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Stridor in children

Marta Celmina, Simona Paule
Breathe 2018 14: e111-e117; DOI: 10.1183/20734735.017018
Marta Celmina
1Children's Clinical University Hospital, Riga, Latvia
2University of Latvia, Riga, Latvia
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  • For correspondence: marta.celmina@gmail.com
Simona Paule
3Riga Stradins University, Riga, Latvia
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    Figure 1

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

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    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.

Tables

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  • Table 1

    Characteristics and additional diagnostic techniques to differentiate the causes of stridor in children

    CharacteristicsAdditional diagnostic techniques
    Acute
     Foreign body aspiration or ingestion [5–7]Peak age 1–3 years
    Sudden-onset coughing and choking that might be followed by symptom-free period, and thus be misinterpreted as resolution
    Potentially life threatening
    Chest radiography
    CT when suspected that negative result might avert bronchoscopy
    Bronchoscopy
     AnaphylaxisPotentially life threatening
    Possible additional symptoms (skin and/or gastrointestinal)
    Detail history of the episode
     Infection
      Bacterial tracheitis [7]Any age; most commonly, first 6 years
    ARVI-like prodromal period
    Croup-like symptoms that do not respond to standard croup therapy
    Direct laryngoscopy and/or bronchoscopy gives a definitive diagnosis but is not routinely performed
    Specimens for aetiological diagnosis during endoscopy immediately after intubation; older patients might provide sputum
      Epiglottitis [7]Decreased incidence and increased age at presentation (previously 3 years, now 6–12 years) since Hib vaccine was introduced
    Sudden onset, rapid progression
    Hallmark: three D's (dysphagia, drooling and distress), fever, toxic appearance, hoarse voice, stridor, pharyngitis
    Various degrees of severity
     Young children: respiratory distress, anxiety, “tripod”/ “sniffing” posture, drooling; cough not characteristic
     Older children: might just have severely sore throat
    Often clinical diagnosis
    Direct laryngoscopy (swollen epiglottitis)
    Lateral radiography of the neck, looking for the “thumb sign”
    Laboratory tests and microbiology only if the airways are safe
    Need for a very cautious examination is warranted in theatre with experienced anaesthetist and an ENT specialist capable of performing an emergency airway procedure
      Diphtheria [7]Presenting symptoms: malaise, sore throat, fever (low grade), cervical lymphadenopathy
    Mild pharyngeal erythema → isolated exudate (grey, white) → pseudomembrane (at least one third of cases); pseudomembrane can extend to lower parts of respiratory system
    Laryngeal diphtheria (pseudomembrane covers larynx) might be isolated (cough, hoarseness) or a part of malignant diphtheria (stridor, respiratory insufficiency)
    Systemic manifestations: myocarditis, neuropathies
    Culture of Corynebacterium diphtheriae from respiratory tract
    Toxin detection
    Laryngoscopy: pseudomembrane
     Airway burns
      Thermal epiglottitis and upper airway burns [8]Clinical presentation similar to that of infectious epiglottitis; might not correlate with severity, especially in younger children
    With/without cutaneous burn injury
    Risk of rapid airway obstruction (because of developing oedema)
    Direct laryngoscopy
    Bronchoscopy
      Caustic burns [9]More common 1–3 years of age
    Upper airway involvement: hoarseness, stridor, nasal flaring, retractions
    Other symptoms: food refusal, drooling, dysphagia (oropharyngeal/oesophageal injury)
    Symptoms might not correlate with severity, especially in younger children
    May be misdiagnosed as anaphylaxis
    Direct laryngoscopy
    Bronchoscopy
    Subacute
     Retropharyngeal 
 abscess [7, 10, 11]Peaks at 2–4 years of age
    Often after upper airway infection (tonsillitis, pharyngitis, lymphadenitis)
    Early stage: symptoms indistinguishable from uncomplicated pharyngitis
