Stridor

a study on stridor

1. Stridor Congenital lesions of larynx Dr Manpreet Singh Nanda Associate Professor ENT MMMC&H Solan

2. Stridor Abnormal high pitched noisy respiration due to flow of air through a partially obstructed narrowed lower airway mainly larynx and tracheobronchial tree Types Inspiratory – supraglottis , glottis, hypopharynx Expiratory (wheeze) – thoracic trachea, bronchi, bronchioles Biphasic – cervical trachea, subglottis Stertor – snoring low pitched noise due to obstruction in nasopharynx and oropharynx Rales and crepitations – distal portion of bronchial tree and alveoli

3. Etiology Neonates – laryngomalacia (mc), laryngeal webs, cysts, subglottic stenosis , laryngeal paralysis Children – laryngotracheobronchitis (croup), acute epiglottis, laryngeal FB Nose – choanal atresia Tongue – macroglossia , haemangioma, lymphangioma Mandible – micrognathia Pharynx – abscess Larynx – paralysis, trauma Trachea – tumours, FB, stenosis , TOF Oesophagus – FB Neck – tumours, abscess

4. Children affected more – narrrow airway, softer cartilage collapse easily Adults Malignancy of larynx, pharynx, tongue, neck, trachea (mc) Infections – ludwigs angina Allergy – angioneurotic oedema Trauma – fractures, iatrogenic, radiotherapy, caustic agents Neurogenic - paralysis

5. Assessment Mc physical sign of larynx History Age – at birth (congenital), after few weeks ( laryngomalacia ) Onset – sudden (FB) Progress – rapid (acute epiglottitis ), gradual ( subglottic haemangioma, malignancy) h/o fever – infective h/o cough – aspiration, TOF h/o hoarseness – vc h/o apnoea and cyanosis – tracheobronchomalacia h/o trauma, intubation h/o FB Improves in prone position – laryngomalacia , macroglossia , micrognathia Improves during crying – B/L chonal atresia Worsens during crying - laryngomalacia

6. Examination Note the type of stridor Note the sound of stridor - musical quality – laryngomalacia - breathy – vc paralysis - aspiration – vc paralysis - barking cough – tracheomalacia Note associated symptoms - hoarseness – larynx - wheeze – bronchi - dysphagia – hypopharynx Note the severity - subcostal , intercostal , suprasternal recession - cyanosis

7. Detailed examination of oral cavity, nasal cavity, pharynx and larynx (IDL) INVESTIGATIONS Oxygen saturation monitoring - arterial blood gas estimation, pulse oxymetry Radiographs - x ray chest, neck - CT, MRI pH monitoring

8. Endoscopy – - Bronchoscopy - Oesophagoscopy - Laryngoscopy Along with intubation in OT Flexible endoscopy Videofluoroscopy – chest movements USG Neck

9. Treatment Acute condition Admit Conservative - oxygen and humidification - antibiotics - IV steroids - Nebulized epinephrine - mucolytics - IV fluids - CPAP (Continued Positive Airway Pressure)

10. Intubation Endotracheal intubation – nasal (secure) Preferred Ventilatory bronchoscopy Endoscopy and FB removal Not done in acute epiglottitis , impacted FB, trismus , severe subglottic stenosis , mandible fracture, supraglottic tumours

11. Tracheostomy Cricothyroidotomy Chronic - Anti reflux treatment - Systemic steroids - Prophylactic antibiotics - Treat the cause

12. Congenital lesions of larynx Laryngomalacia Subglottic stenosis Laryngeal web/ atresia /cyst Vocal cord paralysis Subglottic haemangioma Laryngocele Laryngo oesophageal cleft

13. Laryngomalacia Congenital laryngeal stridor Excessive flaccidity of supraglottic larynx which gets sucked in during inspiration producing stridor and sometimes cyanosis Pathology Excessive softening of laryngeal skeletal framework -> indrawing of aryepiglottic folds -> narrowing -> stridor

