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==Intial Work-Up==
{{AdultPage|stridor (peds)}}
*Assess stability of airway
==Background==
**If unstable, see [[Difficult Airway Algorithm]], see [[Intubation]] and consider surgical intervention/consultation
*Stridor refers to harsh upper airway sounds caused by turbulent airflow through a narrowed airway<ref>Ida JB, Thompson DM. Pediatric stridor. Otolaryngol Clin North Am. 2014 Oct;47(5):795-819. PMID 25213283</ref>
**If stable consider imaging with video laryngoscope [[GEMC:Airway Procedures]]  
*Classically inspiratory, indicating extrathoracic obstruction
***CT of neck can be considered if mass/infection suspected but not dynamic like laryngoscope
*A true airway emergency — rapidly assess for need for definitive airway management
*In adults, the differential differs significantly from pediatrics due to larger airway caliber
*Most common adult causes: [[anaphylaxis]], foreign body, [[angioedema]], infection (peritonsillar/retropharyngeal abscess, epiglottitis), post-extubation edema, and malignancy
 
==Clinical Features==
===Phase of Respiration===
*Inspiratory stridor: extrathoracic obstruction (supraglottic or glottic level)
**Pressure<sub>trach</sub> < Pressure<sub>atm</sub> causes dynamic collapse
**Examples: [[epiglottitis]], [[angioedema]], foreign body, laryngeal mass
*Expiratory stridor (vs. [[wheezing]]): intrathoracic obstruction (subglottic/tracheal level)
**Pressure<sub>trach</sub> < Pressure<sub>pleura</sub>
**Examples: tracheal mass, goiter, tracheomalacia
*Biphasic stridor: fixed obstruction (critical narrowing at glottis or subglottis)
**Examples: subglottic stenosis, bilateral vocal cord paralysis, large foreign body
 
===Associated Features===
*Drooling, dysphagia, muffled voice (supraglottic process)
*Hoarseness (glottic or recurrent laryngeal nerve involvement)
*Fever (infectious etiology)
*Facial/lip/tongue swelling ([[angioedema]], [[anaphylaxis]])
*History of intubation, neck surgery, or radiation (subglottic stenosis, recurrent laryngeal nerve injury)
*Preceding choking event (foreign body)


==Differential Diagnosis==
==Differential Diagnosis==
===Trauma===
{{Stridor DDx}}
#[[Neck Trauma|Larynx fracture]]
 
#Tracheobronchial tear/injury
==Evaluation==
#Thyroid gland injury/trauma
===Immediate===
#Trachea injury
*Assess airway stability — if in extremis, proceed directly to airway management
#Electromagnetic, Physics, trauma, [[Radiation_Exposure_(Disaster)#Treatment|Radiation Causes]]
*Pulse oximetry (may be normal until late stages)
#[[Burns|Burns]], inhalation
*Allow patient to maintain position of comfort
===Infectious Disorders===
*Do NOT agitate the patient if concern for supraglottic infection (epiglottitis)
#Bacterial tracheitis
 
#[[Diphtheria]]
===Workup===
#Tetanus
*Stable patient:
#Tracheobronchial [[Tuberculosis]]
**Lateral soft tissue neck radiograph (thumbprint sign in epiglottitis, retropharyngeal widening)
#Poliomyelitis, paralytic, bulbar
**CT neck with contrast if mass, abscess, or deep space infection suspected
#Poliomyelitis, acute
**Nasopharyngoscopy or fiberoptic laryngoscopy for direct visualization (if available and safe)
#Fungal Laryngitis
*Unstable patient:
===Abscesses===
**Defer imaging — proceed to airway management
#Abscess, parapharyngeal
**Consider calling anesthesia, ENT for surgical airway backup
#[[Epiglottitis]], acute
 
