Child with stridor

Stridor from the mouth

Stridor from the neck

Stridor is a high pitched, harsh, vibratory noise caused by partial upper airway obstruction & mainly inspiratory.

Is the musical sound Is the musical sound occurring mainly during occurring mainly during expiratory phase and expiratory phase and indicates lower airway indicates lower airway obstruction.obstruction.

Wheeze:Wheeze:

Causes of the stridor:

1- Causes of acute stridor:

Require an urgent evaluation and treatment.

2- Causes of chronic stridor:

Most often caused by anatomic defects.

Divided to supraglottic, glottic and subglottic.

Can be divided to:

1- causes of Acute stridor 1- causes of Acute stridor “acquired”:“acquired”:

The most common are:

laryngotracheobronchitis (Croup): is the number one cause of acute stridor.

Inhaled foreign body.

Bacterial tracheitis.

Acute epiglottitis.

Other causes of acute stridor:

metabolic hypocalcaemia.metabolic hypocalcaemia.

Tonsillitis.Tonsillitis.

Allergic edema Allergic edema “angioneurotic”“angioneurotic”

Diphtheria.Diphtheria.

Retro pharyngeal abscess.Retro pharyngeal abscess.

Lymphadenopathy.Lymphadenopathy.

Hot fumes.Hot fumes.

1- Causes of chronic stridor:

» Supraglottic causes:

• Laryngomalacia*: (most common)

• Cysts: aryepiglottic cyst & dermoid cyst.

• Lingual thyroid.

• Micrognathia.

• Macroglossia.

1- Causes of chronic stridor:

•Laryngeal web*

• Vascular ring*.

• Haemangioma and lymphangioma.

• Bilateral vocal cord paralysis (BVCP).

• Polyps & papilloma.

• Congenital subglottic stenosis.

• Traumatic: post-intubation or after surgery.

• Neoplastic: thyroid carcinoma, mediastinal tumor.

» Glottic and subglottic causes:

Laryngotracheobronchitis or viral Laryngotracheobronchitis or viral croup: an infection of both the croup: an infection of both the upper and lower respiratory tracts. upper and lower respiratory tracts. Cause: Cause: Parainfluenza virus type I.Parainfluenza virus type I.Sex:Sex: male-to-female ratio is 2:1.male-to-female ratio is 2:1. Age:Age: 6 months to 3 years. The 6 months to 3 years. The mean age is 18 months.mean age is 18 months.

• Mild URTI with coryza,Mild URTI with coryza,

• Nasal congestion,Nasal congestion,

• Sore throat,Sore throat,

• Insidious onset of fever (38-39°C).Insidious onset of fever (38-39°C).

Hoarse voice and harsh, brassy, Hoarse voice and harsh, brassy, barklike cough follow.barklike cough follow.

• Inspiratory stridor usually develops Inspiratory stridor usually develops at nightat night

Mild expiratory wheezing may Mild expiratory wheezing may occur.occur.Inspiratory stridor Inspiratory stridor Signs of RD.Signs of RD.Air entry may be poor.Air entry may be poor.Lethargy or agitation may be a Lethargy or agitation may be a result of hypoxemia.result of hypoxemia.Tachypnea, tachycardia, pallor, Tachypnea, tachycardia, pallor, and hypotonia. Dehydration. and hypotonia. Dehydration. Cyanosis is a late ominous Cyanosis is a late ominous sign.sign.

CBC: lymphocytosis and leukopeniaCBC: lymphocytosis and leukopeniaTranscutaneous oximetry: Transcutaneous oximetry: ABGs: unnecessary unless sever.ABGs: unnecessary unless sever.Direct laryngoscopy: “not routinely” Direct laryngoscopy: “not routinely” if suspected bacterial infection. if suspected bacterial infection. Viral and bacterial cultures: if atypical Viral and bacterial cultures: if atypical presentations.presentations.Neck x-ray: steeple sign on AP view Neck x-ray: steeple sign on AP view in 50-60% of cases.in 50-60% of cases.

Treatment may include:Treatment may include:Humidification: “hHumidification: “humidified umidified oxygen” increased humidity oxygen” increased humidity decreases the viscosity of the decreases the viscosity of the secretions and facilitates clearance.secretions and facilitates clearance.Vasoconstrictors: “eVasoconstrictors: “epinephrine”pinephrine”To relieve edema & relax the To relieve edema & relax the bronchial smooth muscles.bronchial smooth muscles.