14. Clinical features M:F 2:1 Low socio economic group Intermittent low pitched inspiratory stridor develops during first two weeks of life (rare at birth) Aggravates on crying, feeding, exertion Relieved in prone position, rest and sleep Seen maximum at 9-12 months of age Completely disappears after 2 years of age (5 years) Normal cry and voice In severe cases – feeding difficulty, failure to thrive and cyanosis

15. Signs Awake flexible laryngoscopy Anterior collapse of arytenoid Posterior collapse of epiglottis Inward collapse of aryepiglottic folds Omega shaped/tubular epiglottis Prominent arytenoids Normal vocal cords

16. Complications – GERD, recurrent URTI, OSA D/D – laryngeal webs, cysts Treatment Conservative (90%) - Reassurance - Observation - Treat the URTI Tracheostomy Surgery (10%) – when failure to thrive or cyanosis - Supraglottoplasty ( Aryepiglottoplasty )

17. Congenital laryngeal haemangioma Subglottic haemangioma Benign vascular malformation involving subglottis C/F Females mc Asymptomatic for 3 to 6 months of age With increase size progressive disease Inspiratory or mostly biphasic stridor which is progressive Appears with URTI Aggravated by crying or agitation Dyspnoea and cyanosis Associated with cutaneous haemangioma or mediatinal haemangioma Rapid growth till 1 year of age then regress

18. Diagnosis X Ray Neck – soft tissue seen CT Scan/MRI with contrast – mass in larynx DL Scopy – Reddish blue mass in subglottis Biopsy Treatment Observation Antibiotics and anti inflammatory Steroids –IV dexamethasone , intra lesional Intubation/ tracheostomy Resection – Co2 and KTP lasers/ laryngofissure

19. Congenital subglottic stenosis Abnormal thickening of cricoid cartilage or fibrous tissue below the vc Here subglottic diameter in full term <3.5 – 4 mm (normal 4.5 – 5.5 mm) and in preterm 3 mm (normal 3.5mm) C/F Evident after 1 st week of life with URTI Biphasic stridor Dyspnoea Normal cry Grading I - <50% obstruction, II – 51-70% obstruction, III – 71-99% obstruction, IV – no detectable lumen..

20. Diagnosis X Ray Neck, CT/MRI Bronchoscopy /MLS/DL Scopy Treatment Observation – improves as larynx grows II/III/IV – tracheostomy Excision – laser (Co2/KTP), Laryngotracheoplasty

21. Laryngeal web Web formation most commonly in anterior part of larynx due to arrest of development of larynx most commonly seen in glottis (between vc ) C/F Since birth Small webs – asymptomatic Inspiratory stridor Dyspnoea or apnoea Weak cry Hoarseness IDL – seen b/w anterior end of vc with concave sharp posterior margin

22. D/D From acquired web due to trauma or infection Treatment Excision by Laser/knife or laryngofissure

23. Acute epiglottitis Supraglottic laryngitis PAEDIATRIC Marked oedema of epiglottis obstructimg the airway Etiology H influenza type B Age – 2 to 7 years Not in newborn as maternal immunity Pathology Severe cellulitis Thick secretions

24. C/F Rapid progress to respiratory distress within ½ hour Abrupt onset and rapid progression High grade fever (>40 C) Dysphagia and odynophagia Drooling of saliva Hoarseness Muffled (hot potato) voice Tripod position - leans forward supporting on upper limb Inspiratory stridor which increases in supine position Retraction, nasal flaring, cyanosis, septicaemia Pharynx is congested

25. Diagnosis No tongue depressor/IDL Examine in OT Red and swollen (cherry red) epiglottis – sun rise sign Oedema and congestion of supraglottis X Ray Neck – swollen epiglottis – thumb sign Throat swab Blood culture Leucocytosis

26. Complications 5-10% mortality Reflux laryngospasm Cardio-respiratory arrest Otitis media Pneumonia Pericarditis Meningitis Prevention Hib vaccine in children

27. Treatment Hospitalization in ICU Complete bed rest and voice rest Intubation/ tracheostomy under GA Antibiotics- ampicillin , cephalosporins IV fluids IV steroids Oxygen

