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Stridor
Authors

Vincent Sicari1; Christopher P. Zabbo2.

Affiliations
1
Kent Hospital
2
Kent Hospital/ UNECOM

Last Update: February 23, 2019.

Introduction
Stridor is a variable, high-pitched respiratory sound that can be assessed during breathing.
Typically, stridor is produced by the abnormal flow of air in the airways, usually the upper
airways, and most prominently heard during inspiration. However, it can also be present during
both inspiration and expiration. Stridor can be due to congenital malformations and anomalies as
well as in the acute phase from life-threatening obstruction or infection. The diagnostic approach
may include x-rays or bronchoscopy by a trained specialist to ascertain the etiology when there is
diagnostic uncertainty. It should be noted that in infants and young children, a small amount of
inflammation can result in significant and rapid airway obstruction.[1]

Etiology
The etiologies for stridor differ depending on whether the patient is pediatric or an adult. For
pediatrics, the most common causes of acute stridor include croup, foreign body aspiration.
However, there are many other causes. The cause of stridor can further be differentiated based on
acuity and based on congenital versus noncongenital causes.

Congenital Causes of Stridor in Pediatrics

 Nasal deformities such as choanal atresia, choanal atresia, septum deformities, turbinate
hypertrophy, vestibular atresia, or vestibular stenosis
 Craniofacial anomalies such as Pierre Robin or Apert syndromes, or conditions causing
macroglossia
 Laryngeal anomalies such as laryngomalacia, laryngeal webs, laryngeal cysts, laryngeal
clefts, subglottic stenosis, vocal cord paralysis, tracheal stenosis, tracheomalacia
Noncongenital Causes of Stridor in Pediatrics

 Acute: Foreign body aspiration, airway burns, bacterial tracheitis, epiglottitis,

anaphylaxis, croup.
 Subacute: Peritonsillar abscess, retropharyngeal abscess.
 Chronic: Vocal cord dysfunction, laryngeal spasm, neoplasm.

(See table below)

Most common cause of chronic stridor in infants is laryngomalacia.[2]

Epidemiology
The epidemiology of stridor is dependant on the original cause for the stridor. Generally, stridor
is more common in pediatrics than adults.

With croup, for example, the peak incidence is between 6 months to 36 months, where there are
about 5 to 6 cases per 100 toddlers. There is also a slight male predominance of 1.4:1.

Moreover, foreign body aspiration accounts for more than 17,000 emergency department visits
per year in the United States, with most cases occurring before the age of 3 years.[3]

Pathophysiology
The pathophysiology of stridor is based upon the anatomic location involved as well as the
underlying disease process. Narrowowing of the supraglottic areas can occur rapidly because
there is no cartilage in these areas. The subglottic area is of most concern in infants in which
minimal airway narrowing here can result in dramatic increases in airway resistance.

Inspiratory Stridor

An obstruction in the extrathoracic region causes inspiratory stridor. During inspiration, the
intratracheal pressure falls below the atmospheric pressure, causing a collapse of the airway.

Expiratory Stridor

An obstruction in the intrathoracic region causes expiratory stridor. During expiration, the
increased pleural pressure compresses the airway causing a decrease in the airway size at the site
of the intrathoracic obstruction.

Both inspiratory and expiratory stridor occur because of bacterial tracheitis and foreign bodies.

Laryngeal webs and vocal cord paralysis occur due to a fixed airway obstruction, which does not
change with respiration.
History and Physical
History

 Neonates: Congenital abnormalities present within the first month of life, with some
presenting later in life.
 Infants to toddlers: The most common cause in this age group is croup or foreign body
aspiration. 
 Young adolescents: Vocal cord dysfunction, peritonsillar abscess
 Acute: Epiglottitis, bacterial tracheitis will present with severe respiratory distress and
secretions, and fever, if fever is not present then suspect foreign body aspiration or
anaphylaxis
 Subacute: Croup will present with intermittent stridor

Symptoms

 Hives: Should prompt evaluation for anaphylaxis secondary to allergic trigger

 A cough: Typically presents with croup
 Drooling: Typically seen with retropharyngeal abscess and epiglottitis, or foreign body
aspiration

Physical Exam

 General appearance: Assess for any swelling of soft tissues of the neck and oropharynx,
and rashes or hives, or any clubbing of digits.
 HEENT: Assess tongue size, pharyngeal edema, or peritonsillar abscess. Be cautious in
manipulating the oropharynx of a suspected epiglottitis patient, and consider doing this in
a controlled setting such as the operating room.
 Lungs: Asses rate and depth of breathing, auscultate for inspiratory and expiratory
stridor. Auscultate over the anterior neck to best hear stridor.[4]

Evaluation
Initial evaluation should begin with a rapid assessment of the patient's airway and effort of
breathing. First, ensure that the airway maintains patent and can move air in and out of the
lungs. Asses the patient's rate and depth of breathing, and evaluate for hypoxia or cyanosis and if
the patient looks like they are decompensating secondary to fatigue.

If the patient is hemodynamic stable with stridor, obtain a thorough history of present illness,
review of systems, and medical history. Keys to the correct diagnosis can be delineated based on
patient age, acuity of onset, history of exposures to allergens or infectious sources.  In the stable
patient with stridor, additional testing including imaging, radiography, and endoscopy may be
performed. 
In the patient is unstable, there may be signs of respiratory distress, gasping, drooling, fatigue,
cyanosis, and these signs prompt a more rapid evaluation and rapid management to ensure
airway patency. This can include endotracheal intubation or emergency surgical airway.

