Stridor

By
Dr Isaac Tan
Otorhinolaryngology (ENT) Hospital Sibu
 ENT UPDATE 2018
March 29 2018
Kingswood Hotel, Sibu

GOVERNMENT
• DOCTOR - MO / SP – RM100
• PARAMEDICS – RM80
PRIVATE
• DOCTOR - MO / SP – RM120
• PARAMEDICS – RM100
Outline
• Definition
• Pre hospital care
• Two major cases
• Two common MISSED scenarios
• Conclusion
Stridor
• harsh, loud sound of constant pitch, produced in the larynx,
glottis or trachea.
• result of turbulent airflow through a narrowed upper airway
• Stridor – Noisy breathing caused by partial obstruction of respiratory
tract at or below the larynx
• Stertor – Noisy breathing caused by partial obstruction of respiratory
tract above the larynx
• Type of stridor depends on site of obstruction
• Most common : Supra glottic and glottic resulting in inspiratory
stridor
Inspiratory stridor
-Produced in obstructive lesion
of supraglottisor pharynx
(eg:laryngomalacia)
Expiratory stridor
-Produced in lesion of thoracic
trachea or
bronchi (eg: tracheal stenosis)
Biphasic stridor
-Produced in lesion
of glottis,subglottis and
cervical trachea (eg:
VC paralysis,subglottic
stenosis)
Presentations of airway emergencies
• Stridor
• High-pitched noise resulting from turbulent airflow through a partially obstructed
upper airway
• inspiratory (glottic, supraglottic)
• Expiratory (tracheal)
• Biphasic (subglottic)
• Differentiate stridor from stertor (snoring)
• Respiratory arrest
• Hoarse voice
• Pain and discomfort
• Drooling
Causes
Congenital Acquired
Larynx Trauma
- Laryngomalacia - Thermal inhalation
- Vocal cord palsy - External blunt/ penetrating
- Web
Trachea and Bronchi Inflammatory / Infection
- Tracheomalacia - Laryngitis
- Web - Epiglottis
- Subglottic stenosis - Supraglottitis
- Croup / Laryngotracheobronchitis
Foreign body
Allergy – Angioneurotic oedema
Neoplasm
- Benign – papillomatosis
- Malignant - SCC
Diagnosis and initial management
STAY CALM and follow ABC
• May need to secure airway first
• Rapid history and careful examination

Team approach
• Anaesthetist, ENT surgeon, Physician, Paediatrician, Radiologist, Nurses
• May need to contact ITU, wards, theatre, referral centre

Management
• Oxygen, Heliox, Adrenaline, Steroid, Antihistamine, Antibiotics
• Nasopharyngeal/oropharyngeal airway
• Intubation
• Cricothyroidotomy (needle/surgical)
• Surgical tracheostomy
What happens if you are in the
• WARDS/ EMERGENCY DEPARTMENT OF GENERAL HOSPITAL
• EMERGENCY DEPARTMENT OF DISTRICT HOSPITAL/PK/KD
• ON THE FIELD
Airway
• Transport - Equipment
• Position
• Oxygen
• Adjusts
• Intubate / LMA
• Surgical airway
Cricothyroidotomy
Tracheostomy
Case 1
• A 6-year-old male presents conscious, alert and oriented,
• sitting up in bed in a “sniffing” position
• complaining of a sore throat.
• strong and rapid radial pulse, and his respiratory rate is normal, but you
note inspiratory stridor with each breath. His skin is warm and dry.
• His mother says he went to bed last night without any complaint but woke
up this morning with a sore throat and fever, so she kept him home from
school as a precaution. Since he awoke 5 hours ago, the patient’s fever
has risen to (39.0ºC), and the stridor developed.
• No significant medical history and takes no medications.
• He has not received all of his vaccinations to date, as the parents are
concerned about vaccine side-effects.
• She is not aware of any recent trauma or potential for foreign body
ingestion.
Case 1
• The child is slightly anxious but willing to answer your questions
and allow you to perform a physical examination. He says his
“throat hurts” and “it hurts to swallow.”
• You note his voice is slightly muffled, and his mother confirms
this is not normal for him.
• The patient’s lung sounds are clear, and he does not complain
of any respiratory distress. There is no accessory muscle use,
nasal flaring, abdominal breathing or retractions. His vital signs
are heart rate 112/min. and regular; respiratory rate 20/min. with
good tidal volume; blood pressure 105/70 mmHg; pulse
oximetry 97% on room air
Differential Diagnosis
• Epiglottis
• Croup
• Foreign Body
Acute epiglottis
• HIB most common
• Rapid onset fever 2- 6 hours
• ➢Sore throat, odynophagia, muffled voice, insp stridor, pyrexia, drooling,
distress
• Neck extended with air hunger
• Resembles croup clinically, but think of epiglottitis if:
• Child can not breathe unless sitting up
• “Croup” appears to be worsening
• Child can not swallow saliva and drools (80%)