28. Adult supraglottitis Less severe Marked oedema of supraglottis Etiology H Influenza, streptococci, staphylococci C/F Sore throat Dysphagia Pale oedematous supraglottis Stridor Treatment Antibiotics, steroids, anti reflux treatment Tracheostomy if needed

29. Acute laryngotracheobronchitis Subglottic croup Most common cause of infectious resp obstruction in children Etiology Viral – parainfluenza I,II Influenza A,B Other viruses – myxovirus , adenovirus Secondary bacterial infection Males>females Age group 3 months to 5 years of age Involves subglottis (mc), trachea and bronchi h/o URTI always

30. C/F Slow onset Starts with URTI Low grade fever, cough cold earlier Hoarseness Brassy or barking cough Biphasic stridor Signs of airway obstruction – nasal flaring, chest retraction Complications Middle ear infection, lung infection, tracheitis

31. Diagnosis Leucocytosis X Ray Neck – tapered narrowing of subglottis – steeple’s sign, wine bottle appearance – bottle sign Chest X Ray – pneumonic patches Flexible laryngobronchoscopy – subglottic narrowing

32. Treatment Hospitalization Humidification- soften crusts and thick secretions Steam inhalation Antibiotics Oxygen IV fluids Steroids Mucolytics – bromhexine Nebulization with racemic adrenaline Intubation/ tracheostomy – if needed Bronchoscopy – to remove secretions

33. Acute simple/non specific laryngitis Acute inflammation of laryngeal mucosa of mild form Etiology Infections – URTI, tonsillitis, rhinitis or rhinosinusitis First viral later bacterial GERD Allergy Voice abuse Burns Trauma ( endotracheal intubation) More severe in children as subglottic area is narrower

34. Pathology Hyperaemia of larynx Formation of pseudo membrane C/F Abrupt onset Hoarseness Dysphonia Pain throat Fever Dry cough worst at night Stridor in children Erythema and oedema of epiglottis, arytenoids and ventricles with normal vocal cords earlier with later hyperemia of vc and subglottis Pharyngeal and nasal congerstion

35. Treatment Bed rest Voice rest Soft bland diet Avoid smoking and alcohol Steam inhalation with inhalant capsules Cough sedatives Antibiotics – cephalosporin, amoxy clav Steroids Anti reflux treatment Tracheostomy /intubation if needed in childrens

36. Laryngeal diptheria Etiology Corynebacterium diptheriae Secondary to faucial diptheria Age < 10 years Both sexes Pesudomembrane formation Exotoxins liberated

37. C/F Gradual onset Low grade fever Sore throat Hoarseness Croupy cough Inspiratory stridor Dyspnoea Diptheritic membrane – grey white on tonsil, pharynx, soft palate, larynx, trachea, on removal leaves a rough bleeding surface Cervical lymphadenopathy – bull neck appearance

38. Complications Cardiac – myocarditis , circulatory failure Neurogenic – paralysis of palate, larynx and pharynx Asphyxia and death due to airway obstruction Diagnosis Clinical Throat swab Smear and culture

39. Treatment Diptheria anti toxin – 20000 to 100000 units IV as a single saline infusion after test dose Antibiotics – benzyl pencillin , erythromycin Complete bed rest for 2 to 4 weeks Oxygen Steroids IV fluids DL Scopy for removal of diptheritic membrane Intubation/ tracheostomy

40. Tubercular laryngitis Etiology Mycobacterium tuberculosis 95% cases secondary to pulmonary TB, 5% primary Route – infected sputum to larynx (mc), lymphatic, haematogenic Males (mc) Age gp 20 – 40 years Involves posterior part of larynx (mc – interarytenoid region)

41. C/F Weak voice Hoarseness Odynophagia and dysphagia Hemoptysis Hyperaemia of vc Impaired adduction of vc Mouse nibbled appearance of vc / moth eaten appearance due to ulcers Pseudo edema of epiglottis – turban epiglottis Bowing of vc

