This document discusses various causes of stridor, which is an abnormal high pitched respiratory noise caused by partial airway obstruction. It covers different types of stridor and their etiologies in neonates, children and adults. Key causes discussed include laryngomalacia, vocal cord paralysis, croup, epiglottitis, diphtheria, tumors and foreign body obstruction. The document provides details on clinical assessment, investigations and management approaches for different stridor conditions.

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2. Stridor
 Abnormal high pitched noisy respiration due to flow of air
through a partially obstructed narrowed lower airway
mainly larynx and tracheobronchial tree
 Types
 Inspiratory – supraglottis, glottis, hypopharynx
 Expiratory (wheeze) – thoracic trachea, bronchi,
bronchioles
 Biphasic – cervical trachea, subglottis
 Stertor – snoring low pitched noise due to obstruction in
nasopharynx and oropharynx
 Rales and crepitations – distal portion of bronchial tree
and alveoli

3. Etiology
 Neonates – laryngomalacia (mc), laryngeal webs, cysts,
subglottic stenosis, laryngeal paralysis
 Children – laryngotracheobronchitis (croup), acute
epiglottis, laryngeal FB
 Nose – choanal atresia
 Tongue – macroglossia, haemangioma, lymphangioma
 Mandible – micrognathia
 Pharynx – abscess
 Larynx – paralysis, trauma
 Trachea – tumours, FB, stenosis, TOF
 Oesophagus – FB
 Neck – tumours, abscess

4.  Children affected more – narrrow airway, softer
cartilage collapse easily
 Adults
 Malignancy of larynx, pharynx, tongue, neck, trachea
(mc)
 Infections – ludwigs angina
 Allergy – angioneurotic oedema
 Trauma – fractures, iatrogenic, radiotherapy, caustic
agents
 Neurogenic - paralysis

5. Assessment
 Mc physical sign of larynx
 History
 Age – at birth (congenital), after few weeks (laryngomalacia)
 Onset – sudden (FB)
 Progress – rapid (acute epiglottitis), gradual (subglottic haemangioma,
malignancy)
 h/o fever – infective
 h/o cough – aspiration, TOF
 h/o hoarseness – vc
 h/o apnoea and cyanosis – tracheobronchomalacia
 h/o trauma, intubation
 h/o FB
 Improves in prone position – laryngomalacia, macroglossia, micrognathia
 Improves during crying – B/L chonal atresia
 Worsens during crying - laryngomalacia

6. Examination
 Note the type of stridor
 Note the sound of stridor
 - musical quality – laryngomalacia
 - breathy – vc paralysis
 - aspiration – vc paralysis
 - barking cough – tracheomalacia
 Note associated symptoms
 - hoarseness – larynx
 - wheeze – bronchi
 - dysphagia – hypopharynx
 Note the severity
 - subcostal, intercostal, suprasternal recession
 - cyanosis

7.  Detailed examination of oral cavity, nasal cavity,
pharynx and larynx (IDL)
 INVESTIGATIONS
 Oxygen saturation monitoring
 - arterial blood gas estimation, pulse oxymetry
 Radiographs
 - x ray chest, neck
 - CT, MRI
 pH monitoring

8.  Endoscopy –
 - Bronchoscopy
 - Oesophagoscopy
 - Laryngoscopy
 Along with intubation in OT
 Flexible endoscopy
 Videofluoroscopy – chest movements
 USG Neck

9. Treatment
 Acute condition
 Admit
 Conservative
 - oxygen and humidification
 - antibiotics
 - IV steroids
 - Nebulized epinephrine
 - mucolytics
 - IV fluids
 - CPAP (Continued Positive Airway Pressure)

10.  Intubation
 Endotracheal intubation – nasal (secure)
 Preferred
 Ventilatory bronchoscopy
 Endoscopy and FB removal
 Not done in acute epiglottitis, impacted FB, trismus,
severe subglottic stenosis, mandible fracture,
supraglottic tumours

11.  Tracheostomy
 Cricothyroidotomy
 Chronic
 - Anti reflux treatment
 - Systemic steroids
 - Prophylactic antibiotics
 - Treat the cause

12. Congenital lesions of larynx
 Laryngomalacia
 Subglottic stenosis
 Laryngeal web/atresia/cyst
 Vocal cord paralysis
 Subglottic haemangioma
 Laryngocele
 Laryngo oesophageal cleft

13. Laryngomalacia
 Congenital laryngeal stridor
 Excessive flaccidity of supraglottic larynx which gets
sucked in during inspiration producing stridor and
sometimes cyanosis
 Pathology
 Excessive softening of laryngeal skeletal framework ->
indrawing of aryepiglottic folds -> narrowing -> stridor

