Define stridor, one year old child is brought with sudden onset of stridor , describe the diagnosis and treatment of this child, 10 mark questions for Final year post graduate paediatric student

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Stridor in a 1-Year-Old Child: Definition, Diagnosis, and Treatment

(10-Mark PG Paediatrics Answer)

Definition of Stridor

Stridor is a high-pitched, harsh respiratory noise produced by turbulent airflow through a partially obstructed or narrowed airway. The Latin root means "a creaking or hissing sound." It is a clinical sign, not a diagnosis.

Inspiratory stridor - obstruction is supraglottic (nose, pharynx, epiglottis)
Biphasic stridor (inspiratory + expiratory) - fixed glottic or subglottic lesion (vocal cord paralysis, laryngeal web)
Expiratory stridor - intrathoracic trachea or lower (bacterial tracheitis, bronchial foreign body)
Stertor - a lower-pitched snoring noise from nasal/nasopharyngeal obstruction; can coexist with stridor

Stridor may be absent in respiratory failure because the lack of airflow eliminates the noise.

Analysis of the Clinical Problem

A 1-year-old child with sudden onset stridor is in the critical age window (>6 months). This age makes congenital causes unlikely as the primary presentation (those typically present in the first 6 months). Sudden onset points strongly to an acquired cause:

Cause	Key Feature
Foreign body aspiration	Most common cause of sudden stridor in 1-3 year olds
Viral croup (laryngotracheobronchitis)	Most common infectious cause; 6 months - 3 years
Epiglottitis	Toxic, drooling, tripod posture, no cough
Bacterial tracheitis	Post-viral fever, toxic, severe obstruction
Retropharyngeal abscess	Neck stiffness, dysphagia, bulging posterior wall
Anaphylaxis	Exposure history, urticaria, hypotension

Most Likely Diagnosis at Age 1 Year with Sudden Onset: Foreign Body Aspiration

Foreign body aspiration (FBA) is the leading cause of sudden-onset stridor in children aged 1 to 3 years, owing to increased mobility and oral exploration at this age. - Tintinalli's Emergency Medicine, p. 836

Clinical Features of FBA

History of sudden coughing and choking - the most predictive symptom
The choking episode is often not witnessed by the caregiver
Child may present hours to >24 hours after the event
Respiratory distress: stridor, wheezing, tachypnoea, retractions, cyanosis
Unilateral decreased breath sounds (if bronchial impaction)
Objects commonly aspirated: peanuts, sunflower seeds, carrots, raisins, grapes, small toy parts

Location and Sound

Location	Stridor type	Examples
Larynx/trachea	High-pitched inspiratory; biphasic	Tracheal FB, subglottic
Bronchus (right > left)	Expiratory; unilateral wheeze	Peanut, seed

Approach to Diagnosis

1. History (Critical)

Exact time of onset (sudden vs gradual)
Choking/coughing episode - even if not witnessed
Fever, rhinorrhoea preceding (suggests croup/epiglottitis)
Drooling, inability to swallow (epiglottitis)
Prior intubation (subglottic stenosis)
Immunisation status (Hib vaccine status for epiglottitis)
Exacerbating factors: prone vs supine, crying

2. Examination

Use the Pediatric Assessment Triangle first: appearance, work of breathing, circulation.

Vital signs: SpO2, RR, HR
Indicators of increased work of breathing: retractions, nasal flaring, grunting, use of accessory muscles
Character of stridor (inspiratory/biphasic/expiratory), voice quality (hoarse, muffled, normal)
Symmetry of air entry - unilateral decrease = likely bronchial FB
Look for: drooling, tripod posture, neck stiffness, skin hemangiomas, oropharyngeal bulging
Do not examine the throat if epiglottitis is suspected (may precipitate complete obstruction)

3. Severity Assessment - Modified Westley Croup Score (for croup)

Parameter	Score
Stridor: none=0, with agitation=1, at rest=2
Intercostal retractions: mild=1, moderate=2, severe=3
Air entry: normal=0, slightly decreased=1, severely decreased=2
Cyanosis: none=0, with agitation=4, at rest=5
Level of consciousness: normal=0, altered=5

Score <4 = Mild croup; 4-6 = Moderate; >6 = Severe
Tintinalli's Emergency Medicine, p. 834

4. Investigations

Airway emergency takes priority over investigations:

Chest X-ray (PA + lateral):
- Radiopaque FB visible directly
- 75% of airway FBs in children <3 years are radiolucent - normal CXR does NOT exclude FB
- Indirect signs: unilateral obstructive emphysema, atelectasis, mediastinal shift
- Inspiratory vs expiratory films: air trapping on expiratory film indicates check-valve obstruction
- Croup: "steeple sign" - subglottic narrowing on AP neck X-ray
- Epiglottitis: "thumb sign" on lateral neck X-ray (enlarged epiglottis)
- Retropharyngeal abscess: widened retropharyngeal space at C2 (>2x the vertebral body diameter)
CT scan/Virtual bronchoscopy: equivocal cases; helps localise FB, defines extent of abscess
Flexible bronchoscopy (diagnostic): significant clinical suspicion of FB despite normal imaging - Rosen's Emergency Medicine, p. 3175
Rigid bronchoscopy: therapeutic - gold standard for FB removal

