Chronic Stridor

Definition

• Continuous or recurrent high-pitched breathing sound caused by partial obstruction in the upper airway

• May be inspiratory, expiratory, or biphasic depending on the level of obstruction

• Often suggests a congenital anomaly or chronic condition if present beyond infancy

Differentials

• Congenital Causes

  • Laryngomalacia: Inspiratory stridor worse with feeding, supine positioning, or crying and improves when prone, typically resolves by 12–18 months but refer if associated with apnoea or failure to thrive

  • Tracheomalacia: Expiratory or biphasic stridor, exacerbated by exertion or infection, can be related to oesophageal atresia, may require CPAP or surgical support if severe

  • Vocal Cord Paralysis: Unilateral presents with a weak cry, bilateral causes biphasic stridor and significant distress, often due to birth trauma, neurological issues, or post-surgery

  • Subglottic Stenosis: Biphasic stridor with possible voice changes, may be congenital or post-intubation, requires imaging and potential surgical correction

  • Choanal Atresia: Unilateral causes nasal discharge, bilateral leads to neonatal cyanosis relieved by crying, confirmed by CT or endoscopy with surgery for bilateral cases

• Infective or Inflammatory

  • Recurrent Croup: Episodic stridor in children, consider underlying anomaly if episodes are severe or atypical

  • Aspiration or GORD: Intermittent stridor after feeding, improve with thickened feeds or acid suppression if reflux is confirmed

• Masses or Compression

  • Laryngeal or Subglottic Mass: Haemangiomas, papillomas, or malignancies can obstruct airflow

  • Extrinsic Compression: Vascular rings, thyroid enlargement, or lymphatic malformations causing airway narrowing

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Investigations

• Endoscopy or Bronchoscopy

  • Direct visualisation of the airway and dynamic assessment, can identify structural lesions or collapse

• Imaging

  • Chest X-ray or neck radiograph to look for airway narrowing, CT or MRI if suspicious of masses or vascular anomalies

• Swallow Study or pH Monitoring

  • Assess for aspiration or severe gastro-oesophageal reflux contributing to airway irritation

• Pulse Oximetry

  • Continuous monitoring in moderate to severe stridor to detect desaturation

• ENT or Paediatric Respiratory Assessment

  • Multidisciplinary input for unclear diagnoses, specialised investigations like laryngoscopy

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Management

• Observation and Support

  • Mild laryngomalacia often resolves spontaneously, ensure adequate feeding and growth

• Medical

  • Manage reflux if aspiration or GORD is contributing, trial acid suppression or feed thickening

  • Consider steroids or nebulised adrenaline if stridor has a croup component

• Surgical or Advanced Interventions

  • Supraglottoplasty for severe laryngomalacia with apnoea or growth failure

  • Tracheostomy or stenting for intractable tracheomalacia or subglottic stenosis

  • Repair or bypass of choanal atresia in neonates with significant obstruction

  • Laser excision for vocal cord lesions or laryngeal papillomas

• Referral

  • Paediatric surgeon or ENT specialist for definitive care of anatomical anomalies

  • Multidisciplinary approach for complex cases with comorbidities

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Complications

• Feeding Difficulties and Poor Growth

  • Excess work of breathing can affect oral intake, leading to failure to thrive

• Recurrent Infections

  • Chronic airway compromise predisposes to lower respiratory tract infections

• Respiratory Distress or Failure

  • Significant obstruction may lead to hypoxaemia, hypercapnia, and acute decompensation

• Need for Long-Term Airway Support

  • Some congenital conditions or severe structural anomalies require prolonged CPAP or tracheostomy