Glucocorticoids: Glucocorticoids: ““Dexamethsone, Dexamethsone, PrednisonePrednisone” to ” to decrease airway inflammationdecrease airway inflammationIntravenous fluid to correct Intravenous fluid to correct dehydrationdehydration

Sever airway obstruction.Sever airway obstruction.Pneumothorax and Pneumothorax and pneumomediastinum.pneumomediastinum.Bacterial superinfection Bacterial superinfection Otitis media.Otitis media.Dehydration.Dehydration.

is an acute inflammation of the epiglottis with inflammation in the supraglottic region

Sex: M:F ratio is about 3:1.

Age: 3-7 years, although any age may be affected.

Cause: H. influenzae type B. Streptococcus pneumoniae, Staphylococcus aureus, and group A beta-hemolytic streptococci were occasionally found. Since the introduction of the HIB vaccine in the late 1980s, the overall incidence of epiglottitis in children has declined, and HIB is less commonly the cause.

Rapid onset and progression of symptoms.Sore throat (95%).Odynophagia/dysphagia (95%).Muffled voice (54%).Usually no prodromal (URTI).

Cervical adenopathyRespiratory distressVery tender larynxToxic appearance.Tripod position

FeverDroolingStridor “late”HypoxiaMild coughIrritability

Secure airways first.Don’t use the tongue depressor.lateral view x-ray of the neck is confirmatory & should be performed in the E.R.“The thumb sign”

The normal epiglottis in the image on the right is contrasted with the markedly thickened one on the left. A column of air can still be seen though the epiglottis is swollen.

Soft-tissue lateral neck x-ray reveals edema of epiglottis consistent with acute epiglottitis

A. Airway Management 1. immediate endotracheal intubation. based on clinical grounds. “extreme agitation and pronounced stridor with R.D. are indications for intubation.2. If the child is cyanotic, bradycardic or sustains respiratory arrest, the child should be intubated immediately with the help of anesthetist.

B. Antibiotic Therapy:1. 3rd generation cephalosporins are

the antibiotics of choice for acute epiglottitis b/c of the high prevalence of ampicillin-resistant strains of Hib (1/3 of all Hib isolates).

- Ceftriaxone -Cefuroxime -Cefotaxime

2. Cephalosporins should be avoided in patients with a history of an allergic reaction to penicillin because of the 10% cross hypersensitivity between penicillin and cephalosporins. Chloramphenicol is an appropriate alternative in penicillin allergic patients.

C. On the ICU mildly sedation with midazolam. Humidification can be maintained by blow-by mist and oxygen.D. Intubation should be maintained for one to three days. The patient is extubated after the presence of a leak around the endotracheal tube is apparent.Dexamethasone is given after extubation to prevent the edema.

Pulmonary edemaEpiglottic abscessPneumoniaMeningitisCervical adenitisSeptic arthritisPericarditis

CellulitisSeptic shock Vocal GranulomaPneumothorax Pneumo-mediastinum (rare)Death (asphyxia)

N.B.: close contacts should be treated with rifampin as prophylaxis

Prognosis: Most patients can be extubated within 1-2 days.Good prognosis with appropriate treatment

B. T. is diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. Sex: M:F ratio = 2:1Age: 3weeks & up with mean age of 4y.Causes: »Staphylococcus aureus.

»H. influenzae type B.»Streptococcus pyogenes.

Prodrome of URTI.

Progression to higher fever.

Cough.

Inspiratory stridor.

①Inspiratory stridor②Barklike or brassy cough③Hoarseness④Variable degrees of R.D.: Nasal flaring, Retractions, Dyspnea, Cyanosis⑤Sore throat.⑥Odynophagia.⑦Dysphonia.

Tracheal secretions & blood for culture.X-ray lateral view of the neck

May reveal subglottic narrowing Laryngotracheobronchoscopy:

Only definitive means of diagnosisMay be therapeutic by performing tracheal toilet and stripping purulent membranes

Antibiotics is the main treatment of B. T.

Bronchopneumonia.

Exacerbation of COPD & may lead to respiratory failure.

