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 soundIs the musical sound
occurring mainly duringoccurring mainly during
expiratory phase andexpiratory phase and
indicates lower airwayindicates lower airway
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
1- causes of Acute stridor1- causes of Acute stridor
The most common are:
laryngotracheobronchitis (Croup): is
the number one cause of acute stridor.
Inhaled foreign body.
1- Causes of chronic stridor:
• 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 viralLaryngotracheobronchitis or viral
croup: an infection of both thecroup: 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. The6 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, barklikeHoarse voice and harsh, brassy, barklike
cough follow.cough follow.
• Inspiratory stridor usually develops atInspiratory stridor usually develops at
Signs of RD.Signs of RD.
Air entry may be poor.Air entry may be poor.
Lethargy or agitation may be aLethargy or agitation may be a
result of hypoxemia.result of hypoxemia.
Tachypnea, tachycardia, pallor, andTachypnea, tachycardia, pallor, and
hypotonia. Dehydration.hypotonia. Dehydration.
Cyanosis is a late ominous sign.Cyanosis is a late ominous sign.
CBC: lymphocytosis and leukopeniaCBC: lymphocytosis and leukopenia
Transcutaneous 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 atypicalViral and bacterial cultures: if atypical
Neck x-ray: steeple sign on AP viewNeck 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: “humidifiedumidified
oxygen” increased humidityoxygen” increased humidity
decreases the viscosity of thedecreases the viscosity of the
secretions and facilitates clearance.secretions and facilitates clearance.
Vasoconstrictors: “eVasoconstrictors: “epinephrine”pinephrine”
To relieve edema & relax theTo relieve edema & relax the
bronchial smooth muscles.bronchial smooth muscles.
““Dexamethsone,Dexamethsone, PrednisonePrednisone” to” to
decrease airway inflammationdecrease airway inflammation
Intravenous fluid to correctIntravenous fluid to correct
is an acute inflammation of the
epiglottis with inflammation in the
Sex: M:F ratio is about 3:1.
Age: 3-7 years, although any age
may be affected.
Cause: H. influenzae type B.
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
Rapid onset and progression of
Sore throat (95%).
Muffled voice (54%).
Usually no prodromal (URTI).
Very tender larynx
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:
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
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
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.
N.B.: close contacts should be treated
with rifampin as prophylaxis
Most patients can be extubated
within 1-2 days.
Good prognosis with appropriate
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 = 2:1
Age: 3weeks & up with mean age of 4y.
Causes: »Staphylococcus aureus.
»H. influenzae type B.
Prodrome of URTI.
Progression to higher fever.
Tracheal secretions & blood for culture.
X-ray lateral view of the neck
May reveal subglottic narrowing
Only definitive means of diagnosis
May be therapeutic by performing
tracheal toilet and stripping purulent
Antibiotics is the main treatment of
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.
Sudden choking after eatingSudden choking after eating
Inspiratory stridor or
expiratory wheezing, with
prolongation of the
expiratory phase and
Signs of R.D.
PA & lateral CXR are
Laryngoscopy if doubt
diagnosis and to remove the
from the tooth
lodged in the
right main stem
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
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
It is the most common cause of
chronic inspiratory stridor in
It has a male-to-female ratio of
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
The classic history and
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
Laryngomalacia generally is a self-
resolving condition & have a good
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
Echo. Or Doppler U.S.
MRI also can be used in the
1.Symptom complex, duration, acuity.
2.The age & the birth history.
3.History of URTI.
4.History of airway instrumentation
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
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.
9.Presence of Haemangioma
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
4.If stridor is persistent, direct exam of airway via
flexible bronchoscope to look at area below
5.A.B.G. or pulse oximetry to assess hypoxia.
Severe laryngomalacia: The epiglottis is rolled in
from side to side, and the arytenoid mucosa is
pulled into the larynx during inspiration.