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Stridor

Stridor is an abnormal, high-pitched respiratory sound produced by turbulent airflow through a narrowed or partially obstructed upper airway, most commonly heard during inspiration but potentially occurring during expiration or both phases (biphasic).^[1] It is a clinical sign rather than a disease itself, often indicating an underlying condition such as infection, foreign body aspiration, or structural abnormality, and is more prevalent in children due to their narrower airways, affecting approximately 2-6% annually with croup as a leading cause.^[2]^[1] The primary causes of stridor are categorized as acute or chronic; acute stridor frequently results from viral infections like croup (caused by parainfluenza virus) or aspirated foreign bodies, and less commonly from bacterial epiglottitis (now rare due to Haemophilus influenzae type b vaccination),^[1]^[3] leading to over 350,000 emergency department visits yearly in the United States for children.^[1] Chronic stridor, by contrast, often stems from congenital anomalies such as laryngomalacia or subglottic stenosis, vocal cord dysfunction, or acquired issues like tumors or post-intubation edema in adults.^[4] Pathophysiologically, inspiratory stridor typically signals extrathoracic obstruction (e.g., at the larynx), while expiratory stridor points to intrathoracic narrowing (e.g., trachea), with biphasic patterns suggesting glottic or subglottic involvement.^[1] Symptoms accompanying stridor may include respiratory distress, retractions, cyanosis, drooling, or cough, escalating to life-threatening airway compromise if untreated, particularly in severe cases like epiglottitis or foreign body aspiration.^[2] Diagnosis involves a thorough history, physical examination assessing vital signs and airway patency, and targeted tests such as neck X-rays (revealing the "steeple sign" in croup), pulse oximetry, or flexible laryngoscopy, while avoiding agitation to prevent worsening obstruction.^[4]^[1] Treatment focuses on addressing the underlying etiology and stabilizing the airway; for croup, nebulized racemic epinephrine and corticosteroids like dexamethasone provide rapid relief, whereas foreign body removal may require bronchoscopy or the Heimlich maneuver, and severe obstruction demands intubation or surgical intervention.^[4] Prompt management is critical, as stridor can progress to respiratory failure, but most cases resolve with appropriate care, emphasizing the need for immediate medical evaluation in affected individuals.^[2]

Definition and Characteristics

Definition

Stridor is a high-pitched, musical, wheezing sound produced by turbulent airflow through a partially obstructed larynx or extrathoracic upper airway.^[5]^[1] This abnormal respiratory noise arises from irregular airflow in narrowed regions above the thoracic inlet, typically heard during inspiration but potentially during expiration or throughout the respiratory cycle depending on the obstruction's severity.^[1]^[2] It is important to distinguish stridor from other adventitious breath sounds: unlike wheezes, which are high-pitched musical tones originating from narrowed lower airways such as the bronchi, stridor localizes to the upper airway.^[6]^[7] Rhonchi produce coarser, low-pitched rumbling noises due to airflow through larger airways containing secretions or strictures, while stertor generates a low-pitched, snoring-like sound from partial obstruction in the nasal passages or pharynx.^[8]^[9]^[10] The onset of stridor is typically acute, emerging within minutes to hours or over days, though it can manifest chronically in conditions involving persistent airway narrowing.^[1]^[11] In either case, it signals partial rather than complete airway obstruction, allowing airflow but with significant turbulence.^[5]^[1] Stridor often accompanies respiratory distress, highlighting the need for prompt evaluation.^[2]

Clinical Features

Stridor manifests primarily as a high-pitched, harsh, inspiratory sound resulting from turbulent airflow through a narrowed upper airway. This audible noise is often the hallmark sign of partial airway obstruction and is most prominent during inspiration due to the negative pressure generated in the extrathoracic airways. In severe cases, it may be accompanied by visible retractions of the intercostal muscles, suprasternal retractions, or nasal flaring, as well as cyanosis indicating hypoxemia and drooling suggesting inability to handle secretions.^[1]^[2] Associated clinical signs include tachypnea, with respiratory rates exceeding age-appropriate norms, and increased use of accessory muscles such as the sternocleidomastoid to maintain airway patency. In emergency situations, patients may exhibit agitation, a tripod positioning to optimize airflow, or altered mental status due to impending respiratory failure. These signs collectively indicate the degree of respiratory distress and the urgency of intervention.^[1]^[12] The severity of stridor is graded based on the extent of respiratory compromise: mild cases present with stridor audible only during exertion or agitation, moderate stridor is heard at rest without significant distress, and severe stridor involves persistent noise at rest accompanied by hypoxia, marked retractions, or cyanosis, signaling a potential airway emergency.^[1]^[2] Stridor is more prevalent in pediatric populations than in adults, primarily because children's narrower and more compliant airways are predisposed to obstruction from even minor edema or foreign bodies, with conditions like croup affecting 2-6% of children annually, peaking between 6 and 36 months of age.^[1]^[2]

