STRIDOR IN NEONATES

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DEFINITION

Stridor is a symptom of upper airway obstruction caused by turbulent airflow through a narrowed segment of the air passages. More specifically, stridor can be defined as a variably pitched respiratory sound caused by tissue vibration from this turbulent airflow through an area of decreased caliber.26 When stridor appears in neonates, it usually induces a significant level of concern and anxiety. It should not be minimized or overlooked as an inconsequential finding; it should be appreciated and

SPECIAL CHARACTERISTICS OF STRIDOR IN NEONATES

The clinical presentation of stridorous neonates varies considerably. Most commonly, stridorous neonates are mildly dyspneic at rest; however, regardless of its severity, stridor must be appreciated as an important symptom of potential airway obstruction.31

The small caliber of the airway of newborn infants is believed to make it inherently more vulnerable to the effects of partial narrowing. In addition, the supporting cartilage of the airway of newborn infants is believed to be less rigid than

HISTORY

A clinical situation that permits a detailed relevant history is important. Key historical facts include birth history, especially the history and reason for neonatal intubation.30 When possible, the duration of intubation, the size of endotracheal tube used, and any suspected intubation trauma should be noted.31 Other useful historical facts include:

  • Age at onset of stridor

  • Duration of stridor

  • Association with precipitating events, such crying or feeding

  • Association with the infant's

PHYSICAL EXAMINATION

The first step in performing the physical examination is to determine the appropriate setting for further manipulation of the stridorous infant. The most important intervention in the primary care setting is a rapid and clear assessment of the severity of the stridor,26 which can be accomplished by attention to the vital signs, especially the heart and respiratory rate, and the skin color and level of consciousness and responsivity of the child.

In general, infants with sudden-onset severe

TRANSPORTATION AND REFERRAL

When stridor is severe and the clinical situation warrants, transportation of infants with stridor should be performed by experienced personnel. The proper equipment and expertise are necessary to institute artificial respiration, oxygen administration, and establishment of an artificial airway. In this setting, it is important to minimize anxiety, avoid intraoral manipulation, and stabilize the child for transport. Initial intervention includes continuous pulse oximetry, cardiac monitoring,

RADIOGRAPHY

Radiographic evaluation should begin with plain films. Radiographs of the chest and soft tissues of the neck and upper airway in the anteroposterior and lateral projection are useful for evaluating the upper and lower airway column and pulmonary parenchyma; they provide useful information in the evaluation of sites of collapse and obstruction. Plain films also can provide a detailed view of the adenoid and tonsil size, nasopharyngeal vault, epiglottic shadow, retropharyngeal soft tissue

ENDOSCOPY

Most infants with stridor require flexible direct laryngoscopy, and some require bronchoscopy to properly visualize the anatomic cause for the stridor. Rigid bronchoscopy also may be essential in securing an unstable airway under direct visualization.26

Flexible fiberoptic nasopharyngolaryngoscopy has been proven to be safe in examining the upper airway in neonates and infants. It allows a careful, detailed, systematic inspection of the nose, choanae, nasopharynx, oropharynx, and hypopharynx of

DIAGNOSIS AND MANAGEMENT OF COMMON LESIONS CAUSING STRIDOR

The most common lesions causing stridor in infants include:

  • Laryngomalacia

  • Vocal cord paralysis

  • Laryngeal webs

  • Laryngotracheal esophageal clefts

  • Laryngotracheal stenosis

  • Tracheoesophageal fistulae

  • Laryngeal and subglottic cysts

  • Subglottic hemangioma

  • Tracheomalacia

  • Tracheal stenosis

  • Tracheal compression

  •  Complete vascular rings

  •  Anomalous innominate artery

  •  Pulmonary artery sling

SUMMARY

Stridor in neonates and infants is a symptom that indicates partial obstruction of the large diameter airways. Its presence should prompt a thorough examination and workup. Steps in evaluating stridor include a careful history and physical examination and rapid assessment of the severity of the clinical situation. Infants with respiratory distress and severe stridor should be safely and urgently transported to a tertiary care center, and colleagues from the departments of otolaryngology and

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    Address reprint requests to Robert F. Mancuso, MD, Pediatric Otolaryngology, Tampa Children's Hospital, 4600 North Habana, Suite 23, Tampa, FL 33614

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    From Tampa Children's Hospital, Tampa, Florida

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