14. Clinical features
 M:F 2:1
 Low socio economic group
 Intermittent low pitched inspiratory stridor develops
during first two weeks of life (rare at birth)
 Aggravates on crying, feeding, exertion
 Relieved in prone position, rest and sleep
 Seen maximum at 9-12 months of age
 Completely disappears after 2 years of age (5 years)
 Normal cry and voice
 In severe cases – feeding difficulty, failure to thrive and
cyanosis

15. Signs
 Awake flexible laryngoscopy
 Anterior collapse of arytenoid
 Posterior collapse of epiglottis
 Inward collapse of aryepiglottic folds
 Omega shaped/tubular epiglottis
 Prominent arytenoids
 Normal vocal cords

16.  Complications – GERD, recurrent URTI, OSA
 D/D – laryngeal webs, cysts
 Treatment
 Conservative (90%)
 - Reassurance
 - Observation
 - Treat the URTI
 Tracheostomy
 Surgery (10%) – when failure to thrive or cyanosis
 - Supraglottoplasty (Aryepiglottoplasty)

17. Congenital laryngeal haemangioma
 Subglottic haemangioma
 Benign vascular malformation involving subglottis
 C/F
 Females mc
 Asymptomatic for 3 to 6 months of age
 With increase size progressive disease
 Inspiratory or mostly biphasic stridor which is progressive
 Appears with URTI
 Aggravated by crying or agitation
 Dyspnoea and cyanosis
 Associated with cutaneous haemangioma or mediatinal
haemangioma
 Rapid growth till 1 year of age then regress

18.  Diagnosis
 X Ray Neck – soft tissue seen
 CT Scan/MRI with contrast – mass in larynx
 DL Scopy – Reddish blue mass in subglottis
 Biopsy
 Treatment
 Observation
 Antibiotics and anti inflammatory
 Steroids –IV dexamethasone, intra lesional
 Intubation/tracheostomy
 Resection – Co2 and KTP lasers/laryngofissure

19. Congenital subglottic stenosis
 Abnormal thickening of cricoid cartilage or fibrous tissue
below the vc
 Here subglottic diameter in full term <3.5 – 4 mm (normal
4.5 – 5.5 mm) and in preterm 3 mm (normal 3.5mm)
 C/F
 Evident after 1st week of life with URTI
 Biphasic stridor
 Dyspnoea
 Normal cry
 Grading I - <50% obstruction, II – 51-70% obstruction, III
– 71-99% obstruction, IV – no detectable lumen..

20.  Diagnosis
 X Ray Neck, CT/MRI
 Bronchoscopy/MLS/DL Scopy
 Treatment
 Observation – improves as larynx grows
 II/III/IV – tracheostomy
 Excision – laser (Co2/KTP), Laryngotracheoplasty

21. Laryngeal web
 Web formation most commonly in anterior part of larynx
due to arrest of development of larynx most commonly
seen in glottis (between vc)
 C/F
 Since birth
 Small webs – asymptomatic
 Inspiratory stridor
 Dyspnoea or apnoea
 Weak cry
 Hoarseness
 IDL – seen b/w anterior end of vc with concave sharp
posterior margin

22.  D/D
 From acquired web due to trauma or infection
 Treatment
 Excision by Laser/knife or laryngofissure

23. Acute epiglottitis
 Supraglottic laryngitis
 PAEDIATRIC
 Marked oedema of epiglottis obstructimg the airway
 Etiology
 H influenza type B
 Age – 2 to 7 years
 Not in newborn as maternal immunity
 Pathology
 Severe cellulitis
 Thick secretions

24.  C/F
 Rapid progress to respiratory distress within ½ hour
 Abrupt onset and rapid progression
 High grade fever (>40 C)
 Dysphagia and odynophagia
 Drooling of saliva
 Hoarseness
 Muffled (hot potato) voice
 Tripod position- leans forward supporting on upper limb
 Inspiratory stridor which increases in supine position
 Retraction, nasal flaring, cyanosis, septicaemia
 Pharynx is congested

25.  Diagnosis
 No tongue depressor/IDL
 Examine in OT
 Red and swollen (cherry red) epiglottis – sun rise sign
 Oedema and congestion of supraglottis
 X Ray Neck – swollen epiglottis – thumb sign
 Throat swab
 Blood culture
 Leucocytosis

26.  Complications
 5-10% mortality
 Reflux laryngospasm
 Cardio-respiratory arrest
 Otitis media
 Pneumonia
 Pericarditis
 Meningitis
 Prevention
 Hib vaccine in children

27.  Treatment
 Hospitalization in ICU
 Complete bed rest and voice rest
 Intubation/tracheostomy under GA
 Antibiotics- ampicillin, cephalosporins
 IV fluids
 IV steroids
 Oxygen

