Differential diagnosis of respiratory obstruction in child less than 7 years old according to standard ENT textbook
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Differential Diagnosis of Respiratory Obstruction in a Child Under 7 Years
(Sources: Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Cummings Otolaryngology Head & Neck Surgery, K.J. Lee's Essential Otolaryngology)
The differential diagnosis is best organized anatomically by level of obstruction, then subdivided into congenital vs. acquired causes.
Key Principle: Stridor Type Localizes the Level
| Type of Stridor | Level of Obstruction |
|---|---|
| Inspiratory stridor | Supraglottic / glottic (larynx) |
| Biphasic stridor | Subglottic / upper trachea |
| Expiratory stridor / prolonged expiratory phase | Lower trachea / bronchi |
| Stertor (low-pitched snoring) | Pharynx / nasopharynx |
I. Naso- and Oropharyngeal Causes (BOX 28.1, Scott-Brown's)
Congenital
| Condition | Notes |
|---|---|
| Choanal atresia / stenosis | Classically bilateral presents at birth (obligate nasal breathers); improves with crying |
| Piriform aperture stenosis | Rare bony nasal inlet narrowing |
| Mid-nasal stenosis | |
| Glioma / Encephalocele / Meningocele | Nasal mass lesions |
| Dermoid / Teratoma | |
| Craniofacial abnormalities (Apert's, Crouzon's) | Midface hypoplasia |
| Micrognathia and glossoptosis | Classic in Pierre Robin sequence; tongue base obstruction worsened in supine position |
| Lingual thyroid | |
| Lymphovascular malformation |
Acquired - Neonates
- Neonatal rhinitis
Acquired - Children (< 7 years)
| Condition | Notes |
|---|---|
| Adenotonsillar hypertrophy | Most common cause of pharyngeal obstruction in children |
| Allergic / non-allergic rhinitis | |
| Retropharyngeal abscess | Causes acute obstruction; neck stiffness, fever, "hot potato" voice |
| Infectious mononucleosis (glandular fever) | Massive tonsillar swelling |
| Ludwig's angina | Floor-of-mouth cellulitis |
| Foreign body (nasopharyngeal / oropharyngeal) | |
| Thermal and caustic burns |
II. Laryngeal Causes (BOX 28.2, Scott-Brown's; TABLE 206.2, Cummings)
Congenital
| Condition | Characteristic Features |
|---|---|
| Laryngomalacia | Most common cause of neonatal/infantile stridor. Flaccid supraglottis, omega-shaped epiglottis; inspiratory stridor worse when supine/feeding/excited, better prone; resolves by 12-18 months. (KJ Lee) |
| Vocal fold paralysis | Second most common cause of newborn stridor. Unilateral (weak cry) or bilateral (severe stridor). Causes: birth trauma, Arnold-Chiari malformation, cardiac surgery, mediastinal mass. (KJ Lee) |
| Laryngeal web | Stridor + aphonia/hoarseness from birth; associated with velocardiofacial syndrome (22q11 deletion) |
| Laryngeal atresia / agenesis | Rare; presents at birth with cyanosis; EXIT procedure needed |
| Subglottic stenosis (congenital) | Fixed biphasic stridor; worsens with URTIs |
| Laryngeal cleft | Recurrent aspiration, TOF-type cough |
| Laryngocele | |
| Saccular cyst |
Acquired - Neonates
- Post-intubation/post-instrumentation subglottic stenosis (extremely important in ex-premature infants)
- Subglottic haemangioma (classically presents 6 weeks - 6 months; cutaneous haemangioma may be a clue; worsens over months)
- Laryngeal papillomatosis (juvenile onset; recurrent hoarseness + stridor)
Acquired - Children (< 7 years)
| Condition | Notes |
|---|---|
| Croup (acute laryngotracheobronchitis) | Most common cause of acute stridor in children 6 months - 3 years; parainfluenza virus; barking cough, biphasic stridor, low-grade fever; steeple sign on X-ray |
| Epiglottitis | Acute life-threatening supraglottic swelling; H. influenzae type B (now rare post-vaccine) or other organisms; high fever, drooling, muffled voice, tripod posture; do NOT examine throat |
| Bacterial tracheitis | Severe croup-like illness; Staph. aureus; toxic-appearing child; requires ICU |
| Paradoxic vocal fold motion (PVFM) | Episodic inspiratory stridor; often related to GERD or anxiety |
| Foreign body (supraglottic / glottic) | Acute onset; history of choking episode |
| Angioedema (anaphylaxis) | Rapid onset; urticaria/allergy history |
| Thermal/caustic injury |
III. Tracheal Causes (BOX 28.3, Scott-Brown's)
Congenital
| Condition | Notes |
|---|---|
| Tracheal stenosis | Fixed biphasic stridor or expiratory noise |
| Tracheal atresia | Rare; neonatal emergency |
| Complete tracheal rings (stovepipe trachea) | |
| Primary tracheomalacia | Expiratory stridor/wheeze; "dying spells"/apnoeic episodes |
| Secondary tracheomalacia - vascular compression | Double aortic arch, right aortic arch, pulmonary artery sling; classically causes expiratory stridor |
| Subglottic haemangioma | Biphasic stridor; worsens 6 weeks - 6 months |
Acquired - Neonates
- Post-intubation / post-instrumentation tracheal stenosis
- Reflux tracheitis
Acquired - Children (< 7 years)
| Condition | Notes |
|---|---|
| Foreign body (tracheal) | Commonest at this age group; sudden onset; radio-opaque or radio-lucent; expiratory wheeze |
| Croup | Also involves trachea (laryngotracheobronchitis) |
| Bacterial tracheitis | See above |
| Post-tracheostomy / post-TOF repair localized malacia | Surgical history |
| Thyroid masses | Rare in children; external tracheal compression |
| Lymphovascular malformation | |
| Mediastinal tumours | Lymphoma, teratoma, thymic lesions; progressive stridor + CXR widened mediastinum |
Summary: Age-Based Approach (Clinically Useful)
| Age | Most Likely Diagnoses |
|---|---|
| At birth (with first breath) | Laryngeal web, subglottic/tracheal stenosis, bilateral vocal cord palsy, choanal atresia |
| First few weeks | Laryngomalacia (most common), vocal cord palsy, vascular ring |
| 6 weeks - 6 months | Subglottic haemangioma (progressive stridor) |
| 6 months - 3 years | Croup (most common acute), foreign body, epiglottitis |
| 3 - 7 years | Adenotonsillar hypertrophy, foreign body, epiglottitis, retropharyngeal abscess, papillomatosis |
Symptoms That Point to Specific Diagnoses (Table 28.1, Scott-Brown's)
| Symptom | Think of |
|---|---|
| Aspiration + stridor | Vocal cord palsy, TOF, laryngeal cleft |
| Hoarseness | Laryngeal lesion (papilloma, cord palsy) |
| Barking cough | Croup |
| "Hot potato" voice + drooling + high fever | Epiglottitis, retropharyngeal abscess |
| Apnoeic spells / "dying spells" | Tracheobronchomalacia |
| Stridor improves with crying | Bilateral choanal atresia |
| Stridor worse supine, better prone | Laryngomalacia, micrognathia/glossoptosis |
| Prolonged expiratory phase | Tracheal/bronchial obstruction |
| Sudden onset + history of playing with small objects | Foreign body |
Important clinical note from Scott-Brown's: "The volume of stridor can paradoxically reduce as the obstruction increases due to diminishing airflow. Cyanosis is a very late event and suggests obstruction has been severe or prolonged." Never be falsely reassured by a quieter child.
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