Stridor Presentation, Workup, and Differential

1
StridorPresentation, Work-up, and Differential

• Lily Love, MD
• Tulane Otolaryngology Grand Rounds
• April 21, 2005

2
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

3
Definition

• Stridor Harsh high-pitched sound produced by
  turbulent airflow through a partially obstructed
  airway
• Symptom

4
Definition

• Stertor low-pitched inspiratory snoring
• nasal or nasopharyngeal
• Wheezing expiratory sound of turbulent flow of
  air through constricted bronchioles
• small airways

5
Definition

• Inspiratory - extra thoracic
• Glottic or supraglottic
• High Pitched
• Expiratory intra-thoracic
• Biphasic glottic or subglottic

6
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

7
Epidemiology

• Pediatric Stridor
• Under 2 ½ yo, ½ of pts less than 4mo
• 87 Congenital
• Laryngeal 60
• Tracheal 16
• Bronchial 5
• 5 Infectious
• 5 Trauma

• Adult Stridor
• Abscess or swelling of the upper airway
• Paralysis or malfunction of the vocal cords
• Tumor

8
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

9
Anatomy
10
Anatomy
11
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

12
Pathophysiology

• Bernoulli (Venturi) Principle
• Gases produce pressure equally in all directions
  however, when a gas moves in a linear direction,
  it produces pressure in the forward vector and
  decreases the lateral pressure

13
Pathophysiology
14
Pathophysiology
15
Pathophysiology
16
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

17
Work-up History

• Severity
• Progression Acute vs. Chronic
• Cry/Voice
• Eating
• Cyanotic episodes
• Sleep vs. Awake
• Positional
• Previous intubation
• Birth history
• Past Surgery
• Cough

18
Work-up Physical Exam

• Look
• Cyanosis
• Suprasternal or intercostal retractions
• Alar flaring
• Position
• Listen
• Type of stridor
• Auscultate
• Hoarseness
• Feel
• Tracheal position
• Neck Mass

19
Work-up Data

• Pulse ox
• ABG
• Sputum cx
• Other labs depending on suspicion

20
Work-up Other

• PFT
• pH probe
• Polysomnography
• EKG
• Echocardiogram

21
Work-up Imaging

• Imaging
• neck films AP lateral
• CXR AP lateral
• CT with contrast Neck /or Chest
• MRI
• Barium esophagram

22
Work-up Imaging
23
Work-up Endoscopy

• Flexible Laryngoscopy
• Direct laryngoscopy bronchoscopy
• Foreign body
• Airway trauma
• Toxic inhalation/aspiration
• Evaluation of laryngeal pathology
• Management of mass lesions of the airway
  (including papillomatosis)
• Management of severe laryngotracheal infections
• Esophagoscopy

24
Work-up Endoscopy
25
Consultations

• Pulmonary
• Cardiology
• Allergy
• Neurology
• Genetics
• Endocrine
• CT surgery
• GI

26
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

27
Differential Neonate

• Congenital
• MC laryngomalacia
• 2nd MC Vocal Cord paralysis
• 3rd MC congenital subglottic stenosis
• Atresia
• Laryngeal Cysts, Webs, Clefts, Laryngoceles
• Tracheomalacia
• Tracheal Stenosis
• Hemangioma
• Vascular rings
• Choanal atresia
• Macroglossia (Pierre Robin)
• Craniofacial
• Iatrogenic
• Vocal cord paralysis

28
Differential Pediatric

• Congenital See Neonate
• Infectious
• MC Laryngotracheal bronchitis (Croup)
• Epiglottitis
• Acute Tonsillitis
• Peritonsillar abscess
• Papilloma
• Viral or Bacterial Tracheitis

29
Differential Pediatric

• Mechanical
• Foreign Body
• Paradoxical Vocal Cord Motion
• Adenotonsillar hypertrophy
• Laryngospasm
• Traumatic
• Intubation subglottic stenosis
• Laryngeal or tracheal fracture
• Caustic ingestion
• Neoplastic
• Hemangioma
• Rhabdomyosarcoma
• Neurofibroma
• Cystic hygroma
• Papilloma
• Allergic