The main complications are:

The most common age group affected is b/w 6m & 5y.

most commonly are lodged in the right main stem and lower lobe. Aspiration has been documented in all lobes including the upper lobes, though with less frequency.

Cough.Cough.

Stridor.Stridor.

Dyspnea.Dyspnea.

Wheezing.Wheezing.

Dysphagia.Dysphagia.

Sudden choking after eatingSudden choking after eating

Inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase and medium-to-coarse rhonchi.Signs of R.D.

PA & lateral CXR are mandatory. Laryngoscopy if doubt diagnosis and to remove the foreign body.

Tooth (molar) was dislodged

during intubation

a lobar pneumonia

from the tooth

Aspirated foreign body lodged in the

right main stem

bronchus

ABC management.Laryngoscope.Dexamethasone after laryngoscopy.

laryngeal web is a congenital disorder due to partial canalisation of the epithelial lamina between the vestibulotracheal canal above, and the pharyngotracheal canal below. 75% are sited in the glottis, the remaining 25% in the supra- or sub-glottis.

Most are situated anteriorly, involving a variable length of the vocal cord. They are often thick and fibrotic, and may cause severe stridor and airway obstruction.

Small laryngeal webs rarely require treatment. Larger, symptomatic ones may be removed by an endoscopic laser or knife.

Laryngomalacia is a congenital abnormality of the laryngeal

cartilage .It is the most common cause of chronic inspiratory stridor in infants.It has a male-to-female ratio of approximately 2:1.

It is due to an intrinsic defect or delayed maturation of supporting structures of the larynx. The airway is partially obstructed during inspiration by the prolapse of the flaccid epiglottis, arytenoids and aryepiglottic folds. The inspiratory stridor is usually worse when the child is in a supine position, when crying or agitated, or when an upper respiratory tract infection occurs.

The classic history and endoscopic examination usually suffice to establish a diagnosis of laryngomalacia.

Most cases of laryngomalacia can be managed by observation,

Surgical management is indicated in rare instances if respiratory complications develop.

Laryngomalacia generally is a self-resolving condition & have a good prognosis.Complications in rare cases include chest deformities, cyanotic attacks, obstructive apnea, pulmonary hypertension, right heart failure, and failure to thrive.

Tracheal compression may result from vascular anomalies such as double aortic arch, right aortic arch with left ligamentum arteriosum, anomalous innominate artery, anomalous left common carotid artery, anomalous left pulmonary artery or aberrant subclavian artery.

The child may prefer to keep the neck hyperextended. The stridor resulting from tracheal compression is often aggravated by feeding.The trachea may also be compressed by a mediastinal cyst, teratoma, lymphoma or lymphadenopathy.

Echo. Or Doppler U.S.Barium swallow.MRI also can be used in the diagnosis

1- Causes of chronic stridor:

1.Symptom complex, duration, acuity.

2.The age & the birth history.

3.History of URTI.

4.History of airway instrumentation (previous intubation)

5.Vaccination history ( H. influenza)

6.Foreign body- abrupt onset

7.Mother has history of HPV infection

Key points for history taking:

1.Inspiratory vs. expiratory vs. biphasic stridor.

2.Fever.

3.Drooling or hyperextension of neck and unusual sitting position, change of symptoms with positioning.

4.Weak or muffled cry.

5.Prolonged inspiratory/expiratory phase.

Key points in physical exam.:

6.Presence of cyanosis.

7.Degree of distress.

8.Facial deformities.

9.Presence of Haemangioma elsewhere.

10.Neck masses.

Key points in physical exam.:

Key points in physical exam. in child with stridor:

A newborn infant with Pierre-Robin syndrome. Note the micrognathia.

Key points in physical exam. in child with stridor:

A two-year-old child with a cystic hygroma on the left side of the neck.

1. AP and endolateral radiographs of the neck can assess adenoidal size, epiglottis, and trachea.

2. AP and lateral CXR to look for foreign body or pulmonary disease.

3. Airway fluoroscopy.

4. If stridor is persistent, direct exam of airway via flexible bronchoscope to look at area below cords.

5. A.B.G. or pulse oximetry to assess hypoxia.

Diagnostic studies:

Diagnostic studies:

Severe laryngomalacia: The epiglottis is rolled in from side to side, and the arytenoid mucosa is pulled into the larynx during inspiration.