xRead - February 2023

Stridor in the Infant Patient

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Chronic stridor suggests a congenital cause, such as laryngomalacia, vocal cord paresis, subglottic stenosis, vascular ring, or glottic web. Questions regarding prena tal and obstetric history are also important, as history of intubation could lead to a diagnosis of acquired subglottic stenosis if symptoms have been present for some time. If symptoms developed acutely without previous history of symptoms, foreign body aspiration is another possible cause of acute stridor. With foreign body aspira tion specifically, history and physical examination are extremely important for an ac curate diagnosis, as radiographic evaluation can routinely come back negative in the acute aspiration period, depending on the type of object aspirated. Quality of the noise is also an important characteristic, as this will aid in determining the possible location of the obstruction. Time of onset of stridor is also important. Some conditions, such as subglottic hemangiomas, do not cause stridor at birth. The presence of associated symptoms is also important, particularly if the patient has a fever or cough. These can point to more infectious causes, such as laryngotra cheitis, or, rarely, epiglottitis. General medical history is also important to gather, particularly if there is concern for genetic, neurologic, or craniofacial abnormalities. Stridor that worsens with crying is concerning for obstruction secondary to laryngo malacia, bilateral vocal cord paresis, subglottic stenosis, or subglottic mass, such as hemangioma. Symptoms suggestive of aspiration or coughing with feeds may indi cate a laryngeal cleft. Positioning is also important to ask about, as stridor that im proves with neck extension is concerning for laryngomalacia. 3 Physical Examination and Follow-up Studies Once a thorough history is complete, the next step in the diagnostic algorithm is phys ical examination ( Fig. 1 ). The first part of the examination is to listen for the stridor regarding its quality, timing, positioning, and severity. Laryngeal- or trachea-based stridor is best heard with auscultation of the anterior neck. The physician must also perform a routine head and neck examination in stridulous patients. Specific attention to the nasal passages for obstruction or persistent drainage, neck musculature for enlarged lymph nodes or masses, intraoral cavity and pharynx, and a cutaneous

Fig. 1. Algorithm for diagnosis and management of stridor.

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