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Stridor () is an extra-
thoracic The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main ...
high-pitched breath sound resulting from turbulent air flow in the
larynx The larynx (), commonly called the voice box, is an organ (anatomy), organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal ...
or lower in the bronchial tree. It is different from a stertor, which is a noise originating in the
pharynx The pharynx (: pharynges) is the part of the throat behind the human mouth, mouth and nasal cavity, and above the esophagus and trachea (the tubes going down to the stomach and the lungs respectively). It is found in vertebrates and invertebrates ...
. Stridor is a physical sign which is caused by a narrowed or obstructed airway. It can be inspiratory, expiratory or biphasic, although it is usually heard during inspiration. Inspiratory stridor often occurs in children with
croup Croup ( ), also known as croupy cough, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of "bar ...
. It may be indicative of serious airway obstruction from severe conditions such as epiglottitis, a foreign body lodged in the airway, or a laryngeal tumor. Stridor should always command attention to establish its cause. Visualization of the airway by medical experts equipped to control the airway may be needed.


Causes

Stridor may occur as a result of: * foreign bodies (e.g., aspirated
foreign body A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object. Most references to foreign bodies involve propulsion through natural orifices into hollow organs. Foreign b ...
, aspirated food bolus); * infections (e.g., epiglottitis, retropharyngeal abscess,
croup Croup ( ), also known as croupy cough, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of "bar ...
); * subglottic
stenosis Stenosis () is the abnormal narrowing of a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' as a term is usually used when narrowing ...
(e.g., following prolonged intubation or congenital); * airway edema (e.g., following instrumentation of the airway,
tracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer c ...
, drug side effect,
allergic reaction Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include Allergic rhinitis, hay fever, Food allergy, food al ...
); * laryngospasm (from aspiration,
GERD Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...
, or complication of
anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...
) * subglottic
hemangioma A hemangioma or haemangioma is a usually benign vascular tumor derived from blood vessel cell types. The most common form, seen in infants, is an infantile hemangioma, known colloquially as a "strawberry mark", most commonly presenting on the sk ...
(rare); * vascular rings compressing the trachea; * thyroiditis such as Riedel's thyroiditis; * vocal cord palsy; * tracheomalacia or tracheobronchomalacia (e.g., collapsed trachea). *
congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...
anomalies of the airway are present in 87% of all cases of stridor in infants and children. *
vasculitis Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both artery, arteries and veins are affected. Lymphangitis (inflammation of lymphatic vessels) is sometimes considered a type of vasculitis. Vasculitis is primarily c ...
. *infectious mononucleosis *peritonsillar abscess *Laryngeal edema is a common cause of stridor post extubation (occurring from pressure of the endotracheal tube on the mucosa as a result of endotracheal tube that is too large (e.g. pediatrics), cuff over inflation, and prolonged intubation times.);Wittekamp, Bastiaan HJ. Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care. 2009; 13(6): 233. * tumor (e.g., laryngeal papillomatosis,
squamous cell carcinoma Squamous-cell carcinoma (SCC), also known as epidermoid carcinoma, comprises a number of different types of cancer that begin in squamous cells. These cells form on the surface of the skin, on the lining of hollow organs in the body, and on the ...
of larynx, trachea or esophagus); * ALL (T-cell ALL can present with mediastinal mass that compresses the trachea and causes inspiratory stridor)


Diagnosis

Stridor is mainly diagnosed on the basis of history and physical examination, with a view to revealing the underlying problem or condition. Chest and neck
x-rays An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
, bronchoscopy, CT-scans, and/or MRIs may reveal structural pathology. Flexible fiberoptic bronchoscopy can also be very helpful, especially in assessing vocal cord function or in looking for signs of compression or infection.


Treatments

The first issue of clinical concern in the setting of stridor is whether or not
tracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer c ...
or
tracheostomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision on the front of the neck to open a direct airway to the trachea. The resulting stoma (hole) can serve independently as an airway ...
is immediately necessary. A reduction in oxygen saturation is considered a late sign of airway obstruction, particularly in a child with healthy lungs and normal gas exchange. Some patients will need immediate tracheal intubation. If intubation can be delayed for a period, a number of other potential options can be considered, depending on the severity of the situation and other clinical details. These include: * Expectant management with full monitoring, oxygen by face mask, and positioning the head on the bed for optimum conditions (e.g., 45 - 90 degrees). * Use of nebulized racemic adrenaline
epinephrine Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands a ...
(0.5 to 0.75 ml of 2.25% racemic epinephrine added to 2.5 to 3 ml of normal saline) in cases where airway edema may be the cause of the stridor. (Nebulized Codeine in a dose not exceeding 3 mg/kg may also be used, but not together with racemic adrenaline ecause of the risk of ventricular arrhythmias) * Use of
dexamethasone Dexamethasone is a fluorinated glucocorticoid medication used to treat rheumatic problems, a number of skin diseases, severe allergies, asthma, chronic obstructive pulmonary disease (COPD), croup, brain swelling, eye pain following eye su ...
( Decadron) 4–8 mg IV q 8 - 12 h in cases where airway edema may be the cause of the stridor; note that some time (in the range of hours) may be needed for dexamethasone to work fully. * Use of inhaled Heliox (70%
helium Helium (from ) is a chemical element; it has chemical symbol, symbol He and atomic number 2. It is a colorless, odorless, non-toxic, inert gas, inert, monatomic gas and the first in the noble gas group in the periodic table. Its boiling point is ...
, 30%
oxygen Oxygen is a chemical element; it has chemical symbol, symbol O and atomic number 8. It is a member of the chalcogen group (periodic table), group in the periodic table, a highly reactivity (chemistry), reactive nonmetal (chemistry), non ...
); the effect is almost instantaneous. Helium, being a less dense gas than nitrogen, reduces turbulent flow through the airways. Always ensure an open airway. In obese patients elevation of the
panniculus The panniculus (often incorrectly referred to as pannus) is a dense layer of fatty tissue consisting of excess subcutaneous fat within the lower abdominal region. Panniculi can form after rapid weight loss, as seen with strict exercise plans—i ...
has shown to relieve symptoms by 80%.


References


External links


Audio Breath Sounds
—Multiple case studies with audio files of lung sounds. * * * *

{{Circulatory and respiratory system symptoms and signs Symptoms and signs: Respiratory system