stridor in child

StridStridor inor in Child Child

DefinitionsDefinitions

StridorStridor Harsh sound Harsh sound

produced by turbulent produced by turbulent airflow through a airflow through a partial obstructionpartial obstruction

May be soft and May be soft and tuneful/musical qualitytuneful/musical quality

CharacteristicCharacteristic of of certain pathology but certain pathology but never diagnosticnever diagnostic

StertorStertor Snoring type of noise Snoring type of noise

often made by often made by nasopharyngeal or nasopharyngeal or oropharyngeal oropharyngeal obstructionobstruction

May occassionally be May occassionally be created by created by supraglottic larynxsupraglottic larynx

Pathophysiology of Pathophysiology of StridorStridor

Based on Venturi Based on Venturi principleprinciple When a gas passes When a gas passes

through a narrowed through a narrowed tube/trachea, the tube/trachea, the lateral pressure that lateral pressure that has held the lumen has held the lumen open can drop very open can drop very quickly causing the quickly causing the tube/lumen to close.tube/lumen to close.

Venturi Vuneralbility Venturi Vuneralbility (Pathophys cont’d)(Pathophys cont’d)

Pediatric airway more flexible Pediatric airway more flexible Forces exerted by Venturi principle cause Forces exerted by Venturi principle cause

the narrowed, flexible airway to be the narrowed, flexible airway to be momentarily closed during either momentarily closed during either inspiration or expiration.inspiration or expiration. Pattern of intermittent flow creates pattern of Pattern of intermittent flow creates pattern of

vibrations yielding audible soundsvibrations yielding audible sounds

AnatomyAnatomy

Infant larynx situated high in the neck Infant larynx situated high in the neck with epiglottis located behind soft palate.with epiglottis located behind soft palate.

Pharyngeal structures in closer proximity Pharyngeal structures in closer proximity compared to adultcompared to adult

Hyoid bone higher Hyoid bone higher

AnatomyAnatomy Anatomic differences associated with Anatomic differences associated with

infant airway create a separation between infant airway create a separation between airway and digestive tract.airway and digestive tract.

Air movement is predominantly transnasalAir movement is predominantly transnasal As child grows, larynx descendsAs child grows, larynx descends

Larger pharynx to facilitate speech productionLarger pharynx to facilitate speech production Common conduit for food and air passageCommon conduit for food and air passage

Increases risk for foreign bodies, food, gastric Increases risk for foreign bodies, food, gastric contents to enter airwaycontents to enter airway

EvaluationEvaluation

History History Helpful pneumonic: Helpful pneumonic: SPECS-RSPECS-R SSeverityeverity PProgressionrogression EEating difficultiesating difficulties CCyanosisyanosis SSleep disturbanceleep disturbance RRadiologic findingsadiologic findings

**Don’t forget to inquire about Don’t forget to inquire about birth history, maternal STD, birth history, maternal STD, history of intubationhistory of intubation

Physical AssessmentPhysical AssessmentFirst Things FirstFirst Things First

Assess severity/need Assess severity/need for emergent airway for emergent airway (ABC’s)(ABC’s) Noninvasive inspectionNoninvasive inspection Indicators of severityIndicators of severity

Respiratory rateRespiratory rate Level of Level of

conciousness/mental conciousness/mental statusstatus

Accessory muscle useAccessory muscle use Signifies significant Signifies significant

obstructionobstruction

AuscultationAuscultation Lung fieldsLung fields NeckNeck MouthMouth NoseNose

Further AssessmentFurther Assessment

If child d/n have impending respiratory If child d/n have impending respiratory failure, a more detailed physical exam failure, a more detailed physical exam should be performedshould be performed General (weight, growth percentile, General (weight, growth percentile,

development)development) Nasal cavity, oral cavity and oropharynx Nasal cavity, oral cavity and oropharynx

more thoroughly examinedmore thoroughly examined Flexible fiberoptic laryngoscopyFlexible fiberoptic laryngoscopy

EndoscopyEndoscopy In unusual/difficult cases In unusual/difficult cases

to determine etiology of to determine etiology of stridor.stridor.

