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stridor-170103103611.pdf
- 1. Dr Manpreet Singh Nanda Associate Professor ENT MMMC&H Solan
- 2. Stridor ο Abnormal high pitched noisy respiration due to flow of air through a partially obstructed narrowed lower airway mainly larynx and tracheobronchial tree ο Types ο Inspiratory β supraglottis, glottis, hypopharynx ο Expiratory (wheeze) β thoracic trachea, bronchi, bronchioles ο Biphasic β cervical trachea, subglottis ο Stertor β snoring low pitched noise due to obstruction in nasopharynx and oropharynx ο Rales and crepitations β distal portion of bronchial tree and alveoli
- 3. Etiology ο Neonates β laryngomalacia (mc), laryngeal webs, cysts, subglottic stenosis, laryngeal paralysis ο Children β laryngotracheobronchitis (croup), acute epiglottis, laryngeal FB ο Nose β choanal atresia ο Tongue β macroglossia, haemangioma, lymphangioma ο Mandible β micrognathia ο Pharynx β abscess ο Larynx β paralysis, trauma ο Trachea β tumours, FB, stenosis, TOF ο Oesophagus β FB ο Neck β tumours, abscess
- 4. ο Children affected more β narrrow airway, softer cartilage collapse easily ο Adults ο Malignancy of larynx, pharynx, tongue, neck, trachea (mc) ο Infections β ludwigs angina ο Allergy β angioneurotic oedema ο Trauma β fractures, iatrogenic, radiotherapy, caustic agents ο Neurogenic - paralysis
- 5. Assessment ο Mc physical sign of larynx ο History ο Age β at birth (congenital), after few weeks (laryngomalacia) ο Onset β sudden (FB) ο Progress β rapid (acute epiglottitis), gradual (subglottic haemangioma, malignancy) ο h/o fever β infective ο h/o cough β aspiration, TOF ο h/o hoarseness β vc ο h/o apnoea and cyanosis β tracheobronchomalacia ο h/o trauma, intubation ο h/o FB ο Improves in prone position β laryngomalacia, macroglossia, micrognathia ο Improves during crying β B/L chonal atresia ο Worsens during crying - laryngomalacia
- 6. Examination ο Note the type of stridor ο Note the sound of stridor ο - musical quality β laryngomalacia ο - breathy β vc paralysis ο - aspiration β vc paralysis ο - barking cough β tracheomalacia ο Note associated symptoms ο - hoarseness β larynx ο - wheeze β bronchi ο - dysphagia β hypopharynx ο Note the severity ο - subcostal, intercostal, suprasternal recession ο - cyanosis
- 7. ο Detailed examination of oral cavity, nasal cavity, pharynx and larynx (IDL) ο INVESTIGATIONS ο Oxygen saturation monitoring ο - arterial blood gas estimation, pulse oxymetry ο Radiographs ο - x ray chest, neck ο - CT, MRI ο pH monitoring
- 8. ο Endoscopy β ο - Bronchoscopy ο - Oesophagoscopy ο - Laryngoscopy ο Along with intubation in OT ο Flexible endoscopy ο Videofluoroscopy β chest movements ο USG Neck
- 9. Treatment ο Acute condition ο Admit ο Conservative ο - oxygen and humidification ο - antibiotics ο - IV steroids ο - Nebulized epinephrine ο - mucolytics ο - IV fluids ο - CPAP (Continued Positive Airway Pressure)
- 10. ο Intubation ο Endotracheal intubation β nasal (secure) ο Preferred ο Ventilatory bronchoscopy ο Endoscopy and FB removal ο Not done in acute epiglottitis, impacted FB, trismus, severe subglottic stenosis, mandible fracture, supraglottic tumours
- 11. ο Tracheostomy ο Cricothyroidotomy ο Chronic ο - Anti reflux treatment ο - Systemic steroids ο - Prophylactic antibiotics ο - Treat the cause
- 12. Congenital lesions of larynx ο Laryngomalacia ο Subglottic stenosis ο Laryngeal web/atresia/cyst ο Vocal cord paralysis ο Subglottic haemangioma ο Laryngocele ο Laryngo oesophageal cleft
- 13. Laryngomalacia ο Congenital laryngeal stridor ο Excessive flaccidity of supraglottic larynx which gets sucked in during inspiration producing stridor and sometimes cyanosis ο Pathology ο Excessive softening of laryngeal skeletal framework -> indrawing of aryepiglottic folds -> narrowing -> stridor
