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BackTable / ENT / Article
Comprehensive Evaluation of Infant Stridor
Olivia Reid • Jan 7, 2024 • 31 hits
Otolaryngologists Gopi Shah and Briac Thierry provide a comprehensive guide to assess and diagnose infants presenting with stridor. The presentation, differential diagnosis, and a thorough history, encompassing respiratory signs, feeding patterns, and growth indicators, are vital in moving towards a targeted treatment for the infant’s specific condition. When conducting a physical exam, a fibroscopy is employed for definitive diagnosis, focusing on preparation, technique, and the art of ensuring comfort during the procedure. An alternative to the fibroscopy includes the emerging ultrasonography which balances various improvements and drawbacks from the fibroscopy technique, such as decreased discomfort for the patient and limited visibility in certain parts of the larynx.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Newborns with stridor, marked by high-pitched inspiratory sounds which result from upper airway obstruction, are predominantly seen in clinic referrals, with laryngomalacia being the most frequent cause.
• When diagnosing for the severity of the stridor, questioning about respiratory signs, stridor permanence, apnea, feeding patterns, growth, weight, voice presence, and potential aspiration is most commonly employed.
• When performing a fibroscopy, a larger four-millimeter scope via the mouth can be used for easier access, aided by a nurse for holding the child.
• During the physical examination of the patient, there is the potential of utilizing ultrasonography to observe vocal fold movements without causing distress in infants during examination, yet this tool does not provide the comprehensive views beyond vocal folds, including epiglottis and laryngeal structures, that a fibroscopy procedure yields.
Table of Contents
(1) Assessing Stridor in Newborns
(2) Use of Fibroscopy in Infant Stridor
(3) Ultrasonography as an Adjunctive Tool in Infant Stridor Diagnosis
Assessing Stridor in Newborns
Doctors Shah and Thierry delve into the intricacies of newborns presenting with stridor, often encountering these cases in the clinic with the root cause being laryngomalacia about 75% of the time. Stridor, a result of upper airway vibration and obstruction, predominantly manifests as inspiratory bradypnea. The severity of the condition can be assessed through questioning the parents regarding newborns respiratory signs, permanence of stridor, apnea episodes, and feeding patterns, including the possibility of aspiration incidents in more severe cases.
When diagnosing in the clinic, Dr. Thierry uses markers such as weight, growth charts, voice presence, and sleep behavior to draw conclusions. Diagnosis can be difficult in milder cases, as laryngomalacia tends to remain silent during the child’s sleep. Additionally, since a variety of conditions can mimic stridor, including vocal fold paralysis, stenosis, and cysts, meticulous evaluation that leans on physical examination and potentially a fibroscopy will be vital for conclusive identification.
[Dr. Gopi Shah]
Tell me a little bit about stridor. There's the big box of noisy breathing. How do you explain it to your trainees or to families?
[Dr. Briac Thierry]
I explain to them that the stridor is due to the vibration of the upper airway of the larynx, and the supraglottic structures because you have an obstruction in the upper airway. This obstruction leads to bradypnea and as it’s an obstruction in the cervical area of the airway, it leads to inspiratory bradypnea. You've got a sound which is inspiratory. When I try to talk about stridor to the resident, it's a high-pitched tone. I'm not an expert about this.
[Dr. Gopi Shah]
When patients and families present to your clinic or if you see them in consultation, what kinds of questions do you ask them?
[Dr. Briac Thierry]
I try to separate the very simple cases from the difficult ones. Does the child have respiratory signs? Does he have a permanent stridor? Does he have apnea? Does he experience the spell? You have to get an idea about the severity of the illness. You have to ask questions about the feeding. How does bottle feeding go? How long does it take to take a bottle? How many milliliters?
Also, you have to ask about growth and weight. It's very important to have a recent weight. Also, you need to have some information about the voice because it's not the same if the child has a voice or if he never has had one. Also, does he make aspiration when he's feeding?
[Dr. Gopi Shah]
Do you ever ask about symptoms relating to sleep at all? Sleep in this age group is, I don't know, hard to assess sometimes too, but do you find that these kids have noisy breathing or stridor in their sleep? What have you found in your practice when it comes to sleep?
[Dr. Briac Thierry]
Usually, the most frequent etiology of stridors that we will find is laryngomalacia. During sleep, in the mild and in the moderate cases, you don't hear any noise at night. It could be that they make some noise, but it's random. Anyway, you will need to know how they sleep during the night because it's also a severity sign.
[Dr. Gopi Shah]
We say laryngomalacia is the most common. What other etiologies or other differential do you usually have when it comes to the noisy breathing in the newborn?