28. Adult supraglottitis
 Less severe
 Marked oedema of supraglottis
 Etiology
 H Influenza, streptococci, staphylococci
 C/F
 Sore throat
 Dysphagia
 Pale oedematous supraglottis
 Stridor
 Treatment
 Antibiotics, steroids, anti reflux treatment
 Tracheostomy if needed

29. Acute laryngotracheobronchitis
 Subglottic croup
 Most common cause of infectious resp obstruction in
children
 Etiology
 Viral – parainfluenza I,II
 Influenza A,B
 Other viruses – myxovirus, adenovirus
 Secondary bacterial infection
 Males>females
 Age group 3 months to 5 years of age
 Involves subglottis (mc), trachea and bronchi
 h/o URTI always

30.  C/F
 Slow onset
 Starts with URTI
 Low grade fever, cough cold earlier
 Hoarseness
 Brassy or barking cough
 Biphasic stridor
 Signs of airway obstruction – nasal flaring, chest retraction
 Complications
 Middle ear infection, lung infection, tracheitis

31.  Diagnosis
 Leucocytosis
 X Ray Neck – tapered narrowing of subglottis –
steeple’s sign, wine bottle appearance – bottle sign
 Chest X Ray – pneumonic patches
 Flexible laryngobronchoscopy – subglottic narrowing

32.  Treatment
 Hospitalization
 Humidification- soften crusts and thick secretions
 Steam inhalation
 Antibiotics
 Oxygen
 IV fluids
 Steroids
 Mucolytics – bromhexine
 Nebulization with racemic adrenaline
 Intubation/tracheostomy – if needed
 Bronchoscopy – to remove secretions

33. Acute simple/non specific laryngitis
 Acute inflammation of laryngeal mucosa of mild form
 Etiology
 Infections – URTI, tonsillitis, rhinitis or rhinosinusitis
 First viral later bacterial
 GERD
 Allergy
 Voice abuse
 Burns
 Trauma (endotracheal intubation)
 More severe in children as subglottic area is narrower

34.  Pathology
 Hyperaemia of larynx
 Formation of pseudo membrane
 C/F
 Abrupt onset
 Hoarseness
 Dysphonia
 Pain throat
 Fever
 Dry cough worst at night
 Stridor in children
 Erythema and oedema of epiglottis, arytenoids and ventricles with
normal vocal cords earlier with later hyperemia of vc and subglottis
 Pharyngeal and nasal congerstion

35.  Treatment
 Bed rest
 Voice rest
 Soft bland diet
 Avoid smoking and alcohol
 Steam inhalation with inhalant capsules
 Cough sedatives
 Antibiotics – cephalosporin, amoxy clav
 Steroids
 Anti reflux treatment
 Tracheostomy/intubation if needed in childrens

36. Laryngeal diptheria
 Etiology
 Corynebacterium diptheriae
 Secondary to faucial diptheria
 Age < 10 years
 Both sexes
 Pesudomembrane formation
 Exotoxins liberated

37.  C/F
 Gradual onset
 Low grade fever
 Sore throat
 Hoarseness
 Croupy cough
 Inspiratory stridor
 Dyspnoea
 Diptheritic membrane – grey white on tonsil, pharynx,
soft palate, larynx, trachea, on removal leaves a rough
bleeding surface
 Cervical lymphadenopathy – bull neck appearance

38.  Complications
 Cardiac – myocarditis, circulatory failure
 Neurogenic – paralysis of palate, larynx and pharynx
 Asphyxia and death due to airway obstruction
 Diagnosis
 Clinical
 Throat swab
 Smear and culture

39.  Treatment
 Diptheria anti toxin – 20000 to 100000 units IV as a
single saline infusion after test dose
 Antibiotics – benzyl pencillin, erythromycin
 Complete bed rest for 2 to 4 weeks
 Oxygen
 Steroids
 IV fluids
 DL Scopy for removal of diptheritic membrane
 Intubation/tracheostomy

40. Tubercular laryngitis
 Etiology
 Mycobacterium tuberculosis
 95% cases secondary to pulmonary TB, 5% primary
 Route – infected sputum to larynx (mc), lymphatic,
haematogenic
 Males (mc)
 Age gp 20 – 40 years
 Involves posterior part of larynx (mc – interarytenoid
region)

41.  C/F
 Weak voice
 Hoarseness
 Odynophagia and dysphagia
 Hemoptysis
 Hyperaemia of vc
 Impaired adduction of vc
 Mouse nibbled appearance of vc/ moth eaten appearance
due to ulcers
 Pseudo edema of epiglottis – turban epiglottis
 Bowing of vc

