STRIDOR – DIAGNOSIS
& MANAGEMENT
STRIDOR
• Stridor is a symptom of upper airway obstruction, and can not only be
heard but also visualized.
• It is an abnormal (stridulent or harsh) noise that is caused by a turbulent
airflow in the impaired airway.
PATHOPHYSIOLOGY OF STRIDOR
• Mediated by 2 basic principles of physics: Poiseuille's law and the
Bernoulli principle.
• Poiseuille’s law of fluid dynamics :
Flow rate in laminar flow is proportional to the 4th power of the
radius of the tube
• 1 mm of mucosal edema will decrease the cross-sectional area of the
airway by 75% and increase the resistance of airflow
• Bernoulli principle - states that as the velocity of airflow increases, the
pressure exerted by airflow decreases
• In a narrowed pediatric airway predicts that increased airflow velocity
exerts negative pressure on the walls of the lumen, precipitating airway
collapse.
• Resultant alteration of laminar flow and turbulence of the airflow creates a
vibratory resonant effect on tissues which produces the sound described as
stridor.
ANATOMY OF STRIDOR
• Stridor can originate from a narrowing at any level of the airway.
• May have multiple levels of the airway involved.
• The site of obstruction and the nature of its structural support combined
with increased airflow and the patient’s respiratory effort influence the
observed characteristics of stridor.
• More common in infants and young children
TYPES OF STRIDOR
• Inspiratory stridor: It is because of obstruction from larynx and pharynx.
• Expiratory stridor: Expiratory stridor and prolonged expiratory phase are
because of bronchial and low tracheal obstruction.
• Biphasic stridor: It is because of obstruction at the level of cervical
trachea.
LEVEL OF OBSTRUCTION CORRELATES WITH PHASE OF STRIDOR
STERTOR
• Stertor is a snoring type of noise, which is made by nasopharyngeal and
oropharyngeal obstruction.
• Must be differentiated from stridor.
• Stertor can be heard on inspiration, expiration, or both and is caused by the
reverberation of soft structures from the level of the nasopharynx and
pharynx.
• Stertor can occur in conjunction with stridor
ETIOLOGY OF STRIDOR
• According to the site of origin
1. Nose: Choanal atresia in newborn.
2. Tongue: Macroglossia due to cretinism, haemangioma or lymphangioma,
dermoid at base of tongue, lingual thyroid.
3. Mandible: Micrognathia, Pierre-Robin syndrome.
4. Pharynx: Congenital dermoid, adeno tonsillar hypertrophy, retropharyngeal
abscess, tumours.
5. Larynx.
(a) Congenital: Laryngeal web, laryngomalacia, cysts, vocal cord paralysis,
subglottic stenosis.
(b) Inflammatory: Epiglottitis, laryngotracheitis, diphtheria, TB.
(c) Neoplastic: Haemangioma and juvenile multiple papillomas, carcinoma
in adults.
(d) Traumatic: Injuries of larynx, foreign bodies, oedema following
endoscopy, or prolonged intubation.
(e) Neurogenic: Laryngeal paralysis due to acquired
lesions.
(f) Miscellaneous: Tetanus, tetany, laryngismus stridulus
6. Trachea and bronchi
(a) Congenital: Atresia, stenosis, tracheomalacia.
(b) Inflammatory: Tracheobronchitis.
(c) Neoplastic: Tumours of trachea.
(d) Traumatic: Foreign body, stenosis trachea (e.g. following prolonged
intubation or tracheostomy).
7. Lesions outside respiratory tract
(a) Congenital: Vascular rings (cause stridor and dysphagia), oesophageal
atresia, tracheo-oesophageal fistula, congenital goitre, cystic hygroma.
(b) Inflammatory: Retropharyngeal and retro-oesophageal abscess.
(c) Traumatic: FB oesophagus (secondary tracheal compression).
(d) Tumours: Masses in neck.
CAUSES OF STRIDOR IN INFANTS AND
CHILDREN
ACQUIRED CAUSES OF STRIDOR
ASSESSMENT OF PATIENT
• If the situation is not acute and does not require immediate intervention,
proceed with diagnostic assessment
• Assessment includes focused history and examination and selected
investigations involving endoscopy and imaging.
