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Stridor in Children: Differential Diagnoses

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Overview

Stridor is a continuous breath sound that originates in the upper airway and occurs on inspiration. It is high-pitched and occurs due to upper airway narrowing and requires urgent assessment as some of its differentials can include serious illnesses such as epiglottitis, or foreign bodies.

Differential Diagnoses

Croup

  • Most common in children aged 6 months – 3 years
  • Most cases are due to the parainfluenza virus
  • Acute seal-like barking cough with stridor that is worse at night
  • There may be a prodrome of fever and coryza for 12-72 hours

Epiglottitis

  • Most common in children aged 2-5 years and adults aged 40-50 years
  • Due to Haemophilus influenzae type B (Hib)
  • There may be a history of no previous Hib immunisation
  • Acute sore throat, high fever, muffled voice, drooling, and stridor – the child may appear ‘toxic’ – seriously unwell, lethargy, cyanosis and poor perfusion, inconsolably irritable
  • ‘Tripod position’ – easier to breathe leaning forward with the neck extended
    • In younger children, they may want to sit upright than lie down
  • Do not examine the airway or do anything that may agitate the child (e.g. separating them from a parent), as this may precipitate the closure of the airway.
  • Immediately refer to the emergency department

Inhaled foreign body

  • Sudden cough, shortness of breath, and stridor
  • Auscultation shows focal wheezing
  • No fever or prodrome of symptoms of viral illness

Laryngomalacia

  • Congenital ‘floppy larynx’ due to immature laryngeal cartilage
  • Stridor and noisy breathing within the first 6 weeks of life – worse when supine, feeding, or agitated
  • Infants are usually otherwise well and happy
  • Infant’s cry is normal – differentiates laryngomalacia from other conditions such as vocal cord palsy

Anaphylaxis 

  • Acute A and/or B and/or C features after exposure to allergen:
    • Airway – stridor and hoarse voice due to swollen face and tongue
    • Breathing – wheezing, shortness of breath
    • Circulation – hypotension, tachycardia
  • There may be associated urticaria and/or pruritus

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