Pathophysiology

Airway Obstruction Mechanisms

Stridor arises from the partial obstruction of the upper airway, where the narrowing increases airflow velocity, transitioning laminar flow to turbulent flow.^[5] This turbulence generates vibrations in the airway structures, producing the characteristic high-pitched, musical sound. The degree of narrowing determines the intensity of turbulence; as the airway diameter decreases, the Reynolds number—a dimensionless parameter indicating flow regime—increases, favoring turbulence over smooth laminar flow.^[13] The primary anatomical sites of obstruction leading to stridor are the larynx, subglottic region, and trachea, each contributing uniquely to sound production due to their structural properties. The larynx, with its mobile vocal cords and cartilaginous framework, is a common site for dynamic obstructions that amplify vibrations during airflow disruption. The subglottic area, narrower in children and prone to edema or stenosis, facilitates rapid velocity changes that induce turbulence. The trachea, a more rigid tube, produces stridor when compressed or malformed, with vibrations propagating from its walls during high-velocity flow. These sites are critical because the upper airway's relatively large diameter under normal conditions requires significant narrowing to produce audible turbulence.^[5]^[14] Obstructions can be classified as fixed or variable, influencing the respiratory phase in which stridor predominates. Fixed obstructions, such as those from tumors or strictures, maintain constant narrowing regardless of respiratory cycle pressures, resulting in biphasic stridor during both inspiration and expiration. Variable obstructions, particularly extrathoracic ones like vocal cord dysfunction, worsen during inspiration; the negative intrathoracic pressure generated pulls the airway walls inward, exacerbating the collapse in compliant structures. This dynamic interaction highlights how respiratory mechanics modulate obstruction severity.^[14] Bernoulli's principle underlies the exacerbation of variable obstructions by describing how increased fluid velocity in a constricted segment lowers local pressure. In the narrowed airway, accelerated airflow reduces lateral wall pressure below atmospheric levels, creating a suction effect that draws flexible airway tissues inward and further diminishes the lumen. This self-reinforcing collapse intensifies turbulence and stridor, particularly in extrathoracic sites during inspiration when negative pressures peak. The principle explains the rapid progression of symptoms in dynamic obstructions, emphasizing the interplay between airflow dynamics and airway compliance.^[5]^[11]

Types of Stridor

Stridor is classified according to its timing during the respiratory cycle—inspiratory, expiratory, or biphasic—which correlates with the location and nature of the airway obstruction. This classification reflects the effects of intrathoracic and extrathoracic pressure changes on the airway during breathing. Inspiratory stridor occurs predominantly during inhalation, indicating a variable extrathoracic obstruction, such as at the laryngeal level, where negative pressure causes tissue collapse above the vocal cords.^[15]^[5]^[16] Expiratory stridor, which is rarer, manifests mainly during exhalation and suggests an intrathoracic obstruction, typically in the lower trachea or bronchi, exacerbated by positive intrathoracic pressure that compresses the airway.^[15]^[5]^[16] Biphasic stridor, present in both inspiratory and expiratory phases, points to a fixed obstruction, such as subglottic stenosis, and is often more severe due to persistent narrowing regardless of respiratory phase.^[5]^[1]^[17] In progressive or worsening airway obstruction, stridor may shift from primarily inspiratory to biphasic, reflecting increasing severity of the compromise.^[1] These patterns stem from the underlying mechanisms of pressure gradients across the obstruction during respiration.^[11]

