Stridor with drooling in a child: emergency airway priorities

What it is

Stridor is noisy breathing from obstruction of the upper airway, and the phase of the noise tells where the obstruction sits. Supraglottis and above gives inspiratory stridor, glottis and subglottis give biphasic stridor, and obstruction below the subglottis gives expiratory stridor. A child who is drooling and sitting in the tripod position is telling you that the supraglottic airway is obstructed, and the airway comes before any test.

Causes and risk

The differential separates by tempo. Acute and sub-acute stridor is either non-infectious (foreign body aspiration, anaphylaxis, airway burn) or infectious (bacterial tracheitis, epiglottitis, croup, retropharyngeal abscess). Chronic stridor is either congenital (laryngomalacia, choanal atresia, thyroglossal cyst, tongue dermoid or teratoma) or acquired (vocal cord dysfunction, vocal cord paralysis, subglottic stenosis, laryngeal spasm, tumor).

• Croup is caused by a viral infection (parainfluenza virus, RSV) and affects 6 months to 6 years.
• Bacterial tracheitis affects children older than the croup age group (4-6 year olds); the organisms are Staphylococcus aureus and Group A Streptococcus.
• Epiglottitis is seen primarily in children 3 to 7 years old, although adults may be affected too; Hemophilus influenzae is now less common because of vaccination.
• Laryngomalacia is soft laryngeal cartilage and gives stridor during inspiration from birth; crying increases the stridor and the prone position improves it.
• Subglottic hemangioma is a vascular neoplasm that presents with stridor at 3-6 months of age, because it is small at birth.