Good Morning!!!Morning Report Tuesday, November 8th, 2011

What is Stridor?

•Monophonic, high-pitched sound usually caused by upper airway narrowing and partial obstruction

•Can be:▫Inspiratory▫Expiratory ▫Biphasic

The Anatomy of Stridor

•Inspiratory stridor is caused by extrathoracic obstruction▫Extrathoracic region

Supraglottic area Nasopharynx, epiglottis, larynx, aryepiglottic

folds, false vocal cords Glottic and subglottic area

Vocal cords to the extrathoracic segment of the trachea

The Anatomy of Stridor

The Anatomy of Stridor

•Expiratory stridor (wheezing) is caused by intrathoracic obstruction▫Includes portion of the trachea that lies

within the thoracic cavity and the mainstem bronchi

•Biphasic stridor is caused by critical and fixed airwary obstruction at any level

PathophysiologyExtrathoracic Intrathoracic

Anatomic Differential Diagnosis

•Inspiratory Stridor▫Immobile cords▫Noid (adenoid) and tonsil enlargement▫Soft cartilage (laryngomalacia)▫Pharyngeal and hypopharyngeal masses

•Expiratory Stridor▫Tracheomalacia▫Bronchomalacia▫Vascular ring/ sling

Anatomic Differential Diagnosis

•Biphasic Stridor▫Subglottic stenosis▫Critical fixed airway obstruction▫Vocal cord lesions*▫Croup*

Historical Pearls

•Age:▫Laryngomalacia, subglottic stenosis,

tracheomalacia: congenital disorders▫Foreign body aspiration: >6mos▫Croup: 6-36mos▫Retropharyngeal abscess: <4 yo▫Peritonsillar abscess: >10 yo

Historical Pearls• Acuity of onset:

▫Abrupt FB aspiration Allergic reactions Infectious processes (epiglottitis, tracheitis, etc…)

▫ Insidious Viral croup Delayed airway burns

▫Recurrent FB Subglottic stenosis Vascular ring Tumor

Historical Pearls

•PMHx/ Birth Hx▫Prenatal/ perinatal complications?▫Intubations? Length?▫Surgical history?▫Exposure to allergens?

Physical Exam

•Gen: **Quickly identify any patients with impending airway obstruction**

•HEENT: Size of tongue and mandible, ?craniofacial malformations

•Neck: scars, edema•Lungs: WOB, location of stridor*•Ext: clubbing •Lymphatics: peripheral LAD•Skin: hemangiomas, café-au-lait spots

Imaging

•Plain neck films▫Non-specific▫May reveal changes associated with

Retropharyngeal abscess Epiglottitis Croup Foreign body

Plain Neck FilmsCroup Retropharyngeal

abscess

Imaging• CXR

▫ Important when an intrathoracic problem is suspected Mediastinal LAD or mass R aortic arch (vascular ring) Foreign body

• Airway fluoroscopy▫Tracheomalacia

• CT/MRI▫Retropharyngeal cellulitis/ abscess▫Tumors/ LAD▫Abnormal vasculature

Other Diagnostic Modalities

•Spirometry▫Difficult to perform in small children

Other Diagnostic Modalities

•Airway visualization▫Emergent, flexible or rigid laryngoscopy:

Epiglottitis Tracheitis

▫Non-urgent, nasopharyngoscopy: Laryngomalacia Anatomic defects b/t nose and pharynx

▫Non-urgent, flexible or rigid laryngoscopy: Thorough evaluation needed for diagnosis Foreign body

Case #14 yo M with a 2 day history of fever to 103.5. Today, Mom noticed that his breathing was noisy and he was refusing to eat and drink. In the office, he is leaning forward, drooling with stridor…

Questions…Case #1

•Diagnosis?▫Epiglottitis

•Inspiratory or expiratory stridor?▫Inspiratory

•Associated symptoms?▫Drooling▫Dysphagia▫Distress▫Leans forward (refuses to lie down)

Case #2A mother brings in her 2 week old ex 37 wga F with c/o noisy breathing. She describes it as an inspiratory noise that seems to worsen when she cries and when she is lying down. The infant is growing and gaining weight appropriately.

Questions…Case #2

•Diagnosis?▫Laryngomalacia

•Inspiratory or expiratory stridor?▫Inspiratory

•Associated symptoms▫Can have retractions▫Stridor worse with agitation and supine

position▫Stridor improves with expiration▫Symptoms improve with time

Case #3When you walk into an exam room to see your 2 month old WCC, you appreciate a loud wheeze. You notice the infant is feeding and ask Mom if this noise is a common occurrence with feeds. She says that it is and that the infant also seems to have difficulty “getting down” the formula…

Questions…Case#3

•Diagnosis?▫Vascular ring

•Inspiratory or expiratory stridor?▫Expiratory

•Associated symptoms▫Stridor worse with feeds▫Feeding difficulty

Case #43 mo M with Trisomy 21 presents to the ED with noisy/ difficult breathing. Per Mom, she saw her PCP yesterday for the noisy breathing. He said it was “wheezing from a cold” and gave her Albuterol nebs to give q4. Since the meds, the infant’s respiratory distress has worsened…

Questions…Case #4• Diagnosis?

▫Tracheomalacia• Inspiratory or expiratory stridor?

▫Expiratory• Associations

▫Confused with asthma Asthma: wheeze high-pitched, diffuse and musical;

improves with beta-agonists Tracheomalacia: wheeze low-pitched, central and

homophonous; worsens with beta-agonists▫Associated with Trisomy 21, TEF s/p repair,

mechanical ventilation, and BPD

Thanks for your attention!Noon Conference: VLBW Infant, Dr. Rivera