A 2-year-old presents with sudden onset of cough and stridor; what is the next best step in evaluation?

• A. Lateral soft tissue x-ray of the neck
• B. Indirect laryngoscopy
• C. Thoracocentesis
• D. Barium swallow

Answer: (B)

When a toddler suddenly develops cough and stridor, think that an acute airway obstruction from a foreign body is high on the differential until proven otherwise. The best next step is to visualize the larynx directly at the bedside. Indirect laryngoscopy lets you inspect the laryngeal inlet quickly without needing general anesthesia, so you can identify any foreign body, edema, or other laryngeal pathology that’s causing the obstruction. If a foreign body is seen, prompt management or referral for removal can be arranged, often preventing progression to complete airway compromise.

Imaging like a lateral soft tissue neck x-ray can be helpful in certain scenarios, but it may miss nonradiopaque objects and doesn’t provide the immediate, dynamic view of the airway that direct visualization offers. The other options listed aren’t appropriate for evaluating an airway obstruction: thoracocentesis and a barium swallow target thoracic or esophageal issues, not the airway. If indirect laryngoscopy is negative but suspicion remains high, bronchoscopy under anesthesia is the next step to evaluate and potentially remove any object from the lower airway.