[Dr. Briac Thierry]
Plenty.
[Dr. Gopi Shah]
It's like a box, right? Box of chocolates. There's lots to choose from.
[Dr. Briac Thierry]
Yes, it's plenty. You will find plenty of diseases that can cause some noise. Well, I'm thinking about bilateral vocal fold paralysis, congenital laryngeal stenosis, tracheal stenosis, but also vallecular cysts and subglottic cysts. You can make some noises if you have some papillomas. You have plenty of etiology of obstruction. Any obstruction of the larynx and the upper airway can cause a noise at night. It's quite difficult for the pediatrician or for the family to differentiate the stridor from another noise that appears in an inspiratory phase of the respiration, so there are plenty of diseases.
[Dr. Gopi Shah]
Are you able to differentiate stridor due to mild laryngomalacia from other etiologies? When you see the baby, are there physical signs or the sound?
[Dr. Briac Thierry]
Just about the sound, the stridor, the laryngomalacia is quite typical, but it can be difficult to differentiate this sound from, for example, bilateral vocal fold paralysis. It's also a high-pitched sound. I would say, yes, probably, but in fact, I really don't know. You have some other signs and your physical examination is going to be quite important also. Definitely, you would perform a fibroscopy and this one is going to make the diagnosis.
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Use of Fibroscopy in Infant Stridor
After the initial verbal exam to determine some of the qualities and potential causes of the stridor, an in-depth physical exam is needed to assess signs of congenital anomalies and severity markers like retractions, and also inspect the larynx for anomalies. This physical exam often utilizes a fibroscopy to get a better look at the larynx. Dr. Thierry provided several tips for performing a fibroscopy on an infant, highlighting preparation as the most important piece for a smooth procedure. The infant needs to fast for at least three hours prior to the procedure to prevent vomiting. Additionally, a large four-millimeter scope can be placed through the mouth instead of through the nose for a better visual and easier procedure, utilizing the nurse to hold the child still.
The positioning of the scope and camera enhances the practicality through the use of the doctor’s pinky finger in the patient’s mouth to aid suction and improve scope maneuvering, allowing for the patient to relax during the examination. Furthermore, the positioning of the scope through the mouth yields comprehensive viewing and diminishes the concerns about nasal issues that arise from the commonly used transnasal skinny scope.
[Dr. Briac Thierry]
It's really quite simple. We're going to perform a very simple examination of the child. We are going to look for signs of congenital anomaly as we talked about previously, like syndromic sign of microdeletion, cardiothoracic anomaly, et cetera. We are going to look for a severity sign of breathing like retraction. We are going to look in the larynx for a laryngeal anomaly, and after, we are going to perform the fibroscopy. The fibroscopy, it could be challenging, so, yes, I've got plenty of tips for this. The child has to fast for at least three hours so you don't have any vomiting issues during the examination. You have to be helped by a nurse. I think it's very important because you need to hold the child and they perform a much better job than the parents do at this time because they're afraid and because the baby's going to cry. You need a nurse and you will perform the fibroscopy by the mouth. I think it's definitely the most easy and by the mouth, you can put a bigger tube, a bigger scope than in the nose, so you can put a four-millimeter scope without any problem in the mouth. It's quite difficult to put this in the nose of a neonate. You don't need any anesthesia for this because it's not painful. You don't need any gas.
Then, I'm ready to perform the scope. I make myself quite comfortable, so I raise the table and also if I have any suspicion of a bilateral vocal fold immobility, and I know that the scope is going to last for four, five minutes, I place the fibrescope and the camera on my right shoulder so I will be comfortable and I wouldn't hurt my arm during the scope. Well, this is just a tip, but you can make the scope much longer if you perform it this way. Then, you need to see the vocal folds and you need to see the larynx because this is what you want to perform. I put with my left hand, I put my little finger in the mouth so that the child has some suction on my finger and I can hold the tip of my scope with my thumb and my index finger and then I will just look at the larynx and if it's difficult, with my little finger also, I can put some extension, some neck extension, and then I will, in the end, see the larynx and what I want to see is the mobility of the vocal fold.
[Dr. Gopi Shah]
That's a very different way than I do it. That's very interesting. I love it. My usual go-to is transnasal with a skinny scope, but now I understand why they don't eat for three hours because you're going to go transoral, but with a larger scope, you're going to see more. That's pretty cool. Then you don't have to worry about nosebleeds or if the baby has choanal atresia, pyriform stenosis, whatever, it's okay because you're going through the mouth. Then, does the pinky help pull the tongue out a little bit too or when the little finger is in the mouth, does that help move the tongue out a little bit? Everything's so tiny. Maybe the tongue doesn't really get in the way.
