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m4 ENT > Stridor > Flashcards

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

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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

Inspiratory stridor
Hoarseness
Barking cough
Fever

*symptoms worse at night

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13
Q

Causative organism of croup

A

Viral infection (parainfluenza virus)

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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
  • 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
- but 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

Fever
Stridor
Sore throat
Drooling
Respiratory distress
Sitting in tripod position
Sniffing posture
Dysphagia
Muffled voice
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
  • 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
Q

What happens during laryngomalacia?

A

Inward collapse of supraglottic structures during inspiration

26
Q

Laryngomalacia presents as

A

Intermittent, low-pitched inspiratory stridor

27
Q

Progression of laryngomalacia

A

Appears within first 2 weeks of life
Worst by 6 months of age
Improve by 18-24 months as cartilage hardens

28
Q

What is seen from the flexible fibreoptic laryngoscopy in laryngomalacia?

A
  • Short arytenoidepiglottic fold
  • Redundant arytenoid tissue
  • Omega epiglottis
  • Arytenoid tissue and epiglottis prolapse into airway with inspiration
29
Q

Laryngomalacia can be exacerbated by?

A

Exertion
Crying
Agitation
Feeding
Supine positioning

30
Q

Severe obstruction in laryngomalacia can result in

A

substernal retractions, pectus excavatum

31
Q

Laryngomalacia has a significant relationship with?

A

GERD

32
Q

Complications of laryngomalacia

A

Failure to thrive
Feeding issues
Cyanosis
ALTE (Apparent life-threatening event in infancy)
Cardiac failure

33
Q

Management of laryngomalacia

A
  • Self-limiting (Observe, not tracheo)
    If complicated:
  • Supraglottoplasty: Trim redundant obstructing supraglottic tissue
    Takes 20 mins under GA
    *Indicated by complications of laryngomalacia
34
Q

Laryngeal web

A

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
Q

Pathophysiology of laryngeal papillomatosis/ recurrent respiratory papillomatosis

A
  • Via inhalation
  • Most common sites Is vocal cord –> Hoarseness
  • Severe –> Stridor
  • May involve the whole respiratory tree, including trachea, rarely bronchi
36
Q

Causative organism of RRP

A

HPV organism 6 and 11

37
Q

Clinical features of RRP

A
  • P/w hoarse voice or breathing difficulties (Narrowed airway)
  • Severe: stridor
  • May involute at puberty
38
Q

What can be seen in the nasoendoscope in RRP?

A
  • On nasopharyngoscopy: Diffuse papillomatous erythematous masses
39
Q

In a stable RRP patient, what must always be done?

A

Do a biopsy TRO malignancy

40
Q

Management of RRP

A

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
Q

What is Ludwig’s angina?

A

Cellulitis of submental, sublingual and submandibular spaces

42
Q

Risk factors for Ludwig’s angina

A

Malnutrition
Poor oral hygiene
Recent dental extraction
DM

43
Q

Common organism causing Ludwig’s angina

A

Strep viridans

44
Q

Causes of bilateral vocal cord palsy/paralysis

A
  • 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
Q

Bilateral vs unilateral vocal cord palsy

A

Bilateral will present with stridor vs unilateral will present with hoarseness

46
Q

Laryngeal carcinoma is mostly what type of carcinoma?

A

Squamous cell carcinoma

47
Q

Risk factors for laryngeal ca

A
  1. smoke
  2. alcohol
  3. reflux
  4. paint
  5. hpv
48
Q

Symptoms of laryngeal ca

A
  1. Chronic hoarseness
  2. Cough
  3. Neck lump
  4. Globus feeling
  5. Throat irritation
  6. Blood stained sputum
49
Q

Treatment of laryngeal ca

A

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
Q

Speech rehabilitation options post-larynectomy/for laryngeal speech

A

Esophageal speech
Electrolarynx
Transesophageal puncture and voice prosthesis

51
Q

Why does subglottic stenosis occur?

A

Due to prolonged intubation

52
Q

Pathophysiology of supraglottic stenosis

A
  • 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
Q

Classification for supraglottic stenosis

A

Cotton myer

54
Q

Management of supraglottic stenosis

A

AP graft
Balloon dilatation
Steroids injection
Open airway reconstruction
- for grade 3 and selected grade 4 SGS

55
Q

What is PHACES syndrome?

A

Posterior fossa anomalies Haemangioma
Arterial anomalies
Cardiac anomalies
Eye anomalies

Tx: Propranolol
Do brain scan to check for hemangioma in brain

56
Q

FB is more commonly lodged in which bronchus/lung?

A

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
Q

Anatomy of infant’s larynx

A

AP length of glottis: 6-8mm
Width of posterior glottis: 3-4mm
Narrowest point: subglottis

Cricoid: C4
Tip of epiglottis: C1

58
Q

Length of trachea in newborn

A

4cm (12cm in adult)

59
Q

What law determines the reason for stridor?

A

Poiseuille’s law
- resistance is inversely proportional to the radius to the 4th power

60
Q

Chronological onset of stridor in Paeds

A
  • 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

m4 ENT (25 decks)

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