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Emergency and Acute Medicine: Stridor
Stridor is a high-pitched, harsh, vibratory sound predominantly heard during inspiration and indicates obstruction of airflow through the upper airway. It reflects narrowing at the level of the larynx or trachea and is a clinical sign of potentially serious airway compromise. Because it signifies upper airway obstruction, stridor must always be approached as an emergency, especially in children where deterioration can be rapid.
The causes of stridor are diverse and can be broadly divided into congenital, infectious, structural, and obstructive categories. Congenital causes include conditions such as laryngomalacia, vocal cord abnormalities, and subglottic stenosis. Infectious causes are particularly important in acute presentations and include viral croup, epiglottitis, bacterial tracheitis, and deep neck space infections like peritonsillar or retropharyngeal abscesses. Extrinsic compression from trauma, hematoma, or vascular anomalies may also compromise the airway. Intraluminal obstruction can occur due to foreign bodies, tumors, cysts, or tracheomalacia, while conditions like angioedema can cause rapid airway swelling.
Patients typically present with breathing difficulty and audible noisy respiration that worsens with agitation, crying, feeding, or lying supine. Associated symptoms may include hoarseness, a muffled “hot potato” voice, drooling, sore throat, cough, and dysphagia. Infants may have feeding difficulties, apnea, or cyanotic episodes. On examination, signs of respiratory distress are common, including tachypnea, nasal flaring, intercostal and subcostal retractions, and use of accessory muscles. Cyanosis and paradoxical breathing are late and concerning findings. Certain features, such as trismus, may suggest deep neck infections.
Diagnosis is primarily clinical, and unnecessary investigations should be avoided if they risk agitating the patient, particularly children. Imaging is reserved for very mild or unclear cases. Definitive evaluation is achieved through direct visualization of the airway, typically with laryngoscopy. However, this must only be performed in a controlled setting, such as an operating room, with immediate availability of a surgical airway, as manipulation can precipitate complete obstruction.
Management focuses first on airway stabilization. In prehospital and early care, the patient—especially a child—should be kept calm, given oxygen, and monitored closely. Agitation must be minimized as it can worsen airway obstruction. In the emergency setting, stridor is treated as a difficult airway, and clinicians must be prepared for rapid deterioration.
If intubation is required, it should ideally be performed in a controlled environment with experienced personnel. A smaller endotracheal tube is recommended due to airway narrowing. Ketamine is often preferred for induction because it preserves spontaneous breathing. Blind nasotracheal intubation should be avoided. If intubation fails or the airway is lost, an emergency surgical airway such as cricothyrotomy or tracheostomy is required.
Adjunctive treatments depend on the underlying cause. Nebulized epinephrine and corticosteroids such as dexamethasone are commonly used in conditions like croup. Antibiotics, such as ceftriaxone, are indicated when a bacterial infection is suspected. Sedation and paralysis may be required after securing the airway.
All patients with unresolved stridor require hospital admission for monitoring and further evaluation. Discharge is only appropriate when symptoms have completely resolved and a non-threatening cause is identified. Early involvement of specialists such as otolaryngologists or pediatric surgeons is essential.
A key clinical pitfall is attempting airway examination without adequate preparation for emergency airway intervention. Stridor should always prompt urgent evaluation and careful airway management, as delay or improper handling can lead to sudden and catastrophic airway obstruction.
Stridor is a high-pitched, harsh, vibratory sound predominantly heard during inspiration and indicates obstruction of airflow through the upper airway. It reflects narrowing at the level of the larynx or trachea and is a clinical sign of potentially serious airway compromise. Because it signifies upper airway obstruction, stridor must always be approached as an emergency, especially in children where deterioration can be rapid.
The causes of stridor are diverse and can be broadly divided into congenital, infectious, structural, and obstructive categories. Congenital causes include conditions such as laryngomalacia, vocal cord abnormalities, and subglottic stenosis. Infectious causes are particularly important in acute presentations and include viral croup, epiglottitis, bacterial tracheitis, and deep neck space infections like peritonsillar or retropharyngeal abscesses. Extrinsic compression from trauma, hematoma, or vascular anomalies may also compromise the airway. Intraluminal obstruction can occur due to foreign bodies, tumors, cysts, or tracheomalacia, while conditions like angioedema can cause rapid airway swelling.
Patients typically present with breathing difficulty and audible noisy respiration that worsens with agitation, crying, feeding, or lying supine. Associated symptoms may include hoarseness, a muffled “hot potato” voice, drooling, sore throat, cough, and dysphagia. Infants may have feeding difficulties, apnea, or cyanotic episodes. On examination, signs of respiratory distress are common, including tachypnea, nasal flaring, intercostal and subcostal retractions, and use of accessory muscles. Cyanosis and paradoxical breathing are late and concerning findings. Certain features, such as trismus, may suggest deep neck infections.
Diagnosis is primarily clinical, and unnecessary investigations should be avoided if they risk agitating the patient, particularly children. Imaging is reserved for very mild or unclear cases. Definitive evaluation is achieved through direct visualization of the airway, typically with laryngoscopy. However, this must only be performed in a controlled setting, such as an operating room, with immediate availability of a surgical airway, as manipulation can precipitate complete obstruction.
Management focuses first on airway stabilization. In prehospital and early care, the patient—especially a child—should be kept calm, given oxygen, and monitored closely. Agitation must be minimized as it can worsen airway obstruction. In the emergency setting, stridor is treated as a difficult airway, and clinicians must be prepared for rapid deterioration.
If intubation is required, it should ideally be performed in a controlled environment with experienced personnel. A smaller endotracheal tube is recommended due to airway narrowing. Ketamine is often preferred for induction because it preserves spontaneous breathing. Blind nasotracheal intubation should be avoided. If intubation fails or the airway is lost, an emergency surgical airway such as cricothyrotomy or tracheostomy is required.
Adjunctive treatments depend on the underlying cause. Nebulized epinephrine and corticosteroids such as dexamethasone are commonly used in conditions like croup. Antibiotics, such as ceftriaxone, are indicated when a bacterial infection is suspected. Sedation and paralysis may be required after securing the airway.
All patients with unresolved stridor require hospital admission for monitoring and further evaluation. Discharge is only appropriate when symptoms have completely resolved and a non-threatening cause is identified. Early involvement of specialists such as otolaryngologists or pediatric surgeons is essential.
A key clinical pitfall is attempting airway examination without adequate preparation for emergency airway intervention. Stridor should always prompt urgent evaluation and careful airway management, as delay or improper handling can lead to sudden and catastrophic airway obstruction.
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