Treatment

A. Immediate Stabilisation (ABC Priority)

Do not agitate the child - allow position of comfort (usually sitting upright)
Oxygen - provide if it does not further distress the child; aim SpO2 >94%
Avoid direct throat examination if epiglottitis suspected
Establish IV/IO access once the child is stable
Have emergency airway equipment ready (ETT sizes, suction, bag-mask, surgical airway kit)

B. Treatment by Diagnosis

1. Foreign Body Aspiration (Sudden onset - most likely at 1 year)

Acute complete obstruction (choking infant):

In infants: 5 back blows between shoulder blades + 5 chest thrusts (NOT abdominal thrusts - risk of organ injury)
Blind finger sweeps are contraindicated - may push FB deeper
If unconscious: chest compressions as in CPR; laryngoscopy + Magill forceps removal
If ventilation fails: push FB distally into right mainstem bronchus to ventilate the left lung
Needle cricothyrotomy as last resort in infants (surgical cricothyrotomy not recommended <8-10 years)

Partial/stable obstruction:

Allow child to cough and maintain own airway
Do NOT use RSI (rapid sequence induction) - paralysis may convert partial to complete obstruction
Arrange urgent rigid bronchoscopy for FB removal under GA by otolaryngologist
Diagnostic flexible bronchoscopy if clinical suspicion is high but imaging is normal

2. Viral Croup (Laryngotracheobronchitis)

Most common infectious cause; peak age 1-2 years, parainfluenza virus type 1 most common.

Severity	Treatment
Mild (<4)	Single dose dexamethasone 0.15-0.6 mg/kg PO/IM (max 10 mg); discharge criteria met
Moderate (4-6)	Dexamethasone as above + nebulised L-epinephrine 0.5 mL/kg of 1:1000 (max 5 mL)
Severe (>6)	Dexamethasone IM 0.6 mg/kg + nebulised epinephrine (repeat if needed) + oxygen + ICU monitoring
Vomiting (can't take PO)	Nebulised budesonide 2 mg as alternative to oral steroid

Observe for minimum 3 hours after epinephrine (rebound effect possible)
Discharge criteria: no stridor at rest, normal SpO2 and color, tolerates oral fluids, caregiver can recognise deterioration
Tintinalli's Emergency Medicine, p. 833-834

3. Epiglottitis

Do not disturb the child - keep in position of comfort
Most skilled clinician performs intubation in the OR/ICU setting with ENT + anaesthesia on standby
Awake fiberoptic nasotracheal intubation preferred in spontaneously breathing child
Antibiotics: ceftriaxone + vancomycin (cover S. pneumoniae, S. aureus, H. influenzae, MRSA) for 7-10 days
Steroids to reduce mucosal edema
Admit to ICU - all cases

4. Bacterial Tracheitis

OR for sedation, intubation, and diagnostic + therapeutic bronchoscopy (removes pseudomembranes)
Antibiotics: vancomycin or clindamycin + third-generation cephalosporin
Steroids NOT clearly beneficial
Most require ventilatory support in ICU

5. Retropharyngeal Abscess

Airway stabilisation first; intubate unstable patients before CT
IV antibiotics (amoxicillin-clavulanate or ceftriaxone + metronidazole)
Surgical drainage for mature abscess

Summary Table: Differential Diagnosis at a Glance

Feature	Foreign Body	Viral Croup	Epiglottitis	Bacterial Tracheitis
Age	1-3 years	6 mo - 3 years	6-12 years (post-Hib)	3-8 years
Onset	Sudden	Gradual (URI prodrome)	Rapid (hours)	Gradual then acute
Fever	No	Low grade	High, toxic	High, toxic
Cough	Choking cough	Barking cough	Absent	Present
Voice	Normal/hoarse	Hoarse	Muffled	Hoarse
Drooling	No	No	Yes	Variable
X-ray sign	Air trapping/radiopaque	Steeple sign	Thumb sign	Irregular trachea
Treatment	Bronchoscopy	Dexamethasone ± epinephrine	Intubation + antibiotics	Intubation + antibiotics

Key Points for Examiner

Sudden onset in a 1-year-old = foreign body aspiration until proven otherwise
The choking episode is often not witnessed - high clinical suspicion is required
Normal CXR does NOT exclude FBA - >75% are radiolucent at this age
Do not perform abdominal thrusts in infants - use back blows + chest thrusts
Avoid RSI in suspected FB if child is maintaining airway - paralysis converts partial to complete obstruction
In croup, dexamethasone is the mainstay even for mild disease; epinephrine is added for moderate-severe
In epiglottitis, do not agitate the child - intubate in OR with ENT standby
Modified Westley score quantifies croup severity and guides management

References:

Tintinalli's Emergency Medicine: A Comprehensive Study (Chapter 126 - Stridor in Children, pp. 831-836)
Rosen's Emergency Medicine: Concepts and Clinical Practice (Chapter 162 - Upper Airway Obstruction, pp. 3165-3175)

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