with airway obstruction at or above the level of the larynx often hyperextend the neck and lean forward (“sniffing” position) in an effort to straighten the upper airway and maximize air entry Finally, response to therapies, such as nebulized racemic epinephrine, should be noted FIGURE 75.2 Inspiratory (A ) and expiratory (B ) lateral neck radiographs of a child with upper airway obstruction secondary to a granuloma (arrow ) in the upper trachea Note ballooning of the pharynx during inspiration (A ) and narrowing of the trachea (arrowheads ) below the level of obstruction On expiration (B ), note the normal pharyngeal lumen and dilation (arrowheads ) of the trachea distal to the obstruction The “bunching up” of the pharyngeal tissues (PT ) and the buckling of the trachea (B ) are normal findings on expiratory films Emergency management of the child with stridor depends on its severity and its likely cause Oxygen, nebulized epinephrine, corticosteroids, laryngoscopy, intubation, and even emergency cricothyroidotomy or tracheostomy all have specific roles in the emergency department (ED) management of stridor, depending on its cause (see Chapters 106 ENT Trauma and 118 ENT Emergencies ) Febrile Child In the febrile child with stridor, the onset is generally acute with croup being the most common cause Other diagnostic possibilities to consider include bacterial tracheitis, supraglottitis, and much less likely retropharyngeal abscess The child whose clinical picture is consistent with mild to moderate croup needs no further evaluation History and physical examination alone are the most important diagnostic tools for croup Radiographs are not necessary, in the evaluation of routine clinically diagnosed croup However, anteroposterior and lateral neck radiographs should be obtained if the diagnosis of croup is in question or if the child does not respond to therapy as expected If supraglottitis is strongly suspected, a lateral neck radiograph should only be obtained in stable and cooperative patients Otherwise the child should have their airway secured by the most senior or skilled clinician prior to other interventions, in the controlled setting of the operating room whenever possible Airway radiographs must be interpreted with care because they are affected by positioning, crying, swallowing, and the phase of respiration To properly interpret the prevertebral space, the lateral neck radiograph must be taken with the patient’s head extended and during inspiration Normal tracheal buckling, which is seen during expiration in a young child, may be misinterpreted as tracheal mass lesion or deviation from an extrinsic mass ( Fig 75.2 ) Abnormal findings on a lateral neck radiograph include a swollen epiglottis or aryepiglottic folds (supraglottis), irregular tracheal borders or stranding across the trachea (bacterial tracheitis), and increased prevertebral width (retropharyngeal abscess) ( e-Figs 75.1 and 75.2 ) In children, the prevertebral space should be less than the width of the adjacent cervical vertebral body Radiographic findings consistent with croup are a narrowed subglottic area on anteroposterior view (the “steeple sign”) and possibly ballooning of the hypopharynx best appreciated on the lateral view Afebrile Child In the afebrile child with acute onset of stridor, the child’s age, the duration of symptoms, and the likelihood of foreign-body aspiration are all key elements to consider Emergent otolaryngologic or surgical consultation should be obtained in a child with an evidence of airway obstruction if either aspirated foreign body or trauma is a likely cause of stridor Stridor from anaphylaxis follows exposure to an allergen, and may be associated with vomiting, wheezing, facial or oral edema, urticaria, or hypotension Angioneurotic edema, an autosomal-dominant trait, is characterized by rapid onset of swelling without discoloration, urticaria, or pain Symptoms may occur in affected patients as young as years of age but usually are not severe until adolescence Symptoms may be precipitated by trauma, emotional stress, or menses Determination of the C1 -esterase inhibitor level should be considered if angioneurotic edema is suspected (See Chapter 85 Allergic Emergencies ) A child with chronic stridor generally does not require an extensive evaluation in the ED unless significant respiratory distress is present or a significant change in the quality of the stridor is noted The infant with chronic stridor who is otherwise well should be referred to the primary pediatrician or to an otolaryngologist Once a neoplastic cause is deemed unlikely, the older child with chronic stridor should be referred to otolaryngology for evaluation, including nasopharyngoscopy and possible direct laryngoscopy for evaluation of the vocal cords The Children’s Hospital of Philadelphia Clinical Pathways ED Pathway for the Evaluation/Treatment of the Child With Croup URL: https://www.chop.edu/clinical-pathway/croup-emergentevaluation-clinical-pathway Authors: J Piccione, MD; M Mittal, MD; J Seiden, MD; B Jenssen, MD; M Dunn, MD; R Hughes, PharmD; K Cohn, MD; E Hysinger, MD; A Buzi, MD; E Walker, RT; M.F Duff, RT; J.M Malpass, RT; S.M Gaines, RN Posted: September 2014, last revised December 2016, reviewed December 2018 ED Clinical Pathway for the Evaluation/Treatment of the Child With a Suspected Deep Neck Space Infection URL: https://www.chop.edu/clinical-pathway/neck-infection-clinicalpathway Authors: R Abaya, MD; M Joffe, MD; L Vella, MD; M Dunn, MD; S MacFarland, MD; M Rizzi, MD; K Shekdar, MD; R Bellah, MD; J Lavelle, MD Posted: February 2017, reviewed October 2019 Suggested Readings and Key References Cherry JD Croup N Engl J Med 2008;358(4):384–391 Guldfred LA, Lyhne D, Becker BC Acute epiglottitis: epidemiology, clinical presentation, management, and outcome J Laryngol Otol 2008;122(8):818– 823 Hopkins A, Lahiri T, Salerno R, et al Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis Pediatrics 2006;118(4):1418–1421 Ida JB, Thompson DM Pediatric stridor Otolaryngol Clin North Am 2014;47(5):795–819 Tyler A, McLeod L, Beaty B, et al Variation in inpatient croup management and outcomes Pediatrics 2017;139(4):e20163582 Additional Resources Online ... life-threatening upper airway infections: the reemergence of bacterial tracheitis Pediatrics 2006;118(4):1418–1421 Ida JB, Thompson DM Pediatric stridor Otolaryngol Clin North Am 2014;47(5):795–819 Tyler... is noted The infant with chronic stridor who is otherwise well should be referred to the primary pediatrician or to an otolaryngologist Once a neoplastic cause is deemed unlikely, the older child... 2014;47(5):795–819 Tyler A, McLeod L, Beaty B, et al Variation in inpatient croup management and outcomes Pediatrics 2017;139(4):e20163582 Additional Resources Online