42.  D/D – malignancy, syphilis, chronic laryngitis
 Diagnosis
 DL Scopy and biopsy
 Mantoux test
 Chest X Ray
 Sputum examination
 Stages
 1 – inflammation
 2- granulomatous (yellowish grey nodule)
 3- ulcerative
 4- cicatrization (healing)

43.  Treatment
 Multi drug ATT – rifampicin, isoniazid, pyrazinamide,
ethambutol for 6-9 months
 Voice rest
 NSAID
 Anti inflammmatory gargles
 Tracheostomy if stridor
 Laryngeal reconstruction

44. Chronic non specific laryngitis
 Chronic irritation of larynx
 Types
 1. hyperemic – diffuse inflammation and symmetrical
involvement of larynx (true cords, false cords, inter
arytenoid region and root of epiglottis)
 2. localised – nodules, polyp
 Pathology
 Pseudo stratified columnar epithelium changes into
squamous epithelium
 Keratinization (leukoplakia) of statified squamous
epithelium of vc
 Hyperplasia

45.  Etiology
 Age >20 years/30-50 years
 Males (8:1 mc)
 Infections – PNS, tonsil, teeth, lungs
 Allergy
 Dust, fumes and other atmospheric pollutants
 Smoking and alcohol
 Spices
 GERD
 Voice abuse
 Mouth breathing
 Chronic throat clearing
 Chronic cough
 Inadequate hydration

46.  C/F
 Hoarseness – worst in morning due to dryness of mouth
 Constant clearing of throat
 Throat discomfort/ FB sensation
 Dry and irritating cough
 Hyperaemia of larynx, vc dull red
 Viscid secretions at vc and interarytenoid region
 D/D – chronic specific laryngitis
 Diagnosis – X Ray PNS/Chest X Ray, throat swab, flexible
laryngoscopy/biopsy

47.  Treatment
 Treat infections
 Life style modifications for LPR
 Avoid smoking, alcohol
 Voice therapy/voice rest
 Steam inhalation
 Expectorant
 Treat allergy
 Steroid topic inhalers
 Surgical – MLS, stripping of vc (one vc at a time)

48. Pachyderma laryngitis
 Chronic lartyngitis affecting posterior part of larynx
 Interarytenoid region, post vc
 Males
 Etiology
 Alcohol, smoking, GERD
 C/F
 Hoarseness, irritation in throat
 Symmetrical red grey granulations or whitish mass on both
vc (post part) and interarytenoid region, ulcer
 Diagnosis – biopsy
 Treatment – removal of granulations, anti reflux, speech
therapy

49. Atrophic laryngitis
 Laryngitis sicca
 Atrophy of laryngeal mucosa with crust formation associated
with atrophic rhinitis and pharyngitis
 Females
 C/F
 Hoarseness of voice which improves on coughing and removal of
secretions
 Dry irritating cough, dyspnoea
 Atrophic mucosa covered with crusts which bleed on removal
 Treatment – humidification, loosening of secretions (laryngeal
sprays containing glucose in glycerine, expectorants)

50. Lupus of larynx
 Indolent tubercular infection associated with lupus of nose
and pharynx due to increased host resistance or decreased
bacterial virulence involving anterior parts of larynx
 Epiglottis
 Females
 C/F
 Painless, asymptomatic, no pulmonary TB
 Scattered yellowish pink nodules in epiglottis which can
ulcerate
 Complications – perichondritis, cartilage destruction
 Treatment - ATT

51. Syphilis of larynx
 Etiology – Treponema Pallidium
 C/F
 Hoarseness, dyspnoea, inspiratory stridor
 Gumma over epiglottis, anterior commissure and
anterior vocal cords
 Diagnosis – biopsy, VDRL
 Complications – laryngeal stenosis, perichondritis
 Treatment
 Procaine pencillin, doxycycline
 Tracheostomy

52. Leprosy of larynx
 Etiology – M Leprae (Hansen bacilli)
 Associated with leprosy of skin and nose
 Affects epiglottis, aryepiglottic folds and arytenoids
 C/F – hoarseness, muffled voice, no pain
 Dull grey nodules which may ulcerate
 Diagnosis – biopsy
 Complications – laryngeal stenosis, deformity
 Treatment – dapsone, rifampicin, clofazimine for 5 – 10
years
 Steroids
 Tracheostomy

53. Scleroma of larynx
 Klebsiella Rhinoscleromatis (Frisch bacilli)
 Subglottis
 C/F
 Hoarseness, wheeze, dyspnoea, cough
 Smooth red or pink swelling in subglottic region which can
spread to trachea
 Diagnosis – biopsy
 Complications – subglottic stenosis
 Treatment – streptomycin, doxycycline, tetracycline
 Steroids
 Tracheostomy