30
Differential Adult

• Traumatic
• Intubation subglottic stenosis
• Laryngeal or tracheal fracture
• Caustic ingestion
• Infectious
• Epiglottitis (supraglottitis)
• Acute Tonsillitis
• Peritonsillar abscess
• Parapharyngeal space abscess
• Prevertebral space abscess
• Submental space abscess (Ludwigs Angina)

31
Differential Adult

• Mechanical
• Foreign Body
• Paradoxical Vocal Cord Motion
• Neoplastic
• Mass effect external
• Obstructing Mass
• Allergic
• Angioedema
• Iatrogenic

32
Differential Zebras

• Tuberculous mediasteinal lymphadenitis
• Superior mediastinal and internal jugular venous
  thrombosis
• Ectopic thymus
• Pseudosarcomatous fibrovascular proliferative
  tissue masquerading as a primary subglottic
  angiosarcoma
• Schwannoma
• Tracheal juvenile xanthogranuloma
• Laryngeal rhinosporidiosis
• Multiple myeloma (subglottic stenosis amyloid)
• Etc.

33
Outline

• Definition
• Epidemiology
• Anatomy
• Pathophysiology
• Work-up
• History
• Physical
• Data
• Imaging
• Endoscopy
• Consults
• Differential
• Neonate
• Pediatric
• Adult
• Treatment
• Complications Emergencies

34
Treatment Laryngomalacia

• Flaccid laryngeal tissues
• Inward collapse of aryepiglottic folds
• Omega epiglottis
• Anterior medial collapse of arytenoid cartilage
• Short aryepiglottic folds

• Observation
• Med - Treat reflux
• Surg - Excision of obstructing supraglottic
  tissues supraglottoplasty

35
Treatment Laryngomalacia
36
Treatment Vocal Cord Paralysis

• Unilateral or Bilateral
• Arnold Chiari
• s/p PDA ligation
• s/p thyroidectomy
• Tumors
• Viral

• Unilateral
• Injection
• Thyroplasty
• Arytenoid adduction
• Bilateral
• Intubate or tracheotomy
• Speech therapy
• Arytenoidopexy (Cordopexy)
• Posterior cartilage graft
• Cordotomy
• Arytenoidectomy
• Pacing reinervation

37
Treatment Vocal Cord Paralysis
38
Treatment Subglottic Stenosis

• Cartilaginous
• Membranous
• Congenital vs. acquired
• Biphasic or Inspiratory stridor
• Rigid endoscopy

• Grade I supportive
• Grade II surgery
• Endoscopic (laser)
• Grade III surgery
• Open
• Anterior Cricoid split
• Laryngotracheal split
• Cricoid resection
• /- stent
• /- graft

39
Treatment Subglottic Stenosis
40
Treatment Subglottic Stenosis
41
Treatment Webs

• 75 glottic
• Weak or absent cry

• Surgical lysis of web
• Thin web
• Thick web
• Anterior
• Posterior

42
Treatment Webs
43
Treatment Hemangioma

• Cutaneous hemangiomas
• Worse with crying
• Grow from 2 wks 10mo
• Resolve by 5 yo

• Steroids
• Laser partial excision
• Open resection
• Interferon a-2A
• Tracheotomy

44
Treatment Hemangioma
45
Treatment Lymphangioma

• Regional lymphatic dilatation
• lt2yo
• 50 recurrence if some left behind

• Tracheotomy
• Surgical excision (partial ok)
• Chemotherapy (sclerosing)

46
Treatment Lymphangioma
47
Treatment Laryngotracheobronchitis

• 1-3 yo
• Low mod fever
• Parainfluenza 1 2 influenza A virus
• Recent URI
• Inspiratory stridor
• Barking cough

• Supportive
• Racemic epinephrine
• Steroids
• Intubation or tracheostomy

48
Treatment Laryngotracheobronchitis
49
Treatment Epiglottitis

• High fever
• H influenza b
• Group A beta-hemolytic strep
• Rapid onset progress
• Odynophagia, drooling, sniffing position
• X-ray Thumb print
• Do not disturb

• Intubate or trach
• Controlled extubation
• Cephalosporins 2nd or 3rd
• Vancomycin
• Azithromycin
• Steroids

50
Treatment Epiglottitis
51
Treatment Epiglottitis
52
Treatment Abscess

• Peritonsillar
• Uvula deviation
• Tonsil asymmetry
• Retropharyngeal
• Torticollis
• Fever, dysphagia
• Parapharyngeal
• Fever, pain, stiff neck
• Submandibular Ludwig's
• Rapid spreading firm cellulitis, non-pitting,
  originates intraorally, involves submandibular
  sublingual space