Etiology

Pediatric Causes

Stridor in pediatric patients predominantly manifests during infancy and often resolves without intervention in mild cases.^[1] The condition peaks in the first year of life, particularly between 6 and 36 months for many etiologies, and accounts for significant emergency department visits, such as those related to infectious causes.^[1] Among congenital causes, laryngomalacia is the most common etiology of stridor in infants, responsible for 60-75% of cases.^[18] It results from the immature collapse of supraglottic structures, such as the arytenoid cartilages and epiglottis, during inspiration, leading to high-pitched inspiratory stridor that worsens with agitation or feeding.^[19] Most cases are mild and self-resolve by 18-24 months as laryngeal structures mature, though severe instances may require supraglottoplasty.^[20] Vocal cord paralysis ranks as the second most frequent congenital cause, comprising 10-20% of laryngeal anomalies in children and often presenting with biphasic stridor shortly after birth due to unilateral or bilateral immobility.^[21] It may stem from birth trauma, iatrogenic injury, or neurological conditions and can persist for weeks to months, sometimes necessitating tracheostomy in bilateral cases.^[1] Subglottic hemangioma, a rare vascular lesion, causes progressive airway narrowing in infants, typically manifesting as stridor and hoarseness in the first few months of life and often requiring laser therapy or systemic beta-blockers for resolution.^[22] Infectious etiologies are prominent in young children, with croup (acute laryngotracheobronchitis) being the leading cause, affecting 2-6% of children annually and primarily linked to parainfluenza virus.^[1] It produces barking cough and inspiratory stridor due to subglottic edema, with highest incidence in males aged 6-36 months and resolution typically within days using corticosteroids or nebulized epinephrine.^[1] Epiglottitis, historically caused by Haemophilus influenzae type b, has become rare following widespread Hib vaccination, now more often due to other bacteria like Streptococcus species in unvaccinated or incompletely immunized children.^[23] This acute bacterial infection leads to rapid supraglottic swelling and life-threatening obstruction, demanding immediate airway securing and antibiotics.^[3] Bacterial tracheitis, also known as pseudomembranous croup, involves purulent exudate in the trachea from pathogens like Staphylococcus aureus or Moraxella catarrhalis, presenting with high fever, toxic appearance, and persistent stridor unresponsive to typical croup therapy.^[13] Acquired causes include foreign body aspiration, which occurs in over 17,000 pediatric emergency visits yearly, mainly in children under 3 years, causing sudden-onset unilateral or biphasic stridor and requiring bronchoscopy for removal.^[1] Airway trauma from burns, blunt injury, or caustic ingestion can induce edema or scarring leading to stridor, often managed supportively or surgically depending on severity.^[24] Post-intubation subglottic stenosis arises as a complication of prolonged mechanical ventilation in neonates or infants, resulting in chronic fixed obstruction and potential need for dilation or resection.^[24]

Adult Causes

In adults, stridor often arises from acquired conditions that lead to upper airway obstruction, differing from pediatric presentations which more commonly involve congenital or acute infectious etiologies.^[24] Neoplastic causes predominate in adults due to the higher incidence of malignancies affecting the larynx and surrounding structures. Laryngeal cancer, primarily squamous cell carcinoma, can cause stridor through direct invasion or mass effect narrowing the glottic or subglottic airway; major risk factors include heavy tobacco smoking and alcohol consumption, with their combined use synergistically increasing the risk.^[25] Thyroid tumors, such as multinodular goiters or malignant lesions like anaplastic carcinoma, may compress the trachea extrinsically, leading to progressive stridor and dyspnea, particularly when tumors exceed 5 cm in diameter or invade adjacent structures.^[26]^[27] Iatrogenic causes are common following airway interventions or oncologic treatments. Post-extubation laryngeal edema occurs in up to 10-20% of intubated adults, resulting from mucosal trauma and inflammation that reduces the laryngeal lumen and manifests as acute inspiratory stridor within hours of tube removal.^[28] Tracheostomy complications, including granulation tissue formation or stenosis at the stoma site, can cause late-onset stridor due to cicatricial narrowing, affecting 5-15% of long-term tracheostomy patients.^[29] Radiation-induced stenosis, often a sequela of head and neck cancer therapy, develops in 10-20% of cases from fibrotic scarring of the laryngotracheal mucosa, presenting with exertional stridor months to years post-treatment.^[30] Inflammatory and infectious causes involve rapid-onset edema or suppuration compromising the airway. Anaphylaxis triggers laryngeal edema via mast cell degranulation, producing stridor in severe cases, often accompanied by urticaria and hypotension.^[31] Angioedema, particularly bradykinin-mediated forms from ACE inhibitors, affects 0.3% of users and can cause isolated upper airway swelling with stridor and hoarseness in adults over 50.^[32] Retropharyngeal abscess, though rarer in adults than children, arises from odontogenic or traumatic spread of infection and leads to stridor through posterior pharyngeal bulging and potential airway displacement, occurring in approximately 1-4% of deep neck infections.^[33]^[34] Other causes include neuromuscular disruptions. Bilateral vocal cord paralysis, frequently iatrogenic from thyroidectomy (incidence 0.5-2%), results in adductor immobility and glottic narrowing, causing biphasic stridor and respiratory distress in 70-80% of affected patients.^[35] Large goiters can also contribute to extrinsic compression, exacerbating stridor in euthyroid or hyperthyroid states.^[36]