• ➢DO NOT UPSET THE CHILD

Acute epiglottis
• Lateral X-ray – thumb sign
• In severe cases – treatment should not be delayed to take xray

Management
• Call for help
• Paeds + anaesthetist if stridor
• Do not attempt cannulation, exam
• Requires gas induction and intubation then transfer to PICU
• Then: IV Abx, steroids pre decannulation
 Acute epiglottitis
Croup
●Age : <3 years ●Age : >3 years
●Onset : gradual(days) ●Onset : acute(hours)
●Cough : barky ●Cough : normal
●Posture : supine ●Posture : Sitting
●Drooling : no ●Drooling : yes
●X-ray : steeple sign
●X-ray : thumb sign
●Cause : viral
●Cause : bacterial
●Treatment : supportive
●Treatment : airway,antibiotic
Croup
• Croup (ie Acute Laryngotracheitis) is a viral infection of the larynx and
trachea
• Virus : Parainflunzae 1
• Affects children<5 years
• The illness lasts from 3 to 7 days,
• First develop febrile URTI followed several days later by the classical
barky or croupy cough
• The cough usually non-productive and worsens at night
Croup
• Most cases is self – limited
• Significant edema may develops
• The diagnosis is usually based on history.
• Neck radiographs – classic ‘ steeple
sign’(subglottic edema)- AP view
• Main site of inflammation – the subglottis,
loss of epithelial cells,
thick mucoid secretions.
• Secondary infection – streptoccoci,
staphylococci, pneumococci
Croup
Management
• to reduce edema
• thinning the secretions
• secure airway (severe cases)
• Intensive humidification and hydration (to help thin the secretions
and soften the crusts)
• Steroid to prevent further edema progression
• Airway obstruction – intubation or tracheotomy
• Antibiotics – indicated for secondary infections.
Foreign body inhalation / Ingestion
Foreign body inhalation / ingestion
• Nose/ oropharynx
• Common in children/ under influence
• Items – vegetative matters 80%; plastic pieces 15%
• Common site – right main bronchus
• Ingestion – coin, fish bone
• Just below cricopharyngeal muscle
Foreign body inhalation / ingestion
• Symptoms
• Three clinical phases
1. Choking – gagging sudden coughing or airway obstruction
2. Asymptomatic phase – FB lodged and reflexes fatigue – last for
hours to weeks
3. Complication – pneumonia, erosion, abscess, obstruction
• Larynx – biphasic stridor, hoarseness
• Trachea – asthemtoid wheeze, palpable thud, reduced breath sound
• Esophageal – vomiting, odynophagia, dysphagia
Foreign body inhalation
• Nose/ oropharynx
• Common in children/ under influence
• Items – beads, peanuts
• Common site – right main bronchus
• CXR
• Rigid bronchoscopy
Case 2
• A 37-year-old male presents sitting up in a chair, tripoding,
leaning forward and drooling, in obvious distress with inspiratory
stridor.
• normal respiratory rate, a rapid and strong radial pulse, and
warm, dry skin.
• alert and oriented
• complains of a sore throat and pain with swallowing. You note
that talking also causes him pain, and he indicates that any
movement of his neck or jaw is painful, so you both agree on
yes or no answers to questions. You also note his voice is
muffled.
• taking antibiotics for the past 5 days for a sore throat he
developed after having a molar extracted from his right
mandible one week ago.
• His sore throat rapidly worsened over the past 24 hours,
• he developed severe neck pain with movement and swallowing
• Over the past 6 hours he has been placing himself in the tripod
position, drooling, and his breathing has become noticeably
worse. His wife called EMS when he started exhibiting stridor.
• has no other significant medical history, takes no other
medications and has no allergies.
Differential Diagnosis
• Epiglottis
• Ludwig’s angina
• Retropharyngeal abscess
Ludwig angina
Ludwig angina
• Spread rapidly,
• Facial odema, swelling
• Elevated floor of mouth,
posterior displacement of
tongue
• Painful neck swelling
• Tooth ache, dysphagia
• SOB, Trismus
• Stridor, Cyanosis
Ludwig angina
• AIRWAY
• ANTIBIOTIC
• InD
Parapharyngeal/ retropharyngeal abscess
• Fever
• Stridor
• SOB/difficulty in breathing
• Stiff neck
• Torticolis
• Dysphagia

