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  • Writer's pictureNalaka de Silva

Paediatric Stridor

Updated: Jun 16, 2019

please note that the following is a general guideline only.

Paediatric Stridor: Overview


Stridor – High Pitched abnormal noise due to turbulent airflow

Stertor – snoring type noise made by naso-/oropharyngeal obstruction

Causes of stridor can be grouped according to anatomical region involved, BUT in reality very difficult to separate the 2 types.Most cases of stridor usually require endoscopy as history and examination.


History and examination is done with an understanding of the common causes of stridor which is discussed separately. Its important to determine the severity and to see the child needs urgent endoscopy and intervention. Also, the history and examination may give clues as to the likely anatomical site or the cause.

Full pregnancy history, including..

? Neonatal infections



Intubation resuscitation

Stridor history, including..

Timing? – At birth or developed later?

Timing in the breathing cycle: inspiratory-glottic, Biphasic-tracheal, Expiratory-pulmonary wheeze)

Precipitants – Position, if upset, feeding other?


Vital signs,

Oxygen if necessary


Stridor- (timing, duration)

Nasal obstruction

Recession/ tracheal tug

Type of cry?


Tongue and oral cavity anomaly?

Syndromic Facies

Symptoms suggestive of severity-needs urgent admission and endoscopy

Increased respiratory effort

Cyanotic spells, hypoxia

Feeding difficulties, associated with cough and gagging (aspiration), loss of weight

Dyspnoea or tachypnoea


If severe symptoms, urgent ENT endoscopy in a paediatric ENT unit. Fibre-optic endoscopy can be done safely in most paediatric ENT units without general anaesthesia.

Other investigations include

Chest X-ray/ c spine X ray

MRI (brain, neck, chest)

Sleep study (if symptoms suggestive of OSA)

Laryngotracheobronchoscopy – general anaesthetic, may involve treatment as well

Causes of paediatric stridor

Several ways of classifyingCongenital-then according to locationAlso according to aetiology

Congenital Nasopharyngeal

- Choanal atresia, stenosis

- Craniofacial abnormalities

- Encephalocele, Meningocele

- Nasal glioma

- Haemangioma, lymphangioma

- Lingual thyroid

- Thyroglossal cyst

Congenital Laryngeal-


- Posterior laryngeal cleft

- Laryngeal cysts, vallecula cysts

- Webs

- Stenosis

- Arytenoid fixation

- Vocal cord paralysis

- Haemangiomas and lymphangiomas

Congenital Tracheal-


- Atresia

- Abnormal cartilaginous rings

- Tracheobronchomalacia

- Vascular compression

- Haemangiomas and lymphangiomas


- Always think about foreign bodies-

Thermal or chemical injuries

- Haematomas

- Intubation trauma (IATROGENIC)

- Traumatic fracture of larynx

- Damage to recurrent laryngeal nerve


- Adenotonsillar hypertrophy

- Parapharyngeal abscess

- Peritonsillar abscess

- Retropharyngeal abscess

- Lymphadenopathy

- Ludwig’s angina

- Epiglottitis

- Croup and other forms of tracheitis


Paediatric Stridor: Specific Conditions

1 Laryngomalacia


Abnormal flaccidity of the neonatal larynx which leads to collapse during inspiration


most common cause of stridor in infants

M>F, 2:1


? cartilaginous structures are weak,

? neuromuscular "immaturity" exists within the supraglottis leading to laryngeal GORD and Laryngomalacia: Unclear if its a cause or an effect!!


Newborn typically will develop intermittent, inspiratory, 2 weeks of life

Spontaneous resolution of stridor is 9 months of age, and 75% will have no stridor by 18 months of age

Infrequently-severe, resulting in feeding difficulties, failure to thrive, apnea, pectus excavatum, or cyanosis

In these severe cases surgical intervention is recommended to prevent cardiac failure

Isolated finding in the otherwise healthy infant or may be associated with other neurologic disorders such as cerebral palsy