Diagnosis

History and Examination

The evaluation of stridor begins with a detailed history to identify the underlying cause and urgency of the condition. Key elements include the onset, which is classified as acute (developing over minutes to hours, often due to foreign body aspiration or infection) or chronic (persisting for weeks or longer, such as in laryngomalacia or vocal cord dysfunction).^[1] Triggers should be explored, including exposure to allergens (e.g., in anaphylaxis), trauma, recent intubation, or environmental factors like cold air.^[4] Associated symptoms are critical, such as dysphagia, hoarseness, barking cough (suggesting croup), drooling (indicating supraglottic obstruction), or fever; in infants, stridor during feeding may point to tracheoesophageal fistula or reflux.^[16] Risk factors encompass smoking history, alcohol use, obesity (particularly in adults for obstructive sleep apnea), and prior neck surgery or intubation.^[24] Age-specific considerations guide the history. In pediatric patients, particularly infants, inquire about perinatal complications, vaccination status (e.g., Haemophilus influenzae type B), and feeding difficulties, as stridor often emerges in the first few months due to congenital anomalies like laryngomalacia.^[16] For adults, focus on voice changes (dysphonia), weight loss, or night sweats, which may signal malignancy such as laryngeal cancer.^[24] Red flags in the history include progressive worsening of symptoms, unilateral findings suggesting a mass lesion, altered mental status, or sudden onset in adults, warranting immediate intervention.^[4] Physical examination prioritizes assessing the degree of airway compromise without exacerbating obstruction. Vital signs, including pulse oximetry, are evaluated first to detect hypoxia (oxygen saturation below 90%) or tachypnea.^[4] Signs of respiratory distress, such as nasal flaring, intercostal retractions, tripod positioning (leaning forward with neck extension), or use of accessory muscles, indicate severity; in severe cases, cyanosis or fatigue may signal impending respiratory failure.^[1] Auscultation is performed over the neck (anteriorly for upper airway sounds) and chest to characterize stridor—typically high-pitched and inspiratory for extrathoracic obstruction, though biphasic or expiratory phases may occur depending on the site.^[16] The head and neck exam includes gentle inspection of the oral cavity and pharynx for edema, abscesses, or foreign bodies, though manipulation is avoided in suspected acute infections like epiglottitis to prevent spasm.^[4] Neck assessment checks for masses, lymphadenopathy, tracheal deviation, or subcutaneous emphysema. Airway evaluation may involve indirect visualization, such as noting tongue size or macroglossia in infants, but formal scoring like Mallampati is reserved for procedural contexts and not routine here.^[24] In children, observe for failure to thrive or associated cutaneous findings like hemangiomas; in adults, palpate for thyroid enlargement or tumors. Red flags on exam include drooling with agitation, unilateral diminished breath sounds (suggesting mass or foreign body), or toxicity with fever.^[16]

