Stridor + Hoarse Voice Flashcards
Obstruction in which anatomical locations might cause stridor?
Supraglottic
Glottic
Subglottic
Tracheal
What is stertor?
Low pitched snoring sound caused by obstruction above the supraglottic level
What are some acute causes of stridor?
Foreign body Epiglottitis Laryngotracheobronchitis (croup) Laryngitis Anaphylaxis Neck space abscess
What are some causes of chronic stridor?
Laryngomalacia Subglottic stenosis Vocal cord paralysis Subglottic haemangioma Respiratory papillomatosis Macroglossia or micrognathia Malignancy
What is the most common cause of subglottic stenosis?
Secondary to prolonged intubation
Which important signs must be assessed for in a patient with stridor?
Torticollis or trismus Inability to swallow + drooling Absence of cough Systemic signs of infection Cyanosis Decreasing volume of stridor sound (becoming tired, less air movement)
What is torticollis?
Asymmetrical head/neck position
What is trismus?
Lockjaw
In which situations should you not examine a patient with stridor?
Croup or epiglottitis
Which investigations should be done for a chronic (non-emergency) stridor?
Fiberoptic nasal endoscopy
Further imaging:
- CT for abscess or malignancy
- bronchoscopy for visualising below vocal cords
What is the acute management of stridor?
ABCDE –>
- stabilise, high flow oxygen, alert ENT/anaesthetics
- suction secretions, remove obvious foreign bodies
- adrenaline or steroids if required
- bloods +/- ABG, cultures
If initial management does not improve stridor, what should be considered?
Intubation or emergency cricothyroidotomy
What causes epiglottitis?
Usually H. influenza type B
–> reduced since vaccination
Which age group most commonly gets epiglottitis?
Age 2 - 7
What are the clinical features of epiglottitis?
Initially sore throat, fever + SOB
–> absence of cough
Late signs: drooling, dysphagia, inspiratory stridor
Which position might a child with epiglottitis be in?
Tripod position
How is epiglottitis managed?
Urgent ENT/anaesthetic review in HDU/ICU Do not examine, avoid upsetting child --> adrenaline nebs + IV dexamethasone EUA + intubation in theatre Blood + throat cultures IV ceftriaxone, analgesia + fluids
What needs to be done for close contacts of a patient with epiglottitis?
Antibiotic prophylaxis for any close contacts who haven’t been vaccinated
What causes croup?
Viral –> parainfluenza, influenza, RSV, rhinovirus
Which age group most commonly get croup?
6 months - 2 years
What are the clinical features of croup?
URTI –> dyspnoea, barking cough + fever
Worse at night
Gets worse over 48 hours and then self limiting
How is croup severity graded?
Barking cough + stridor + …
- grade 1: expiratory stridor
- grade 2: pulsus paradoxus
- grade 3: cyanosis or reduced cognition
How is croup managed initially?
Single dose oral dexamethasone
+ paracetamol + ibuprofen as required
How is croup managed if admission is required?
Oxygen + IV fluids
+/- inhaled steroids + adrenaline nebs
Intubation if very severe
Pathology affecting which structures causes hoarseness?
True vocal cords
Recurrent + superior laryngeal nerves
What is the technical word for hoarseness?
Dysphonia (change in voice)
What is the technical word for complete loss of voice?
Aphonia
Which diagnosis needs to be ruled out/identified when investigating hoarseness?
Laryngeal cancer
Which examinations should be done in a patient with hoarseness?
Oral cavity: tongue, palate, tonsillar fossa
Cervical lymph nodes
Thyroid
What is the first line investigation fr hoarseness?
Flexible nasal endoscopy (FNE)
What are you looking at on flexible nasal endoscopy?
Check post nasal space –> nasopharynx –> pharynx –> larynx
Base of tongue, epiglottis, vocal cords, pyriform fossa, posterior pharyngeal wall
Look for masses, ulcers + asymmetry
How long should a patient have a hoarse voice for to be referred to ENT?
> 3 weeks
What are the infective causes of a hoarse voice?
Laryngitis
Acute epiglottitis
Candida
What are the features of laryngitis?
Inflammation of vocal cords, commonly after URTI
Examination normal
Inflamed larynx on FNE
What might cause candida infection leading to a hoarse voice?
Inhaled steroids
Which neurological pathology causes a hoarse voice?
Recurrent laryngeal nerve palsy
What might cause a recurrent laryngeal nerve palsy?
Thyroid cancer Lung cancer Aortic aneurysm MS Stroke
How should a recurrent laryngeal nerve palsy be investigated?
Neck and cranial nerve exam
CT skull base to diaphragm
Which benign laryngeal conditions may cause a hoarse voice?
Vocal cord nodules Muscle tension dysphonia Vocal cord polyps Laryngeal papillomas Reflux laryngitis Reinke's oedema
What are vocal cord nodules and what causes them?
Benign, often bilateral nodules at junction between anterior + middle third of vocal folds
Secondary to phono trauma (vocal abuse)
How are vocal cord nodules managed?
SALT (speech and language therapy)
Surgery if severe/resistant
What is muscle tension dysphonia?
Hoarseness worse at the end of day or after prolonged use
How is muscle tension dysphonia diagnosed and managed?
Diagnosis –> stroboscopy (voice clinic for vocal cord dysfunction)
Management –> SALT
How can you tell the different between vocal cord polyps and nodules?
Polyps are unilateral
How are vocal cord polyps managed?
Excise to exclude malignancy
What are laryngeal papillomas and how are they managed?
Benign lesions caused by HPV
Excision or debulking as can grow and obstruct airway
Which investigations should be done for reflux laryngitis?
FNE –> erythematous larynx
OGD
How is reflux laryngitis managed?
PPI + H. pylori eradication
What is Reinke’s oedema and how is it managed?
Oedema of the vocal cords caused by smoking
–> smoking cessation + voice therapy
