Wheeze and slurred speech

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karina Zavaleta, MD [2], Iqra Qamar M.D.[3], Anmol Pitliya, M.B.B.S. M.D.[4]

Differential diagnosis of Wheeze and slurred speech

Etiology on the basis of anatomy	Diseases	Clinical manifestations							Diagnosis					Other features
		Symptoms					Physical exam		Labs	Pulmonary function testing	Imaging
		Onset	Cough	Dyspnea	Fever	Slurred speech	Cyanosis	Auscultation			Chest imaging	Other	Gold standard
Extrathoracic upper airway diseases	Laryngeal edema (Anaphylaxis)	Acute	+	+	–	+	+	Hoarseness Stridor	High levels of serum tryptase Increased levels of plasma histamine Skin allergy test	Not specific	Not required	Not required	Acute onset with one of them: Respiratory compromise Reduced blood pressure (BP) Two or more after the exposure to a likely allergen Respiratory compromise Reduced BP Gastrointestinal symptoms Skin–mucosal involvement BP reduced after exposure of a known allergen Adult BP systolic <90 mmHg Children: Low systolic BP	Nasal discharge, altered mental status, redness and hives of the skin Common allergens: Food, insect sting, biologic materials, natural rubber latex, etc
	Cricoarytenoid arthritis	Acute	+	+	–	+	–	Hoarseness Stridor	Test for rheumatoid arthritis	Forced inspiratory flowdecreased Forced expiratory flowdecreased	Clear chest	Hyperdense intra–articular sclerotic cricoid and arytenoid cartilages in CT	Direct laryngoscopy	Cartilage erosion can lead on joint luxation and immobilization of the cord
	Vocal fold edema/hematoma/paralysis	Acute	+	+	–	+	–	Hoarseness Short breathing	Not specific	Variable	Clear chest	Not required	Laryngoscopy	Associated with neck surgery
	Paradoxical vocal fold motion	Acute	+	+	–	+	–	Inspiratory stridor	Hypercapnia in arterial blood gases when distress is severe	Forced inspiratory flow decrease but normal between episodes	Clear chest	CT and color flow doppler to rule out other diseases	Abnormal adduction of vocal fold visualized in laryngoscopy	Throat tightness, choking sensation Associated with exercise, asthma, post–extubation, etc.
	Laryngeal stenosis	Acute, Chronic	+	+	–	+	+	Glottic or supraglottic: Inspiratory stridor Glottis through trachea: biphasic stridor	Not specific	FV loop variable	Clear chest	Stenosis visualized in neck x–ray	Palpation of arytenoid for passive mobility and laryngoscopy	History of neck trauma or intubation
Etiology on the basis of anatomy	Diseases	Clinical manifestations							Diagnosis					Other features
		Symptoms					Physical exam		Labs	Pulmonary function testing	Imaging
		Onset	Cough	Dyspnea	Fever	Slurred speech	Cyanosis	Auscultation			Chest imaging	Other	Gold standard
Extrathoracic upper airway diseases	Epiglottitis (supraglottitis)	Acute	–	+	+	+	–	Hoarseness Stridor	Leukocytosis Epiglottal culture	Normal function	Clear chest	More than 8 mm of size epiglottal and distend hypopharynx in neck x–ray	An edematous epiglottis is visualized on laryngoscopy	Tripod posture Drooling Tenderness of the anterior part of the neck
	Retropharyngeal abscess	Subacute	–	+	+	+	–	Stridor Tachypnea	Leukocytosis Aerobic and anaerobic blood cultures may be helpful	Normal function	Lateral chest x–ray to determine the extension of the abscess	Increased vertebral space in lateral neck x–ray Cervical lordosis and gas collection in retropharyngeal space in neck CT with intravenous contrast	Neck CT or presence of pus during the surgical procedure	Pain with neck extension Dysphagia Head in sniffing position
	Tonsillar hypertrophy	Acute, chronic	–	+	–	+ hyponasal speech	–	Stridor	Not specific	Flow loop shows inspiratory slowing	Clear chest	Not required	Direct visualization of enlarged tonsils in oropharyngeal exam	More in children and adolescents
Central airway diseases (Intrathoracic upper airway obstruction)	Respiratory papillomatosis	Chronic	+	+	–	+	–	Hoarseness Stridor	Not specific	Not specific	Solid or cavitated pulmonary nodules	Nodules which involves mucosal surface observed in CT	Polypoid lesions observed on bronchoscopy	Etiology: HPV 6 and 11 Biopsy to determine the type of virus