Good Morning!!!

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

2. What is Stridor? • Monophonic, high-pitched sound usually caused by upper airway narrowing and partial obstruction • Can be: • Inspiratory • Expiratory • Biphasic

3. The Anatomy of Stridor • Inspiratorystridor 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

4. The Anatomy of Stridor

5. 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

6. Pathophysiology Extrathoracic Intrathoracic

7. Anatomic Differential Diagnosis • InspiratoryStridor • Immobile cords • Noid (adenoid) and tonsil enlargement • Soft cartilage (laryngomalacia) • Pharyngeal and hypopharyngeal masses • Expiratory Stridor • Tracheomalacia • Bronchomalacia • Vascular ring/ sling

8. Anatomic Differential Diagnosis • Biphasic Stridor • Subglotticstenosis • Critical fixed airway obstruction • Vocal cord lesions* • Croup*

9. Historical Pearls • Age: • Laryngomalacia, subglotticstenosis, tracheomalacia: congenital disorders • Foreign body aspiration: >6mos • Croup: 6-36mos • Retropharyngeal abscess: <4 yo • Peritonsillar abscess: >10 yo

10. Historical Pearls • Acuity of onset: • Abrupt • FB aspiration • Allergic reactions • Infectious processes (epiglottitis, tracheitis, etc…) • Insidious • Viral croup • Delayed airway burns • Recurrent • FB • Subglotticstenosis • Vascular ring • Tumor

11. Historical Pearls • PMHx/ Birth Hx • Prenatal/ perinatal complications? • Intubations? Length? • Surgical history? • Exposure to allergens?

12. 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

13. Imaging • Plain neck films • Non-specific • May reveal changes associated with • Retropharyngeal abscess • Epiglottitis • Croup • Foreign body

14. Plain Neck Films Croup Retropharyngeal abscess

15. 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

16. Other Diagnostic Modalities • Spirometry • Difficult to perform in small children

17. 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

18. Case #1 4 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…

19. Questions…Case #1 • Diagnosis? • Epiglottitis • Inspiratory or expiratory stridor? • Inspiratory • Associated symptoms? • Drooling • Dysphagia • Distress • Leans forward (refuses to lie down)

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

21. 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

22. Case #3 When 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…

23. Questions…Case#3 • Diagnosis? • Vascular ring • Inspiratory or expiratory stridor? • Expiratory • Associated symptoms • Stridor worse with feeds • Feeding difficulty

24. Case #4 3 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…

25. 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

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