    Later stage: dysphagia, odynophagia, drooling, torticollis, neck pain, dysphonia, respiratory distress, stridor, trismus, fever, chest pain
    Symptoms might be similar to that of epiglottitis but progress slower
    Lateral neck radiograph (might be false positive if the child is crying)
    CT scan with intravenous contrast
     Peritonsillar abscess [7, 12]More often in adolescents
    Severe sore throat (mainly unilateral), fever, muffled voice, trismus, drooling
    Pus drainage from abscess confirms diagnosis
    Laboratory tests not necessary
    Imaging studies not routinely performed; might help differentiate peritonsillar abscess from cellulitis (intraoral or submandibular US), deep space neck infection (CT scan with contrast) and epiglottitis (direct laryngoscopy, lateral neck radiograph)
    Chronic/recurrent
     Congenital
      Laryngomalacia [5, 7, 13]Usually begins at neonatal period: 4–5 weeks, peaks at 4–8 months; may resolve by 12–18 months
    Inspiratory “wet” low-pitch stridor; hoarseness is atypical
    May worsen in the supine and improve in the prone position
    Worsens during respiratory infections
    Mild to moderate: louder when sleeping and feeding; may disappear when crying
    Severe: louder when crying.
    Severe: associated with other problems (sleep disordered breathing, failure to thrive etc.)
    Higher incidence of gastro-oesophageal reflux
    Flexible laryngoscopy if associated problems are noted (failure to thrive, apnoea, significant/progressive stridor, etc.)
    Sleep endoscopy: suspicion of state dependent laryngomalacia (during sleep)
      Tracheomalacia [5, 14, 15]Usually manifests from 2–3 months of age
    More common in children with oesophageal atresia
    Barking or brassy cough, stridor
    Moderate: more frequent lower airway infections
    Severe: upper respiratory tract obstruction, cyanosis, apnoeic spells
    Symptoms might become more evident with activities (crying, eating)
    Dynamic airway endoscopy: diagnostic tool of choice
    CT scan: end-expiratory and end-inspiratory images (endotracheal intubation needed in young kids)
    Free-breathing cine CT scan (can be used in young children, does not require breathing manoeuvres cooperation)
    Barium oesophagography (evaluating tracheal compression by oesophagus or other structures)
      Vocal cord paralysis 
  [5, 7, 16]Onset of symptoms: birth to 5 years
    Bilateral (birth trauma, neurological, unknown reason): stridor, respiratory insufficiency, cyanosis
    Flexible fibreoptic nasopharyngolaryngoscopy
    Direct laryngoscopy
    Laryngeal ultrasound
      Vascular ring [17]Great clinical variability from critical airway obstruction to asymptomatic (incomplete vascular ring)
    Stridor (usually louder during expiration), wheezing, cough, respiratory distress, respiratory infections
    Digestive system complaints: dysphagia, feeding difficulty, vomiting (complete vascular ring)
    Associated anomalies: congenital heart disease, tracheo-oesophageal fistula, cleft lip/palate, subglottic stenosis, genetic or malformation syndromes
    Anterior, posterior, lateral chest radiograph (compressed trachea, anterior bowing of the trachea)
    CT scan or MRA
    Echocardiography
    Bronchoscopy (not routinely performed)
    Barium swallow (not routinely performed)
      Bronchogenic cyst [14]Usually presents in adolescence with recurrent cough, wheezing (might simulate asthma), pneumonia
    Starting in infancy: respiratory distress, cyanosis, feeding difficulty
    Chest radiograph
    CT scan, MRI
      Laryngeal malformations 
  [13]Cyst (vallecular, saccular), laryngocele, stenosis, cleft usually present in infancy/early childhood
    Stridor, wheezing, noisy breathing, hoarseness, aspiration, recurrent respiratory infections, feeding difficulty, failure to thrive
    Endoscopy
      Infantile haemangiomas 
  [5, 7, 13, 18]Symptoms typically start at 1–3 months and resolve by 5–12 years of age
    Presentation similar to that of subglottic stenosis; recurrent croup, biphasic stridor (may progress to respiratory distress)
    Initially might be misdiagnosed as croup; response to standard croup therapy is transient
