Stridor

Harsh, usually high pitched, turbulent sound due to partial obstruction in the larynx/ tracheo-bronchial tree and is usually associated with dyspnoea.

Other types of noisy breathing

Stertor: Harsh, low-pitched turbulent sound during respiration due to partial obstruction proximal to the larynx and may be associated with dyspnoea Snoring: Same+ only during sleep Apnea: Cessation of breathing Sleep apnea syndrome: >30 apnea episodes during 8 hours of sleep

Stridor: Things to know

Types Pitch Site of obstruction Severity Causes

Types
Inspiratory (croup)
Glottic Supraglottic Hypopharynx

Expiratory (wheeze)
Distal trachea Bronchi

Biphasic
Subglottic Proximal trachea

Severity
Mild
Only on unaccustomed exertion Deep breathing

Moderate
On minimal exertion Not able to do day-to-day activities

Severe
Even at rest Accessory muscles are active Recession Features of hypoxemia like tachycardia, tachypnoea, cyanosis, irritability and restlessness

Pitch
Low pitch
Proximal

High
Distal

Site of obstruction
Type Pitch Associated symptoms
Examples: Hoarseness: Larynx Dysphagia/ FB sensation in throat: Hypopharynx Hot-potato voice: Supraglottic/ oropharynx

Etiology in children
tridor in children

ongenit l

cq ired

ryngo l ci y t or teno i

yre i l n ecti e c

yre i l

r or e rologic l etc

Congenital
Proximal to larynx
Nose: Choanal atresia Tongue: Macroglossia, haemangioma, lymphangioma, lingual thyroid, etc. Mandible: Micrognathia

Laryngeal
Supraglottic: LARYNGOMALACIA, cysts, tumors Glottic: Webs, palsy, cyst Subglottic: Stenosis, tumors

Tracheobronchial
Vascular loops T.E.Fistula Mediastinal congenital tumors Atresia, stenosis

A uired
INFECTIVE Acute epiglottitis Acute laryngo-tracheo-bronchitis Laryngeal diphtheria Laryngeal odema secondary to uinsy, acute tonsillitis, ludwigs angina, retro/ parapharyngeal abscess, etc.

TRAUMATIC FB in upper aero-digestive tract Thermal Chemical Physical- RTA Radiation

TUMORS Juvenile laryngeal papillomatosis Chondroma Thymoma Cystic hygroma

OTHERS Neurological: Bil. VC palsy Allergy: Angioneurotic odema Laryngismus stridulus Tetany Tetanus

ETIOLOGY IN ADULTS
Trauma: Laryngotracheal trauma, laryngotracheal stenosis-RTA/ iatrogenic, FB Tumor: Larynx, pharynx, trachea, bronchus, esophagus, thyroid, any neck/ mediastinal mass
Ca. Larynx Ca. Hypopharynx

Infection: TB laryngitis, neck space infections Allergy: Angioneurotic odema Neurological: Bilateral abductor palsy
Post thyroidectomy/ CTS

Evaluation
Objectives
Site Severity Cause Best way to secure the airway

Methods
History Clinical examination Investigations

First aid management as you evaluate Hospitalize/ early referral

History
Onset: Congenital/ later, How? Duration:
Short- inflammatory/ traumatic Moderate- Malignancy Long-Benign, VC palsy

Progression Fever +/Voice Feeding FB/ trauma/ corrosive poisoning Cyanotic speels Choking spells at night Relation to posture Aspiration Other throat/ neck/ chest symptoms

Clinical examination
Type Severity Systemic features of infection Postural relation Se uential auscultation Complete ENT, neck and RS examination ILS- done with caution/ contraindicated in moderate-severe stridor Voice/ cry

Investigations
Radiography
Plain X-ray neck AP/ lateral Chest X-ray- PA/ lateral Barium swallow CT scan- neck/ mediastinum Angiography

Endoscopy
Rigid/ flexible Laryngoscope- Caution: Can give rise to laryngospasm Rigid/ flexible Bronchoscope- after securing airway

Treatment
Conservative Intubation Cricothyroidotomy Tracheostomy

Conservative
Antibiotics- parenteral Steroids- parenteral and high dose Humidification Mucolytics O2 administration IV fluids Feeding Positioning SOS bronchodilators NO SEDATION

Intubation
ADVANTAGES Easy and uick in some cases DISADVANTAGES Difficult intubation Prolonged intubation- stenosis Morbid RT feeds Difficult to maintain Tracheo-bronchial toilet- difficult Airway resistance and deadspaceincreased

Tracheostomy
ADVANTAGES By pass Prolonged periods Maintainance easy Morbidity: less Airway resistance reduced Dead space reduced Tracheobronchial toilet better Swallow DISADVANTAGES More time to secure airway Surgical procedure Major in children Difficult in children Expertise Complications

Crico-thyroidotomy
Cricothyroid membrane in the midline Large bore needle Stab incisioncatheter

Other methods
Trans tracheal O2 administration Mini-tracheostomy Per-cutaneous tracheostomy

Multidisciplinary approach Treatment of the cause