- 14. Clinical features ο M:F 2:1 ο Low socio economic group ο Intermittent low pitched inspiratory stridor develops during first two weeks of life (rare at birth) ο Aggravates on crying, feeding, exertion ο Relieved in prone position, rest and sleep ο Seen maximum at 9-12 months of age ο Completely disappears after 2 years of age (5 years) ο Normal cry and voice ο In severe cases β feeding difficulty, failure to thrive and cyanosis
- 15. Signs ο Awake flexible laryngoscopy ο Anterior collapse of arytenoid ο Posterior collapse of epiglottis ο Inward collapse of aryepiglottic folds ο Omega shaped/tubular epiglottis ο Prominent arytenoids ο Normal vocal cords
- 16. ο Complications β GERD, recurrent URTI, OSA ο D/D β laryngeal webs, cysts ο Treatment ο Conservative (90%) ο - Reassurance ο - Observation ο - Treat the URTI ο Tracheostomy ο Surgery (10%) β when failure to thrive or cyanosis ο - Supraglottoplasty (Aryepiglottoplasty)
- 17. Congenital laryngeal haemangioma ο Subglottic haemangioma ο Benign vascular malformation involving subglottis ο C/F ο Females mc ο Asymptomatic for 3 to 6 months of age ο With increase size progressive disease ο Inspiratory or mostly biphasic stridor which is progressive ο Appears with URTI ο Aggravated by crying or agitation ο Dyspnoea and cyanosis ο Associated with cutaneous haemangioma or mediatinal haemangioma ο Rapid growth till 1 year of age then regress
- 18. ο Diagnosis ο X Ray Neck β soft tissue seen ο CT Scan/MRI with contrast β mass in larynx ο DL Scopy β Reddish blue mass in subglottis ο Biopsy ο Treatment ο Observation ο Antibiotics and anti inflammatory ο Steroids βIV dexamethasone, intra lesional ο Intubation/tracheostomy ο Resection β Co2 and KTP lasers/laryngofissure
- 19. Congenital subglottic stenosis ο Abnormal thickening of cricoid cartilage or fibrous tissue below the vc ο Here subglottic diameter in full term <3.5 β 4 mm (normal 4.5 β 5.5 mm) and in preterm 3 mm (normal 3.5mm) ο C/F ο Evident after 1st week of life with URTI ο Biphasic stridor ο Dyspnoea ο Normal cry ο Grading I - <50% obstruction, II β 51-70% obstruction, III β 71-99% obstruction, IV β no detectable lumen..
- 20. ο Diagnosis ο X Ray Neck, CT/MRI ο Bronchoscopy/MLS/DL Scopy ο Treatment ο Observation β improves as larynx grows ο II/III/IV β tracheostomy ο Excision β laser (Co2/KTP), Laryngotracheoplasty
- 21. Laryngeal web ο Web formation most commonly in anterior part of larynx due to arrest of development of larynx most commonly seen in glottis (between vc) ο C/F ο Since birth ο Small webs β asymptomatic ο Inspiratory stridor ο Dyspnoea or apnoea ο Weak cry ο Hoarseness ο IDL β seen b/w anterior end of vc with concave sharp posterior margin
- 22. ο D/D ο From acquired web due to trauma or infection ο Treatment ο Excision by Laser/knife or laryngofissure
- 23. Acute epiglottitis ο Supraglottic laryngitis ο PAEDIATRIC ο Marked oedema of epiglottis obstructimg the airway ο Etiology ο H influenza type B ο Age β 2 to 7 years ο Not in newborn as maternal immunity ο Pathology ο Severe cellulitis ο Thick secretions
- 24. ο C/F ο Rapid progress to respiratory distress within Β½ hour ο Abrupt onset and rapid progression ο High grade fever (>40 C) ο Dysphagia and odynophagia ο Drooling of saliva ο Hoarseness ο Muffled (hot potato) voice ο Tripod position- leans forward supporting on upper limb ο Inspiratory stridor which increases in supine position ο Retraction, nasal flaring, cyanosis, septicaemia ο Pharynx is congested
- 25. ο Diagnosis ο No tongue depressor/IDL ο Examine in OT ο Red and swollen (cherry red) epiglottis β sun rise sign ο Oedema and congestion of supraglottis ο X Ray Neck β swollen epiglottis β thumb sign ο Throat swab ο Blood culture ο Leucocytosis
- 26. ο Complications ο 5-10% mortality ο Reflux laryngospasm ο Cardio-respiratory arrest ο Otitis media ο Pneumonia ο Pericarditis ο Meningitis ο Prevention ο Hib vaccine in children
- 27. ο Treatment ο Hospitalization in ICU ο Complete bed rest and voice rest ο Intubation/tracheostomy under GA ο Antibiotics- ampicillin, cephalosporins ο IV fluids ο IV steroids ο Oxygen
