Stridor With Acute Onset in the Febrile Child Laryngotracheitis (croup) is by far the most common cause of stridor in the febrile child Other diagnoses that should be considered include bacterial tracheitis, epiglottitis, and much less commonly retropharyngeal abscess or laryngeal diphtheria in the unimmunized child (see Chapter 94 Infectious Disease Emergencies ) Though less common than croup, these diseases have a greater potential for life-threatening airway compromise Croup most commonly affects children between and 36 months of age with peak incidence around years of age but can be seen throughout childhood It is the most common cause of upper airway obstruction in children in this age group Croup typically begins with symptoms of an upper respiratory tract infection and fever, usually ranging from 38° to 39°C (100.4° to 102.2°F) Within 12 to 48 hours, a barky, “seal-like” cough and inspiratory stridor are noted The stridor is worsened when the child is agitated and often improves with nebulized racemic epinephrine Supraclavicular and subcostal retractions may be present Most children appear mildly to moderately ill, though the loud breathing and respiratory distress can be alarming to family members Bacterial tracheitis has a varied presentation but can resemble croup Patients tend to be older, appear more toxic, and may not improve as much as expected with nebulized racemic epinephrine Dysphagia is common, and drooling may be present The verbal child may complain of anterior neck pain or a painful cough Epiglottitis is an infection of the supraglottic structures, and therefore often called supraglottitis Historically, epiglottitis was most commonly caused by Haemophilus influenzae type B Other causative pathogens include Staphylococcus aureus, Streptococcus pneumoniae, β-hemolytic streptococci, and viral agents (parainfluenza, HSV 1, and varicella) Noninfectious causes can include direct trauma and thermal injury The incidence of epiglottitis due to H influenzae has plummeted to as low as 0.02 per 100,000 in Western countries following the introduction of the conjugate vaccine Sporadic cases are seen in unimmunized children or vaccine failures Patients with H influenzae epiglottitis typically appear toxic with fever and drooling Respiratory distress and a tripod stance (i.e., upright position, neck extended, and mouth open) are characteristic symptoms Sudden airway compromise may occur and can be precipitated by the manipulation of the oropharynx In contrast, epiglottitis caused by pathogens other than H influenzae has a more insidious onset, is more common in older children and adults, and is almost universally associated with dysphagia or sore throat Importantly, there is less risk of airway compromise with this presentation However, any child with suspected epiglottitis should be managed as if he or she has disease caused by H influenzae with risk of imminent airway compromise A retropharyngeal abscess is an infrequent cause of stridor Patients more commonly present with fever, limitation of neck movement, drooling, agitation, or lethargy Physical examination may reveal midline fullness of the oropharynx and decreased neck extension TABLE 75.1 CAUSES OF STRIDOR BY ANATOMIC LOCATION Nose and pharynx Congenital anomalies Lingual thyroid Choanal atresia Craniofacial anomalies (Apert and Down syndromes; Pierre Robin sequence) Cysts (dermoid, thyroglossal) Macroglossia (Beckwith syndrome) Encephalocele Inflammatory Abscess (parapharyngeal, retropharyngeal, peritonsillar) Allergic polyps Adenotonsillar enlargement (acute infection, infectious mononucleosis) Neoplasm (benign, malignant) Adenotonsillar hyperplasia Foreign body Neurologic syndromes with poor tongue/pharyngeal muscle tone Larynx Congenital anomalies Laryngomalacia Web, cyst, laryngocele Cartilage dystrophy Subglottic stenosis Cleft larynx Inflammatory Croup Epiglottitis/Supraglottitis Tracheitis Anaphylaxis Angioneurotic edema Miscellaneous: tuberculosis, fungal infection, diphtheria, sarcoidosis Vocal cord paralysis (multiple causes) Psychogenic stridor (vocal cord dysfunction) Neoplasm Subglottic hemangioma