Chapter I

Introduction

1.1 Background
The word "stridor" is derived from the Latin word "stridulus," which means
creaking, whistling or grating. Stridor is a harsh, vibratory sound of variable
pitch caused by partial obstruction of the respiratory passages that results in
turbulent airflow through the airway. Although stridor may be the result of a
relatively benign process, it may also be the first sign of a serious and even
life-threatening disorder. Stridor is a distressing symptom to its victims and
their parents, and presents a diagnostic challenge to physicians. As such,
stridor demands immediate attention and thorough evaluation to uncover the
precise underlying cause.
Stridor is a sign of upper airway obstruction. It sounds high pitch resulting
from turbulent air flow in the upper airway. In children, laryngomalacia is the
most common cause of chronic stridor, while croup is the most common cause
of acute stridor. Generally, an inspiratory stridor suggests airway obstruction
above the glottis while an expiratory stridor is indicative of obstruction in the
lower trachea. A biphasic stridor suggests a glottic or subglottic lesion.
Laryngeal lesions often result in voice changes. A child with extrinsic airway
obstruction usually hyperextends the neck. The airway should be established
immediately in children with severe respiratory distress. Treatment of stridor
should be directed at the underlying cause.
Stridor is indicative of a potential medical emergency and should always
command attention. Wherever possible, attempts should be made to
immediately establish the cause of the stridor (e.g., foreign body, vocal cord
edema, tracheal compression by tumor, functional laryngeal dyskinesia, etc.)
That examination requires visualization of the airway to control the airway.

1.2 Etiology and Clinical Manifestation

1.2.1 Causes of stridor in children
These may be acute or chronic and the presentation and causes are
considered below.
Historical data Possib
le
etiolog
y

Age of onset
Birth Vocal cord paralysis, congenital lesions such as choanal
atresia, laryngeal web and vascular ring
4 to 6 weeks Laryngomalacia

1 to 4 years Croup, epiglottitis, foreign body aspiration

Chronicity
Acute onset Foreign body aspiration, infections such as croup and
epiglottitis
Long duration Structural lesion such as laryngomalacia, laryngeal web or
larynogotracheal stenosis
Precipitating factors

Worsening with straining or Laryngomalacia, subglottic hemangioma

crying
Worsening in a supine Laryngomalacia, tracheomalacia, macroglossia, micrognathi
position
Worsening at night Viral or spasmodic croup

Worsening with feeding Tracheoesophageal fistula, tracheomalacia, neurologic

disorder, vascular compression
Antecedent upper respiratory Croup, bacterial tracheitis
tract infection
Choking Foreign body aspiration, tracheoesophageal fistula

Associated symptoms
Barking cough Croup
Brassy cough Tracheal lesion
Drooling Epiglottitis, foreign body in esophagus, retropharyngeal or
peritonsillar abscess
Weak cry Laryngeal anomaly or neuromuscular disorder

Muffled cry Supraglottic lesion

Hoarseness Croup, vocal cord paralysis
Snoring Adenoidal or tonsillar hypertrophy
Dysphagia
Past health
Endotracheal intubation
Birth trauma, perinatal
asphyxia, cardiac problem
Atopy
Supraglottic lesion
Vocal cord paralysis, laryngotracheal stenosis
Vocal cord paralysis
Angioneurotic edema, spasmodic croup

Family history
Down syndrome Down syndrome
Hypothyroidism Hypothyroidism
Psycosocial history
Psychosocial stress Psychogenic stridor

1.2.1.1 Acute stridor in children

Croup or laryngotracheobronchitis:
• The most common acute stridor in children.
• Usually age 6 months to 2 years.
• Barking, seal-like cough, low fever and worse at night.

Inhaled foreign body:

• Common especially in children aged 1 to 2 years.
• Preceded by choking or coughing.

Tracheitis:
• Uncommon cause.
• Usually occurs under age 3 years.
• Bacterial infection following a viral infection in
toddlers.

Abscesses:
 • May be retropharyngeal (under age 6 years).
• Or peritonsillar (usually in adolescents).
• Present with high fever and difficulty swallowing.
• Retropharyngeal abscesses present with pain on
swallowing and hyperextension of the neck.
• Peritonsillar abscess presents with trismus, difficulty
with swallowing and difficulty with speaking.

Anaphylaxis:
• Hoarseness and inspiratory stridor.
• Accompanied by other symptoms of an allergic
reaction.
• Usually within 30 minutes of exposure to an allergen.

Epiglottitis:
• Usually occurs between ages 2 and 7 years.
• A medical emergency with high fever, sore throat,
drooling and dysphagia accompanying the acute stridor.

1.2.1.2 Chronic stridor in children

Laryngomalacia:
• This is the most common cause of stridor.
• It occurs in neonates and early infancy.
• The stridor is often exacerbated by the prone position,
and crying and feeding.

Vocal cord dysfunction:

• This is the next most common cause of infant stridor.
• The stridor is biphasic and associated with a weak cry.
• Unilateral vocal cord palsy is most common and can be
secondary to birth trauma or intrathoracic surgery.
• It usually resolves in the first 2 years of life.

Subglottic stenosis:
• This may be congenital with narrowing of the subglottis
and cricoid rings.
• It can be acquired after prolonged intubation.
• It causes inspiratory stridor but this can be biphasic and
misdiagnosed as asthma.

Laryngeal disorders:
• Congenital laryngeal webs can cause biphasic stridor.
• Laryngeal dyskinesia, exercise-induced laryngomalacia
and other disorders produce stridor.
• Laryngeal tumours may cause stridor. These may be
laryngeal cysts, haemangiomas (rare), or papillomas (vertical
transmission of human papillomavirus).

Tracheomalacia:
• This is caused either by external compression or, more
commonly, by a defective tracheal cartilage
• It is the most common cause of expiratory stridor.

Choanal atresia:
• Most common congenital anomaly of the nose in
infants.
• Unilateral may be asymptomatic.
• Bilateral may present with apnoea or cyanosis during
feeding.
• It can be diagnosed by an inability to pass a nasal
catheter.

Tracheal stenosis:
• Congenital tracheal stenosis is usually caused by
tracheal rings and presents with persistent stridor and a
prolonged expiratory phase.
• Other congenital causes of tracheal stenosis include
external compression from aortic arch abnormalities.