- 28. Adult supraglottitis ο Less severe ο Marked oedema of supraglottis ο Etiology ο H Influenza, streptococci, staphylococci ο C/F ο Sore throat ο Dysphagia ο Pale oedematous supraglottis ο Stridor ο Treatment ο Antibiotics, steroids, anti reflux treatment ο Tracheostomy if needed
- 29. Acute laryngotracheobronchitis ο Subglottic croup ο Most common cause of infectious resp obstruction in children ο Etiology ο Viral β parainfluenza I,II ο Influenza A,B ο Other viruses β myxovirus, adenovirus ο Secondary bacterial infection ο Males>females ο Age group 3 months to 5 years of age ο Involves subglottis (mc), trachea and bronchi ο h/o URTI always
- 30. ο C/F ο Slow onset ο Starts with URTI ο Low grade fever, cough cold earlier ο Hoarseness ο Brassy or barking cough ο Biphasic stridor ο Signs of airway obstruction β nasal flaring, chest retraction ο Complications ο Middle ear infection, lung infection, tracheitis
- 31. ο Diagnosis ο Leucocytosis ο X Ray Neck β tapered narrowing of subglottis β steepleβs sign, wine bottle appearance β bottle sign ο Chest X Ray β pneumonic patches ο Flexible laryngobronchoscopy β subglottic narrowing
- 32. ο Treatment ο Hospitalization ο Humidification- soften crusts and thick secretions ο Steam inhalation ο Antibiotics ο Oxygen ο IV fluids ο Steroids ο Mucolytics β bromhexine ο Nebulization with racemic adrenaline ο Intubation/tracheostomy β if needed ο Bronchoscopy β to remove secretions
- 33. Acute simple/non specific laryngitis ο Acute inflammation of laryngeal mucosa of mild form ο Etiology ο Infections β URTI, tonsillitis, rhinitis or rhinosinusitis ο First viral later bacterial ο GERD ο Allergy ο Voice abuse ο Burns ο Trauma (endotracheal intubation) ο More severe in children as subglottic area is narrower
- 34. ο Pathology ο Hyperaemia of larynx ο Formation of pseudo membrane ο C/F ο Abrupt onset ο Hoarseness ο Dysphonia ο Pain throat ο Fever ο Dry cough worst at night ο Stridor in children ο Erythema and oedema of epiglottis, arytenoids and ventricles with normal vocal cords earlier with later hyperemia of vc and subglottis ο Pharyngeal and nasal congerstion
- 35. ο Treatment ο Bed rest ο Voice rest ο Soft bland diet ο Avoid smoking and alcohol ο Steam inhalation with inhalant capsules ο Cough sedatives ο Antibiotics β cephalosporin, amoxy clav ο Steroids ο Anti reflux treatment ο Tracheostomy/intubation if needed in childrens
- 36. Laryngeal diptheria ο Etiology ο Corynebacterium diptheriae ο Secondary to faucial diptheria ο Age < 10 years ο Both sexes ο Pesudomembrane formation ο Exotoxins liberated
- 37. ο C/F ο Gradual onset ο Low grade fever ο Sore throat ο Hoarseness ο Croupy cough ο Inspiratory stridor ο Dyspnoea ο Diptheritic membrane β grey white on tonsil, pharynx, soft palate, larynx, trachea, on removal leaves a rough bleeding surface ο Cervical lymphadenopathy β bull neck appearance
- 38. ο Complications ο Cardiac β myocarditis, circulatory failure ο Neurogenic β paralysis of palate, larynx and pharynx ο Asphyxia and death due to airway obstruction ο Diagnosis ο Clinical ο Throat swab ο Smear and culture
- 39. ο Treatment ο Diptheria anti toxin β 20000 to 100000 units IV as a single saline infusion after test dose ο Antibiotics β benzyl pencillin, erythromycin ο Complete bed rest for 2 to 4 weeks ο Oxygen ο Steroids ο IV fluids ο DL Scopy for removal of diptheritic membrane ο Intubation/tracheostomy
- 40. Tubercular laryngitis ο Etiology ο Mycobacterium tuberculosis ο 95% cases secondary to pulmonary TB, 5% primary ο Route β infected sputum to larynx (mc), lymphatic, haematogenic ο Males (mc) ο Age gp 20 β 40 years ο Involves posterior part of larynx (mc β interarytenoid region)
- 41. ο C/F ο Weak voice ο Hoarseness ο Odynophagia and dysphagia ο Hemoptysis ο Hyperaemia of vc ο Impaired adduction of vc ο Mouse nibbled appearance of vc/ moth eaten appearance due to ulcers ο Pseudo edema of epiglottis β turban epiglottis ο Bowing of vc
