Seminar

STRIDOR IN CHILDREN

By: Maj Vishal Gaurav Moderator: Dr A Sethi

OUTLINE

• Introduction

• Etiological factors

• The challenge of managing a stridulous child

• Assessment of the stridulous child

• Management

Introduction• Noise originating in the larynx or trachea is typically high-

pitched made by turbulent airflow in the airway and termed stridor

• Stertor

• Wheezing

• Stridor may be characteristic of a particular pathology but is

never diagnostic

Introduction

PHYSICS:

• Poiseuille’s Law: Resistance inversely proportional to radius to 4th power

• Bernoulli’s Law: Pressure decreases as velocity increases, causing tendency to collapse

Introduction

ANATOMY:• LARYNX IN CHILDREN– HIGHER– LUMEN SMALLER– EPIGLOTTIS: tubular & less rigid– OTHER LARYNGEAL CARTILAGES: less rigid

Predictably stridor is more in children

• Intrinsic causes (lesions of larynx itself):– Congenital- congenital laryngeal stridor

(Laryngomalacia), Bifid epiglottis, Congenital stenosis (webs in larynx), VC palsy, Subglottic stenosis

– Traumatic: Birth injuries, intubation injuries & injuries by foreign bodies

– Inflammatory: Epiglottitis, Acute laryngitis, laryngotracheobronchitis, diphtheria, TB

– Exanthematous: Measles, whooping cough, TB of larynx

Etiological factors

– Neoplastic: Papillomata (they are multiple & recurring rapidly on removal upto the age of puberty), Cysts of epiglottis &aryepiglottic fold, Haemangioma

– Neurological: Tetany (Laryngismus Stridulus & Neonatal Tetany due to deficient function of parathyroids), Tetanus, RLN palsy ( In children this may be due to birth injuries of breach presentation & pull on infant’s shoulders; or by infections of childhood like measles, pneumonia and TB; or due to new growths).

Etiological factors

• Extrinsic causes: – Congenital: Tracheomalacia, Tracheo bronchial

atresia/stenosis, Congenital vascular rings (constrict the trachea & cause stridor & dysphagia), tracheo- oesophageal fistula, Congenital goitre

– Traumatic: Trauma by foreign bodies in trachea , tracheal stenosis (e.g. following prolonged intubation or tracheostomy)& also in esophagus if longstanding (secondary tracheal compression)

Etiological factors

– Inflammatory: Retropharyngeal , Parapharyngeal& Retro-oesophageal abscess, Thymic abscess, Mediastinal lymphadenitis

–Neoplastic: Hyperplasia of thymus, Cystic hygroma, Thyroglossal cyst & other lingual cysts, Tracheal tumors

Etiological factors

Miscellaneous Choanal atresia in newborn, macroglossia due

to cretinism, lingual thyroid / haemangioma/ lymphangioma/ dermoid at base of tongue, both micrognathia & Pierre-Robin syndrome cause stridor due to falling back of tongue, Congenital dermoid of pharynx, pharyngeal tumors & adenotonsillar hypertrophy.

Etiological factors

• Prompt attention • Deciding which patients to investigate • Flexible endoscopy • The definitive diagnostic technique of

laryngotracheobronchoscopy (LTB)• The infant airway can deteriorate rapidly

The challenge of managing a stridulous child

History taking • Presentation of stridor Described as per: Onset, duration, severity,

aggravating & relieving factors, positional/diurnal variation

• PATTERN OF STRIDOR

Assessment of the stridulous child

ASSOCIATED FEATURES• Stertor: Nasopharyngeal obstruction e.g.,

neonatal rhinitis• Cough: TEF, FB, VC palsy, Tracheomalacia, Cleft

larynx, Reflux• Aspiration: TEF, Cleft larynx, VC palsy• Hoarseness: Laryngeal lesion, VC palsy

Assessment of the stridulous child

• Acute airway obstruction: Retropharyngeal abscess, Epiglottitis, Tonsillitis, Croup, Glandular fever, Bacterial tracheitis, Foreign bodies

• Dysphagia and feeding difficulties: Epiglottitis (feeding affected with many causes of severe airway obstruction and aspiration), Tonsillitis, Retropharyngeal abscess

• Apneas:Tracheobronchomalacia, Reflex apnea• Dying spells: (apnoea with cyanosis)