• Depending upon the general status of the patient, the assessment can include
following elements.
1. Time of onset. To find whether cause is congenital or acquired.
2. Mode of onset. Sudden onset (foreign body, oedema), gradual and
progressive (laryngomalacia, subglottic haemangioma, juvenile papillomas).
3. Duration. Short (foreign body, oedema, infections), long
(laryngomalacia, laryngeal stenosis, subglottic haemangioma, anomalies of
tongue and jaw).
4. Relation to feeding. Aspiration in laryngeal paralysis, oesophageal
atresia, laryngeal cleft, vascular ring, foreign body oesophagus.
5. Cyanotic spells. Indicate need for airway maintenance.
6. Aspiration or ingestion of a foreign body.
7. Laryngeal trauma. Blunt injuries to larynx, intubation, endoscopy.
PHYSICAL EXAMINATION
1. Any associated respiratory distress.
2. Whether stridor is inspiratory, expiratory or biphasic which indicates the probable site of obstruction.
3. Associated characteristics of stridor.
(a) Snoring or snorting sound-nasal or nasopharyngeal cause.
(b) Gurgling sound and muffled voice-pharyngeal cause.
(c) Hoarse cry or voice-laryngeal cause at vocal cords and is normal in laryngomalacia and subglottic
stenosis.
(d) Expiratory wheeze-bronchial obstruction.
4. Associated fever indicates infective condition, e.g. acute laryngitis,
epiglottitis, laryngo-tracheo-bronchitis or diphtheria.
5. Stridor of laryngomalacia, micrognathia, macroglossia and innominate
artery compression – improves in prone position.
6. Sequential auscultation over the nose, neck and the chest helps to localize
the probable site.
7. Examination of nose, tongue, jaw and pharynx and larynx can exclude local
pathology in these areas.
8. Birthmarks: They may be associated with subglottic hemangioma.
9. Sound of stridor
Musical quality: Laryngomalacia
Breathy quality: Vocal cord palsy
Barking cough: Tracheomalacia
INVESTIGATIONS
1. Flexible Fibreoptic Laryngoscopy.
• Done under topical anaesthesia as an outdoor procedure and allows
examination of nose, nasopharynx and larynx.
2. Soft tissue lateral and PA view of neck and X-ray chest in PA and lateral
view help in diagnosing the foreign bodies of the airway.
3. X-ray chest in inspiratory and expiratory phases or a fluoroscopy of chest
help to diagnose radiolucent foreign bodies.
4. CT scan with contrast is helpful for mediastinal mass and other congenital vascular
anomalies compressing
the trachea or bronchi, e.g. anomalous innominate artery, double aortic arch or an anomalous
left pulmonary
Artery.
5. Angiography may be needed for above vascular anomalies before operation.
6. Oesophagogram with contrast may be needed for tracheobronchial fistula or aberrant
vessels or oesophageal atresia.
ENDOSCOPY
• Microlaryngoscopy and bronchoscopy under general anaesthesia.
• Done in operation theatre with full preparation for resuscitative measures to deal with
respiratory distress.
• Patient is monitored for oxygen saturation, pulse, blood pressure and electrocardiography.
• Services of an expert anaesthetist are essential.
• Anaesthesia is induced with insufflation and i.v. route established.
• Patient is kept on spontaneous respiration.
• After a quick and short direct laryngoscopy, bronchoscope is inserted to
examine the air passage
• Secretions can be collected for culture and sensitivity, crusts and foreign
body if any removed.
• After bronchoscopy, child is intubated and examination of larynx or
oesophagus can be done.
• Micro laryngoscopy can be done without intubation with patient on
spontaneous breathing and oxygen and gases being delivered through a
catheter via the laryngoscope.
• Magnification can be provided with telescope or microscope.
COMMON CAUSES OF STRIDOR IN INFANTS AND
YOUNG CHILDREN
LARYNGOMALACIA
• Most common cause of neonatal stridor
• Inspiratory stridor that is aggravated by feeding, sleep, irritability, and supine
position
• Diagnosis relies primarily on awake flexible endoscopy
• Presence of congenitally small, tubular epiglottis and prominent supra-arytenoid
tissues are seen.
• Self resolving by 2yrs, if not corrected surgically.
