Stridor in Children

What is Stridor in Children?

Stridor is a high-pitched abnormal breathing sound that’s a result of uneven airflow through a narrowed airway. This sound usually signals a serious blockage in the upper part of the airway and is typically most noticeable when you breathe in. Finding out the root cause of stridor is important for managing the symptoms. Things like medical history, age, and the suddenness of a child’s symptoms can help identify the actual cause of stridor.

Stridor can be caused by birth defects, severe blockages, or infections that come on suddenly. When the cause is not clear, health care workers might use methods like x-rays or bronchoscopy (a procedure where a doctor uses a thin tube with a light and camera to look at your airway) to figure out the reason behind the stridor. In young children and babies, even a small amount of swelling can cause a significant obstruction in the airway quickly.

The timing of stridor in the breathing cycle can reveal the degree of the blockage. Stridor that happens when inhaling indicates a blockage in the voice box, whereas stridor that happens when exhaling suggests a blockage in the windpipe or bronchial tubes. Stridor that occurs during both inhaling and exhaling is usually linked with abnormal conditions of the area below the vocal cords (‘subglottic’) or the vocal cords themselves (‘glottic’). This discussion covers both birth-related and acquired causes of stridor, as well as how it’s evaluated and treated in children.

What Causes Stridor in Children?

Stridor is a high-pitched, wheezing sound caused by disrupted airflow. It signifies a problem that might have come on suddenly or gradually. Symptoms associated with sudden causes of stridor can show up anywhere from within a few minutes to a few hours, and can even take several days to develop. Patients with sudden stridor may find their symptoms worsening quickly.

On the other hand, chronic stridor is caused by abnormalities that can be either present from birth or developed later on. These usually persist for weeks, and while they usually show up within the first few weeks of a baby’s life, they can sometimes appear later during childhood.

In babies and kids, the most common cause of stridor is a condition called croup, often due to a virus called parainfluenza virus. Another common cause in infants is laryngomalacia, which is when certain structures in the throat collapse when breathing in and this leads to a blockage in the windpipe. Other causes of stridor can stem from bacterial infections caused by bacteria like Neisseria meningitidis, Pasteurella multocida, and Staphylococcus aureus, and viruses like influenza A and B, herpes simplex virus and several others. These pathogens can cause conditions like epiglottitis, croup, peritonsillar abscesses, and retropharyngeal abscesses.

Acute, or sudden, causes of stridor include conditions such as croup, bacterial tracheitis, epiglottitis, retropharyngeal abscess, foreign body aspiration, peritonsillar abscess, airway burns, anaphylaxis, therapeutic hypothermia, and post-extubation complications.

On the other hand, chronic or long-term causes of stridor include abnormalities such as craniofacial anomalies like Pierre Robin or Apert syndromes, enlargement of the tongue, laryngomalacia, laryngeal webs, cysts or clefts in the larynx, narrowing of the windpipe, vocal cord paralysis, tracheal stenosis, constriction of the windpipe, vascular ring, bronchogenic cysts, infantile hemangiomas, tumors, respiratory papillomatosis, and spasm of the larynx due to low calcium levels.

Stridor should not be confused with stertor, which is a low-pitched snoring sound that comes from constriction in the nasal, nasopharyngeal, or oropharyngeal regions during sleep.

Risk Factors and Frequency for Stridor in Children

Stridor, which is often more common in children than adults, is a condition that can vary greatly based on its cause. For instance, a condition called ‘croup’ typically affects children between 6 to 36 months old. This leads to approximately 350,000 to 400,000 emergency department visits annually due to croup-related issues. Plus, it’s seen that 2% to 6% of babies and kids experience croup each year, with it being slightly more common in boys than girls, a ratio of 1.4 to 1.

On the other hand, swallowing a foreign object – also known as foreign body aspiration – leads to over 17,000 emergency department visits each year in the U.S. Mostly, children under the age of 3 are most likely to swallow a foreign object.

• Stridor is more common in children than in adults.
• Croup, a cause of stridor, peaks between the ages of 6 and 36 months.
• Each year, between 350,000 to 400,000 emergency visits are related to croup.
• Croup affects 2% to 6% of infants and children each year.
• Croup is slightly more common in males (boys) than in females (girls), with a ratio of 1.4:1.
• Foreign body aspiration leads to more than 17,000 emergency visits a year.
• Children under the age of 3 are most prone to foreign body aspiration.

Signs and Symptoms of Stridor in Children

Understanding a patient’s medical history is crucial for accurately diagnosing their condition. The patient’s age, the severity and quickness of symptom onset, and any history of long-lasting stridor (a harsh, vibrating sound when breathing) can steer doctors towards the right diagnosis. Various possibilities may be considered depending on the age or symptom onset.