prevertebral soft tissue, normally 5 – 7 mm wide at the

level of the second cervical vertebrae.
Parapharyngeal/ retropharyngeal abscess
• LATERAL XRAY
REFER ENT
• SECURE AIRWAy
• IV ANTIBIOTICS

prevertebral soft tissue, normally 5 – 7 mm wide at the

level of the second cervical vertebrae.
Infection
• Parapharyngeal/ retropharyngeal abscess
• Peritonsillar abscess
• Ludwig angina
• Epiglottis
• Croup
• Supraglottis
Peritonsillar abscess
Peritonsillar abscess
• Unilateral sore throat
• occasionally accompanied by ipsilateral
ear pain
• Fever
• Muffled "hot potato" voice
• Dysphagia with pooling of saliva and
drooling
• Trismus: inability to open the mouth
due to muscle inflammation and
spasm of the masticator muscle
• Caused by irritation and reflex spasm of
the Internal Pterygoid muscle
• Torticollis
Peritonsillar abscess
• Antimicrobial Therapy - begin with
Penicillin
• Drainage
• Needle aspiration should be
attempted and will alleviate the
symptoms.
• Incision and Drainage - out patient
procedure with topical analgesia.
More painful and involves more
bleeding than aspiration. Send
specimens for culture.
Laryngitis
• One or more symptoms
• dysphonia/hoarseness (ie, abnormal voice)
• odynophonia (ie, painful speaking)
• dysphagia (ie, difficulty swallowing)
• odynophagia (ie, painful swallowing)
• Stridor (ie noisy breathing)
• dyspnoea (ie, difficulty breathing)
Angioneurotic odema
• Acquired angioedema – is an inflammatory reaction characterized
by venule and capillary dilatation and increased vascular permeability.
• Mediated by histamine
• Caused by :
• Drugs ie. Aspirin, penicillin
• Foods and food additives
• Insect bites
• Transfusions
• Infections
• Connective tissue disorders
Angioneurotic odema
• Oxygen
• Clinical diagnosis
• Steroids, piriton , adrenaline, salbutamol neb
• Iv access
• Secure airway
Pharyngeal wall haematoma/ swelling
• Anterior – blunt trauma/ choking
• Posterior – ruptured thoracic Aortic aneurysm, cervical fracture
• Circumferential - burns
Cancers/Tumors/Metastasis
Vocal cord palsy
• Bilateral abductor palsy – stroke, TB, cancer
• Cancer – Npc, lymphoma, thyroid, oesophageal
• Post thyroid surgery
• Ortner syndrome – major thoracic aneurysm, pulmonary embolism
Tracheal stenosis
• Prolonged intubation
• Faulty intubation
• Tracheostomy
Summary
• RECOGNITION
• DIAGNOSIS – Anatomy
• AIRWAY AIRWAY AIRWAY
 ENT UPDATE 2018
March 29 2018
Kingswood Hotel, Sibu

GOVERNMENT
• DOCTOR - MO / SP – RM100
• PARAMEDICS – RM80
PRIVATE
• DOCTOR - MO / SP – RM120
• PARAMEDICS – RM100
Thank you