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Stridor

Medicine > Infection

Differential Diagnosis Schema 🧠

Acute Causes of Stridor

  • Croup (laryngotracheobronchitis): Most common in children aged 6 months to 3 years, with a barking cough, hoarseness, and inspiratory stridor.
  • Epiglottitis: Rapidly progressive, life-threatening condition, more common in children; presents with high fever, sore throat, drooling, and muffled voice.
  • Foreign body aspiration: Sudden onset of stridor, coughing, and respiratory distress, often in toddlers or children under 3 years.
  • Anaphylaxis: Rapid onset stridor with associated signs of allergic reaction, such as urticaria, swelling, and hypotension.
  • Bacterial tracheitis: Severe bacterial infection, typically following a viral URI, presents with high fever, toxic appearance, and stridor.
  • Acute laryngitis: Hoarseness and mild stridor, often viral in origin, affecting older children and adults.
  • Trauma: Blunt or penetrating neck trauma causing airway obstruction and stridor.
  • Acute angioedema: Swelling of the larynx or pharynx, often due to allergic reactions or hereditary angioedema, leading to stridor.

Chronic Causes of Stridor

  • Laryngomalacia: Most common congenital cause of stridor, typically presents in infants, with stridor worse when supine or feeding.
  • Subglottic stenosis: Can be congenital or acquired (e.g., post-intubation); presents with persistent stridor and may require surgical intervention.
  • Vocal cord paralysis: May be unilateral or bilateral, with hoarseness, weak cry, and stridor, often due to congenital causes or following surgery.
  • Laryngeal papillomatosis: Caused by HPV, presents with chronic, progressive stridor and hoarseness in children.
  • Vascular rings: Congenital anomalies of the aortic arch causing compression of the trachea, leading to stridor, often with feeding difficulties.
  • Tumours: Benign or malignant tumours of the larynx or trachea causing progressive stridor.
  • Gastroesophageal reflux disease (GORD): Chronic irritation of the larynx and vocal cords, leading to intermittent stridor, especially in children.
  • Neuromuscular disorders: Conditions like cerebral palsy can cause poor control of the airway muscles, leading to chronic stridor.

Key Points in History 🥼

Onset and Duration

  • Acute onset: Sudden onset suggests causes like foreign body aspiration, anaphylaxis, or epiglottitis.
  • Chronic or progressive onset: Gradual development suggests congenital anomalies, vocal cord paralysis, or tumours.
  • Intermittent vs. continuous: Intermittent stridor may be related to positional factors (e.g., laryngomalacia), while continuous stridor may suggest a fixed obstruction.

Associated Symptoms

  • Fever: Presence of fever suggests an infectious cause such as croup, epiglottitis, or bacterial tracheitis.
  • Cough: Barking cough is characteristic of croup; productive cough may suggest bacterial tracheitis.
  • Drooling and dysphagia: Suggests severe airway obstruction or epiglottitis, especially in children.
  • Voice changes: Hoarseness or muffled voice may indicate vocal cord involvement or epiglottitis.
  • Cyanosis: Indicates significant airway compromise and hypoxia, requiring urgent intervention.
  • Gastrointestinal symptoms: Recurrent vomiting or acid reflux may suggest GORD as an underlying cause.
  • Trauma history: Recent trauma, particularly to the neck or chest, may suggest a mechanical cause of stridor.

Background

  • Past Medical History: Include any history of previous intubation, recurrent respiratory infections, or known congenital anomalies.
  • Drug History: Review recent medications, especially new ones that could cause an allergic reaction leading to stridor.
  • Family History: Consider hereditary conditions like hereditary angioedema, which could present with stridor.
  • Social History: Inquire about environmental exposures, smoking in the household, or recent travel that could have introduced new allergens or infections.

Possible Investigations 🌡️

Imaging Studies

  • Neck X-ray: Lateral neck X-ray can be useful in diagnosing croup (steeple sign) or epiglottitis (thumbprint sign).
  • Chest X-ray: To identify foreign bodies, subglottic narrowing, or signs of lung involvement.
  • CT or MRI: Consider if a mass, vascular ring, or other structural anomalies are suspected.
  • Fluoroscopy: Useful in diagnosing dynamic airway conditions like tracheomalacia.
  • Bronchoscopy: Direct visualisation of the airway for diagnosis of foreign body, tracheal stenosis, or tumours.

Laboratory Tests

  • Complete blood count (CBC): May show elevated white blood cells in infection or eosinophilia in allergic conditions.
  • C-reactive protein (CRP) and ESR: Elevated in bacterial infections such as epiglottitis or bacterial tracheitis.
  • Blood cultures: Indicated in cases of suspected sepsis or systemic infection.
  • Allergy testing: Consider if an allergic cause of stridor is suspected, such as food or environmental allergens.
  • Arterial blood gas (ABG): Useful in assessing the degree of respiratory compromise in severe cases of stridor.

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Infection