#Peritonsillar abscess
===Laboratory===
#Laryngotracheobronchitis, acute
*Generally not helpful acutely
#[[Retropharyngeal Abscess]]
*Consider [[CBC]], blood cultures if infectious etiology suspected
===Neoplastic Disorders===
*[[Tryptase]] if [[anaphylaxis]] suspected
#Neoplasms/tumors
 
===Allergic and Auto-Immune Disorders===
==Management==
#[[Croup]], spasmodic/tracheobronchitis
===Airway Management===
#[[Angioedema]]/Angioneurotic edema
*Prepare for [[difficult airway]] — have backup equipment ready including surgical airway kit
===Metabolic, Storage Disorders===
*[[Intubation]] with a smaller-than-expected endotracheal tube (due to narrowed airway)
#Cerebral Gaucher's of infants (acute)
*Consider awake fiberoptic intubation if expertise available
#Tracheobronchial amyloidosis
*Surgical airway ([[cricothyrotomy]]) if unable to intubate/ventilate
===Biochemical Disorders===
*Call for help early (anesthesia, ENT)
#Tetany
 
===Congenital, Developmental Disorders===
===Condition-Specific===
#[[Angioedema]]/Angioneurotic edema, hereditary
*'''[[Anaphylaxis]]''': [[epinephrine]] IM 0.3-0.5mg, repeat q5-15min; adjuncts per [[anaphylaxis]] protocol
===Psychiatric Disorders===
*[[Angioedema]]: distinguish allergic vs. [[ACE inhibitor]]-induced vs. hereditary
#Somatization disorder
**Allergic: [[epinephrine]], [[antihistamines]], [[corticosteroids]]
===Anatomical or Mecanical===
**[[ACE inhibitor]]-induced: [[epinephrine]] if severe, consider icatibant or C1-esterase inhibitor concentrate
#Foreign Body Aspiration
**[[Hereditary angioedema]]: C1-esterase inhibitor concentrate, icatibant, or ecallantide
#Acute gastric acid/aspiration syndrome
*[[Epiglottitis]]: IV antibiotics (ceftriaxone + vancomycin), airway management in OR if possible
##Airway obstruction
*Peritonsillar/retropharyngeal abscess: IV antibiotics, surgical drainage, ENT consultation
##Neck compartment hemorrhage/hematoma
*Foreign body: direct laryngoscopy or bronchoscopy for removal
===Vegetative, Autonomic, Endocrine Disorders===
*Post-extubation stridor: racemic [[epinephrine]] nebulized, IV [[dexamethasone]], consider [[Heliox]]
#Esophageal free reflux/GERD syndrome
*Malignancy: ENT/oncology consultation, [[dexamethasone]] for tumor-related edema
#Laryngospasm, acute
 
##Bilateral vocal cord paralysis
==Disposition==
#Hypoparathyroidism
*All patients with stridor should be closely monitored
===Poisoning===
*Most require admission for airway observation
##Smoke inhalation
*ICU admission for: tenuous airway, requiring repeated treatments, post-intubation
##[[Caustics|Chemical burn/esophagus]]
*Discharge is rare — only if complete resolution of mild post-procedural or allergic stridor after observed treatment and monitoring


==See Also==
==See Also==
[[Stridor (Peds)]]
*[[Stridor (Peds)]]
*[[Difficult Airway Algorithm]]
*[[Anaphylaxis]]
*[[Angioedema]]
*[[Epiglottitis]]
 
==External Links==


[[Category:Airway/Resus]]
==References==
<references/>


[[Category:ENT]]
[[Category:ENT]]
[[Category:Symptoms]]
[[Category:Pulmonology]]

Revisión actual - 10:43 22 mar 2026

This page is for adult patients. For pediatric patients, see: stridor (peds)

Background

  • Stridor refers to harsh upper airway sounds caused by turbulent airflow through a narrowed airway[1]
  • Classically inspiratory, indicating extrathoracic obstruction
  • A true airway emergency — rapidly assess for need for definitive airway management
  • In adults, the differential differs significantly from pediatrics due to larger airway caliber
  • Most common adult causes: anaphylaxis, foreign body, angioedema, infection (peritonsillar/retropharyngeal abscess, epiglottitis), post-extubation edema, and malignancy

