212  SECTION VI  •  Disorders of the Head, Neck, and Upper Airway
Stridor
Soorena Khojasteh and Paul L. Aronson
S tridor is a clinical finding reflecting partial extrathoracic
airway obstruction. Although it is not pathognomonic for
any single disease process, its presence can indicate a life-
threatening upper airway obstruction. In addition, although
stridor is traditionally thought to be inspiratory in nature, it can
also be expiratory or biphasic, presenting in both phases of the
respiratory cycle.
ETIOLOGY AND PATHOGENESIS
Stridor can be caused by any upper airway obstruction. When
thinking about the causes of stridor, it is helpful to first
understand the anatomy of the larynx (Figure 36-1) and
then to separate the causes of stridor into chronic and acute
processes.
Chronic Stridor
The most common cause for inspiratory stridor is laryngoma-
lacia, which accounts for approximately 75% of all cases of
neonatal stridor. Laryngomalacia results from the immature
cartilage of the upper larynx collapsing inward during inhala-
tion, causing airway obstruction. Vocal cord dysfunction, the
second leading cause of stridor in the neonatal period, can be
congenital or iatrogenic, such as from damage to the left recur-
rent laryngeal nerve during ligation of a patent ductus arterio-
sus or from direct injury to the vocal cord during endotracheal
intubation. Congenital subglottic stenosis occurs when there is
incomplete canalization of the subglottic airway and cricoid
rings. Subglottic stenosis is most often acquired after prolonged
intubation in the neonatal period, usually in the setting of
extreme prematurity. Tracheomalacia results from a defect in
the tracheal cartilage that causes a “floppy” airway lacking the
rigidity necessary to maintain patency. Tracheomalacia is the
leading cause of expiratory stridor. Tracheal stenosis can be
caused by the presence of complete tracheal rings instead of the
normally C-shaped rings. Stridor can also result from tracheal
compression caused by vascular rings such as a double aortic
arch. Other less common causes of chronic stridor include
laryngeal papillomas caused by maternal human papillomavirus
infection, webs, cysts, hemangiomas, and laryngeal dyskinesia.
Acute Stridor
The causes of acute stridor are primarily infectious in cause with
two notable exceptions, foreign body aspiration and allergic
reaction. The most common cause of acute stridor is laryngo-
tracheobronchitis, or croup (Figure 36-2). Croup is classically
caused by parainfluenza virus but can also be caused by respira-
tory syncytial virus, influenza, adenovirus, and Mycoplasma pneu-
moniae. Bacterial tracheitis, usually caused by Staphylococcus
aureus, is an uncommon but life-threatening condition that
Downloaded from ClinicalKey.com at Royal College Medicine of Perak June 14, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
36 
occurs most frequently as a bacterial superinfection in patients
who have viral croup.
Retropharyngeal and peritonsillar abscesses are common
infections that can present with acute stridor. Both infections
are usually polymicrobial, including β-hemolytic streptococci;
oral anaerobic bacteria; and in retropharyngeal abscess, S.
aureus. Finally, epiglottitis, traditionally caused by Haemophilus
influenzae type B (Hib), is now a rare cause of stridor as a result
of the widespread use of the conjugated Hib vaccine.
CLINICAL PRESENTATION
Chronic Stridor
Laryngomalacia can present at birth but usually presents at 2 to
4 weeks of age. The inspiratory stridor of laryngomalacia is
exacerbated when the infant lies supine, cries, or when feeding
and is alleviated when the infant is prone.
Vocal cord paralysis can be unilateral or bilateral. Bilateral
vocal cord paralysis results in aphonia and high-pitched biphasic
stridor, with significant respiratory distress. Unilateral paralysis
can cause inspiratory or biphasic stridor, as well as a weak or
hoarse cry.
Whereas subglottic stenosis and vascular rings may likewise
present with inspiratory or biphasic stridor, tracheomalacia
usually presents with expiratory stridor. Tracheomalacia may
present with a monophonic wheeze if the obstruction is
intrathoracic.
Acute Stridor
Croup occurs most commonly in children age 6 months to 2
years and is characterized by a harsh cough described as “barky”
or “seal-like.” Associated upper respiratory symptoms are
common, and stridor can be mild, occurring only with crying,
or in severe cases, can occur at rest with severe respiratory dis-
tress. Bacterial tracheitis is a rare complication of croup, and in
addition to stridor. the child also will have high fever and a toxic
appearance.
Retropharyngeal abscess usually occurs in children younger
than 6 years old before the retropharyngeal lymph nodes
atrophy. Patients often have a viral prodome followed by the
abrupt onset of high fever, limited neck movement (especially
resistance to extension), and occasionally stridor. Unilateral
neck swelling may occur as the infection tracks from the retro-
pharyngeal space, and a bulge of the posterior oropharynx may
sometimes be present on physical examination. Peritonsillar
abscess occurs in preadolescents and adolescents and can present
with sore throat, trismus, dysphagia, a “hot potato” or muffled
voice, and tender unilateral neck swelling. Asymmetric tonsils,
deviation of the uvula, and a fluctuant area are present on physi-
cal examination (Figure 36-3). Stridor may be heard if tracheal
compression is present. Epiglottitis classically presents with the
 CHAPTER 36  •  Stridor  213