42. D/D – malignancy, syphilis, chronic laryngitis Diagnosis DL Scopy and biopsy Mantoux test Chest X Ray Sputum examination Stages 1 – inflammation 2- granulomatous (yellowish grey nodule) 3- ulcerative 4- cicatrization (healing)

43. Treatment Multi drug ATT – rifampicin , isoniazid , pyrazinamide , ethambutol for 6-9 months Voice rest NSAID Anti inflammmatory gargles Tracheostomy if stridor Laryngeal reconstruction

44. Chronic non specific laryngitis Chronic irritation of larynx Types 1. hyperemic – diffuse inflammation and symmetrical involvement of larynx (true cords, false cords, inter arytenoid region and root of epiglottis) 2. localised – nodules, polyp Pathology Pseudo stratified columnar epithelium changes into squamous epithelium Keratinization ( leukoplakia ) of statified squamous epithelium of vc Hyperplasia

45. Etiology Age >20 years/30-50 years Males (8:1 mc) Infections – PNS, tonsil, teeth, lungs Allergy Dust, fumes and other atmospheric pollutants Smoking and alcohol Spices GERD Voice abuse Mouth breathing Chronic throat clearing Chronic cough Inadequate hydration

46. C/F Hoarseness – worst in morning due to dryness of mouth Constant clearing of throat Throat discomfort/ FB sensation Dry and irritating cough Hyperaemia of larynx, vc dull red Viscid secretions at vc and interarytenoid region D/D – chronic specific laryngitis Diagnosis – X Ray PNS/Chest X Ray, throat swab, flexible laryngoscopy /biopsy

47. Treatment Treat infections Life style modifications for LPR Avoid smoking, alcohol Voice therapy/voice rest Steam inhalation Expectorant Treat allergy Steroid topic inhalers Surgical – MLS, stripping of vc (one vc at a time)

48. Pachyderma laryngitis Chronic lartyngitis affecting posterior part of larynx Interarytenoid region, post vc Males Etiology Alcohol, smoking, GERD C/F Hoarseness, irritation in throat Symmetrical red grey granulations or whitish mass on both vc (post part) and interarytenoid region, ulcer Diagnosis – biopsy Treatment – removal of granulations, anti reflux, speech therapy

49. Atrophic laryngitis Laryngitis sicca Atrophy of laryngeal mucosa with crust formation associated with atrophic rhinitis and pharyngitis Females C/F Hoarseness of voice which improves on coughing and removal of secretions Dry irritating cough, dyspnoea Atrophic mucosa covered with crusts which bleed on removal Treatment – humidification, loosening of secretions (laryngeal sprays containing glucose in glycerine, expectorants)

50. Lupus of larynx Indolent tubercular infection associated with lupus of nose and pharynx due to increased host resistance or decreased bacterial virulence involving anterior parts of larynx Epiglottis Females C/F Painless, asymptomatic, no pulmonary TB Scattered yellowish pink nodules in epiglottis which can ulcerate Complications – perichondritis , cartilage destruction Treatment - ATT

51. Syphilis of larynx Etiology – Treponema Pallidium C/F Hoarseness, dyspnoea, inspiratory stridor Gumma over epiglottis, anterior commissure and anterior vocal cords Diagnosis – biopsy, VDRL Complications – laryngeal stenosis , perichondritis Treatment Procaine pencillin , doxycycline Tracheostomy

52. Leprosy of larynx Etiology – M Leprae (Hansen bacilli) Associated with leprosy of skin and nose Affects epiglottis, aryepiglottic folds and arytenoids C/F – hoarseness, muffled voice, no pain Dull grey nodules which may ulcerate Diagnosis – biopsy Complications – laryngeal stenosis , deformity Treatment – dapsone , rifampicin , clofazimine for 5 – 10 years Steroids Tracheostomy

53. Scleroma of larynx Klebsiella Rhinoscleromatis (Frisch bacilli) Subglottis C/F Hoarseness, wheeze, dyspnoea, cough Smooth red or pink swelling in subglottic region which can spread to trachea Diagnosis – biopsy Complications – subglottic stenosis Treatment – streptomycin, doxycycline , tetracycline Steroids Tracheostomy