Assessment of the stridulous child

• PERINATAL HISTORY

• GENERAL MEDICAL CONDITIONS

ACUTE OBSTRUCTION

Assessment of the stridulous child

Assessment of the stridulous child

• Examination–GPE: Vitals, Cyanosis,

Degree of respiratory obstruction –Examination for other

congenital anomalies–ENT evaluation:

Characteristics of stridor

Assessment of the stridulous child

Investigations• BLOOD GAS ANALYSIS

• IMAGING X-ray CT & MRIOthers:– Videofluoroscopy– Bronchography

Assessment of the stridulous child

iii) RESPIRATORY FUNCTION TESTS

iv) Endoscopy Can be diagnostic as well as

therapeutic • FLEXIBLE ENDOSCOPY • LARYNGOTRACHEOBRONCH

OSCOPY (LTB)

• ANAESTHESIA FOR AIRWAY ENDOSCOPY– Induction– Intubation–Nonintubation technique– Jet ventilation– Laryngeal mask– Tracheostomy tube anaesthesia–Maintenance of anaesthesia

Assessment of the stridulous child

Assessment of the stridulous child

• MICROLARYNGOTRACHEOSCOPY TECHNIQUE

• BRONCHOSCOPY

• DYNAMIC ASSESSMENT OF LARYNX ON RECOVERY FROM ANAESTHESIA

v) ASSESSMENT OF REFLUX

STRIDOR WITH ACUTE AIRWAY OBSTRUCTION• Acute onset of stridor:laryngotracheobronchitis (croup),

bacterial tracheitis, and acute epiglottitis, Foreign body inhalation, Postextubation stridor and immediate airway obstruction postpartum.

• Principles of management: i) To secure the airway ii) To identify & treat the underlying cause • The management options in acute stridor usually include

medical management and stabilization, diagnostic endoscopy, and possibly intubation (tracheostomy and open laryngeal surgery are rarely used).

MANAGEMENT

Medical management & stabilization (Usually for inflammatory conditions)

• OXYGEN THERAPY• PHARMACOTHERAPY– Antibiotics – Intravenous (and oral) steroids – Haemophilus influenzae B vaccine – Adrenaline inhalation

• HUMIDIFICATION OF INSPIRED AIR (benefit controversial)

MANAGEMENT

Surgical management(Most commonly performed to secure the airway)– For short lasting conditions endotracheal intubation is

preferable. In case of failed intubation Emergency tracheostomy/ cricothyrotomy can be performed

• Emergency tracheostomy• Other surgical procedures– Endoscopic removal of FB– I&D of abscesses– Surgery for B/L choanal atresia– Single-Stage Laryngeal Reconstruction

MANAGEMENT

• Postpartum Airway Obstruction(Antenatal Diagnosis of High Airway Obstruction)– Cervical teratoma, cystic hygroma and rhabdomyosarcoma. – The terms: CHAOS ,OOPS, EXIT

• Unexpected Airway Obstruction at Birth– Nasopharyngeal– Laryngeal

• When intubation is not possible

• Unexpected Airway Obstruction at Birth—Tracheobronchial

MANAGEMENT

• Principles of management: i) To identify the underlying cause ii) Management with function preservation

• The management options then include medical, intubation, endoscopic procedures, tracheostomy, and other open surgical procedures.

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Medical Management in the Non-acute Situation

• Conservative management • antireflux treatment • Systemic steroids • Prophylactic antibiotics • Medical Treatment of specific conditions: e.g.

Interferon, cidofovir, and mitomycin C

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Surgical management• Endoscopic treatment of the

Larynx and Tracheobronchial tree– Endoscopic removal of FB.– Resection of small subglotticcysts – Injection of steroids– Minor laryngeal clefts – Aryepiglottic trimming for

laryngomalacia– The CO2 laser for the larynx & KTP

laser for the trachea and bronchi

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Surgical management• Tracheostomy

• Techniques to Avoid Tracheostomy

• Open Laryngeal Procedures– Laryngotracheal Stenosis

• Scott-Brown's Otorhinolaryngology, Head and Neck Surgery Vol I

• Cummings Otolaryngology, Head & Neck Surgery 4thed

• Logan Turner’s Diseases of ear, nose & throat 11thed

References

Thank you…….