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Stridor Flashcards

1
Q

Types of airway noise

A
  1. Stertor
  2. Stridor
  3. Wheeze
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2
Q

What is stertor?

A
  • Uvula + Base of tongue falls backwards and partially obstructs airway above the level of the larynx
  • Has a snoring quality, low-pitched and variable
  • Common in children with nasopharyngeal obstruction, enlarged tonsils and adenoids with obstructed airway
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3
Q

What is stridor?

A
  • Harsh, high-pitched, inspiratory generated by turbulent airflow through partially obstructed upper airway
  • Monophonic
  • Can be inspiratory, expiratory or biphasic
  • Affects larger airways (Larynx, trachea, main bronchus)
  • Heard w/o stethoscope
  • Maximally heard in neck and upper sternum
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4
Q

What is wheeze?

A
  • High-pitched, musical
  • Polyphonic
  • Usually on expiration
  • Affects smaller airways within lungs (bronchi and bronchioles)
  • May need stethoscope to hear
  • Maximally heard in lungs
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5
Q

Inspiratory stridor suggests pathology at

A

Supraglottis
Glottis

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6
Q

Biphasic stridor suggests pathology at

A

Subglottis

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7
Q

Expiratory stridor suggests pathology at

A

Trachea
Main bronchus

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8
Q

What conditions can cause inspiratory stridor?

A

Epiglottitis
Bilateral vocal cord paralysis
(if unilateral, will present with hoarseness)
Upper airway FB
Croup - acute laryngotracheobronchitis

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9
Q

What conditions can cause expiratory stridor?

A

Tracheomalacia
Main bronchus FB

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10
Q

What conditions can cause biphasic stridor?

A

Subglottic stenosis (from prolonged intubation)

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11
Q

Causes of stridor

A

Infection
- Croup (biphasic stridor)
- Epiglottitis (inspiratory stridor)
- Ludwig Angina

Inflammatory
- Anaphylaxis causing laryngeal edema

Neoplastic
- Cancer of larynx or hypopharynx (Opening of oesophagus)
- ?Subglottic haemangioma (But will resolve on its own!)

Neurological
- Bilateral vocal cord paralysis

Congenital
- Laryngomalacia
- Laryngeal web

Trauma
- Subglottic stenosis (From prolonged intubation)
- Laryngeal fracture
- Severe maxillofacial trauma

Extrinsic compression
- Thyroid goitre

Foreign Body

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12
Q

Clinical features of croup/acute laryngotracheobronchitis

A

CROUP is a URTI + LRTI

Initially: URTI sx (viral infection) over 1-3 days with coryzal symptoms
- Fever, cough, runny nose

Thereafter rapid progression:
Inspiratory stridor*
Hoarseness*
Barking cough*
Dysphagia
Drooling

*symptoms worse at night

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13
Q

Causative organism of croup

A

Viral infection (parainfluenza virus, types I and II)

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14
Q

Age of incidence for croup

A

6 months - 3 years old

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15
Q

Secondary bacterial superinfection in croup is caused by

A

Staph aureus (give abx)

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16
Q

What can be observed in anterior neck xray in croup?

A

Steeple sign
(Subglottic tracheal narrowing mimics shape of church steeple)

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17
Q

Management of croup

A

Typically self limiting, resolves within 3 days

  • Anti-pyretics
  • Mist Tx
  • Avoid smoking at home
  • Humidified air, oxygen

If severe
- IV fluids
- Oral dexamethasone to reduce airway swelling (IV too)
- Nebulized adrenaline
- Intubation

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18
Q

Peak incidence of epiglottitis/supraglottitis

A

4 years old

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19
Q

Most common causative organism of epiglottitis in Paeds

A

Haemophilus Influenza Type B

*other organisms:
Streptococcus pneumonia
B-hemolytic streptococcus
Staphylococcus aureus

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20
Q

Risk factors for epiglottitis

A

Unvaccinated against Hib
Immunocompromised
DM

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21
Q

Symptoms of epiglottitis in Paeds

A

Rapid onset of symptoms over hours
No preceding coryzal symptoms

Fever > 38.5 degrees
Stridor
Sore throat
Drooling
Respiratory distress
Sitting in tripod position
Sniffing posture
Dysphagia
Muffled voice, unwilling to talk
Anxiety, restlessness

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22
Q

Lateral neck xray findings in epiglottitis

A
  • Thumbprint/ Thumb sign
  • Loss of cervical lordosis (due to pre-vertebral muscle spasm)
  • Overdistended/ Dilated hypopharynx
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23
Q

Management of epiglottitis

A

Medical emergency

  • Avoid triggering patient
  • Maintenance of airway/ Secure airway (ETT/ Surgical cricothyroidotomy/ tracheostomy)/ Bag-Valve-Mask while waiting
  • Humidified oxygen
  • Blood culture and epiglottic culture, followed by IV 3rd generation cephalosporin (Ceftriaxone/ Cefotaxime) with cover for MRSA via vancomycin
  • IV Steroids (Dexamethasone 8mg STAT) to reduce airway edema
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24
Q

What is the commonest cause of stridor in children?

