17 Stridor

Stridor

“Harsh, usually high pitched, turbulent sound due to partial obstruction in the larynx/ tracheo-bronchial tree and is usually associated with dyspnoea”.

Other types of noisy breathingStertor: Harsh, low-pitched turbulent

sound during respiration due to partial obstruction proximal to the larynx and may be associated with dyspnoea

Snoring: Same+ only during sleepApnea: Cessation of breathingSleep apnea syndrome: >30 apnea

episodes during 8 hours of sleep

Stridor: Things to knowTypesPitchSite of obstructionSeverityCauses

Types Inspiratory (croup)

Glottic Supraglottic Hypopharynx

Expiratory (wheeze) Distal trachea Bronchi

Biphasic Subglottic Proximal trachea

Severity Mild

Only on unaccustomed exertion Deep breathing

Moderate On minimal exertion Not able to do day-to-day activities

Severe Even at rest Accessory muscles are active Recession Features of hypoxemia like tachycardia, tachypnoea,

cyanosis, irritability and restlessness

PitchLow pitch

ProximalHigh

Distal

Site of obstruction

TypePitchAssociated symptomsExamples: Hoarseness: Larynx Dysphagia/ FB sensation in throat:

Hypopharynx Hot-potato voice: Supraglottic/ oropharynx

Etiology in children

S trid or in ch ild ren

L aryn g om alac iaC ys ts

Tu m orsS ten os is

C on g en ita l

P yrexia lIn fec tive cau se

A p yrexia lTrau m a/ F B

Tu m orN eu ro log ica l, e tc .

A cq u ired

CongenitalProximal to larynx

Nose: Choanal atresia Tongue: Macroglossia, haemangioma,

lymphangioma, lingual thyroid, etc. Mandible: Micrognathia

Laryngeal Supraglottic: LARYNGOMALACIA, cysts,

tumors Glottic: Webs, palsy, cyst Subglottic: Stenosis, tumors

Tracheobronchial Vascular loops T.E.Fistula Mediastinal congenital tumors Atresia, stenosis

Aquired

INFECTIVEAcute epiglottitisAcute laryngo-tracheo-bronchitisLaryngeal diphtheriaLaryngeal odema secondary to quinsy,

acute tonsillitis, ludwig’s angina, retro/ parapharyngeal abscess, etc.

TRAUMATICFB in upper aero-digestive tractThermalChemicalPhysical- RTARadiation

TUMORSJuvenile laryngeal papillomatosisChondromaThymomaCystic hygroma

OTHERSNeurological: Bil. VC palsyAllergy: Angioneurotic odemaLaryngismus stridulusTetanyTetanus

ETIOLOGY IN ADULTS Trauma: Laryngotracheal trauma,

laryngotracheal stenosis-RTA/ iatrogenic, FB Tumor: Larynx, pharynx, trachea, bronchus,

esophagus, thyroid, any neck/ mediastinal mass Ca. Larynx Ca. Hypopharynx

Infection: TB laryngitis, neck space infections Allergy: Angioneurotic odema Neurological: Bilateral abductor palsy

Post thyroidectomy/ CTS

EvaluationObjectives Site Severity Cause Best way to secure the airway

Methods History Clinical examination Investigations

First aid management as you evaluate Hospitalize/ early referral

History Onset: Congenital/ later, How? Duration:

Short- inflammatory/ traumatic Moderate- Malignancy Long-Benign, VC palsy

Progression Fever +/- Voice Feeding FB/ trauma/ corrosive poisoning Cyanotic speels Choking spells at night Relation to posture Aspiration Other throat/ neck/ chest symptoms

Clinical examination Type Severity Systemic features of infection Postural relation Sequential auscultation Complete ENT, neck and RS examination ILS- done with caution/ contraindicated in

moderate-severe stridor Voice/ cry

InvestigationsRadiography Plain X-ray neck AP/ lateral Chest X-ray- PA/ lateral Barium swallow CT scan- neck/ mediastinum Angiography

Endoscopy Rigid/ flexible Laryngoscope- Caution: Can give

rise to laryngospasm Rigid/ flexible Bronchoscope- after securing airway

TreatmentConservative IntubationCricothyroidotomyTracheostomy

Conservative Antibiotics- parenteral Steroids- parenteral and high dose Humidification Mucolytics O2 administration IV fluids Feeding Positioning SOS bronchodilators NO SEDATION

Intubation ADVANTAGES Easy and quick in

some cases

DISADVANTAGES Difficult intubation Prolonged

intubation- stenosis Morbid RT feeds Difficult to maintain Tracheo-bronchial

toilet- difficult Airway resistance

and deadspace- increased

Tracheostomy

ADVANTAGES By pass Prolonged periods Maintainance easy Morbidity: less Airway resistance

reduced Dead space reduced Tracheobronchial

toilet better Swallow

DISADVANTAGES More time to secure

airway Surgical procedure Major in children Difficult in children Expertise Complications

Crico-thyroidotomy Cricothyroid

membrane in the midline

Large bore needle Stab incision-

catheter

Other methodsTrans tracheal O2 administrationMini-tracheostomyPer-cutaneous tracheostomy

Multidisciplinary approachTreatment of the cause