eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Stridor: Differential Diagnoses & Workup

Author: Brian E Benson, MD, Staff Physician, Division of Otolaryngology, New Jersey Medical School
Coauthor(s): Soly Baredes, MD, Associate Professor of Clinical Surgery, Chief, Section of Otolaryngology-Head and Neck Surgery, Director, Division of Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Mudra Kumar, MD, MBBS, MRCP, Associate Professor, Department of Pediatrics, University of South Florida College of Medicine
Contributor Information and Disclosures

Updated: Aug 29, 2006

Differential Diagnoses

Congenital Arterial and Venous Anomalies: Surgical Perspective
Congenital Stridor
Gastroesophageal Reflux
Laryngomalacia
Subglottic Stenosis
Tracheomalacia

Other Problems to Be Considered

Wheezing
Cardiac failure
Laryngeal stenosis

Workup

Laboratory Studies

  • On initial evaluation, pulse oximetry may be useful to determine the extent and severity of the stridor and respiratory compromise.
  • For moderate-to-severe cases, arterial blood gas may be needed.
  • Other laboratory evaluations may be performed as dictated by the clinical situation.
  • Generally, no investigations are required for mild stridor.

Imaging Studies

  • Anteroposterior (AP) and lateral radiographs of the neck and chest are useful to evaluate the airway and lungs.
  • High-kilovoltage, short-exposure, endolateral airway radiographs (useful to demonstrate upper airway structures) or inspiratory and expiratory or lateral decubitus radiographs to demonstrate air trapping may be used to supplement AP and lateral radiographs.
  • Barium esophagram may be performed if vascular compression, tracheoesophageal fistula, GER, or neurological dysfunction is suspected.
  • Contrast-enhanced CT scanning can demonstrate mediastinal masses or aberrant vessels.
  • An MRI may be helpful in delineating lesions of the upper airway and vascular anomalies.
  • If GER is suspected, a pH probe or barium swallow may be performed to support the diagnosis.

Other Tests

  • Pulmonary function testing may be useful to differentiate restrictive and obstructive lung processes and to define whether the obstruction is upper or lower airway.
  • Polysomnography may be required under certain circumstances, especially if history suggests obstructive sleep apnea.

Procedures

  • The key to defining stridor of all phases is to look at the airway. Direct laryngoscopy and bronchoscopy is the criterion standard for making a diagnosis in infants and children with stridor.
  • In children with stable oxygen saturations and in whom findings on a lateral neck radiograph or the clinical picture does not indicate acute epiglottitis, the initial procedure to evaluate stridor should be a flexible laryngoscopy performed by an otolaryngologist in the clinic with topical vasoconstrictor and/or topical anesthetic as needed. The status of the larynx can be addressed, looking for abnormalities such as laryngomalacia, true vocal cord paresis or paralysis, laryngeal tumors or cysts, or signs and symptoms of GER. Often, a good evaluation is possible, or, occasionally, only a glimpse of the subglottis is observed, which may help direct further evaluation, such as a formal direct laryngoscopy and bronchoscopy in the operation room.

More on Stridor

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

  1. Bailey BJ, Calhoun KH, Healy GB, eds. Head & Neck Surgery - Otolaryngology, 3rd Ed. Philadelphia, Penn: Lippincott, Williams, & Wilkins; 2001.

  2. Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. Philadelphia, Penn:. WB Saunders;1996.

  3. Bent J. Pediatric laryngotracheal obstruction: current perspectives on stridor. Laryngoscope. Jul 2006;116(7):1059-70. [Medline].

  4. Cotton RT, Reilly JS. Stridor and airway obstruction. In: Bluestone C, Stool S, Kenna M, eds. Pediatric Otolaryngology. 3rd Ed. Philadelphia, Penn: WB Saunders co; 1995: 1275-88. 1275-1286.

  5. Geelhoed GC. Croup. Pediatr Pulmonol. May 1997;23(5):370-4. [Medline].

  6. Klassen TP. Croup. A current perspective. Pediatr Clin North Am. Dec 1999;46(6):1167-78. [Medline].

  7. Lalakea M, Messner AH. Retropharyngeal abscess management in children: current practices. Otolaryngol Head Neck Surg. Oct 1999;121(4):398-405. [Medline].

  8. Mancuso RF. Stridor in neonates. Pediatr Clin North Am. Dec 1996;43(6):1339-56. [Medline].

  9. Pryor MP. Noisy breathing in children: history and presentation hold many clues to the cause. Postgrad Med. Feb 1997;101(2):103-12. [Medline].

  10. Tan HKK, Holinger LD. How to evaluate and manage stridor in children. J Respir Dis. 1994;15(3):245-260.

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Further Reading

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Keywords

stridor, inspiratory stridor, expiratory stridor, biphasic stridor, croup

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Contributor Information and Disclosures

Author

Brian E Benson, MD, Staff Physician, Division of Otolaryngology, New Jersey Medical School
Brian E Benson, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Soly Baredes, MD, Associate Professor of Clinical Surgery, Chief, Section of Otolaryngology-Head and Neck Surgery, Director, Division of Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Soly Baredes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, American Society for Head and Neck Surgery, New York Academy of Medicine, New York Academy of Sciences, New York Head and Neck Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Mudra Kumar, MD, MBBS, MRCP, Associate Professor, Department of Pediatrics, University of South Florida College of Medicine
Mudra Kumar, MD, MBBS, MRCP is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology
Disclosure: Nothing to disclose.

Medical Editor

Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Maureen Strafford, MD is a member of the following medical societies: American Medical Women's Association, American Pain Society, American Society of Anesthesiologists, International Anesthesia Research Society, Society for Education in Anesthesia, Society for Pediatric Anesthesia, and Society of Cardiovascular Anesthesiologists
Disclosure: Nothing to disclose.

 
 
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