- 42. ο D/D β malignancy, syphilis, chronic laryngitis ο Diagnosis ο DL Scopy and biopsy ο Mantoux test ο Chest X Ray ο Sputum examination ο Stages ο 1 β inflammation ο 2- granulomatous (yellowish grey nodule) ο 3- ulcerative ο 4- cicatrization (healing)
- 43. ο Treatment ο Multi drug ATT β rifampicin, isoniazid, pyrazinamide, ethambutol for 6-9 months ο Voice rest ο NSAID ο Anti inflammmatory gargles ο Tracheostomy if stridor ο Laryngeal reconstruction
- 44. Chronic non specific laryngitis ο Chronic irritation of larynx ο Types ο 1. hyperemic β diffuse inflammation and symmetrical involvement of larynx (true cords, false cords, inter arytenoid region and root of epiglottis) ο 2. localised β nodules, polyp ο Pathology ο Pseudo stratified columnar epithelium changes into squamous epithelium ο Keratinization (leukoplakia) of statified squamous epithelium of vc ο Hyperplasia
- 45. ο Etiology ο Age >20 years/30-50 years ο Males (8:1 mc) ο Infections β PNS, tonsil, teeth, lungs ο Allergy ο Dust, fumes and other atmospheric pollutants ο Smoking and alcohol ο Spices ο GERD ο Voice abuse ο Mouth breathing ο Chronic throat clearing ο Chronic cough ο Inadequate hydration
- 46. ο C/F ο Hoarseness β worst in morning due to dryness of mouth ο Constant clearing of throat ο Throat discomfort/ FB sensation ο Dry and irritating cough ο Hyperaemia of larynx, vc dull red ο Viscid secretions at vc and interarytenoid region ο D/D β chronic specific laryngitis ο Diagnosis β X Ray PNS/Chest X Ray, throat swab, flexible laryngoscopy/biopsy
- 47. ο Treatment ο Treat infections ο Life style modifications for LPR ο Avoid smoking, alcohol ο Voice therapy/voice rest ο Steam inhalation ο Expectorant ο Treat allergy ο Steroid topic inhalers ο Surgical β MLS, stripping of vc (one vc at a time)
- 48. Pachyderma laryngitis ο Chronic lartyngitis affecting posterior part of larynx ο Interarytenoid region, post vc ο Males ο Etiology ο Alcohol, smoking, GERD ο C/F ο Hoarseness, irritation in throat ο Symmetrical red grey granulations or whitish mass on both vc (post part) and interarytenoid region, ulcer ο Diagnosis β biopsy ο Treatment β removal of granulations, anti reflux, speech therapy
- 49. Atrophic laryngitis ο Laryngitis sicca ο Atrophy of laryngeal mucosa with crust formation associated with atrophic rhinitis and pharyngitis ο Females ο C/F ο Hoarseness of voice which improves on coughing and removal of secretions ο Dry irritating cough, dyspnoea ο Atrophic mucosa covered with crusts which bleed on removal ο Treatment β humidification, loosening of secretions (laryngeal sprays containing glucose in glycerine, expectorants)
- 50. Lupus of larynx ο Indolent tubercular infection associated with lupus of nose and pharynx due to increased host resistance or decreased bacterial virulence involving anterior parts of larynx ο Epiglottis ο Females ο C/F ο Painless, asymptomatic, no pulmonary TB ο Scattered yellowish pink nodules in epiglottis which can ulcerate ο Complications β perichondritis, cartilage destruction ο Treatment - ATT
- 51. Syphilis of larynx ο Etiology β Treponema Pallidium ο C/F ο Hoarseness, dyspnoea, inspiratory stridor ο Gumma over epiglottis, anterior commissure and anterior vocal cords ο Diagnosis β biopsy, VDRL ο Complications β laryngeal stenosis, perichondritis ο Treatment ο Procaine pencillin, doxycycline ο Tracheostomy
- 52. Leprosy of larynx ο Etiology β M Leprae (Hansen bacilli) ο Associated with leprosy of skin and nose ο Affects epiglottis, aryepiglottic folds and arytenoids ο C/F β hoarseness, muffled voice, no pain ο Dull grey nodules which may ulcerate ο Diagnosis β biopsy ο Complications β laryngeal stenosis, deformity ο Treatment β dapsone, rifampicin, clofazimine for 5 β 10 years ο Steroids ο Tracheostomy
- 53. Scleroma of larynx ο Klebsiella Rhinoscleromatis (Frisch bacilli) ο Subglottis ο C/F ο Hoarseness, wheeze, dyspnoea, cough ο Smooth red or pink swelling in subglottic region which can spread to trachea ο Diagnosis β biopsy ο Complications β subglottic stenosis ο Treatment β streptomycin, doxycycline, tetracycline ο Steroids ο Tracheostomy