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Searching for the Source of Stridor

April 21, 2010

David Tunkel, M.D.

Pediatricians are well familiar with the high-pitched breathing sound called stridor, but pinning down its source in infants is another matter. At Hopkins Children’s recent Pediatric Trends conference, pediatric otolaryngologist David Tunkel offered some tips on recognizing common causes of stridor in infants and strategies for prompt treatment. 

“Evaluation of a child with stridor requires a search for both static or fixed airway lesions like masses or stenoses,” Tunkel noted, “and dynamic airway lesions like laryngomalacia and vocal cord paralysis.” 

While the history and general examination can usually determine the location and severity of the airway obstruction, Tunkel said, radiographic imaging and endoscopic exams are needed to determine the actual diagnosis and the type of airway lesion. CT and MRI, he added, are not the primary modalities for assessing young children with stridor. 

Laryngomalacia – collapse of the tissues in the larynx above the vocal cords – is the most common culprit in young infants, while tracheomalacia – an abnormal collapse of the tracheal walls – is rare. Vocal cord paralysis is even less common, though Tunkel noted that “the sooner a neonate has stridor, the more likely we are to find vocal cord paralysis. In other words, children with stridor in the delivery suite commonly have vocal cord paralysis.” 

Most children with laryngomalacia resolve within 18 to 24 months of birth and require no specific treatment, though children with severe laryngomalacia may develop marked upper airway obstruction resulting in life-threatening apneic episodes, feeding difficulties, obstructive sleep apnea, and failure to thrive. Most young children with stridor do need evaluation by an otolaryngologist, and the urgency for referral is dictated by severity of associated signs and symptoms. While many children with stridor can be evaluated on an ambulatory basis, Tunkel concluded, severely affected children may best be evaluated on an inpatient or emergent basis.  

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