• Nalaka de Silva

Paediatric Stridor

Updated: Jun 16, 2019




please note that the following is a general guideline only.




Paediatric Stridor: Overview


Definition


Stridor – High Pitched abnormal noise due to turbulent airflow

Stertor – snoring type noise made by naso-/oropharyngeal obstruction


Causes of stridor can be grouped according to anatomical region involved, BUT in reality very difficult to separate the 2 types.Most cases of stridor usually require endoscopy as history and examination.



History

History and examination is done with an understanding of the common causes of stridor which is discussed separately. Its important to determine the severity and to see the child needs urgent endoscopy and intervention. Also, the history and examination may give clues as to the likely anatomical site or the cause.


Full pregnancy history, including..


? Neonatal infections


Prematurity


APGARs


Intubation resuscitation




Stridor history, including..


Timing? – At birth or developed later?


Timing in the breathing cycle: inspiratory-glottic, Biphasic-tracheal, Expiratory-pulmonary wheeze)


Precipitants – Position, if upset, feeding other?




Examination

Vital signs,


Oxygen if necessary


Airway



Stridor- (timing, duration)


Nasal obstruction


Recession/ tracheal tug


Type of cry?


Retrognathia


Tongue and oral cavity anomaly?


Syndromic Facies





Symptoms suggestive of severity-needs urgent admission and endoscopy


Increased respiratory effort


Cyanotic spells, hypoxia


Feeding difficulties, associated with cough and gagging (aspiration), loss of weight


Dyspnoea or tachypnoea




Investigations

If severe symptoms, urgent ENT endoscopy in a paediatric ENT unit. Fibre-optic endoscopy can be done safely in most paediatric ENT units without general anaesthesia.


Other investigations include


Chest X-ray/ c spine X ray


MRI (brain, neck, chest)


Sleep study (if symptoms suggestive of OSA)


Laryngotracheobronchoscopy – general anaesthetic, may involve treatment as well





Causes of paediatric stridor

Several ways of classifyingCongenital-then according to locationAlso according to aetiology



Congenital Nasopharyngeal



- Choanal atresia, stenosis

- Craniofacial abnormalities

- Encephalocele, Meningocele

- Nasal glioma

- Haemangioma, lymphangioma

- Lingual thyroid

- Thyroglossal cyst




Congenital Laryngeal-


Laryngomalacia

- Posterior laryngeal cleft

- Laryngeal cysts, vallecula cysts

- Webs

- Stenosis

- Arytenoid fixation

- Vocal cord paralysis

- Haemangiomas and lymphangiomas



Congenital Tracheal-


Stenosis

- Atresia

- Abnormal cartilaginous rings

- Tracheobronchomalacia

- Vascular compression

- Haemangiomas and lymphangiomas



Traumatic

- Always think about foreign bodies-


Thermal or chemical injuries

- Haematomas

- Intubation trauma (IATROGENIC)

- Traumatic fracture of larynx

- Damage to recurrent laryngeal nerve



Infectious

- Adenotonsillar hypertrophy

- Parapharyngeal abscess

- Peritonsillar abscess

- Retropharyngeal abscess

- Lymphadenopathy

- Ludwig’s angina

- Epiglottitis

- Croup and other forms of tracheitis



Neoplastic






Paediatric Stridor: Specific Conditions



1 Laryngomalacia






Definition

Abnormal flaccidity of the neonatal larynx which leads to collapse during inspiration





Epidemiology

most common cause of stridor in infants

M>F, 2:1


Aetiology

? cartilaginous structures are weak,

? neuromuscular "immaturity" exists within the supraglottis leading to laryngeal GORD and Laryngomalacia: Unclear if its a cause or an effect!!


Symptoms

Newborn typically will develop intermittent, inspiratory, 2 weeks of life

Spontaneous resolution of stridor is 9 months of age, and 75% will have no stridor by 18 months of age

Infrequently-severe, resulting in feeding difficulties, failure to thrive, apnea, pectus excavatum, or cyanosis

In these severe cases surgical intervention is recommended to prevent cardiac failure

Isolated finding in the otherwise healthy infant or may be associated with other neurologic disorders such as cerebral palsy

Associated GORD


Signs

respiratory distress

Flexi if possible may be diagnostic

17 % have a second lesion hence if severe need LBO

Lat Neck XR


Treatment

90% medical

Observation/ higher calorie feeding if not gaining weight

Fatten up: add fat cream etc to feeds start solids earlier even at 8 weeks

Rx GORD-Ranitidien (safe in infancy)n2-4 mg/ kg per dose tds po or IV

Omeprazole (safe in infancy < 1 yr not established)-about 2/3 mg / kg per day

Surgical Rx

Laryngoscopy bronchoscopy for assessment and treatment surgical -rarely needed

Emergency tracheostomy Rare








2 Sub-Glottic Stenosis


Definition



narrowing of a new born < 4mm

narrowing of a preterm < 3.5 mm















Epidemiology

M:F= 2:1

3rd most common congenital anomaly of pediatric airway



Aetiology

1 Congenital: Due to incomplete re canalization of the laryngo-tracheal tube

2 Acquired

-ETT-trauma

-Infection/ inflammmatory/ reflux (all unlikely in the infant)



