a serious medical condition

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