Associated GORD


respiratory distress

Flexi if possible may be diagnostic

17 % have a second lesion hence if severe need LBO

Lat Neck XR


90% medical

Observation/ higher calorie feeding if not gaining weight

Fatten up: add fat cream etc to feeds start solids earlier even at 8 weeks

Rx GORD-Ranitidien (safe in infancy)n2-4 mg/ kg per dose tds po or IV

Omeprazole (safe in infancy < 1 yr not established)-about 2/3 mg / kg per day

Surgical Rx

Laryngoscopy bronchoscopy for assessment and treatment surgical -rarely needed

Emergency tracheostomy Rare

2 Sub-Glottic Stenosis


narrowing of a new born < 4mm

narrowing of a preterm < 3.5 mm


M:F= 2:1

3rd most common congenital anomaly of pediatric airway


1 Congenital: Due to incomplete re canalization of the laryngo-tracheal tube

2 Acquired


-Infection/ inflammmatory/ reflux (all unlikely in the infant)


1 Stridor

inspiratory or biphasic

mild stenosis may be asymptomatic until an URTI -recurrent croup croup

2 Dysphonia

3 associated with other anomaly-10% of laryngomalacia has SG stenosis/ Down syndrome


Rx reflux

Steroids if oedema


Endoscopic: Dilatation / laser/ cold steel devision and dilate-local kenocort or Mit mic C

Open Procedures



Hamartomatous vascular neoplasms endothelial hyperplasia


Most common tumour in infancy, 2% can become apparent up to 10%

F:M 3:1

Increased incidence with maternal age, multiple gestations and with C villous sampling/ prem babies

Etiology and pathogenisis

Some familial


Congenital (rare)

congenital-rare, fully formed at birth

RICH & NICH types

Infantile (common)-grows then involutes. Infantile type has GLUT 1 receptor and can be treated with B blockers


Most (Infantile type) grow -6 months (proliferative phase)

stabilise for 1 yr (stable phase)

slowly involute most gone by the age of 3 years (involution phase)

Laryngeal symptoms

first 6 months of life with inspiratory or biphasic stridor

recurrent croup -responds temporarily to oral steroids

diagnosis is made at the time of direct laryngoscopy

Extra laryngeal symptoms

1/2 have other cutaneous haemangiomas


L&B: Biopsy- GLUT1 glucose transporter protein (infantile is GLUT1 positive, congenital-ve)

MRI brain / H&N


1 Steroids

2 Propranalol if Gute 1 positive

2 Surgery-Laser-

KTP pulse dye laser

Laryngeal Web


a membrane in the larynx due to incomplete re-canalization of the larynx


rare, 75% glottic level, mostly anterior webs


Failure of recanalisation of the larynx during embryonic development-10th week

Assoicated with CATCH22/ VCF syndrome ( Ch 22 q 11)


No sy , hoarse/ apnea

Syndrome features


Flexible scope


Lat Neck XR-sail sign

Flexi scope


All undergo genetics- CATCH 22, Cardiac evaluation


Mild can observe

Rest Surgery

Bilateral Vocal Cord Palsy


another common cause of neonatal stridor



Birth trauma/ Hypoxia/ intubation trauma


peripheral neurologic diseases

Thoracic-diseases or iatrogenic


stridor-inspiratory or biphasic, with a high-pitched musical quality

weak cry


flexible laryngoscopy: paediatric ENT unit

vocal fold fixation vs neurogenic vocal -direct laryngoscopy is performed under GA and the glottis palpated


laryngeal EMG → fixation vs paralysis

MRI - ? Arnold-Chiari malformation or other intracranial cause

If idiopathic congenital bilateral vocal cord paralysis is present → genetics consultation

TREATMENT Unilateral

Unilateral-Non surgical

Manage airway patency

usually not an issue

Manage aspiration & feeding, speech pathology, barium sallow

TREATMENT Bilateral vocal cord paralysis

Surgery unless stable

Recurrent Respiratory Papillomatosis


The most common benign neoplasm of the larynx caused by the HPV virus


Juvenile< 5yrs of age

Incidence 4/100,000



M:F 3:2


more in poor

Overall prevalence of HPV in women nearly 33% and the most common STD


Vertical transmission children,

adults, sexual or reactivation

Presenting symptoms

3 yrs age mean

Sy of recurrent croup dysphonia, barking type cough,

Failure to thrive



Chest infections



Gardisil- Quadrivalent vaccine against HPV 6, 11, 16, and 18 or placebo to evaluate prevention of high-grade cervical lesions

Expected reduced prevalence of the Virus in vaccinated women hence likely lower vertical transmission

HPV vaccine may play a role in the prevention of RRP in children and newborns.


Goal is to get a balance between going too often and letting tumor burden increase

Coblation, Microdebrider, Laser

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