• Medical trial of antibiotics if cellulitis only
• Peritonsillar
• Needle vs. ID vs. Quincy tonsillectomy
• Retropharyngeal
• Aspiration then Transoral ID
• Parapharyngeal
• Open ID
• Submandibular Ludwig's
• Release tension
• Trach

53
Treatment Abscess
54
Treatment Abscess
55
Treatment Abscess
56
Treatment Papilloma

• HPV 16 18
• Juvenile recur resolve at puberty
• Senile rarely recur
• Gradual or acute onset

• Microlaryngoscopy
• Laser
• Debridement
• Interferon
• Cidofovir
• Acyclovir
• Indole 3 Carbinol
• Mumps vaccine
• Retinoids
• Photodynamic therapy

57
Treatment Papilloma
58
Treatment Trauma

• Subcutaneous emphysema
• Aphonia
• Tender to palpation
• Do not disturb

• Tracheotomy
• Direct Panendoscopy
• Mucosal lacerations
• Cartilage bone fx
• Stents

59
Treatment Trauma
60
Treatment Foreign Body

• Acute onset
• Coughing, gagging, throat clearing
• Hot dogs, candies, nuts, grapes, marbles

• No finger sweep!
• Responsive Infant
• Prone back blows
• Supine chest thrusts
• Responsive Child
• Heimlich
• Unresponsive
• Tongue-jaw lift look
• Rescue breaths
• Infant back blow chest thrusts
• Child -abdominal thrusts
• DLB

61
Treatment Foreign Body
62
Treatment Angioedema

• Hereditary C1 esterase inhibitor deficiency
• Medication ACE-I
• Allergic IgE
• Face, palate, tongue edema

• Fiberoptic intubation vs. tracheotomy
• C1 esterase inhibitor concentrate or FFP
• Androgens (danozol stanozol)

63
Treatment Angioedema
64
Complications/ Emergencies

• decrease in stridor -gt Fatigue
• Respiratory distress
• Obstruction
• Intubate or
• Tracheotomy

65
Final points

• A intubate or tracheotomy
• History is Key
• Age Progression Type
• Imaging
• Scope all
• Direct is definitive

66
Bibliography

• Bluestone CD, et al. Pediatric Otolaryngology.
  Philadelphia Saunders, 2003.
• Yanagisawa, E. Color Atlas of Diagnostic
  Endoscopy in Otorhinolaryngology. New York
  Igaku-Shoin, 1996.
• Kleinsasser, O. Microlaryngoscopy and
  Endolaryngeal Microsurgery Technique and Typical
  Findings. Philadelphia Hanley Belfus Inc.
  1990.
• Tucker, H. The Larynx. New York Thieme, 1993.
• Montgomery, W. Surgery of the Larynx, Trachea,
  Esophagus, and Neck. Philadelphia Saunders,
  2002.
• Cummings CW, et al. Cummings Otolaryngology.
  Philadelphia Mosby, 2005.
• Bailey, B and Biller, H. Surgery of the Larynx.
  Philadelphia Saunders, 1985.
• Lee, KJ, et al. Essential Otolaryngology.
• Pai I et al. Ectopic thymus presenting as a
  subglottic mass diagnostic and management
  dilemmas. Int J Pediatr Otorhinolaryngol. 2005
  Apr69(4)573-6. Epub 2005 Jan 20.
• De Casso C Superior mediastinal and internal
  jugular venous thrombosis presenting to the
  otolaryngologist. J Laryngol Otol. 2005
  Jan119(1)40-5.
• Venkateswaran RV A forgotten old disease
  mediastinal tuberculous lymphadenitis in
  children.Eur J Cardiothorac Surg. 2005
  Mar27(3)401-4. Epub 2005 Jan 13.
• Zbar RI Incidence of vocal fold paralysis in
  infants undergoing ligation of patent ductus
  arteriosus.Ann Thorac Surg. 1996 Mar61(3)814-6.
• http//www.emedicine.com/med/topic135.htm
• http//www.emedicine.com/ent/topic348.htm
• http//www.emedicine.com/ent/topic347.htm