Laryngoscope, Hopkins Laryngoscope, Hopkins rod-lens telescopes, rod-lens telescopes, bronchoscopebronchoscope Verify all equipment/light Verify all equipment/light

sources work!sources work! Trach tray in room just in Trach tray in room just in

case.case. Good communication Good communication

btwn endoscopist and btwn endoscopist and anesthesiologist is a anesthesiologist is a must. must.

OutlineOutline

I.I. Nose & Nose & NasopharynxNasopharynx

II.II. Oropharynx or Oropharynx or hypopharynxhypopharynx

III.III. Supraglottic larynxSupraglottic larynx

IV.IV. Glottic larynxGlottic larynx

V.V. Subglottic larynxSubglottic larynx

VI.VI. TracheobronchialTracheobronchial

CCongenitalongenital IInfectiousnfectious TTraumaticraumatic NNeoplasticeoplastic VVascularascular IIatrogenicatrogenic TToxic/metabolicoxic/metabolic

Choanal Atresia (CA)Choanal Atresia (CA)

EpidemiologyEpidemiology Rare: 1 in 10,000 birthsRare: 1 in 10,000 births Females >malesFemales >males 50% unilateral, 50% bilateral50% unilateral, 50% bilateral

2 types: membranous or bony2 types: membranous or bony 29% bony29% bony 71% mixed bony-membranous 71% mixed bony-membranous (Brown et al, L(Brown et al, Laryngoscopearyngoscope

1996)1996)

Pathogenesis controversalPathogenesis controversal

Choanal Atresia (CA)Choanal Atresia (CA)

Clinical signs & sxClinical signs & sx Respiratory Respiratory

distress/paradoxical distress/paradoxical cyanosiscyanosis

Feeding difficultyFeeding difficulty Associated abnormalities Associated abnormalities

CC- Coloboma- Coloboma HH- Heart anomaly- Heart anomaly AA- Atresia of choana- Atresia of choana RR- Retarded growth- Retarded growth GG- Genital hypoplasia- Genital hypoplasia EE- Ear anomalies and/or- Ear anomalies and/or

deafnessdeafness

Clues to diagnosisClues to diagnosis Inability to pass 8 Fr Inability to pass 8 Fr

catheter beyond 3.5 cm catheter beyond 3.5 cm from nasal vestibulefrom nasal vestibule

Flexible scope hits a “brick Flexible scope hits a “brick wall” during examwall” during exam

Mirror under nares fails to Mirror under nares fails to fog on expirationfog on expiration

Axial CT confirms Axial CT confirms diagnosisdiagnosis

ManagementManagement InitialInitialMcGovern nippleMcGovern nipple

Oral airway or McGovern nippleOral airway or McGovern nipple SurgicalSurgical

TranspalatalTranspalatal Better visualization, high success rateBetter visualization, high success rate Can damage palate growth plate=cross bite deformitiesCan damage palate growth plate=cross bite deformities

TransnasalTransnasal Less blood loss, faster procedureLess blood loss, faster procedure Increased CSF leak and meningitis riskIncreased CSF leak and meningitis risk

LaserLaser COCO22, KTP, Holmium:YAG, KTP, Holmium:YAG Good success with KTP + endoscopic techniquesGood success with KTP + endoscopic techniques Operating microscope with COOperating microscope with CO22 laser also being employed laser also being employed

Choanal Atresia Choanal Atresia

LaryngomalaciaLaryngomalacia

GeneralGeneral Most common cause of congenital stridorMost common cause of congenital stridor May manifest days/weeks after birthMay manifest days/weeks after birth Symptoms usually resolve by 12-18monthsSymptoms usually resolve by 12-18months

PathophysiologyPathophysiology Stridor caused by prolapse of supraglottic Stridor caused by prolapse of supraglottic

structures into laryngeal inlet structures into laryngeal inlet


Signs/SymptomsSigns/Symptoms low, pitched fluttering inspiratory stridor low, pitched fluttering inspiratory stridor

