What’s Behind Stridor? Case Studies in Diagnosis and Care
Airway obstruction could be imminent with this alarming sound
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Objectives
- Review the signs and symptoms of epiglottitis
- Review the signs and symptoms of Ludwig’s angina
- Discuss prehospital management of the patient with stridor
Few clinical signs command the attention of an EMT or paramedic more than stridor. Whether it’s present in a neonate, pediatric, adult or geriatric, it means the same thing: impending airway compromise.
Stridor is a harsh, loud sound of constant pitch, produced in the larynx, glottis or trachea. It is the result of turbulent airflow through a narrowed upper airway. Narrowing of the airway at or above the vocal cords (trachea or larynx) produces inspiratory stridor. Narrowing of the airway below the vocal cords (intrathoracic) produces expiratory or biphasic stridor.1 Stridor is a sign that indicates critical narrowing of the airway and represents a medical emergency with potential for complete airway obstruction and subsequent asphyxiation. The timing and acuity of onset of stridor are important in determining the seriousness of the airway problem. Rapid onset suggests a high potential for immediate airway deterioration and total occlusion, while a more gradual onset suggests less of a risk.
This month’s article uses a case-based approach to explore some of the more common and life-threatening causes of stridor. For each case we work through a differential diagnosis to show how to evaluate the evidence supporting and opposing various etiologies and arrive at a best guess for a diagnosis. Lists of possible diagnoses are not inclusive; rather, they simply serve as a starting point for discussion.
Case #1
• Stridor and fever in a 6-year-old male.
• Differential to consider: foreign body airway obstruction, epiglottitis, croup.
A 6-year-old male presents conscious, alert and oriented, sitting up in bed in a “sniffing” position and complaining of a sore throat. He has a strong and rapid radial pulse, and his respiratory rate and tidal volume are normal, but you note inspiratory stridor with each breath. His skin is warm and dry. His mother says he went to bed last night without any complaint but woke up this morning with a sore throat and fever, so she kept him home from school as a precaution. Since he awoke 5 hours ago, the patient’s fever has risen to 102.3ºF (39.0ºC), and the stridor developed. The mother reports the patient has no significant medical history and takes no medications. He has not received all of his vaccinations to date, as the parents are concerned about vaccine side-effects. She is not aware of any recent trauma or potential for foreign body ingestion.
The child is slightly anxious but willing to answer your questions and allow you to perform a physical examination. He says his “throat hurts” and “it hurts to swallow.” You note his voice is slightly muffled, and his mother confirms this is not normal for him. The patient’s lung sounds are clear, and he does not complain of any respiratory distress. There is no accessory muscle use, nasal flaring, abdominal breathing or retractions. His vital signs are heart rate 112/min. and regular; respiratory rate 20/min. with good tidal volume; blood pressure 105/70 mmHg; pulse oximetry 97% on room air; and tympanic temperature 102.0ºF (38.8ºC). His blood glucose is 91 mg/dL.
