eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Congenital Stridor: Differential Diagnoses & Workup

Author: Timothy D Murphy, MD, Assistant Professor, Department of Pediatrics, Division of Pulmonology, University of Pittsburgh; Consulting Staff, Division of Pulmonology, Children's Hospital of Pittsburgh
Coauthor(s): Clement L Ren, MD,, Chief, Division of Pediatric Pulmonology, Department of Pediatrics, Associate Professor, Golisano Children's Hospital at Strong, University of Rochester, New York
Contributor Information and Disclosures

Updated: Feb 17, 2009

Differential Diagnoses

Laryngomalacia
Vascular Ring, Double Aortic Arch
Pulmonary Artery Sling
Vascular Ring, Right Aortic Arch
Stridor
Subglottic Stenosis
Tracheomalacia

Other Problems to Be Considered

Gastroesophageal reflux (GER)
Foreign body aspiration
Laryngeal stenosis

Workup

Imaging Studies

  • Chest radiography may be helpful in diagnosing a vascular ring if a right-sided aortic arch is observed in patients with congenital stridor.
  • Standard neck radiography is rarely helpful unless a large mass is responsible for the obstruction. High-kilovoltage radiography can highlight the tracheal structures better and may provide more information. These radiographs use a higher radiation dose.
  • CT scanning of the neck and chest may be helpful, especially if the radiology facility can perform airway reconstruction imaging. However, the need for cooperation in generating such images limits the use of CT imaging in infants and young children with congenital stridor.
  • Barium esophagraphy can be helpful in diagnosing vascular rings if an indentation in the esophagus is present. The pattern of indentation may also be helpful in indicating what type of vascular anomaly may be present. However, the lesion of anomalous innominate artery does not yield abnormal findings on esophagraphy.

Other Tests

  • A multichannel sleep study that measures airflow, chest wall excursion, oxygen saturation, and heart rate can provide useful information about the severity of obstruction.
  • An ABG study can reveal the presence of carbon dioxide retention or chronic hypoxemia.
  • In cases of suspected gastroesophageal reflux (GER), 24-hour mid esophageal pH monitoring may be helpful in establishing the diagnosis.

Procedures

  • Fiberoptic laryngoscopy and bronchoscopy, valuable diagnostic tools for the evaluation of congenital stridor, offer several important advantages over radiographic imaging, including the following:
    • Lesions can be directly visualized. Evidence of inflammation or bleeding can be observed. Characteristics of the lesion, such as vascularity, can be determined.
    • Biopsies and bronchoalveolar lavage samples can be taken if necessary.
    • The examination is conducted while the patient is actively breathing, allowing assessment of dynamic events.
  • Fiberoptic direct laryngoscopy can be performed in the office. However, in the pediatric population this procedure can be performed most safely while the patient is sedated. Bronchoscopy in a child requires intravenous conscious sedation or general anesthesia.

More on Congenital Stridor

Overview: Congenital Stridor
Differential Diagnoses & Workup: Congenital Stridor
Treatment & Medication: Congenital Stridor
Follow-up: Congenital Stridor
References
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References

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  2. Berdon WE, Baker DH. Vascular anomalies and the infant lung: rings, slings, and other things. Semin Roentgenol. Jan 1972;7(1):39-64. [Medline].

  3. Zalzal GH, Anon JB, Cotton RT. Epiglottoplasty for the treatment of laryngomalacia. Ann Otol Rhinol Laryngol. Jan-Feb 1987;96(1 Pt 1):72-6. [Medline].

  4. Cotton RT. Pediatric laryngotracheal stenosis. J Pediatr Surg. Dec 1984;19(6):699-704. [Medline].

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  6. Cotton RT, Schreiber JT. Management of laryngotracheoesophageal cleft. Ann Otol Rhinol Laryngol. Jul-Aug 1981;90(4 Pt 1):401-5. [Medline].

  7. McSwiney PF, Cavanagh NP, Languth P. Outcome in congenital stridor (laryngomalacia). Arch Dis Child. Mar 1977;52(3):215-8. [Medline].

  8. Nielson DW, Heldt GP, Tooley WH. Stridor and gastroesophageal reflux in infants. Pediatrics. Jun 1990;85(6):1034-9. [Medline].

  9. Orenstein SR, Kocoshis SA, Orenstein DM, Proujansky R. Stridor and gastroesophageal reflux: diagnostic use of intraluminal esophageal acid perfusion (Bernstein test). Pediatr Pulmonol. Nov-Dec 1987;3(6):420-4. [Medline].

  10. Parnell FW, Brandenburg JH. Vocal cord paralysis. A review of 100 cases. Laryngoscope. Jul 1970;80(7):1036-45. [Medline].

  11. Richardson MA, Cotton RT. Anatomic abnormalities of the pediatric airway. Ear Nose Throat J. Jan 1985;64(1):47-60. [Medline].

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  13. Weiss LN. The diagnosis of wheezing in children. Am Fam Physician. Apr 15 2008;77(8):1109-14. [Medline].

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Further Reading

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Keywords

congenital stridor, congenital croup, chronic congestion, obstruction of airway, noisy breathing, obstruction of trachea, trachea obstruction, micrognathia, bilateral vocal cord paralysis, subglottic hemangioma, airway obstruction, respiratory distress, failure to thrive, increased work of breathing, laryngomalacia, Arnold-Chiari malformation, webs, cysts, papillomata, and laryngotracheoesophageal clefts, subglottic stenosis, double aortic arch, pulmonary artery sling, bronchogenic cyst, tracheomalacia, gastroesophageal reflux, GER, cardio-vocal syndrome, airway foreign body

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Contributor Information and Disclosures

Author

Timothy D Murphy, MD, Assistant Professor, Department of Pediatrics, Division of Pulmonology, University of Pittsburgh; Consulting Staff, Division of Pulmonology, Children's Hospital of Pittsburgh
Disclosure: Nothing to disclose.

Coauthor(s)

Clement L Ren, MD,, Chief, Division of Pediatric Pulmonology, Department of Pediatrics, Associate Professor, Golisano Children's Hospital at Strong, University of Rochester, New York
Clement L Ren, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Thomas Scanlin, MD, Chief, Division of Pediatric Pulmonary & Cystic Fibrosis, Assistant Professor, Department of Pediatrics, Robert Wood Johnson University Medical Group
Thomas Scanlin, MD is a member of the following medical societies: American Thoracic Society and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Charles Callahan, DO, Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center
Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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