Stridor in Children

Differential Diagnosis

Common Diagnoses

  • Viral Croup (Laryngotracheobronchitis)
  • Acute Epiglottitis
  • Acute Laryngitis
  • Acute Airways Obstruction: Foreign Body (Small Toy, Peanut)
  • Laryngeal Paralysis (Congenital: Accounts for 25% of Infants with Stridor)

Occasional Diagnoses

  • Laryngomalacia
  • Laryngeal Trauma
  • Bacterial Tracheitis
  • Pseudomembranous Croup (Staphylococcal)
  • Upper Airway Burn

Rare Diagnoses

  • Laryngeal Stenosis
  • Laryngeal Tumours (Papilloma, Haemangioma) and Mediastinal Tumours
  • Laryngeal Oedema (Angioneurotic: Oedema also Present in Other Tissues)
  • Anomalous Blood Vessels (e.g. Double Aortic Arch)
  • Diphtheria
  • Retropharyngeal Abscess

Ready Reckoner

Key distinguishing features of the most common diagnoses

Viral CroupEpiglottitisLaryngitisObstructionLaryngeal Paralysis
Very Sudden OnsetNoYesNoYesNo
Continuous StridorPossibleYesNoYesYes
Toxic and FeverishPossibleYesNoNoNo
Drooling SalivaNoYesNoNoNo
Very Sore ThroatNoYesNoPossibleNo

Possible Investigations

  • There are no investigations likely to be performed in primary care. The following might be performed in hospital: FBC (WCC raised in infection), lateral X-ray of pharynx (enlarged epiglottis in epiglottitis), CXR (may show foreign body, distal collapse or external compression of larynx or trachea) and laryngoscopy (for direct visualisation of the larynx).

Top Tips

  • In practice, the first step is to exclude those conditions requiring immediate admission (epiglottitis or inhaled foreign body), leaving a probable diagnosis of viral croup. Management then depends on the child’s general condition – in particular, the level of respiratory distress.
  • Children with viral croup may have marked stridor and some recession when crying. It is reasonable to observe such children at home provided these signs disappear when the child is settled.
  • When managing a child at home, make absolutely sure that the parents understand the signs of deterioration. If in doubt, arrange review.

Red Flags

  • The toxic child with low-pitched stridor (often not marked), severe sore throat or difficulty in swallowing, and respiratory distress has epiglottitis until proved otherwise. Admit immediately and do not examine the throat (this can provoke respiratory obstruction).
  • Restlessness, rising pulse and respiratory rate, increasing intercostal recession, fatigue and drowsiness are ominous signs – admit urgently regardless of precise diagnosis.
  • Consider an inhaled foreign body if the onset is very sudden and there are no other symptoms or signs of respiratory infection.
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