Diagnostic Tests

Diagnostic tests for stridor encompass a range of imaging, endoscopic, laboratory, and specialized procedures aimed at identifying the underlying cause of airway obstruction. These tests are selected based on clinical suspicion from history and examination, with the goal of visualizing structural abnormalities, assessing dynamic airway function, or detecting associated systemic conditions. In pediatric patients, where stridor is most common, noninvasive imaging often serves as an initial step, while endoscopy provides definitive visualization.^[1] Imaging modalities play a crucial role in evaluating stridor, particularly to rule out acute infections or structural lesions. A lateral neck X-ray is commonly used in suspected croup, where subglottic narrowing may appear as the characteristic steeple sign, indicating edema in the subglottic region. This finding supports the diagnosis of viral laryngotracheobronchitis without needing further immediate intervention in typical cases. For more complex etiologies, such as suspected masses or vascular anomalies, computed tomography (CT) or magnetic resonance imaging (MRI) offers detailed cross-sectional views of the airway and surrounding structures, helping to identify tumors, cysts, or extrinsic compression. Dynamic assessment is essential for conditions like tracheomalacia, where fluoroscopy captures real-time airway collapse during respiration, providing functional insights beyond static images.^[37]^[38]^[1]^[39]^[40] Endoscopic procedures are considered the gold standard for direct visualization of the upper and lower airways in stridor evaluation. Flexible laryngoscopy, performed in an awake patient, allows real-time assessment of laryngeal structures and is particularly valuable for diagnosing laryngomalacia or vocal cord dysfunction, as it reveals dynamic collapse or paradoxical motion without requiring general anesthesia. For involvement of the lower airway, such as in tracheobronchomalacia or foreign body aspiration, bronchoscopy—either flexible or rigid—enables inspection of the trachea and bronchi, biopsy if needed, and intervention in select cases. These techniques provide superior diagnostic accuracy compared to imaging alone, especially in neonates and infants where anatomical variations are common.^[41]^[42]^[1]^[43] Laboratory tests support the diagnosis by identifying infectious, inflammatory, or hypoxic contributors to stridor. A complete blood count (CBC) with differential is indicated when bacterial superinfection is suspected, as elevated white blood cell counts may suggest epiglottitis or other suppurative processes. Arterial blood gas analysis assesses for hypoxemia or respiratory acidosis in severe cases, guiding the urgency of intervention. In patients with a history suggestive of anaphylaxis, such as sudden-onset stridor following allergen exposure, allergy testing—including skin prick tests or serum IgE levels—helps confirm hypersensitivity as the etiology once the acute phase has resolved.^[1]^[44]^[38]^[45] Specialized tests address less common or multifactorial causes of stridor. Esophageal pH monitoring, often via a 24-hour probe, detects gastroesophageal reflux disease (GERD) as a trigger for laryngospasm or aspiration-related stridor, particularly in infants with recurrent episodes; this is considered the gold standard for quantifying reflux events temporally associated with symptoms. For stridor linked to sleep-disordered breathing, polysomnography (sleep study) evaluates obstructive apnea-hypopnea indices and airway patency during sleep, aiding diagnosis in cases of laryngomalacia with comorbid obstructive sleep apnea. These tests are pursued when standard evaluations suggest extracardiopulmonary involvement.^[46]^[47]^[48]

Management

Emergency Interventions

In cases of acute stridor indicating potential airway compromise, emergency management prioritizes rapid assessment and stabilization to prevent respiratory failure. The initial approach follows the ABC (airway, breathing, circulation) framework, beginning with evaluation of airway patency using pulse oximetry and supplemental oxygen via mask if hypoxemia is present (SpO₂ <92%).^[24] Healthcare providers must summon an airway team or code response in hospital settings for patients showing signs of distress, such as stridor at rest or increased work of breathing.^[24] Securing the airway is paramount if compromise is imminent, with endotracheal intubation reserved for severe cases like epiglottitis or bacterial tracheitis where respiratory failure is evident. In children, blind nasotracheal intubation should be avoided due to the risk of further obstruction; instead, orotracheal intubation under controlled conditions, often in an operating room with anesthesia and otolaryngology support, is preferred. For adults, awake fiberoptic intubation may be used for supraglottic obstructions, while cricothyroidotomy serves as a surgical airway option in cannot-intubate scenarios, involving a vertical incision between the cricoid and thyroid cartilages followed by insertion of a size 6 endotracheal tube. Pharyngeal manipulation or agitation must be minimized to avoid precipitating complete obstruction, particularly in suspected infectious etiologies.^[1]^[24]^[49] Pharmacologic interventions target edema and inflammation to alleviate obstruction. Nebulized racemic epinephrine (0.5 mL of 2.25% solution, equivalent to 5 mL of 1:1000 L-epinephrine) is administered for moderate to severe stridor, providing vasoconstriction and symptom relief within 10-30 minutes, though effects last only 1-2 hours; repeat dosing may be needed every 2 hours, with observation for 2-4 hours post-administration to monitor for rebound. Systemic corticosteroids, such as dexamethasone (0.15-0.6 mg/kg orally or intravenously, maximum 10-12 mg as a single dose), are given early to reduce subglottic inflammation, with benefits emerging in 2-3 hours and persisting 24-48 hours; oral administration is preferred unless vomiting or severe distress precludes it.^[50]^[38]^[51] Heliox (70% helium-30% oxygen mixture) can be trialed in refractory cases to decrease airflow resistance and work of breathing, though it is not superior to standard therapies and requires specialized delivery equipment. Beta-agonists should be avoided, as they may worsen upper airway edema.^[1] Positioning the patient in an upright or tripod posture (sitting forward with hands on knees) facilitates breathing by maximizing airway diameter and reducing obstruction, particularly in pediatric patients with epiglottitis or croup. Minimal disturbance is essential to prevent agitation that could exacerbate symptoms.^[24]^[1] Escalation to advanced care is indicated for impending respiratory failure, defined by persistent stridor at rest despite initial interventions, severe retractions, hypoxemia (PaO₂ <60 mmHg or SpO₂ <90% despite oxygen), altered mental status, or inability to handle secretions. Such patients require transfer to a pediatric or adult intensive care unit, with approximately 50% of community-presenting adult cases needing invasive ventilation and ICU admission. In pediatric emergencies, common causes like croup or foreign body aspiration often respond to these measures, but non-response warrants immediate surgical consultation.^[50]^[49]^[1]

