Vascular Ring: A Rare Cause of Stridor in Infants

Vascular Ring: A Rare Cause of Stridor in Infants

After reading “Stridor in the Neonate and Young Child: Evaluation and Treatment of Underlying Causes” (CONSULTANT FOR PEDIATRICIANS, November 2011, page 379) by Drs Sharon E Mace, Christiana Olaru, and David Effron, I was concerned that vascular ring was not mentioned as a possible cause of stridor in children.1

—— Ashraf S. Harahsheh, MD
Pediatric Cardiologist
Children’s National Medical Center/
  George Washington University
Washington, DC

 Kussman BD, Geva T, McGowan FX. Cardiovascular causes of airway compression. Paediatr Anaesth. 2004;14:60-74.

We thank Dr Harahsheh for his comments. We agree that vascular ring can be a cause of stridor. The purpose of our article was to demonstrate how simple measures, such as plain radiographs, can aid in the diagnostic evaluation of stridor. It was not intended to be an all-inclusive list of causes of stridor. Our focus was on common and easily diagnosable causes of stridor, in particular, those that can be diagnosed by the history, physical examination, and plain films (eg, soft tissue lateral radiographs of the neck or chest radiographs). Plain radiography is generally accessible to the practitioner in an emergency department, clinic, or office, whereas advanced diagnostic measures (MRI, CT, echocardiography) are not always readily available.

In the diagnosis of vascular rings, standard radiographic examination is not usually helpful.1 In patients with a vascular ring, the finding of an abnormality on a plain film may not be diagnostic, and patients may have a vascular ring and be asymptomatic. Plain films that show indentation or displacement of the airway, which represents slight deviation of the tracheal column caused by a right aortic arch, may suggest the presence of a vascular ring.2 Diagnostic investigations for vascular ring may consist of barium esophagography, MRI, CT, cardiac catheterization, and bronchoscopy.3

Vascular ring is a much less common cause of stridor than croup or foreign body aspiration. Other less common causes of stridor include other congenital anomalies (such as laryngeal web, cysts, tracheoesophageal fistula, lingual thyroid), trauma (accidental trauma, child maltreatment, burns/inhalation injury, caustic ingestion), lymph node enlargement, tumors, laryngospasm, and bleeding/hematoma. Upper airway obstruction caused by psychogenic stridor has also been reported.

— Sharon E. Mace, MD
Professor, Department of Emergency Medicine
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Faculty, MetroHealth Medical Center
 Emergency Medicine Residency
Director, Pediatric Education/Quality Improvement
Director, Observational Unit
Director, Research Rapid Response Team
Cleveland Clinic