VOCAL CORD PARALYSIS
• UVCP is more common than BVCP
• Stridor is more common in BVCP
• BVCP can be congenital or acquired, generally requiring tracheostomy
followed by definitive intervention if there is no recovery.
• Congenital BVCP can be caused by a Chiari malformation, an intracranial
neurologic abnormality, a hereditary disease, or may be idiopathic
Unilateral VC paralysis Congenital BVCP
CROUP
• Croup is the most common cause of acute stridor in young children and
toddlers.
• Commonly caused by a viral infection of the larynx and upper trachea.
• Stridor in the presence of a barking cough and URI are the
pathognomonic.
• A radiographic steeple sign confirms the diagnosis and precludes the need
for laryngoscopy in most patients.
• Treatment includes supportive oxygenation, humidification, and
intravenous corticosteroids
ACUTE EPIGLOTTITIS
• Acute inflammation in the supraglottic region, with inflammation of the
epiglottis, vallecula, arytenoids, and aryepiglottic folds.
• Most common organisms that cause acute epiglottitis are Haemophilus
influenzae (25%), followed by H parainfluenzae, Streptococcus pneumoniae, and
group A streptococci.
• Symptoms often include shortness of breath, difficulty swallowing, sore throat
and fever.
• Treatment includes antibiotics. ET intubation and ventilator may be required in
severe cases
SUBGLOTTIC STENOSIS
• SGS can be congenital or acquired.
• Congenital SGS can present insidiously and not immediately after birth.
• As the breathing requirements of the infant or young child increase, worsening exertional
dyspnea is caused by the congenitally narrowed airway.
• Acquired SGS is a result of intubation injury, presentation is often 3 to 6 weeks after
extubation.
• Spectrum of SGS includes oxygen desaturation, stridor, and increased work of breathing
with use of accessory muscles of respiration
• Initial management with inhaled racemic epinephrine and systemic steroids.
• If not resolving, PPV, tracheostomy or surgical reconstruction required.
SUBGLOTTIC HEMANGIOMA
• SGH is a rare vascular tumor of the larynx, presents after 4 to 6 weeks.
• Undergoes 3 to 6 months of rapid proliferation, and then a slow involution
phase follows.
• Complete resolution in most patients by 5 to 7 years of age.
• Stridor that worsens with crying because of vascular engorgement, and edema
from increased air flow turbulence across the subglottic mucosa.
• Symptoms improve with steroids.
• Most cases are now managed with propranolol
Subglottic hemangioma.
Typically posterior, smooth,
round, and compressible
HOW TO TREAT ?
TREATMENT OF PATIENT WITH STRIDOR
• Active resuscitation: Such as setting up humidified oxygen and preparation
for intubation/tracheostomy.
• In cases of inadequate ventilation, airway must be secured through either
medical or surgical means.
• Oral airway helps in managing cases of nasal obstruction due to choanal
atresia.
• Mini tracheostomy handles bronchopulmonary secretions
TECHNIQUES TO SECURE AIRWAY
. Oral airway • Mini tracheostomy
• Orotracheal intubation • Cricothyrotomy (laryngotomy)
• Nasotracheal intubation • Needle cricothyrotomy
• Fiberoptic intubation • Transtracheal needle ventilation
• Laryngeal mask airway • Percutaneous dilational tracheostomy
• Continuous positive airway pressure (CPAP) • Surgical procedures in children to avoid tracheostomy
• Ventilating bronchoscope – Cricoid split
• Tracheotomy and tracheostomy – Single stage laryngeal reconstruction
MEDICAL MANAGEMENT
Steroids
• Dexamethasone 0.15–0.6 mg/kg IM (may be given intravenous and oral)
with inhaled steroids in cases of LTB.
• Nebulized budesonide (2 mg) for home use in cases of recurrent LTB.
• Nebulized L-Epinephrine (5 ml of 1:1,000) or racemic epinephrine (0.5
ml) in croup children with moderate-to-severe distress.
• Continuous positive airway pressure via nasal cannula: Continuous
positive airway pressure (CPAP) takes care of tracheobronchial malacia.
TRY TO REMEMBER
• Definition
• Pathogenesis
• Types
• Etiology
• Work up
• Management
THANK YOU…….