Laboratory testing may include a complete blood count (CBC), if an infectious source is
suspected, however, this is usually not necessary for diagnosis. A rapid viral panel may be
obtained to assess for parainfluenza viruses in the pediatric patient.

Radiography including a lateral plain film may be obtained to assess for the size of the
retropharyngeal space, in which a widened space may indicate a retropharyngeal abscess. A
mnemonic can be used "6 at C2, and 22 at C6" to remember that the normal retropharyngeal
space should not be greater than 6mm at the level of C2 and not more than 22 mm at the level of
C6. This view may also aid in visualizing of an enlarged epiglottis. An anteroposterior view to
assessing for subglottic narrowing such as the "steeple" sign in croup.  A chest radiograph can be
obtained in suspected foreign body aspiration. However, a negative chest radiograph does not
rule this out.[5]

Computed tomography (CT) can be considered when there is diagnostic uncertainty in the stable
patient with stridor. CT of the chest and neck can evaluate for an infectious source such as
cellulitis as well as stenotic lesions, or foreign bodies. Magnetic resonance imaging (MRI) can
help discern tracheal stenosis in pediatric patients.

Laryngoscopy and bronchoscopy can help visualize the airways to establish a definitive
diagnosis. If the patient appears critically ill, then endotracheal intubation should be performed if
the cause of stridor is thought to be from epiglottitis or bacterial tracheitis.

Treatment / Management
Management of stridor should be undertaken from the time of initial assessment in the critically
ill-appearing patient. Specific treatment should be tailored to the underlying diagnosis. In
general, the following precautions should be maintained when managing/treating stridor.[6]

 Avoid agitating child with stridor

 Monitor for rapid deterioration due to respiratory failure
 Avoid direct examination or manipulation of the pharynx (if epiglottitis is suspected). In
such situations, securing the airway takes precedence over diagnostic evaluation.
 Skilled personnel in airway management should accompany the patient at all times.
Further evaluation should be performed where definitive airway management can be
achieved in a controlled environment such as the operating room.
 Consider foreign body aspirations if symptoms develop acutely such as sudden coughing
and choking in a previously healthy child.
 Avoid beta-agonists in croup; they are a possible risk of worsening upper airway
obstruction.

Differential Diagnosis
Differential diagnosis of stridor can include infectious, inflammatory, or anatomical etiologies.
The emergency physician should always recognize croup, epiglottitis, anaphylaxis, bacterial
tracheitis, abscess, and foreign aspiration as a cause of stridor. The differential can be narrowed
down based on the patients presenting age and the duration of the stridor.

Enhancing Healthcare Team Outcomes

Given that the etiology of stridor is a robust, effective diagnosis and management of stridor relies
on the clinical suspicion of the healthcare team, along with imaging modalities in unclear cases.
Appropriate treatment then becomes directed toward the underlying cause and disease process.
When a patient is presenting in extremis with stridor, it is up to the healthcare provider to rapidly
recognize impending deterioration, gather the appropriate resources which many include rapid
consultation with anesthesiology and appropriate surgical teams. In terms of croup, for instance,
there have been many clinical trials demonstrating appropriate management based on the clinical
presentation and clinical severity scores, which have led to decreased endotracheal intubations,
as well as decreased hospital course length of stay, with the use of corticosteroids.[7] [Level II]
When the cause of stridor is in question, it is crucial to communicate effectively, and as quickly
as possible with the entire healthcare team including nurses, pharmacists, and surgical staff to
ensure proper management and provide the appropriate treatment for each patient.

Questions
To access free multiple choice questions on this topic, click here.

References
1.
Pfleger A, Eber E. Assessment and causes of stridor. Paediatr Respir Rev. 2016
Mar;18:64-72. [PubMed: 26707546]
2.
Zoumalan R, Maddalozzo J, Holinger LD. Etiology of stridor in infants. Ann. Otol.
Rhinol. Laryngol. 2007 May;116(5):329-34. [PubMed: 17561760]
3.
Zochios V, Protopapas AD, Valchanov K. Stridor in adult patients presenting from the
community: An alarming clinical sign. J Intensive Care Soc. 2015 Aug;16(3):272-273.
[PMC free article: PMC5606433] [PubMed: 28979428]
4.
Sasidaran K, Bansal A, Singhi S. Acute upper airway obstruction. Indian J Pediatr. 2011
Oct;78(10):1256-61. [PubMed: 21559808]
5.
Goodman TR, McHugh K. The role of radiology in the evaluation of stridor. Arch. Dis.
Child. 1999 Nov;81(5):456-9. [PMC free article: PMC1718121] [PubMed: 10519726]
6.
Marchese A, Langhan ML. Management of airway obstruction and stridor in pediatric
patients. Pediatr Emerg Med Pract. 2017 Nov;14(11):1-24. [PubMed: 29045097]
7.
Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013 Oct 15;185(15):1317-23.
[PMC free article: PMC3796596] [PubMed: 23939212]

Figures

Stridor causes. Contributed by Omar Afandi, MD

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