Stridor in children

A 16-month-old boy was referred to the emergency department of the Children's Clinical University Hospital (Riga, Latvia) due to cough and noisy breathing for 3 months. The complaints seemed to have worsened over time with coughing fits 2–4 days a week and the boy not being able to tolerate solid food (leading to vomiting) during the fits. In between the bouts, he felt fine. Diminished food intake was noted over the last month. Over the 3-month period, no other symptoms were noted. The father of the child was fixated on a diagnosis of asthma and categorically denied the possibility of any choking attacks after eating or playing with small objects. The boy had been seen by pulmonologist once over the preceding 3-month period and was treated with salbutamol and high-dose fluticasone propionate inhalations that offered no alleviation of the symptoms. No imaging studies had been performed.

On physical examination, the patient was a happy 16-month-old with loud, high-pitch inspiratory stridor heard only when the boy started crying. The patient became uncooperative on examination, which led to agitation and crying, and proper auscultation could not be done.

Chest radiography (figure 1) revealed a round foreign body (2 cm in diameter) at the level of the second oesophageal constriction with no other pathological findings. An immediate endoscopic evaluation, performed under sedation, confirmed the presence of a lithium battery at the level of the second oesophageal constriction with local granulation tissue and a fibrin coating (figure 2). Unfortunately, the initial removal manoeuvres failed as the foreign body slipped out in the nasopharynx; it was evacuated by an ear, nose and throat specialist.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Chest radiogram of a 16-month-old child with history of stridor for 3 months.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Endoscopic evaluation of oesophagus in a 16-month-old child with history of stridor for 3 months. a) Foreign body at the level of the second oesophageal constriction. b) Foreign body (lithium battery) after removal from the oesophagus.

Review of the case performed at 12 and 15 days after the first endoscopy revealed chemical oesophagitis and mild scarring deformation.

Stridor is a high-pitched, monophonic sound caused by partial obstruction of the large airways that results in turbulent airflow in the respiratory passages [1–3]. It is quite common and can be observed in children of various ages. Stridor is usually loud and can be heard without a stethoscope [2] but the volume of stridor does not correlate with the severity of obstruction [3]. It is a symptom not a diagnosis and underlying pathology must be determined as it may be life threatening [3].

The differential diagnosis of stridor is vast with upper respiratory tract infections (croup most commonly), foreign body aspirations (common in childhood) and laryngomalacia (the most frequently seen underlying pathology in case of congenital stridor) [4, 5]. The characteristics of the pathologies and diseases causing stridor are reviewed in table 1.

Undoubtedly, careful history and clinical examination are the primary steps in diagnosing the underlying pathology. The following information should be gathered to differentiate the cause of stridor.

• Prenatal and obstetric history

• Onset of symptoms: acute, chronic or subacute (table 1)

• Age at onset of symptoms

• Associated symptoms (voice change, fever, cough, drooling, rash, wheezing, regurgitation, etc.)

• Any known adverse events (operations, intubation, exposure to smoke or hot air, ingesting hot liquids or caustic agents, playing with small objects, choking, etc.)

• Association of stridor with body position, feeding, stress, etc.

• Associated and underlying disorders (genetic diseases, oesophageal atresia, etc.)

• Vaccination history, particularly Haemophilus influenzae type b

• Previously performed investigations and therapy

Stress, crying and agitation (separation from parents, blood tests, examination of the throat, etc.) should be limited in a child with acute stridor since they can significantly worsen airway obstruction [3]. The breathing pattern, behaviour and the characteristics of the stridor may act as clues to the level of airway obstruction. In general, inspiratory stridor originates from obstruction in the extrathoracic region above the vocal cords (e.g. croup or epiglottitis); expiratory stridor, in the intrathoracic region (e.g. tracheomalacia, bronchomalacia or airway compression); and biphasic stridor is caused by fixed central airway obstruction at or below the cords (e.g. bilateral vocal cord paralysis, laryngeal web, haemangioma or subglottic stenosis) [1–3]. If epiglottitis is strongly suspected, cautious examination is warranted in order to avoid anxiety, respiratory effort and imminent functional airway obstruction [5, 29].

Often, the diagnosis can be made clinically and additional investigations are not always necessary.