Definitive Treatments

Definitive treatments for stridor are tailored to the underlying etiology, aiming to resolve the obstruction and restore normal airflow, with options spanning medical, surgical, and supportive modalities.^[1]^[52] In pediatric cases, common causes like viral croup or bacterial infections often respond to targeted medical interventions, while structural anomalies may necessitate surgery; in adults, neoplastic or paralytic etiologies frequently require more invasive procedures.^[1]^[49] A thorough diagnostic evaluation precedes treatment selection to ensure specificity and efficacy.^[52] Medical therapies address infectious, inflammatory, or reflux-related causes. Antibiotics such as ampicillin-sulbactam or ceftriaxone are indicated for bacterial tracheitis or epiglottitis, targeting pathogens like Staphylococcus aureus or Haemophilus influenzae to reduce suppuration and edema.^[1]^[52] For gastroesophageal reflux disease (GERD)-induced stridor, particularly in infants with laryngomalacia, antireflux measures including proton pump inhibitors (e.g., omeprazole) and lifestyle modifications like upright positioning alleviate laryngopharyngeal irritation and improve symptoms within days to weeks.^[53]^[54] In anaphylaxis-associated stridor, intramuscular epinephrine (0.01 mg/kg, maximum 0.3-0.5 mg) is the cornerstone, rapidly reversing airway edema and bronchospasm, often supplemented by antihistamines and corticosteroids for sustained relief.^[55]^[56] Surgical interventions are reserved for persistent or severe structural obstructions unresponsive to medical management. Tracheotomy provides a secure bypass for critical upper airway compromise, such as in bilateral vocal cord paralysis or subglottic stenosis, allowing decannulation once the primary issue resolves.^[1]^[52]^[49] Laser resection, using CO2 or KTP lasers, effectively removes benign tumors like laryngeal papillomas or hemangiomas, restoring patency with minimal bleeding in endoscopic settings.^[52] For vocal cord paralysis causing stridor, endoscopic arytenoidectomy enlarges the glottic aperture by partial or total removal of the arytenoid cartilage, improving airflow in up to 80% of cases while preserving some voice function.^[57]^[58]^[59] Supportive measures complement definitive therapies, particularly for self-resolving conditions. Humidified oxygen via cool mist or nebulization soothes mucosal inflammation in viral etiologies, enhancing comfort without altering disease course.^[1] Observation with close monitoring suffices for mild, self-limiting stridor as in croup, where symptoms typically abate within 48-72 hours without intervention beyond hydration and rest.^[60]^[52] Management of stridor benefits from a multidisciplinary approach involving otolaryngologists (ENT specialists) for surgical expertise, pulmonologists for respiratory optimization, and anesthesiologists for airway security during procedures, ensuring coordinated care for complex cases like congenital anomalies or post-intubation strictures.^[1]^[15]^[49]

Prognosis and Complications

Outcomes

The prognosis for stridor is generally favorable, particularly in pediatric cases where laryngomalacia—the most common cause—exhibits a benign trajectory, with approximately 90% of affected infants experiencing spontaneous resolution of symptoms by age 2 years.^[61] This resolution typically occurs as the laryngeal structures mature, often within 12 to 24 months, though some cases may persist longer without intervention.^[19] Overall mortality associated with stridor remains low across most etiologies when appropriately managed, reflecting advances in diagnostic and therapeutic approaches.^[1] However, historical data indicate significantly elevated risks in untreated epiglottitis, with mortality rates reaching up to 20% prior to widespread antibiotic and vaccination use.^[62] Key prognostic factors influencing resolution include the timeliness of intervention, which mitigates risks of airway compromise; the underlying etiology, where benign congenital conditions outperform malignant or infectious causes; and patient age, with infants and young children demonstrating superior recovery rates compared to adults due to anatomical adaptability.^[1] In chronic or severe cases, persistent stridor may contribute to long-term sequelae such as recurrent respiratory infections secondary to aspiration.^[63]