Median glosso-epiglottic ligament

Root of tongue (lingual tonsil)

Vocal folds Epiglottis

(true cords)
(glottis)
Ventricular folds
(false cords) (glottis)

Trachea
Aryepiglottic fold

Piriform fossa
Cuneiform tubercle
Corniculate
tubercle
Interarytenoid incisure
Esophagus

Figure 36-1  Normal larynx: inspiration.

Acute laryngitis
abrupt onset of high fever, stridor, drooling, “tripod” position-
ing, and toxicity.
Foreign body aspiration should be suspected when stridor
occurs acutely in an unobserved toddler. A history of choking
or coughing preceded by eating or playing with small objects
may be present. Focal wheezing or reduced breath sounds can
be heard if the object is lodged in the smaller airways.
Allergic reactions, or anaphylaxis, may present with stridor
or wheeze after exposure to a known food or drug allergen but
should be suspected in any patient who presents with the acute
onset of respiratory distress occurring within 30 minutes of food
ingestion. Other signs of anaphylaxis include urticaria, gastro-
intestinal distress, and hypotension.

EVALUATION AND MANAGEMENT

Evaluation
Although taking a thorough history is an essential part of elu-
cidating the cause of stridor, initial rapid assessment of airway,
breathing, and circulation (the ABCs) can be lifesaving. The
practitioner must assess first for impending complete airway
obstruction or respiratory failure; observing the patient for
severity of work of breathing, intercostal and suprasternal
retractions, cyanosis, perfusion, and responsiveness will guide
initial management. Although a complete blood count, inflam-
matory markers (C-reactive protein, erythrocyte sedimentation
rate), and blood culture may help guide treatment, none are
essential to the initial care of patients with stridor. Arterial
blood gas analysis may be helpful in assessing the degree of
respiratory compromise, but the physical examination and
pulse oximetry are the best tools for developing an immediate
treatment plan.
Anteroposterior and lateral radiographs of the neck and chest
will allow evaluation of both the upper and lower airways and
may be indicated for specific diagnoses. Other imaging modali-
ties such as contrast-enhanced computed tomography and fluo-
roscopy may also be used. Further imaging may be indicated for
specific cases (Table 36-1).
Subglottic inflammation and swelling in inflammatory croup
Figure 36-2  Croup.
Management
Congenital causes of stridor often self-resolve but may neces-
sitate surgical intervention. Laryngomalacia usually resolves
spontaneously by 2 years of age. Surgical intervention such as
supraglottoplasty or laryngeal reconstruction is indicated if
obstruction is significant or if the patient exhibits severe failure
to thrive. Similarly, unilateral vocal cord paralysis in infancy
usually resolves by age 2 years with no intervention. However,
in the setting of bilateral vocal cord paralysis or persistent aspi-
ration, tracheostomy is often indicated. The presence of sub-
glottic stenosis may necessitate tracheostomy, particularly if
the patient has persistent respiratory compromise. Definitive

Downloaded from ClinicalKey.com at Royal College Medicine of Perak June 14, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
214  SECTION VI  •  Disorders of the Head, Neck, and Upper Airway

