Seminar

STRIDOR IN CHILDREN

By: Maj Vishal Gaurav Moderator: Dr A Sethi

OUTLINE
Introduction Etiological factors

The challenge of managing a stridulous child

Assessment of the stridulous child Management

Introduction
Noise originating in the larynx or trachea is typically highpitched made by turbulent airflow in the airway and termed stridor Stertor

Wheezing

Stridor may be characteristic of a particular pathology but is never diagnostic

Introduction
PHYSICS: Poiseuilles Law: Resistance inversely proportional to radius to 4th power Bernoullis Law: Pressure decreases as velocity increases, causing tendency to collapse

Introduction
ANATOMY:
LARYNX IN CHILDREN HIGHER LUMEN SMALLER EPIGLOTTIS: tubular & less rigid OTHER LARYNGEAL CARTILAGES: less rigid
Predictably stridor is more in children

Etiological factors
Intrinsic causes (lesions of larynx itself):
Congenital- congenital laryngeal stridor (Laryngomalacia), Bifid epiglottis, Congenital stenosis (webs in larynx), VC palsy, Subglottic stenosis Traumatic: Birth injuries, intubation injuries & injuries by foreign bodies Inflammatory: Epiglottitis, Acute laryngitis, laryngotracheobronchitis, diphtheria, TB Exanthematous: Measles, whooping cough, TB of larynx

Etiological factors
Neoplastic: Papillomata (they are multiple & recurring rapidly on removal upto the age of puberty), Cysts of epiglottis &aryepiglottic fold, Haemangioma Neurological: Tetany (Laryngismus Stridulus & Neonatal Tetany due to deficient function of parathyroids), Tetanus, RLN palsy ( In children this may be due to birth injuries of breach presentation & pull on infants shoulders; or by infections of childhood like measles, pneumonia and TB; or due to new growths).

Etiological factors
Extrinsic causes:
Congenital: Tracheomalacia, Tracheo bronchial atresia/stenosis, Congenital vascular rings (constrict the trachea & cause stridor & dysphagia), tracheo- oesophageal fistula, Congenital goitre Traumatic: Trauma by foreign bodies in trachea , tracheal stenosis (e.g. following prolonged intubation or tracheostomy)& also in esophagus if longstanding (secondary tracheal compression)

Etiological factors
Inflammatory: Retropharyngeal , Parapharyngeal& Retro-oesophageal abscess, Thymic abscess, Mediastinal lymphadenitis Neoplastic: Hyperplasia of thymus, Cystic hygroma, Thyroglossal cyst & other lingual cysts, Tracheal tumors

Etiological factors
Miscellaneous
Choanal atresia in newborn, macroglossia due to cretinism, lingual thyroid / haemangioma/ lymphangioma/ dermoid at base of tongue, both micrognathia & PierreRobin syndrome cause stridor due to falling back of tongue, Congenital dermoid of pharynx, pharyngeal tumors & adenotonsillar hypertrophy.

The challenge of managing a stridulous child

Prompt attention Deciding which patients to investigate Flexible endoscopy The definitive diagnostic technique of laryngotracheobronchoscopy (LTB) The infant airway can deteriorate rapidly

Assessment of the stridulous child

History taking Presentation of stridor Described as per: Onset, duration, severity, aggravating & relieving factors, positional/diurnal variation

PATTERN OF STRIDOR

Assessment of the stridulous child

ASSOCIATED FEATURES
Stertor: Nasopharyngeal obstruction e.g., neonatal rhinitis Cough: TEF, FB, VC palsy, Tracheomalacia, Cleft larynx, Reflux Aspiration: TEF, Cleft larynx, VC palsy Hoarseness: Laryngeal lesion, VC palsy

Assessment of the stridulous child

Acute airway obstruction: Retropharyngeal abscess, Epiglottitis, Tonsillitis, Croup, Glandular fever, Bacterial tracheitis, Foreign bodies Dysphagia and feeding difficulties: Epiglottitis (feeding affected with many causes of severe airway obstruction and aspiration), Tonsillitis, Retropharyngeal abscess Apneas:Tracheobronchomalacia, Reflex apnea Dying spells: (apnoea with cyanosis)