Clinical

1 Stridor

inspiratory or biphasic

mild stenosis may be asymptomatic until an URTI -recurrent croup croup

2 Dysphonia

3 associated with other anomaly-10% of laryngomalacia has SG stenosis/ Down syndrome


Treatment

Rx reflux

Steroids if oedema

Surgery

Endoscopic: Dilatation / laser/ cold steel devision and dilate-local kenocort or Mit mic C

Open Procedures





Haemangioma


Definition

Hamartomatous vascular neoplasms endothelial hyperplasia



Epidemiology

Most common tumour in infancy, 2% can become apparent up to 10%

F:M 3:1

Increased incidence with maternal age, multiple gestations and with C villous sampling/ prem babies



Etiology and pathogenisis

Some familial



Classification

Congenital (rare)

congenital-rare, fully formed at birth

RICH & NICH types

Infantile (common)-grows then involutes. Infantile type has GLUT 1 receptor and can be treated with B blockers



Clinical

Most (Infantile type) grow -6 months (proliferative phase)

stabilise for 1 yr (stable phase)

slowly involute most gone by the age of 3 years (involution phase)


Laryngeal symptoms

first 6 months of life with inspiratory or biphasic stridor

recurrent croup -responds temporarily to oral steroids

diagnosis is made at the time of direct laryngoscopy


Extra laryngeal symptoms

1/2 have other cutaneous haemangiomas




Investigations

L&B: Biopsy- GLUT1 glucose transporter protein (infantile is GLUT1 positive, congenital-ve)

MRI brain / H&N




Treatment

1 Steroids

2 Propranalol if Gute 1 positive



2 Surgery-Laser-

KTP pulse dye laser







Laryngeal Web

Definition

a membrane in the larynx due to incomplete re-canalization of the larynx


Epidemiology

rare, 75% glottic level, mostly anterior webs



Aetiology

Failure of recanalisation of the larynx during embryonic development-10th week

Assoicated with CATCH22/ VCF syndrome ( Ch 22 q 11)



Clinical

No sy , hoarse/ apnea

Syndrome features



Examination

Flexible scope



Investigation

Lat Neck XR-sail sign

Flexi scope

L&B

All undergo genetics- CATCH 22, Cardiac evaluation



Treatment

Mild can observe

Rest Surgery







Bilateral Vocal Cord Palsy


EPIDEMIOLOGY

another common cause of neonatal stridor


PATHOPHYSIOLOGY

Idiopathic

Birth trauma/ Hypoxia/ intubation trauma

CNS

peripheral neurologic diseases

Thoracic-diseases or iatrogenic



CLINICAL

stridor-inspiratory or biphasic, with a high-pitched musical quality

weak cry



EXAMINATION

flexible laryngoscopy: paediatric ENT unit

vocal fold fixation vs neurogenic vocal -direct laryngoscopy is performed under GA and the glottis palpated



INVESTIGATIONS

laryngeal EMG → fixation vs paralysis

MRI - ? Arnold-Chiari malformation or other intracranial cause

If idiopathic congenital bilateral vocal cord paralysis is present → genetics consultation



TREATMENT Unilateral

Unilateral-Non surgical

Manage airway patency

usually not an issue

Manage aspiration & feeding, speech pathology, barium sallow



TREATMENT Bilateral vocal cord paralysis

Surgery unless stable








Recurrent Respiratory Papillomatosis





Definition

The most common benign neoplasm of the larynx caused by the HPV virus












Epidemiology

Juvenile< 5yrs of age

Incidence 4/100,000

M=F

Adults20-40s

M:F 3:2

Incidence-2/100,000

more in poor

Overall prevalence of HPV in women nearly 33% and the most common STD



Aetiology

Vertical transmission children,

adults, sexual or reactivation



Presenting symptoms

3 yrs age mean

Sy of recurrent croup dysphonia, barking type cough,

Failure to thrive

Stridor

Dysphagia

Chest infections



Treatment

Vaccination


Gardisil- Quadrivalent vaccine against HPV 6, 11, 16, and 18 or placebo to evaluate prevention of high-grade cervical lesions


Expected reduced prevalence of the Virus in vaccinated women hence likely lower vertical transmission


HPV vaccine may play a role in the prevention of RRP in children and newborns.


Surgery

Goal is to get a balance between going too often and letting tumor burden increase


Coblation, Microdebrider, Laser


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