Peaks at 6-9monthsPeaks at 6-9months Positional variationsPositional variations Exacerbated by activity (i.e. feeding, exertion)Exacerbated by activity (i.e. feeding, exertion)

Rarely produces cyanosisRarely produces cyanosis Cyanosis should prompt suspicion for other Cyanosis should prompt suspicion for other

pathologypathology


Physical examPhysical exam Fiberoptic Fiberoptic

laryngoscopy while laryngoscopy while child is awakechild is awake

Direct Direct laryngoscopy/broncholaryngoscopy/broncho-scopy sometimes -scopy sometimes needed to rule out needed to rule out synchronous lesionssynchronous lesions


ManagementManagement Self-limited condition; majority of cases Self-limited condition; majority of cases

resolveresolve Surgical treatment (~10% of cases)Surgical treatment (~10% of cases)

SupraglottoplastySupraglottoplasty Indicated for cases with severe stridor, failure to thrive, Indicated for cases with severe stridor, failure to thrive,

apneas, cor pulmonale, pulmonary HTNapneas, cor pulmonale, pulmonary HTN

Congenital Laryngeal Congenital Laryngeal WebWeb

PathogenesisPathogenesis Arise from failure of recanalization of larynx in embryoArise from failure of recanalization of larynx in embryo

LocationLocation Predominantly in the anterior glottisPredominantly in the anterior glottis

Associated findingsAssociated findings Severe webbing assoc. with subglottic stenosis.Severe webbing assoc. with subglottic stenosis. Laryngeal atresia requires trach at birthLaryngeal atresia requires trach at birth Anterior glottic webs assoc. w/ velocardiofacial Anterior glottic webs assoc. w/ velocardiofacial

syndrome (22q11 deletion) syndrome (22q11 deletion) (Oto Head & Neck 2004 130: 415-17)(Oto Head & Neck 2004 130: 415-17)

SymptomsSymptoms Present with abnormal cry, stridorPresent with abnormal cry, stridor

Congenital Laryngeal Congenital Laryngeal WebWeb

Diagnostic endoscopyDiagnostic endoscopy Required for diagnosisRequired for diagnosis Other abnormalities must be ruled out as wellOther abnormalities must be ruled out as well

TreatmentTreatment Simple insicion for small websSimple insicion for small webs Laryngofissure with stenting for severe Laryngofissure with stenting for severe

webbing.webbing. Endoscopic laser treatment also an optionEndoscopic laser treatment also an option

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Vocal Cord ParalysisVocal Cord Paralysis GeneralGeneral

10% of congenital laryngeal 10% of congenital laryngeal lesionslesions

May be congenital or acquiredMay be congenital or acquired Most often cause is idiopathicMost often cause is idiopathic

EtiologiesEtiologies Traumatic/IatrogenicTraumatic/Iatrogenic

Obstetric/birth traumaObstetric/birth trauma Cardiac surgeryCardiac surgery Esophageal surgeryEsophageal surgery

Other congenital abnormalitiesOther congenital abnormalities Cardiac anomaliesCardiac anomalies CNS originCNS origin

Chiari malformationChiari malformation

Chiari malformation

Vocal Cord ParalysisVocal Cord Paralysis

UnilateralUnilateral Breathy voice/cryBreathy voice/cry Mild stridor and/or Mild stridor and/or

dyspneadyspnea AspirationAspiration TreatmentTreatment

Speech therapySpeech therapy If tracheotomy needed,If tracheotomy needed,

decannulation is usually decannulation is usually possible as child/larynx possible as child/larynx developesdevelopes

BilateralBilateral Severe stridorSevere stridor AspirationAspiration TreatmentTreatment

tracheotomy usually tracheotomy usually requiredrequired

Serial endoscopiesSerial endoscopies

Surgery after at least 1 Surgery after at least 1 year after trach w/o year after trach w/o improvementimprovement

Vocal Cord ParalysisVocal Cord Paralysis EvaluationEvaluation

Can be seen with FOL while pt is awakeCan be seen with FOL while pt is awake Laryngotracheobronchoscopy must be performedLaryngotracheobronchoscopy must be performed

