The most important issue in diagnosing stridor in infants and children is determining whether it is acute or chronic. The most common cause of acute stridor is croup, a viral infection with a straightforward diagnosis when patients have typical signs and symptoms (ie, inspiratory or biphasic stridor, barking cough, hoarse voice or cry, chest wall retractions). Management of mild and severe cases includes steroids. Patients with severe croup should undergo evaluation in an urgent care center or emergency department; hospital admission may be required. When symptoms are atypical for croup, physicians should consider other causes of acute stridor, including foreign body aspiration, bacterial tracheitis, and epiglottitis. The most common cause of chronic stridor is laryngomalacia, an abnormality in the laryngeal structures that causes the collapse of supraglottic structures over the airway. Symptoms typically develop in the first 1 to 2 months of life, are positional, and do not interfere with growth and development. However, if the diagnosis is in doubt or if the laryngomalacia is severe and the patient has cyanosis, worsening stridor after feeding, or inadequate weight gain, consultation with an otolaryngology subspecialist can be helpful. Most infants outgrow symptoms as the airway enlarges, but some may need pharmacotherapy for gastroesophageal reflux disease and careful feeding until this occurs. Others may need supraglottoplasty. Other causes of chronic stridor include vocal fold paralysis, subglottic hemangiomas, and glottic webs.
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