Potential Complications

Untreated stridor, indicative of partial upper airway obstruction, can progress to complete obstruction, leading to severe respiratory distress, hypoxia, and respiratory failure if not addressed promptly.^[1] In pediatric cases, particularly those involving laryngomalacia—the most common cause of congenital stridor—this progression may also result in failure to thrive due to chronic airway compromise affecting feeding and growth.^[1] Similarly, tracheomalacia can predispose children to recurrent aspiration pneumonia from airway collapse during swallowing or respiration.^[1] In adults, stridor often signals a life-threatening emergency with a reported mortality rate of approximately 6.4% across cases requiring intervention, and about 50% of patients necessitating definitive airway management, invasive ventilation, or intensive care unit admission.^[49] Acute complications include bradycardia, fatigue, loss of consciousness, and cardiorespiratory arrest, especially in scenarios like foreign body aspiration or post-extubation laryngeal edema.^[24] Chronic untreated obstruction, such as in obstructive sleep apnea associated with stridor, heightens risks of cardiovascular disease, metabolic syndrome, and impaired daily function.^[24] Overall, the potential for fatality underscores the urgency of rapid diagnosis and treatment, with outcomes improving significantly through timely airway stabilization to prevent irreversible hypoxic damage.^[49]

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However, causes of stridor are numerous (table 1): anaphylaxis, vocal cord oedema, laryngeal stenosis by a tumour, or following irradiation, endotracheal ...Missing: etiology | Show results with:etiology
[27]
Respiratory manifestations in endocrine diseases - PMC
The increase in size of parathyroid glands by cysts or other benign and malignant tumors may cause tracheal compression with stridor and speech disorders.
[28]
Airway management, symptom relief, and best supportive care ... - NIH
The most frequent symptoms are hoarseness (40%), dysphagia (40%), and dyspnea or stridor (24%) [8]. Acute enlargement of the neck mass usually indicates tumor ...
[29]
Post-Intubation Laryngeal Edema - StatPearls - NCBI Bookshelf
About two-thirds of post-extubation stridor is caused by severe post-intubation laryngeal edema, and nearly half of the patients with post-extubation laryngeal ...Introduction · Etiology · Evaluation · Treatment / Management
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The “forgotten zone”: Acquired disorders of the trachea in adults - PMC
May 10, 2013 · Histopathologic examination may reveal submucosal fibrosis with chronic inflammation. Patients may present with stridor, dyspnea, and dry cough.
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A Novel Trans-Tracheostomal Retrograde Inhalation Technique ...
Mar 10, 2023 · The etiology for laryngotracheal stenosis was prolonged intubation in 75% of cases (cases 1–3), and Case 4 in this study suffered irradiation- ...<|control11|><|separator|>
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Anaphylaxis - StatPearls - NCBI Bookshelf - NIH
Other respiratory symptoms include hoarseness, wheezing, and stridor. Rapid treatment should be initiated with intramuscular epinephrine if any of these ...
[33]
Angioneurotic Edema - StatPearls - NCBI Bookshelf
Jul 24, 2023 · Airway concerns should be suspected in patients who present with hoarseness of voice, stridor, dysphonia, difficulty in breathing, and wheezing.
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Retropharyngeal Abscess - StatPearls - NCBI Bookshelf - NIH
Retropharyngeal abscesses are rare but potentially life-threatening infections that primarily affect children of age 5 and younger and, occasionally, adults.Continuing Education Activity · Etiology · History and Physical · Evaluation
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Bilateral Vocal Cord Paralysis - StatPearls - NCBI Bookshelf
Vocal cord paralysis refers to the immobility of a vocal cord, which can be due to pathology of the vocal ford (also known as the vocal fold) itself.
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Critical Airway Obstruction Caused by a Giant Multinodular Goiter
Aug 14, 2025 · Our patient presented with acute tracheal compression caused by a long-standing multinodular goiter, demonstrating stridor, orthopnea, and ...Missing: tumors | Show results with:tumors
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Croup - StatPearls - NCBI Bookshelf
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Diagnosis requires dynamic evaluation of the central airways throughout the respiratory cycle. Noninvasive dynamic imaging has traditionally included ...
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Apr 1, 2006 · Airway fluoroscopy is a noninvasive method for confirming the dynamic airway compression that occurs in tracheomalacia, and fiberoptic ...
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Flexible Laryngoscopy in Management of Congenital Stridor - NIH