[Dr. Briac Thierry]
I think if the child is having some suction on your little finger, it can help because the tongue is not getting out, but it helps.
[Dr. Gopi Shah]
Ah, okay. That's really cool. Do you normally record all these?
[Dr. Briac Thierry]
Yes.
[Dr. Gopi Shah]
I find it helpful because I usually record as well, and if it's in the hospital, we use an adapter for the iPhone so we can record it. Then, I like it because you can slow it down. Once you're looking at it, you can slowly watch the cords and see if they close, open, what one side is doing versus the other. Do you do that?
[Dr. Briac Thierry]
Well, not really. I've got another tip for this.
[Dr. Gopi Shah]
Oh, okay. Tell me.
[Dr. Briac Thierry]
If you have any suspicion of immobility of the vocal folds, you can record it. Well, you will record it, but you just need to stay longer. Instead of doing this in one minute, you can perform this for four, five, or six minutes. It's so long. Okay? The parents, they don't like it. The kid doesn't either, but at some point, you will see that the child at first is crying because it doesn't like it and it's difficult to understand if the vocal folds are not moving because of the crying or just because they're not moving. If you put the examination much longer, at some point--
[Dr. Gopi Shah]
They have to relax.
[Dr. Briac Thierry]
Yes, the child relaxes, it does, he is not crying anymore. Then, you will see the vocal folds much better and you will see if you've got a movement or not. You have to accept the fact that it's going to last forever.
Ultrasonography as an Adjunctive Tool in Infant Stridor Diagnosis
Dr. Briac Thierry introduces the potential of ultrasonography as an adjunctive tool for evaluating infant stridor, highlighting its benefits in observing vocal fold mobility without inducing distress in the child. However, this tool has been challenging to adopt universally due to its limitations in providing comprehensive views compared to fibroscopy, which offers a more detailed examination of structures beyond vocal folds, such as the epiglottis and laryngeal itinerary. In terms of other imaging modalities for stridor evaluation, there is a limited role for instruments like X-rays, airway fluoroscopy, and neck X-rays, as these do not allow for direct diagnosis of the condition at hand.
[Dr. Briac Thierry]
Well, there is also something that we could use, but we don't really because well, not yet, is the ultrasonography.
[Dr. Gopi Shah]
Tell me, have y'all started using that in your practice, ultrasound?
[Dr. Briac Thierry]
Yes, I do, a little bit. I think it's useful, but we should perform this in all the children, and for now, well, it is not possible now, but we will. You can see the movement of the vocal folds and since you are not putting the scope in the mouth, the child is not crying. He is relaxed at the beginning of the examination. You don't have to wait forever. I think this should be the way of performing the examination, especially for the mobility of the vocal folds. Well, definitely with the scope, you will also see the epiglottis, you will see the itinerary, you will see the larynx, you will see anything that I cannot see with the ultrasonography because I'm not used to it at this point. I think it should be an exam--
[Dr. Gopi Shah]
A tool.
[Dr. Briac Thierry]
Yes, a tool that we should use more often.
[Dr. Gopi Shah]
Yes. That's cool. Is there ever any role of other imaging, like do you ever get X-rays, airway films, airway fluoroscopy, anything like that, in your practice?
[Dr. Briac Thierry]
Well it has been in the IPOG about laryngomalacia. Well, we don't use it, we don't need an X-ray because the patient has a strider, then you will perform the fiberoscopy and you will see. If you have any suspicion, I think the X-ray is not the first exam that we should do. I'm sorry not to agree with the IPOG.
[Dr. Gopi Shah]
No, I agree and I don't really have a role for airway fluoroscopy or neck X-rays for this particular reason either. I did use the IPOG, the IPOG guidelines for laryngomalacia actually to help me study for our complex pediatric OTO boards that just started about three years ago. They're very helpful, just as a side note, for any of our listeners or audience. I think it's very helpful either way, because the algorithms, the flow sheet chart for just managing these babies come to your clinic, whether you're uber academic peds or a general otolaryngologist in the community, you're going to see these babies. It's nice to have some directions because you might see these all the time or this might be once in every couple of months depending on your practice.
[Dr. Briac Thierry]
It's very helpful anyway, but about X-ray, I'm not sure.
Podcast Contributors
Dr. Briac Thierry
Dr. Briac Thierry is an ENT surgeon with APHP in Paris, France.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 7). Ep. 141 – Stridor in Newborns: Evaluation & Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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