Table 36-1  Diagnostic Approach to Stridor

Cause of Stridor Diagnostic Imaging
Laryngomalacia DL will show inspiratory collapse of the epiglottis. Redundant arytenoids may be present. DL is
also the test of choice for diagnosing laryngeal webs, cysts, and subglottic hemangiomas.
Subglottic stenosis DL or bronchoscopy
Tracheomalacia Airway fluoroscopy or bronchoscopy. Barium swallow to determine the presence of coexisting
conditions.
Vascular ring Barium swallow may show an indentation on the esophagus. Echocardiography is often diagnostic.
Croup Usually a clinical diagnosis. Lateral neck radiograph, if obtained, demonstrates normal epiglottis
but with subglottic narrowing (steeple sign).
Epiglottitis Lateral neck radiograph demonstrates edematous epiglottis (thumb sign)
Retropharyngeal abscess Lateral neck radiograph shows widening of the prevertebral soft tissues to greater than half the
width of the adjacent vertebral body.
Peritonsillar abscess Usually a clinical diagnosis. Contrast-enhanced CT scan of the neck may delineate abscess versus
phlegmon and degree of airway impingement.
Foreign body aspiration Lateral neck or chest radiograph may show the foreign body if radiopaque. Inspiratory and forced
expiratory or lateral decubitus chest radiographs may demonstrate hyperinflation and air
trapping on the affected side. Bronchoscopy is often required for definitive diagnosis.

CT, computed tomography; DL, direct laryngoscopy.

surgical correction with laryngeal reconstruction is often needed
in severe cases.
Similar to other viral processes, croup self-resolves in
approximately 7 days with maximal severity of symptoms usually
occurring on the third or fourth day of illness. A single dose
of oral or intramuscular dexamethasone has been shown to
improve symptoms and prevent return to medical care. If the
stridor occurs at rest or the patient is in moderate to severe
distress, racemic epinephrine can be given via nebulizer for
temporary relief.
The bacterial infectious causes of stridor all require antibiot-
ics (Table 36-2). Peritonsillar and retropharyngeal abscesses
often require drainage as well because antibiotic penetration of
the abscess may not be optimal. Epiglottitis is an entity that
should be considered a medical emergency necessitating imme-
diate intubation for airway protection.
Stridor caused by anaphylaxis requires the immediate intra-
muscular injection of epinephrine, which the patient can self-
administer at home via EpiPen. Adjunctive treatments include
antihistamines and systemic corticosteroids. If foreign body
aspiration is strongly suspected or diagnosed on radiography,
rigid bronchoscopy is necessary to remove the object, often
from the right main stem bronchus.

FUTURE DIRECTIONS
Surfactant therapy and increasing use of noninvasive ventilation
in premature neonates should reduce the incidence of prolonged
intubation and resultant subglottic stenosis. Societal concerns
regarding vaccination have led to reemergence of Hib as a
pathogen in certain areas of the country. Educational efforts
aimed at the general public on the importance of childhood
vaccination are paramount in prevention.

Table 36-2  Treatment for Bacterial Causes of Stridor

Infectious Causes
of Stridor Empiric Antibiotic Therapy
Epiglottitis Ceftriaxone
Retropharyngeal abscess Clindamycin or
ampicillin–sulbactam
Peritonsillar abscess Clindamycin or
ampicillin–sulbactam
Bacterial tracheitis Vancomycin or clindamycin
Figure 36-3  Peritonsillar abscess.

Downloaded from ClinicalKey.com at Royal College Medicine of Perak June 14, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 CHAPTER 36  •  Stridor  215

SUGGESTED READINGS
Bjornson CL, Klassen TP, Williamson J, et al: A randomized trial of a single
dose of oral dexamethasone for mild croup, N Engl J Med 351(13):1306-
1313, 2004.
Craig FW, Schunk JE: Retropharyngeal abscess in children: clinical presen-
tation, utility of imaging, and current management, Pediatrics 111(6 Pt
1):1394-1398, 2003.
Masters IB: Congenital airway lesions and lung disease, Pediatr Clin North
Am 56(1):227-242, xii, 2009.
Sampson HA, Muñoz-Furlong A, Campbell RL, et al: Second symposium
on the definition and management of anaphylaxis: summary report—Second
National Institute of Allergy and Infectious Disease/Food Allergy and
Anaphylaxis Network symposium, J Allergy Clin Immunol 117(2):391-397,
2006.

Downloaded from ClinicalKey.com at Royal College Medicine of Perak June 14, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.