Assessment of the stridulous child

PERINATAL HISTORY GENERAL MEDICAL CONDITIONS

ACUTE OBSTRUCTION

Assessment of the stridulous child

Examination GPE: Vitals, Cyanosis, Degree of respiratory obstruction Examination for other congenital anomalies ENT evaluation: Characteristics of stridor

Assessment of the stridulous child

Investigations
BLOOD GAS ANALYSIS IMAGING X-ray CT & MRI Others: Videofluoroscopy Bronchography

Assessment of the stridulous child

iii) RESPIRATORY FUNCTION TESTS iv) Endoscopy Can be diagnostic as well as therapeutic FLEXIBLE ENDOSCOPY LARYNGOTRACHEOBRONCH OSCOPY (LTB)

Assessment of the stridulous child

ANAESTHESIA FOR AIRWAY ENDOSCOPY
Induction Intubation Nonintubation technique Jet ventilation Laryngeal mask Tracheostomy tube anaesthesia Maintenance of anaesthesia

Assessment of the stridulous child

MICROLARYNGOTRACHEOSC OPY TECHNIQUE BRONCHOSCOPY DYNAMIC ASSESSMENT OF LARYNX ON RECOVERY FROM ANAESTHESIA

v) ASSESSMENT OF REFLUX

MANAGEMENT
STRIDOR WITH ACUTE AIRWAY OBSTRUCTION Acute onset of stridor:laryngotracheobronchitis (croup), bacterial tracheitis, and acute epiglottitis, Foreign body inhalation, Postextubation stridor and immediate airway obstruction postpartum. Principles of management: i) To secure the airway ii) To identify & treat the underlying cause The management options in acute stridor usually include medical management and stabilization, diagnostic endoscopy, and possibly intubation (tracheostomy and open laryngeal surgery are rarely used).

MANAGEMENT
Medical management & stabilization (Usually for inflammatory conditions) OXYGEN THERAPY PHARMACOTHERAPY
Antibiotics Intravenous (and oral) steroids Haemophilus influenzae B vaccine Adrenaline inhalation

HUMIDIFICATION OF INSPIRED AIR (benefit controversial)

MANAGEMENT
Surgical management(Most commonly performed to secure the airway)
For short lasting conditions endotracheal intubation is preferable. In case of failed intubation Emergency tracheostomy/ cricothyrotomy can be performed

Emergency tracheostomy Other surgical procedures

Endoscopic removal of FB I&D of abscesses Surgery for B/L choanal atresia Single-Stage Laryngeal Reconstruction

MANAGEMENT
Postpartum Airway Obstruction(Antenatal Diagnosis of High Airway Obstruction)
Cervical teratoma, cystic hygroma and rhabdomyosarcoma. The terms: CHAOS ,OOPS, EXIT

Unexpected Airway Obstruction at Birth

Nasopharyngeal Laryngeal

When intubation is not possible

Unexpected Airway Obstruction at BirthTracheobronchial

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Principles of management: i) To identify the underlying cause ii) Management with function preservation

The management options then include medical, intubation, endoscopic procedures, tracheostomy, and other open surgical procedures.

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Medical Management in the Non-acute Situation

Conservative management antireflux treatment Systemic steroids Prophylactic antibiotics Medical Treatment of specific conditions: e.g. Interferon, cidofovir, and mitomycin C

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Surgical management Endoscopic treatment of the Larynx and Tracheobronchial tree
Endoscopic removal of FB. Resection of small subglotticcysts Injection of steroids Minor laryngeal clefts Aryepiglottic trimming for laryngomalacia The CO2 laser for the larynx & KTP laser for the trachea and bronchi

MANAGEMENT OF STRIDOR WITHOUT ACUTE AIRWAY OBSTRUCTION

Surgical management
Tracheostomy
Techniques to Avoid Tracheostomy Open Laryngeal Procedures
Laryngotracheal Stenosis

References

Scott-Brown's Otorhinolaryngology, Head and Neck Surgery Vol I

Cummings Otolaryngology, Head & Neck Surgery 4thed Logan Turners Diseases of ear, nose & throat 11thed

Thank you.