• Neonates: Birth defects like laryngomalacia, tracheomalacia, and subglottic stenosis show up within the first month of life. Bronchogenic cysts and laryngeal clefts may appear during infancy and early childhood.
• Infants and toddlers: The main causes in this age group are croup (swelling around the vocal cords) and foreign body aspiration (when a foreign object is breathed into the airway). Epiglottitis, although rare, should also be considered.
• School-aged children and adolescents: Vocal cord dysfunction and peritonsillar abscesses (pockets of pus near the tonsils) are more common in this age group.
• All ages: Anaphylaxis and bacterial tracheitis are significant possible factors in people of all ages.
• Acute symptoms: Epiglottitis and bacterial tracheitis may show up suddenly with severe breathing difficulty, fever, and excess secretions. If there’s no fever, a foreign body might have been inhaled, or it could be anaphylaxis.
• Subacute symptoms: In a more gradual onset of stridor, the cause tends to be croup.
• Chronic symptoms: Possible causes of long-lasting stridor include laryngomalacia, vocal cord dysfunction, and tracheomalacia.

Additional symptoms that may help with diagnosis include:

• Hives: These might mean anaphylaxis due to an allergy.
• Cough: A “barking” cough is typical of croup.
• Drooling: Drooling with a muffled voice might mean the obstruction is above the vocal cords, like a behind-the-throat abscess or epiglottitis. Drooling with difficulty swallowing could mean a foreign body has been inhaled or there’s an outside abnormality squeezing the food pipe.
• Mental status: Changes in mental state, particularly with harder breathing, could indicate a coming loss of airway.
• Stridor during feeding: This could mean an abnormal connection between the windpipe and food pipe, acid reflux, or problems with swallowing.
• Fever: It can accompany croup, epiglottitis, bacterial tracheitis, and retropharyngeal abscess. Children with signs of illness and high fever are more likely to have a bacterial infection.

During a physical examination, doctors will note the patient’s height and weight for any changes. Rapid weight loss might signal an immediate issue, while failure to grow could mean a long-lasting cause of stridor. They’ll also look for hives or swelling on the neck, throat, and skin. They’d also look at the nails for signs of various conditions. They’ll check the size of the patient’s tongue and throat for swelling or an abscess. Stridor can be best heard by listening over the front of the neck. Lastly, they’ll note the patient’s posture. Children who prefer to sit upright or in a “tripod” position might have epiglottitis. However, any significant airway blockage can also cause this. Infants might throw their heads back.

Testing for Stridor in Children

The primary goal when a patient comes in for an evaluation is to quickly assess their breathing. If there are signs of blockage or insufficient oxygen, an immediate intervention might be necessary. Healthcare providers will also closely monitor the patient’s breathing rate and depth. They will look out for signs that the patient isn’t getting enough oxygen, such as a bluish coloration of the skin (cyanosis), or signs of breathing hard and fast due to low oxygen levels (respiratory fatigue).

Once the patient’s condition is stable, they might have to take some additional tests. This might include imaging tests, X-rays, and even a special kind of diagnostic test called an endoscopy. Among the lab tests, complete blood cell count or CBC could be done to track down any infectious source if suspected. This test can help to figure out whether a virus or bacteria caused the infections.

For those with a common respiratory illness in children known as croup, a CBC test often isn’t needed. In some cases, a quick test to look for specific viruses may be done in the hospital for pediatric patients.

X-rays can give doctors a clear picture of the area behind the throat. If this space appears wide on the X-ray image, it might suggest an abscess or pus-filled pocket in that area. A child’s throat space on an X-ray should not be wider than 14 mm, while an adult’s throat space should not be more than 22 mm in certain places. The X-ray can also show if there’s swelling in a flap of tissue at the back of the throat, known as an enlarged epiglottis.

One of the classic signs of croup in a child is known as the “steeple sign,” which is seen on the X-ray due to inflammation and swelling. However, about 70% of children with a sudden, severe, potentially life-threatening infection of the epiglottis may have normal x-rays. In such cases, an enlarged thumb-shaped epiglottis (known as the “thumb sign”) might be observed on X-ray.

An X-ray of the chest can also be used to look for foreign bodies, growths, and swollen lymph nodes. However, a clear chest X-ray does not rule out a foreign object trapped somewhere. If a child is showing any signs of rapid breathing decline, trained healthcare providers should accompany them for these X-ray tests.

