Laryngeal papilloma Cystic hygroma (neck) Malignant (e.g., rhabdomyosarcoma) Laryngospasm (hypocalcemic tetany) Trachea and bronchi Congenital Vascular anomalies Webs, cysts Tracheal stenosis Tracheoesophageal fistula Neoplasm Tracheal Compression by adjacent structure (thyroid, thymus, esophagus) Foreign body (tracheal or esophageal) TABLE 75.2 COMMON CAUSES OF STRIDOR Acute, Febrile Croup Tracheitis Epiglottitis/Supraglottits Acute, Afebrile Foreign body Caustic or thermal injury to airway Spasmodic croup Angioneurotic edema Chronic Laryngomalacia Vascular anomalies Adenotonsillar hyperplasia Stridor With Acute Onset in the Afebrile Child A foreign body in either the trachea or the esophagus may produce stridor The majority of foreign body aspirations occur in children under age or in children with developmental delays There may be a history of choking on food or a small object Physical examination varies, depending on the location of the foreign body (see Chapter 32 Foreign Body: Ingestion and Aspiration ) Both ingestion and inhalation of caustic or thermally damaging substances may result in injury to the airway or hypopharynx (see Chapter 104 Burns ) Symptoms of airway compromise may be delayed for as long as hours Blind finger sweeps have also been reported rarely to result in stridor Other causes to consider include spasmodic croup, anaphylaxis, angioneurotic edema, and trauma Chronic Stridor The differential diagnosis of chronic stridor varies with patient age Stridor noted shortly after birth is most likely caused by an anatomical defect This type of stridor tends to slowly worsen and is severe when the infant is crying or agitated Laryngomalacia is the most common cause of congenital stridor accounting for up to 75% of chronic stridor in children younger than year Stridor associated with laryngomalacia is positional and may be relieved by placing the child in the prone position It frequently disappears when the child cries Other congenital causes of stridor include laryngeal webs, laryngeal diverticula, vocal cord paralysis, subglottic stenosis, tracheomalacia, and vascular anomalies such as a double aortic arch or a vascular sling Stridor in infants has also been reported to be associated with gastroesophageal reflux, possibly related to associated laryngomalacia, or acutely secondary to partial laryngospasm TABLE 75.3 LIFE-THREATENING CAUSES OF STRIDOR Usually febrile Epiglottitis/Supraglottitis Tracheitis Retropharyngeal abscess Usually afebrile Foreign body Anaphylaxis Angioneurotic edema Neck trauma Neoplasm (compressing trachea) Thermal or caustic injury FIGURE 75.1 Diagnostic approach to stridor Stridor in older children may be caused by papillomas or neoplastic processes Patients with papillomas generally present between and years of age with complaints of hoarseness and stridor Neoplastic processes causing tracheal compression can also lead to stridor in the older child Psychogenic or functional stridor (also called vocal cord dysfunction or paradoxical vocal cord movement) is an uncommon cause of stridor, and presents in older children, typically adolescents The diagnosis is three times more common in females than males More than 50% of patients meet diagnostic criteria for a psychiatric disorder This diagnosis can be challenging as many of these patients have asthma as a comorbid condition, and may present with apparent distress and poor aeration Characteristically, stridor improves when the patient is unaware that he or she is being observed, and it may clear with cough The diagnosis can be confirmed by nasopharyngoscopy in the symptomatic patient when the vocal cords are noted to be adducted during inspiration EVALUATION AND DECISION The first priority is to ensure that the airway is adequate by assessing the level of consciousness, color, perfusion, air entry, breath sounds, and work of breathing, including respiratory rate, nasal flaring, and retractions Oxygen saturation should be obtained, although a normal saturation does not rule out severe disease Conversely, a low saturation with upper airway obstruction as the only etiology of illness is an ominous sign If possible, the child should be allowed to assume a position of comfort to minimize agitation and distress and maximize airway patency Immediate resuscitative measures should be instituted as necessary (see Chapter Airway ) The child may then be evaluated systematically In the child with acute onset of stridor, history should focus on associated symptoms such as fever, duration of illness, drooling, rhinorrhea, and history of choking or trauma ( Fig 75.1 ) Immunization status should be verified, particularly H influenzae vaccination In the case of a child with chronic stridor, important historical points include age at onset and progression of stridor, as well as ameliorating and aggravating factors Physical examination should include careful inspection of the nares and oropharynx, with particular attention to trismus, increased secretions or drooling, visible mass, and abnormal phonation Of note, the examination and manipulation of the oropharynx of any child with suspected supraglottitis should be deferred until a secure airway can be established Quality of the voice or cry should be noted as normal, hoarse (e.g., with croup, vocal cord paralysis, papilloma), weak (e.g., with neuromuscular disorder), or aphonic (e.g., with laryngeal obstruction) Regional findings such as adenopathy, neck masses, meningismus, trauma, or bruising should also be sought Position of comfort should be noted Children