A

Laryngomalacia

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25
What happens during laryngomalacia?
Inward collapse of supraglottic structures during inspiration
26
Laryngomalacia presents as
Intermittent, low-pitched inspiratory stridor
27
Progression of laryngomalacia
Appears within first 2 weeks of life Worst by 6 months of age Improve by 18-24 months as cartilage hardens
28
What is seen from the flexible fibreoptic laryngoscopy in laryngomalacia?
- Short arytenoidepiglottic fold - Redundant arytenoid tissue - Omega epiglottis - Arytenoid tissue and epiglottis prolapse into airway with inspiration
29
Laryngomalacia can be exacerbated by?
Exertion Crying Agitation Feeding Supine positioning
30
Severe obstruction in laryngomalacia can result in
substernal retractions, pectus excavatum
31
Laryngomalacia has a significant relationship with?
GERD
32
Complications of laryngomalacia
Failure to thrive Feeding issues Cyanosis ALTE (Apparent life-threatening event in infancy) Cardiac failure
33
Management of laryngomalacia
- Self-limiting (Observe, not tracheo) If complicated: - Supraglottoplasty: Trim redundant obstructing supraglottic tissue Takes 20 mins under GA *Indicated by complications of laryngomalacia
34
Laryngeal web
P/w stridor A/w velocardiofacial syndrome (Check heart) In adults: Iatrogenic (Surgery to vocal cords) Scarring causes adhesions Mx: Excise the web and prevent the 2 sides from sticking to each other
35
Pathophysiology of laryngeal papillomatosis/ recurrent respiratory papillomatosis
- Via inhalation - Most common sites Is vocal cord --> Hoarseness - Severe --> Stridor - May involve the whole respiratory tree, including trachea, rarely bronchi
36
Causative organism of RRP
HPV organism 6 and 11
37
Clinical features of RRP
- P/w hoarse voice or breathing difficulties (Narrowed airway) - Severe: stridor - May involute at puberty
38
What can be seen in the nasoendoscope in RRP?
- On nasopharyngoscopy: Diffuse papillomatous erythematous masses
39
In a stable RRP patient, what must always be done?
Do a biopsy TRO malignancy
40
Management of RRP
Medical Tx - If unstable, stabilise patient's ABCs! - Secure airway with tracheostomy - Systemic steroids - Interferon-alpha - Supplemental oxygen Surgical Tx - Intralesional injection of cidofovir - Laser ablation of papillomata
41
What is Ludwig's angina?
Cellulitis of submental, sublingual and submandibular spaces
42
Risk factors for Ludwig's angina
Malnutrition Poor oral hygiene Recent dental extraction DM
43
Common organism causing Ludwig's angina
Strep viridans
44
Causes of bilateral vocal cord palsy/paralysis
- Idiopathic** - Injury to nerves, vocal cords during Sx - Stroke - Tumours - Infection - Neurological conditions (MS, PD, Arnold-Chiari Malformation) *For young patients, must always screen with MRI brain bc commonly a/w causes like tumours/ infx/ neuro conditions
45
Bilateral vs unilateral vocal cord palsy
Bilateral will present with stridor vs unilateral will present with hoarseness
46
Laryngeal carcinoma is mostly what type of carcinoma?
Squamous cell carcinoma
47
Risk factors for laryngeal ca
1. smoke 2. alcohol 3. reflux 4. paint 5. hpv
48
Symptoms of laryngeal ca
1. Chronic hoarseness 2. Cough 3. Neck lump 4. Globus feeling 5. Throat irritation 6. Blood stained sputum
49
Treatment of laryngeal ca
Histological confirmation via biopsy Stage: CT larynx & thorax Surgical: - Trans-oral laser resection - Open surgery -> Partial laryngectomy -> Total laryngectomy Non Surgical - Radiation - Chemo-radiation
50
Speech rehabilitation options post-larynectomy/for laryngeal speech
Esophageal speech Electrolarynx Transesophageal puncture and voice prosthesis
51
Why does subglottic stenosis occur?
Due to prolonged intubation
52
Pathophysiology of supraglottic stenosis
- Pressure exerted by ETT exceeds capillary hydrostatic pressure --> Mucosal ischemia, edema, erosion and ulceration - Subglottis is the most susceptible bc of the circumferential cricoid ring - Integrity of vascular perichondral layer Is impt as it serves as a vascular bed for normal wound healing - Loss of perichondral layer --> Aberrant wound healing and dense scar formation - Abundant inflammatory response and granulation tissue
53
Classification for supraglottic stenosis
Cotton myer
54
Management of supraglottic stenosis
AP graft Balloon dilatation Steroids injection Open airway reconstruction - for grade 3 and selected grade 4 SGS
55
What is PHACES syndrome?
Posterior fossa anomalies Haemangioma Arterial anomalies Cardiac anomalies Eye anomalies Tx: Propranolol Do brain scan to check for hemangioma in brain
56
FB is more commonly lodged in which bronchus/lung?
Right main bronchus is shorter and has a more vertical course, hence the FB commonly enters the RLL of the lung, leading to RLL consolidation
57
Anatomy of infant's larynx
AP length of glottis: 6-8mm Width of posterior glottis: 3-4mm Narrowest point: subglottis Cricoid: C4 Tip of epiglottis: C1
58
Length of trachea in newborn
4cm (12cm in adult)
59
What law determines the reason for stridor?
Poiseuille's law - resistance is inversely proportional to the radius to the 4th power
60
Chronological onset of stridor in Paeds
* Immediate onset: vocal cord paralysis, congenital SGS, choanal atresia, complete rings, large vallecular cyst * Within 2 wks: laryngomalacia * Within 1-3 months: subglottic hemangioma * > 6 months: croup or bacterial tracheitis
61
Difference between croup and epiglottitis
Croup - 3-36 months - URTI & LRTI - Below vocal cords - self resolving within 3 days - Preceding coryzal symptoms - Initial symptoms around 1-3 days - Rapid progression to inspiratory stridor, barking cough, hoarseness - Symptomatic, other oral dexa + nebulised adrenaline - Parainfluenza virus type I and II - Steeple sign on anterior neck xray Epiglottitis - 4yo - URTI - Above vocal cords - Medical emergency! - No preceding coryzal symptoms - Rapid development of symptoms within hours - Haemophilus influenza type B - Thumbprint sign

m4 ENT (25 decks)

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