularly if accompanied by toxic appearance, sore throat, difficulty swallowing, or respiratory distress, suggests epiglottitis and, in young children, the less common retropharyngeal abscess. Drooling and the tripod position are suggestive of epiglottitis, whereas retropharyngeal abscess may manifest with neck stiffness and inability to extend the neck.

Patients without fever or URI symptoms may have an acute allergic reaction or aspirated foreign body. Acute allergic reaction severe enough to cause stridor usually has other manifestations of airway edema (eg, oral or facial edema, wheezing) or anaphylaxis (itching, urticaria). Foreign body obstruction of the upper airway that causes stridor is always acute but may be occult in toddlers (older children and adults can communicate the event unless there is near-complete airway obstruction, which will manifest as such, not as stridor). Cough is often present with foreign body but rare with allergic reaction.

Chronic stridor that begins early in childhood and without a clear inciting factor suggests a congenital anomaly or an upper airway tumor. In adults, heavy smoking and alcohol use should raise suspicion of laryngeal cancer. Vocal cord paralysis usually has a clear precipitant, such as surgery or intubation, or is associated with other neurologic findings, such as muscle weakness. Patients with tracheomalacia frequently have cough productive of sputum and have a history of recurrent respiratory infections.

Testing

Testing should include pulse oximetry. In patients with minimal respiratory distress, soft-tissue neck x-rays may help. An enlarged epiglottis or retropharyngeal space can be seen on the lateral view, and the subepiglottic narrowing of croup (steeple sign) may be seen on the anteroposterior view. X-rays may also identify foreign objects in the neck or chest.

In other cases, direct laryngoscopy can detect vocal cord abnormalities, structural abnormalities, and tumors. CT of the neck and chest should be done if there is concern about a structural abnormality, such as an upper airway tumor or tracheomalacia. Flow-volume loops can be useful in chronic and intermittent stridor to show the presence of an upper airway obstruction. Abnormal flow-volume loop findings generally require follow up with CT or laryngoscopy.

Treatment

Definitive treatment of stridor involves treating the underlying disorder. As a temporizing measure in patients with severe distress, a mixture of helium and O 2 (heliox) improves airflow and reduces stridor in disorders of the large airways, such as postextubation laryngeal edema, croup, and laryngeal tumors. The mechanism of action is thought to be reduced flow turbulence as a result of lower density of helium compared with O 2 and nitrogen.

Nebulized racemic epinephrine (0.5 to 0.75 mL of 2.25% racemic epinephrine added to 2.5 to 3 mL of normal saline) and dexamethasone (10 mg IV, then 4 mg IV q 6 h) may be helpful in patients in whom airway edema is the cause.

Endotracheal intubation see also Airway Establishment and Control : Tracheal Intubation should be used to secure the airway in patients with advanced respiratory distress, impending loss of airway, or decreased level of consciousness. When significant edema is present, endotracheal intubation can be difficult, and emergency surgical airway measures (eg, cricothyrotomy, tracheostomy) may be required.

Key Points

  • Inspiratory stridor is often a medical emergency.

  • Assessment of vital signs and degree of respiratory distress is the first step.

  • In some cases, securing the airway may be necessary before or in parallel with the physical examination.

  • Acute epiglottitis is uncommon in children who have received HiB vaccine.

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  • ADRENALIN
  • OZURDEX

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