Clinical Features

Phase of Respiration

  • Inspiratory stridor: extrathoracic obstruction (supraglottic or glottic level)
    • Pressuretrach < Pressureatm causes dynamic collapse
    • Examples: epiglottitis, angioedema, foreign body, laryngeal mass
  • Expiratory stridor (vs. wheezing): intrathoracic obstruction (subglottic/tracheal level)
    • Pressuretrach < Pressurepleura
    • Examples: tracheal mass, goiter, tracheomalacia
  • Biphasic stridor: fixed obstruction (critical narrowing at glottis or subglottis)
    • Examples: subglottic stenosis, bilateral vocal cord paralysis, large foreign body

Associated Features

  • Drooling, dysphagia, muffled voice (supraglottic process)
  • Hoarseness (glottic or recurrent laryngeal nerve involvement)
  • Fever (infectious etiology)
  • Facial/lip/tongue swelling (angioedema, anaphylaxis)
  • History of intubation, neck surgery, or radiation (subglottic stenosis, recurrent laryngeal nerve injury)
  • Preceding choking event (foreign body)

Differential Diagnosis

Stridor

Trauma

Infectious Disorders

Abscesses

Neoplastic Disorders

  • Neoplasms/tumors

Allergic and Auto-Immune Disorders

  • Spasmodic/tracheobronchitis
  • Angioedema/Angioneurotic edema

Metabolic, Storage Disorders

  • Cerebral Gaucher's of infants (acute)
  • Tracheobronchial amyloidosis

Biochemical Disorders

Congenital, Developmental Disorders

Psychiatric Disorders

  • Somatization disorder

Anatomical or Mechanical

Vegetative, Autonomic, Endocrine Disorders

Poisoning

Chronic Pediatric Conditions

Evaluation

Immediate

  • Assess airway stability — if in extremis, proceed directly to airway management
  • Pulse oximetry (may be normal until late stages)
  • Allow patient to maintain position of comfort
  • Do NOT agitate the patient if concern for supraglottic infection (epiglottitis)

Workup

  • Stable patient:
    • Lateral soft tissue neck radiograph (thumbprint sign in epiglottitis, retropharyngeal widening)
    • CT neck with contrast if mass, abscess, or deep space infection suspected
    • Nasopharyngoscopy or fiberoptic laryngoscopy for direct visualization (if available and safe)
  • Unstable patient:
    • Defer imaging — proceed to airway management
    • Consider calling anesthesia, ENT for surgical airway backup

Laboratory

  • Generally not helpful acutely
  • Consider CBC, blood cultures if infectious etiology suspected
  • Tryptase if anaphylaxis suspected

Management

Airway Management

  • Prepare for difficult airway — have backup equipment ready including surgical airway kit
  • Intubation with a smaller-than-expected endotracheal tube (due to narrowed airway)
  • Consider awake fiberoptic intubation if expertise available
  • Surgical airway (cricothyrotomy) if unable to intubate/ventilate
  • Call for help early (anesthesia, ENT)

Condition-Specific

Disposition

  • All patients with stridor should be closely monitored
  • Most require admission for airway observation
  • ICU admission for: tenuous airway, requiring repeated treatments, post-intubation
  • Discharge is rare — only if complete resolution of mild post-procedural or allergic stridor after observed treatment and monitoring

See Also

External Links

References

  1. ↑ Ida JB, Thompson DM. Pediatric stridor. Otolaryngol Clin North Am. 2014 Oct;47(5):795-819. PMID 25213283
  2. ↑ Vocal Cord Dysfunction on Internet Book of Critical Care https://emcrit.org/ibcc/vcd/
  3. ↑ Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004
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