Pediatric presentation
Stridor in children
Inspiratory noise means the obstruction is above the chest; the question is how much airway is left and how fast it is closing.
What are you worried about?
- Epiglottitis and bacterial tracheitis
- A foreign body in the airway
- Severe croup progressing to obstruction
- Anaphylaxis with laryngeal edema
- Retropharyngeal or peritonsillar abscess
Differential, by age
Newborn birth to 28 days
- Laryngomalacia (worse supine and with feeds, better prone, thriving)
- Vocal cord paralysis
- Subglottic stenosis after intubation
- Vascular ring
Infant 1 to 12 months
- Laryngomalacia
- Croup
- Subglottic hemangioma
- Foreign body
Toddler 1 to 3 years
- Croup
- Foreign body
- Bacterial tracheitis
- Retropharyngeal abscess
- Epiglottitis if unimmunized
Preschool 3 to 5 years
- Croup
- Bacterial tracheitis
- Foreign body
- Peritonsillar abscess
- Anaphylaxis
School age 6 to 11 years
- Peritonsillar abscess
- Anaphylaxis
- Vocal cord dysfunction
- Inhalation injury
Adolescent 12 to 17 years
- Anaphylaxis
- Peritonsillar abscess
- Vocal cord dysfunction
- Angioedema
Key history
- Onset: over hours with a barking cough and coryza (croup); sudden while eating or playing (foreign body); rapid with fever, drooling and toxicity (epiglottitis, tracheitis)
- Voice: hoarse (croup) versus muffled (supraglottic)
- Ability to swallow; drooling; preferred position
- Immunizations, previous intubation, prematurity, a known hemangioma
Key examination
- Do not upset the child: leave them on the caregiver, no tongue depressor, no forced examination of the throat if epiglottitis is possible
- Stridor at rest or only when agitated; retractions; air entry; saturation
- Colour, drooling, position, toxicity, the cry
- Croup severity: the Westley domains (stridor, retractions, air entry, cyanosis, consciousness)
Red flags
- Stridor at rest with retractions, or a biphasic stridor
- Drooling, dysphagia, a muffled voice, tripod position, toxicity
- Cyanosis, altered consciousness, a quiet chest
- A sudden onset with a witnessed choking event
- No improvement after epinephrine, or recurrence within 2 hours
Initial investigations
- None for typical croup; the diagnosis and the severity are clinical
- A lateral neck film only in a stable child when a retropharyngeal abscess is a question; never delay airway care for imaging
- Suspected epiglottitis or complete obstruction: the examination happens in a place where the airway can be secured, with anesthesia and otolaryngology present
How to interpret them
- A normal saturation says nothing about upper airway obstruction until very late
- Improvement after nebulized epinephrine is temporary; the child is observed for rebound
- A quiet stridor in a tiring child is worse than a loud one
When the child is deteriorating
- Croup: dexamethasone for all, nebulized epinephrine for moderate to severe, oxygen, calm
- Suspected epiglottitis or tracheitis: the airway is secured by the most experienced person available before anything else, then antibiotics
- Foreign body: back blows and chest thrusts in the choking infant, abdominal thrusts in the older child, then rigid bronchoscopy
Conditions under this presentation
The adult frame, for contrast