If the source of the problem is still not clear, a computed tomography (CT) scan can be done. This can provide detailed images of the chest and neck, to pinpoint sources of infection or foreign bodies. A magnetic resonance imaging (MRI) scan is a great tool for seeing narrowness in the windpipe in children.

To get a direct look at the airways, doctors might use a laryngoscopy or bronchoscopy. These tests are especially useful for finding and removing foreign bodies. In severe cases, if the patient is critically ill or suspected to have serious infections causing stridor (harsh or noisy breathing), a tube might be inserted into their windpipe to aid breathing.

Treatment Options for Stridor in Children

The treatment of a harsh, high-pitched breath sound called stridor depends on what’s causing it. A quick assessment of the patient’s breathing is necessary to determine if immediate steps need to be taken. Here are some important things to keep in mind when dealing with a patient experiencing stridor:

One, children with stridor should be kept calm to avoid worsening their condition. It’s also important to watch out for quickly worsening symptoms, as these can signal that the respiratory system is about to fail.

In cases where there’s suspicion of epiglottitis, which is an inflammation of the tissue that covers the windpipe, a direct examination of the throat should be avoided. Instead, priority should be given to ensure the airway is clear and breathing is not obstructed.

Patients with stridor should always have a healthcare professional present. Certain situations might require further evaluation in a controlled environment like an operating room. For instance, if someone suddenly starts coughing and choking, this could mean they’ve accidentally breathed in a foreign object.

Beta-agonists, a type of medication that opens up the airways in the lungs, should not be used in cases of croup, a viral illness that causes inflammation of the windpipe. This could potentially worsen the obstruction in the upper airway.

Antibiotics, which fight against bacteria, are needed for bacterial tracheitis and epiglottitis, inflammations of the windpipe and the tissue that covers it, respectively. Steroids and racemic epinephrine, which reduce inflammation and open up the airways, have been found to be effective in treating croup.

Surgical drainage is required for retropharyngeal and peritonsillar abscesses, which are pus-filled areas behind the throat and around the tonsils, respectively. More serious conditions such as severe floppiness of the voice box (laryngomalacia), narrowing of the voice box or windpipe (laryngeal stenosis, critical tracheal stenosis), tumors of the voice box or windpipe, and foreign objects breathed into the lungs, will need surgical correction.

What else can Stridor in Children be?

Stridor, or noisy breathing, can be caused by a wide range of medical issues. These could include serious emergencies like:

• Epiglottitis (a severe throat infection)
• Anaphylaxis (a severe allergic reaction)
• Bacterial tracheitis (a bacterial infection in the windpipe)
• Abscesses (pockets of pus)
• Foreign body aspiration (inhaling an object)

The exact cause can often be determined by considering the age of the patient and how long they’ve been experiencing stridor.

What to expect with Stridor in Children

The outlook for stridor, a high-pitched sound caused by disrupted airflow, is usually positive when it is quickly and properly treated.

Possible Complications When Diagnosed with Stridor in Children

The main problems linked with stridor are the possibilities of respiratory failure and even death. Kids who have laryngomalacia might not grow or develop at the expected rate, a condition known as failure to thrive. Moreover, people suffering from tracheomalacia are susceptible to a type of lung infection called aspiration pneumonia.

Common Hazards:

• Respiratory failure
• Potential death
• Failure to thrive in children with laryngomalacia
• Aspiration pneumonia in patients with tracheomalacia

Preventing Stridor in Children

Stridor is a unique high-pitched noise that you might hear when a person is breathing in. It’s caused by an obstruction or narrowing in the upper part of the airway, making it difficult for air to pass through normally. There are many things that can cause this problem:

• Illnesses, such as croup, epiglottitis, abscesses either around the tonsils or the back of the throat
• Accidentally swallowing objects or food that get stuck in the airway
• Swallowing toxic chemicals
• Burns inside the airway
• Born with irregularities that affect the nose, throat, vocal cords or windpipe
• Injuries that affect the jaw or neck

If a child shows symptoms of stridor, they might need to undergo various tests. Doctors may use X-rays and CT scans of the chest and neck to get a better idea of what’s going on inside. These can help identify if there’s an infection, a foreign object, or any structural abnormalities. Laryngoscopy and bronchoscopy are techniques that allow doctors to use a small camera to visually examine the back of the throat, and the windpipe and bronchi, which are the smaller tubes leading into the lungs, respectively.

The treatment for stridor will depend on what’s causing the problem. If left untreated, it could potentially block the airway entirely. Doctors may recommend different therapies, medicines like antibiotics or steroids, or in some situations, surgery may be needed.