Stridor of Two Months Duration in a Twelve Month Old
Stridor is the classic high-pitched sound typically associated with an upper airway obstruction caused by a partial or complete obstruction and results from turbulent airflow through narrowed airways. By understanding the anatomic association for each phase of stridor we as clinicians may be better able to focus a differential diagnosis, ultimately leading to the correct final diagnosis sooner. Chronicity of stridor should incite clinicians to delve deeper into its etiology. The purpose of this case is to highlight impressive imaging, assisting in the diagnosis, and focus on the characterization of stridor as this can help with identifying the location of abnormality. We present the case of a 12 month-old previously healthy and thriving female presents to the emergency department with stridor of two months duration. Parents note the stridor to be progressive, occurring with both inspiration and expiration now. Vitals show tachycardia and oxygen saturation of 99% in room air. Exam reveals a child that appears distressed and cries on exam. There is an audible biphasic stridor, loudest with inspiration. Chest X ray shows tracheal narrowing. Given the chronicity of stated symptoms computed tomography scan of the neck obtained to hopefully characterize the anatomic structures of the neck which ultimately showed para- and retro-esophageal inflammation, tracheal stenosis, and mediastinitis. Esophogram was obtained showing a filling defect within the esophagus, concerning for foreign body, but importantly there was no contrast extravasation, decreasing the likelihood of perforation. Bronchoscopy and esophagogastroduodenoscopy were performed yielding a piece of plastic within the esophagus and no involvement of the bronchial tree. Following removal of this foreign body, symptoms dramatically improved with child being discharged the following day without need for continuance of steroids, both inhaled and systemic. As described in our case, an esophageal foreign body highlights the intrathoracic manifestation of biphasic stridor. The inflammatory process secondary to the presence of the foreign body pushing on the airway is creating the stenosis which gives rise to stridor. There are instances where the pathology is primarily located within the respiratory tract and not due to external compression or mass effect. It may take quite some time for the inflammatory insult to worsen to the point of outward symptomatology, mainly, stridor. This is seen even when patients are verbal and able to communicate the ingestion let alone when exacerbated by a patient population without communication ability as evident in our case.