Differential Diagnosis of Stridor in the Newborn: Guidelines for a Time-Efficient and Cost-Effective Evaluation

  • David E. TunkelEmail author
  • Melissa Ortiz


Stridor is an abnormal respiratory noise that usually indicates the presence of a fixed and/or dynamic obstruction of the upper airway. Stridor in a neonate is particularly concerning because it may indicate a severe lesion that can compromise airway patency in an infant with little tolerance for impaired ventilation or oxygenation. We will discuss the differential diagnosis of stridor in neonates using a time and cost-efficient strategy for evaluation. We will discuss the diagnostic tests that are most appropriate for neonates with noisy breathing by emphasizing the use of physical examination and history to determine the location(s) of the airway obstruction(s) and to narrow the differential diagnosis. A focused history centers on perinatal issues and the onset and progression of stridor. We will discuss the relevant associated signs and symptoms, as well as the changes in stridor while an infant is awake, feeding, or sleeping. We will address the most appropriate use of airway endoscopy in the ambulatory setting and in the operating room. Fiberoptic laryngoscopy in awake neonates is perhaps the most useful endeavor for evaluating newborn infants who have stridor. Radiologic tests will be discussed, with a renewed focus on reducing exposure to ionizing radiation by selecting the correct imaging modality and avoiding studies that are not useful.


Stridor Fiberoptic laryngoscopy Direct laryngoscopy and bronchoscopy Laryngomalacia Vocal cord paralysis Subglottic stenosis Larynx Trachea Airway fluoroscopy 


  1. 1.
    Berkowitz RG. Neonatal upper airway assessment by awake flexible laryngoscopy. Ann Otol Rhinol Laryngol. 1998;107:75–80.CrossRefPubMedGoogle Scholar
  2. 2.
    Kelly SM, April MM, Tunkel DE. Obstructing laryngeal granuloma after brief endotracheal intubation in neonates. Otolaryngol Head Neck Surg. 1996;115:138–40.CrossRefPubMedGoogle Scholar
  3. 3.
    Hartl TT, Chadha NK. A systematic review of laryngomalacia and acide reflux. Otolaryngol Head Neck Surg. 2012;147:619–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Bajaj Y, Kapoor K, Jephson CG, Albert DM, Harper JI, Hartley BE. Great Ormond Street Hospital treatment guidelines for use of propranolol in infantile isolated subglottic hemangioma. J Laryngol Otol. 2013;127:295–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Khariwala SS, Lee WT, Koltai PJ. Laryngotracheal consequences of pediatric cardiac surgery. Arch Otolaryngol Head Neck Surg. 2005;131(4):336–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Schumacher RE, Weinfeld IJ, Bartlett RH. Neonatal vocal cord paralysis following extracorporeal membrane oxygenation. Pediatrics. 1989;84:793–6.PubMedGoogle Scholar
  7. 7.
    Smith ME, King JD, Elsherif A, Muntz HR, Park AH, Kouretas PC. Should all newborns who undergo patent ductus arteriosus ligation be examined for vocal fold mobility. Laryngoscope. 2009;119:1606–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Zoumalan R, Maddalozzo J, Holinger LD. Etiology of stridor in infants. Ann Otol Rhinol Laryngol. 2007;116:329–34.CrossRefPubMedGoogle Scholar
  9. 9.
    Chiou HL, Diaz R, Orlino E, Poulain FR. Acute airway obstruction by a sheared endotracheal intubation stylet sheath in a premature infant. J Perinatol. 2007;27:727–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Goske MJ, Applegate KE, Boylan J, Butler PF, et al. The Image Gently Campaign: working together to change practice. Am J Roentgenol. 2008;190:273–4.CrossRefGoogle Scholar
  11. 11.
    Rudman DT, Elmaraghy CA, Shiel WE, Wiet GJ. The role of fluoroscopy in the evaluation of stridor in children. Arch Otolaryngol Head Neck Surg. 2003;129:305–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Berg E, Naseri I, Sobol SE. The role of airway fluoroscopy in the evaluation of children with stridor. Arch Otolaryngol Head Neck Surg. 2008;134:415–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Huntley C, Carr MM. Evaluation of the effectiveness of airway fluoroscopy in diagnosing patients with laryngomalacia. Laryngoscope. 2010;120:1430–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Triglia JM, Nazarian B, Sudre-Levillain I, Marciano S, Moulin G, Giovanni A. Virtual laryngotracheal endoscopy based on geometric surface modeling using spiral computed tomography data. Ann Otol Rhinol Laryngol. 2002;111:36–43.CrossRefPubMedGoogle Scholar
  15. 15.
    Friedman EM. Role of ultrasound in the assessment of vocal cord function in infants and children. Ann Otol Rhinol Laryngol. 1997;106:199–209.CrossRefPubMedGoogle Scholar
  16. 16.
    Bryson PC, Leight WD, Zdanski CJ, Drake AF, Rose AS. High resolution ultrasound in the evaluation of recurrent respiratory papillomatosis. Arch Otolaryngol Head Neck Surg. 2009;135:250–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Thompson DM. Laryngomalacia: factors that influence disease severity and outcomes of management. Curr Opin Otolaryngol Head Neck Surg. 2010;18:564–70.CrossRefPubMedGoogle Scholar
  18. 18.
    King EF, Blumin JH. Vocal cord paralysis in children. Curr Opin Otolaryngol Head Neck Surg. 2009;17:483–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Kussman BD, Geva T, McGowan FX. Cardiovascular causes of airway compression. Pediatr Anesth. 2004;14:60–74.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Surgery, Otolaryngology—Head and Neck Surgery SectionUniversity of Puerto Rico-Medical Sciences CampusSan JuanUSA

Personalised recommendations