The gold standard investigation for evaluation of stridor is rigid laryngotracheobronchoscopy, but this is invasive and requires general anesthesia. Flexible ...
[43]
Flexible nasolaryngoscopy accuracy in laryngomalacia diagnosis
Usually, direct laryngoscopy is the gold standard exam to diagnose stridor3, 4, 5. Since laryngomalacia is the most common cause of stridor and, usually the ...
[44]
The role bronchoscopy in the diagnosis of airway disease in children
In children, the most common indications for bronchoscopy are recurrent croup, chronic stridor and suspected foreign body. Bronchoscopy allows for examination ...
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The Evaluation of Stridor in Pediatric Patients
May 3, 2017 · Biphasic stridor is indicative of a "fixed" obstruction, typically located in the larynx or cricoid cartilage. In addition to auscultating ...Missing: mechanisms turbulent variable<|control11|><|separator|>
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Allergic reactions and anaphylactic syndromes (Chapter 13)
Arterial blood gases may be useful in determining the level of ventilatory ... Immunology, including testing and management of allergy during pregnancy ...
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Gastroesophageal Reflux Causing Stridor - CHEST Journal
This is the first report in which there is clear documentation by pH probe of a temporal association between individual episodes of GER and stridor. We review ...
[48]
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Dec 1, 2001 · The 24-hour pH probe monitoring may be considered the gold standard test for quantitating reflux and for evaluating atypical symptoms such as ...
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Laryngomalacia and Obstructive Sleep Apnea in Children - MDPI
The aim of this review is to investigate the state of the art among the association between Obstructive sleep apnea (OSA) and laryngomalacia, analyzing the ...Missing: tests GERD
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Stridor in adult patients presenting from the community - NIH
Jul 23, 2015 · The commonest local causes were vocal cord conditions (27 patients from 10 papers). Fifty-three patients from three reports had psychogenic ...Missing: etiology | Show results with:etiology
[51]
Acute management of croup in the emergency department - PMC
Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency ...
[52]
Stridor Treatment & Management: Medical Care, Surgical Care, Diet
Mar 5, 2024 · Emergency management consists of ensuring that the airway is adequate. If it is not, appropriate resuscitative measures must be initiated.
[53]
Management of Stridor in Severe Laryngomalacia: A Review Article
Sep 26, 2022 · There are several management options for severe laryngomalacia, which include conservative management, medical treatment with proton pump ...Missing: Academy | Show results with:Academy
[54]
Stridor and gastroesophageal reflux in infants - PubMed
Stridor improved with medical management in 48 hours (five of five infants) and disappeared in 3 weeks (three of five infants) to 2 months (one of five infants) ...
[55]
Anaphylaxis: Recognition and Management - AAFP
Sep 15, 2020 · Acute management of anaphylaxis involves removal of the trigger; early administration of intramuscular epinephrine ... stridor, reduced ...
[56]
Anaphylaxis Treatment & Management - Medscape Reference
Aug 16, 2024 · Treatment with epinephrine and inhaled beta-agonists is effective for these indications. Inhaled beta-agonists are used to counteract ...
[57]
Current Treatment Options for Bilateral Vocal Fold Paralysis - NIH
Removal of arytenoid cartilage (i.e., arytenoidectomy) is a permanent and irreversible surgical procedure, by which the glottal inlet is expanded in its ...
[58]
Bilateral Vocal Fold Paralysis - Medscape Reference
Mar 12, 2024 · Permanent procedures such as posterior vocal fold cordotomy, or partial or complete arytenoidectomy, cordopexy lateralization, and arytenoid ...
[59]
Arytenoidectomy: Definition, risks, and outlook - MedicalNewsToday
Feb 12, 2024 · Arytenoidectomy is a surgical produce doctors use to widen the airway and help a person breathe. It is a common treatment for bilateral vocal fold paralysis ( ...
[60]
Stridor | Pediatrics In Review - AAP Publications
Mar 1, 2015 · Stridor can occur as an acute event or present as a chronic phenomenon. Table 1 details the features of both.
[61]
A systematic review of the evidence on spontaneous resolution of ...
All were retrospective and used stridor resolution as the only endpoint. Resolution rate was 89%, with time to resolution ranging from 4 to 42 months. Level of ...
[62]
[PDF] Epiglottitis - EAR, NOSE, THROAT DISORDERS - HealthPlexus.net
Epiglottits is an acute emergency in ENT practice as mortality is high in children at about 80% and 20% in adults. Before the 1960s epiglottitis was not seen in ...
[63]
Evaluation of Aspiration in Infants With Laryngomalacia and ... - NIH
Dec 27, 2018 · Swallowing discoordination and aspiration were common in patients with laryngomalacia and recurrent respiratory and/or feeding difficulty.Missing: term | Show results with:term