Must palpate arytenoids Must palpate arytenoids Exclude synchronous lesionsExclude synchronous lesions

MRI brain, brain stem, neck and chest reasonable if cause MRI brain, brain stem, neck and chest reasonable if cause not obvious (course of vagus)not obvious (course of vagus)

FEES/MBS may be utilized in cases of aspirationFEES/MBS may be utilized in cases of aspiration ManagementManagement

VFP in infants usually resolves in 6-18mosVFP in infants usually resolves in 6-18mos Scheduled monitoring is reasonable for first 2 yrsScheduled monitoring is reasonable for first 2 yrs Temporary tracheotomy may be necessaryTemporary tracheotomy may be necessary

Vocal Cord ParalysisVocal Cord Paralysis

Surgical methodsSurgical methods COCO22 transverse partial cordotomy transverse partial cordotomy

Costal cartilage graftingCostal cartilage grafting Arytenoidopexy w/wo arytenoidectomyArytenoidopexy w/wo arytenoidectomy

COCO22 laser laser

External approachExternal approach

Subglottic StenosisSubglottic Stenosis

CongenitalCongenital Dx made in absence Dx made in absence

of factors causing of factors causing acquired stenosisacquired stenosis

Moderate-severe Moderate-severe stenosis=Stridor at stenosis=Stridor at birth. birth.

Mild stenosis= Mild stenosis= Intermittent stridorIntermittent stridor

AcquiredAcquired More common than More common than

congenitalcongenital Usually more severe Usually more severe

and difficult to and difficult to managemanage

Endotracheal Endotracheal intubation intubation trauma=most trauma=most commom causecommom cause


Clinical signs/symptomsClinical signs/symptoms Degree of stenosis dictates symptomsDegree of stenosis dictates symptoms

Severe stenosis, infant may have stridor at birthSevere stenosis, infant may have stridor at birth Mild stenosis may not manifest until URI takes Mild stenosis may not manifest until URI takes

place.place.

In acquired SGS, a clue in neonates may be In acquired SGS, a clue in neonates may be failed extubation trial.failed extubation trial. Older children may successfully extubate but Older children may successfully extubate but

present later with progressive worsening present later with progressive worsening respiratory distressrespiratory distress


EvaluationEvaluation Stenosis may be visualized on plain filmsStenosis may be visualized on plain films Direct laryngoscopy/tracheoscopy needed Direct laryngoscopy/tracheoscopy needed

for confirmation and airway may be staged for confirmation and airway may be staged at this point.at this point.

PreventionPrevention Use of uncuffed, polyvinylchloride ETTUse of uncuffed, polyvinylchloride ETT Smaller tubesSmaller tubes Nasotracheal intubationNasotracheal intubation


Treatment optionsTreatment options Primary goal is to Primary goal is to

achieve decannulation achieve decannulation (if tracheostomy (if tracheostomy present) or prevent present) or prevent tracheostomytracheostomy

ConservativeConservative Observation (grades I-Observation (grades I-

II)II)

Temporizing measureTemporizing measure TracheostomyTracheostomy

Definitive Surgical Definitive Surgical OptionsOptions Endoscopic methodsEndoscopic methods

LaserLaser

Anterior cricoid splitAnterior cricoid split Laryngotracheal Laryngotracheal

reconstructionreconstruction Cricotracheal Cricotracheal

resectionresection

TracheomalaciaTracheomalacia Congenital deformity of tracheal ringsCongenital deformity of tracheal rings Expiratory stridor/respiratory distressExpiratory stridor/respiratory distress

Depends on extent of lesionDepends on extent of lesion DiagnosisDiagnosis

Flexible bronchoscopy with awake patientFlexible bronchoscopy with awake patient Collapse of anterior tracheal wall against membranous posterior Collapse of anterior tracheal wall against membranous posterior

portionportion

Treatment rarely needed as most cases are self Treatment rarely needed as most cases are self limitedlimited Some cases may need temporary tracheotomySome cases may need temporary tracheotomy In secondary tracheomalacia, treatment directed at In secondary tracheomalacia, treatment directed at

underlying cause.underlying cause.

stridor in child

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