STRIDOR, ASPIRATION AND COUGH

SUBDIVISI LARING FARING THT- KL RSMH

INTRODUCTION
The complex structures of the upper airway allow for coordination of both respiration and swallowing. The structural and physiologic relationships between the various structures change with growth from infancy through adulthood. The structural and physiologic relationships between the various structures change with growth from infancy through adulthood.

STRIDOR
The signs and symptoms of a child with respiratory distress usually differ, depending on the location and severity of obstruction. Airway obstruction at the level of the nasopharynx or oropharynx produces the inspiratory low-pitched sound called stertor or snoring. Dynamic supraglottic and glottic obstructions produce inspiratory stridor caused by collapse of these structures with negative inspiratory pressure. Intrathoracic airway lesions cause expiratory stridor. Stridor caused by fixed subglottic laryngeal & cervical tracheal lesions is most often biphasic.

STRIDOR
Stridor is the audible noise produced by turbulent airflow through a partially obstructed airway. Obstructing lesions of the airways produce the turbulent airflow. With narrower columns of air, small partial obstructions are more likely to cause significant turbulence. This is why the infant with an upper respiratory tract infection may exhibit the signs of stridor and croup.

STRIDOR
The infant larynx and trachea are much smaller than those of the adult. In the infant, the vocal cords are 6 to 8 mm long and the vocal processes of the arytenoid cartilage extend one half the length. The posterior glottis has a transverse length of 4 mm. The subglottis has a diameter of 5 to 7 mm. The trachea is 4 cm long and has a diameter of 3.6 mm. The ratio of cartilaginous : membranous trachea is 4.5:1.

COUGH
Cough is a complex reflex initiated by sensory receptors in the respiratory epithelium. Receptors are concentrated in the larynx and carina and at other airway bifurcations. No receptors lie beyond the terminal bronchioles. Other receptors are in the nose, nasopharynx, external auditory canals, tympanic membranes, stomach, esophagus, pleura, pericardium, and diaphragm.

COUGH
Afferent pathways in the tenth and, to a lesser extent, the fifth and ninth cranial nerves carry impulses to the cough center in the medulla. Cough can also voluntarily be initiated without stimulation from other afferent pathways. The efferent fibers of the cough reflex carry their signals from the cough center to the diaphragm and intercostal muscles through the phrenic and spinal motor nerves, respectively. The abdominal and pelvic muscles also participate in the efferent limb.

COUGH

The mechanics of a cough involve developing and then sustaining a high velocity column of air. To do this, the cough begins with an initial inspiratory phase in which occur maximal abduction of the vocal cords and an increase in the chest dimensions, filling the lungs with air to a high volume. The second phase follows with rapid closure of the larynx at the supraglottic and glottic levels. Expiratory muscle contraction forces a rise in airway pressure during this compressive phase of coughing. It is the closure of the ventricular bands (false focal folds) that contributes the greatest sphincteric effect in preventing the flow of air during the compressive phase. The third (expiratory) phase occurs as the glottis suddenly opens and rapid airflow expectorates mucus and foreign material. Maintenance of airflow velocity is assisted during expiration by continued narrowing of the opened supraglottic larynx. Vibrations of the laryngeal mucosa also assist in secretion clearance during the expiratory phase.

SWALLOWING
Traditionally, the normal swallow is divided into four stages: preparatory, oral, pharyngeal, and esophageal. The first two are under voluntary control, except in the newborn period, when the swallowing reflex is regulated at the level of the brainstem. The second two are reflex actions. The afferent limb consists of sensory and proprioceptive fibers in the glossopharyngeal, trigeminal, and superior laryngeal nerves that supply the laryngeal and pharyngeal mucosa. Impulses are transmitted to the swallowing center in the floor of the fourth ventricle. The efferent limb consists of general visceral efferent fibers that begin in the nucleus ambiguous and descend through the vagus nerve to supply the laryngeal and pharyngeal musculature.

SWALLOWING
In the preparatory phase, food is taken in and prepared into a bolus held between the hard palate and central anterior two thirds of the tongue. The apposition of the base of tongue and soft palate prevents food from traveling posterior while chewing. During the oral phase, the anterior tongue elevates and contacts the hard palate, the soft palate closes off the nasopharynx, and the food bolus is pushed into the pharynx. Squeezing liquid from the nipple appears to be part of an infant's oral phase. The pharyngeal phase begins as the bolus passes the tonsillar pillars. The palatopharyngeal partition, made up of the apposing pharyngeal constrictors, palate, and palatopharyngeus, directs the food into the hypopharynx, and the pharynx and larynx elevate. At the onset of the esophageal