    Might be associated with other haemangiomas, especially in the “beard” distribution
    Endoscopy
    Radiograph of the neck: asymmetric narrowing of the subglottis
    CT scan with contrast: delineating
      Subglottic stenosis 
  [5, 7, 13, 19]Biphasic stridor, recurrent episodes of croup and barking cough
    Typically improves with time
    Endoscopy
     Acquired
      VCD or paradoxical vocal 
  fold motion [20, 21]Transient improper adduction of the true vocal folds (inspiration and/or expiration)
    Great clinical variability; may also mimic other diseases (e.g. asthma attack), frequently misdiagnosed
    Various triggers: exercise, stress, irritants, infections, etc.
    Stridor, globus sensation, difficulty swallowing, chest tightness, aphonia/dysphonia, sensation of choking that can lead to stress, anxiety, panic
    Usually self limiting
    VCDQ (symptom monitoring)
    Pittsburgh VCD index (differential diagnosis with asthma)
    Direct flexible laryngoscopy (if possible, after bronchoprovocation challenge) is the gold standard
    Pulmonary function testing (possible changes in inspiratory loop)
    Impulse oscillometry
      Recurrent respiratory 
  papillomatosis [22, 23]Juvenile (usually more aggressive; most commonly 2–4 years of age) or adult (diagnosis after 12 years of age) onset
    Hoarseness: usually the presenting symptom, followed by stridor.
    Less often: failure to thrive, chronic cough, dysphagia, dyspnoea, acute respiratory distress, recurrent pneumonia.
    Often misdiagnosed as croup, asthma, allergies, bronchitis, vocal nodules. The diagnosis usually made 1 year after the onset of symptoms
    Laryngoscopy
      Vocal cord paralysisUnilateral (usually iatrogenic): hoarse voice, crying affections; risk for aspirationFlexible fibreoptic nasopharyngolaryngoscopy
    Direct laryngoscopy
    Laryngeal ultrasound
      Subglottic stenosis [24]Symptoms similar but less severe to that of congenital subglottic stenosisEndoscopy
      Hypocalcaemic 
  laryngeal spasm [25]Children with vitamin D deficiency and rickets (mostly); metabolic/endocrine disorders that result in hypocalcaemia
    Stridor: chronic intermittent or acute and severe; rarely as presenting symptom
    Other symptoms due to hypocalcaemia: muscle contractions, anticonvulsant-resistant seizures; in neonates: apnoea, lethargy, poor feeding, abdominal distension, tachycardia, vomiting
    Chvostek or Trousseau sign
    Blood tests: electrolytes, alkaline phosphatase, phosphate, magnesium, PTH, vitamin D metabolites, liver function tests
    ECG: prolonged QTc
    Urine tests: pH, calcium, magnesium, phosphate, creatinine
    Urine calcium/creatinine ratio
      Tumour [26]Tumors that compress the airways may present with expiratory stridor, shortness of breath, cough, hoarse voiceChest radiograph: mediastinal masses are commonly discovered on routine test
      GORD [27, 28]Nocturnal stridor and cough are atypical manifestations of GORD
    Other symptoms
     Infants: feeding refusal, poor weight gain, haematemesis, anaemia, respiratory symptoms
     Preschool: intermittent regurgitation, respiratory symptoms, decreased food intake and poor weight gain; Sandifer syndrome
     School-aged children and adolescents: postprandial cough, chronic cough, hoarseness, dysphagia, globus sensation, bitter taste in mouth, heartburn, nausea
    Empiric treatment
    24-h pH monitoring or impedance monitoring
    Endoscopy and histology

    CT: computed tomography; ARVI: acute respiratory viral infection; Hib: Haemophilus influenzae type b; ENT: ear, nose and throat; US: ultrasonography; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; VCD: vocal cord dysfunction; VCDQ: Vocal Cord Dysfunction Questionnaire; PTH: parathyroid hormone; QTc: QT interval; GORD: gastro-oesophageal reflux disease.

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    Stridor in children
    Marta Celmina, Simona Paule
    Breathe Sep 2018, 14 (3) e111-e117; DOI: 10.1183/20734735.017018

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    Marta Celmina, Simona Paule
    Breathe Sep 2018, 14 (3) e111-e117; DOI: 10.1183/20734735.017018
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