Stridor

Question 1

Stridor definition and causes

Answer 1

Definition: inspiratory continuous Harsh, expiratory) (occasionally to due sound partial obstruction in the extrathoracic airways (larynx & upper trachea). Generally, an inspiratory stridor suggests airway obstruction above the glottis While an expiratory stridor is indicative of obstruction in the upper trachea.

Acute stridor:
1 - Infectious (croup or barking cough):
(most common cause of acute stridor)
Viral:
- Acute laryngitis.
- Laryngo-tracheo-bronchitis
Bacterial:
- Acute epiglottitis.
- Retropharyngeal abscess
- Peritonsillar abscess
- Acute tracheitis (staph. aureus).
- Diphtheritic laryngitis.
2-Non-infectious:
- Laryngeal foreign body.
- Spasmodic laryngitis (allergic).
- Laryngeal oedema (angioneurotic).

Chronic stridor
1-Congenital:
- Laryngomalacia. (most common cause of chronic stridor < 2 years)
- Laryngeal web, cyst, or laryngocele.
- Subglottic stenosis
- Vocal cord paralysis
- Haemangioma
- Congenital vascular ring
2-Acquired:
- Chronic laryngitis 2ry to reflux or
- Laryngotracheal stenosis (congenital or acquired): by tumour or web or cyst.
- Vocal cord paralysis (left side mainly) as in PDA operation or compression by tumour or mediastinal mass.

Question 2

Acute Laryngo-tracheo-bronchitis (ALTB) aetiology, C/P and management?

Answer 2

• The most common cause of upper respiratory obstruction in children (1-6 years)!!! , accounting for about 90% of stridor (15% of upper respiratory tract infection)
• Aetiology: viral mainly by para-influenzas virus type 1, 2, and 3, influenza A & B and respiratory syncytial virus.

Clinical picture:
- Usually starts by clear rhinorrhoea, pharyngitis, light cough, and low-grade fever
- Progress within 12- 48 hours to moderate fever and upper respiratory obstruction (croupy cough, inspiratory and expiratory stridor, hoarseness of voice)
- May progress to severe respiratory distress with suprasternal and substernal retraction up to cyanosis.
- Neck x ray: in anteroposterior view may reveal the trachea terminating into subglottic narrowing (Pencil point or Church Tower sign) (Steeple sign)

Management:
 Calm the baby.
 Humidified oxygen, steam inhalation, fluids, antipyretics
 Adrenaline nebulizer / racemic epinephrine (0.25 ml epinephrine in 3 ml saline) reduce need for intubation → rapid onset of action (30 minutes) for a period of 3 hours and can be repeated once after 2-3 hours → if no improvement after 2 doses → hospitalization.
 Corticosteroids (IM dexamethasone (0.15 mg/kg in mild cases up to 0.6 mg/ kg dose in severe cases) or oral prednisone or budesonide inhalation).
 Heliox (combination of helium and oxygen) can be considered in severe cases.
 Hospitalization is indicated if there is toxaemia, dehydration, severe stridor with retraction especially < 1 year.
 In severe cases: Mechanical ventilation or rarely tracheostomy.

Question 3

Acute laryngitis definition and C/P?

Answer 3

Definition: It is a temporary inflammation (< 2 weeks) of the vocal cords either caused by its overuse, irritation, or infection (viral or bacterial).

Clinical picture:
- Weakened or hoarse voice, or even loss of voice
- Mild to moderate fever associated with croupy cough and throat irritation
- Inspiratory stridor
- Usually, no respiratory distress

Treatment: rest of the child voice plus plenty of fluids → If not improved→ the same ttt like ALTB.

Question 4

Spasmodic Laryngitis causes and C/P?

Answer 4

Non-infectious variant of croup.
Occur secondary to allergy, may be related to GERD, or psychogenic.

Clinical picture: (in children between 3 months to 3 years) and characterized by:
- The classic symptom of croup is a harsh, brassy cough that sounds like a seal’s bark usually at night. Recurrence is common.
- Associated with hoarseness of voice, inspiratory stridor ± respiratory distress.
- No fever or upper respiratory tract infection.

Treatment: reassurance, antihistamines for allergy, and management of GERD.

Question 5

Acute epiglottitis definition, C/P and management ?

Answer 5

Definition: acute inflammation of the epiglottis and adjacent supraglottic structures.
- Usually caused by Hemophilus influenzae type B!!!, rarely by staph, pneumococci, streptococci, or viral in origin.
- Potentially life-threatening infection that can cause fatal airway obstruction if treatment is delayed. (Better prognosis nowadays because of Haemophilus influenzas vaccine).

Clinical picture:
- Peak age between 2-7 years (decreased incidence in Egypt after compulsory vaccine against Haemophilus influenza)
- Rapid onset of high fever, toxic appearance, muffled voice, and sore throat.
- Symptoms progress over few hours to dysphagia, drooling of saliva, and respiratory distress → may progress to respiratory failure from the obstruction
- But croupy cough is minimal, and stridor is a late finding.
- The child usually set in a tripod position, leaning forwards with hyperextended neck to promote airway opening.
- Laryngoscope show large “cherry red” swollen epiglottis but this procedure and any stressful procedures may precipitate complete airway obstruction. So, it must be done by highly experienced practitioner in the operation room.

Management:
- Avoid direct visualization of the oropharynx in the examination room
- Radiographs are not necessary and are not contraindicated if the Patient shows signs of impending or complete airway obstruction
- Emergency admission to ICU once suspected.
- Oxygen inhalation and avoid anxiety or agitation of the child
- Endotracheal intubation in a suitable place (operation room), if failed tracheostomy should be performed.
- Administration of IV antibiotics to cover both Haemophilus influenza and streptococcus → third- generation cephalosporins are most commonly used or ampicillin - sulbactam until the results of culture & sensitivity came (the duration of ttt is for 10 days).