SWALLOWING
The swallowing reflex in children varies from that of adults and undergoes an orderly maturation as the child develops. Before the 34th week of gestation, the premature infant demonstrates a poorly coordinated and insufficient suckling response. Beyond the 34th week, neuromuscular maturation progresses and oral feeding can usually be maintained, with the full-term infant able to suckle at birth. The anatomy of the swallowing mechanism also differs from that of an adult. As mentioned, in children, the hard palate is closer to the skull base and the larynx is higher in the neck, and the adenoid pad, tonsils, and tongue are relatively larger. Therefore, nasopharyngeal closure requires less angulation of the soft palate, whereas the tonsils and tongue assist in oropharyngeal propulsion. With age, the oral cavity and pharynx enlarge, the larynx descends in the neck, the relative size of the tongue decreases, and teeth erupt.

 Airway protection in the normal person is maintained by three interlocking systems. The first system is the swallow mechanism, mentioned above. The second system is the three-tiered system of the laryngeal sphincters : the epiglottis, aryepiglottic folds, and arytenoid cartilages (first level); the false vocal folds (second level); and the true vocal folds (third level). The third system is that of mucociliary clearance and the cough reflex. A breakdown in any of these systems can result in aspiration.

Stridor Evaluation History and Physical Examination

The extent and urgency with which the diagnostic evaluation of a stridorous patient is carried out is determined by the patient's degree of distress. Assessment begins with a careful history, emphasizing the birth history, the age at stridor onset, severity, progression, and fluctuation of respiratory symptoms. Related symptoms, including hoarseness, eating or feeding difficulties, and sleep-disordered breathing, are also noted. The mnemonic SPECS-R (severity, progression, eating difficulties, cyanosis, sleep disturbances, and radiologic findings) can be used to organize the history.

 The initial physical examination assesses the severity of respiratory distress and the need for emergency airway management. Patients with severe respiratory distress, particularly children, require careful, noninvasive inspection to avoid exacerbating airway compromise. Respiratory rate and level of consciousness are the most important indicators of severity. Tachypnea is often the first sign of respiratory distress in children. Relatively quiet shallow breathing characterizes late respiratory failure and exhaustion; a mental status assessment at this stage reveals confusion or lethargy and suggests impending respiratory arrest. Increased work of breathing with suprasternal, subcostal, and intercostal retractions in the stridorous patient indicates P.1099

1. Which condition is most likely to result in clinical aspiration? a. Posterior cricoarytenoid paralysis b. Bilateral recurrent laryngeal nerve injury (upper motor neuron) c. pharyngeal phase dysfunction d. Bilateral recurrent laryngeal nerve injury (lower motor neuron)

Answer : D

2. Which is the earliest sign of respiratory failure a. Cyanosis b. Biphasic stridor c. tachypnea d. Substernal retractions

 Answer : C

3. What is the best indicator of the anatomic level of airway obstruction? a. Posturing b. Respiratory rate c. respiratory phase during which stridor occurs d. Associated eating difficulties

 Answer: C

4. What is the best method to diagnose laryngomalacia a. Flexible laryngoscopy while the patient is awake b. Endolateral airway films c. rigid bronchoscopy d. history

 Answer : A

5. Which of the following statements is false? a. Multiple synchronous airway anomalies occur in 20-40% of patients with congenital stridor b. Congenital stridor always presents at birth c. Congenital stridor most often is due to laryngeal anomalies d. Congenital stridor is more common than acquired stridor in infants

 Answer: B

6. Reccurent croup is most likely a. To respond to steroids b. Due to bacterial infection c. associated with immune deficiency d. Due to underlying subglottic pathology

 Answer : D

7. Supraglottoplasty is indicated for severe laryngomalacia associated with all of the following except a. Failure to thrive b. Recurrent cyanosis c. congenital subglottic stenosis d. Cor pulmonale

 Answer : C

8. Which is the best method to diagnose an anomalous innominate artery a. Endoscopy b. CT scan with contrast c. barium esophagogram d. Arteriography

 Answer : A

9. The immediate response to a respiratory arrest in a 2-year-old-child with croup is a. Steroids and racemic epinephrine b. Intubation with a 4,5 cm (internal diameter) endotracheal tube c. positive pressure ventilation by mask d. cricothyrotomy

 Answer : C

10. Long term relief of severe aspiration due to combined pharyngeal and laryngeal swallowing dysfunction most likely to occur after a. Laryngotracheal separation b. Vocal fold medialization c. tracheotomy d. Surgical closure of the glottis

 Answer : A

11. Cough variant asthma is associated with all of the following except a. Nonproductive cough b. Bronchoconstriction c. a normal chest radiogram d. wheezing

 Answer : D