1 / 32

Differential Diagnosis: Infantile Stridor

Differential Diagnosis: Infantile Stridor. Amy Stinson MS IV KCUMB. Stridor. An expression of partial respiratory tract obstruction 2 ° to external compression or partial occlusion within the airway 1 Character & Intensity: Site & Degree of obstruction

garrison-santana
Download Presentation

Differential Diagnosis: Infantile Stridor

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Differential Diagnosis: Infantile Stridor Amy Stinson MS IV KCUMB

  2. Stridor • An expression of partial respiratory tract obstruction 2° to external compression or partial occlusion within the airway1 • Character & Intensity: • Site & Degree of obstruction • Airflow velocity & Pressure gradient • Stridor

  3. Stridor • Inspiratory – problem at or above vocal cords, usually high pitched at cords, low pitched above cords • Laryngomalacia, unilateral cord paralysis • Expiratory – problem is below cords – tracheobronchial tree, more prolonged • Vascular compression • Biphasic – usually subglottic • Subglottic stenosis, subglottic hemangioma, bilateral cord paralysis

  4. Laryngomalacia • Most common cause of stridor • Most common congenital laryngeal abnormality • “Congenital flaccid larynx” or “Inspiratory laryngeal collapse” • Inspiration: • Prolapse of supraglottic structures • Extreme infolding of “Omega-shaped” epiglottis and aryepiglottic folds

  5. Laryngomalacia • Photographs show a case of laryngomalacia during expiration (A) and inspiration (B). Note the infolding of the aryepiglottic folds. • www.entjournal.com/htmlDocs/Images/ped-0209.jpg

  6. Laryngomalacia • Normal Vs Abnormal • www.meei.harvard.edu/.../images/laryngomal.jpg

  7. Laryngomalacia • Signs & symptoms: • Inspiratory stridor within a few days of birth • Initially mild  more pronounced with a peak at 6 –9 mo4 • Stridor is worse when supine and neck flexion: better when prone and neck extension1 • Symptoms worse when sleeping, feeding, or on exertion • Most commonly – mild stridor that is self limited • Most cases spontaneously resolve by 2 yrs of age

  8. Laryngomalacia • More Severe: • Severe stridor, apneic episodes, feeding problems, & FTT •  pulmonary HTN & cor pulmonale • Presumed etiologies:4 • Abnormally pliable supraglottic cartilage • Neuromuscular abnormalities • GER

  9. Laryngomalacia • DX: • Endoscopy under local anesthesia • Laryngotracheobronchoscopy to R/O other path • Polysomnography to detect desaturations w/hypoxia or hypercapnia • Treatment: • OBSERVE • Temp trach in severe cases • Sx for 10%  supraglottoplasty which reduces amount of laryngeal mucosa • Anti-reflux meds

  10. Laryngomalacia • “State Dependent” Laryngomalacia6 • Neurogenic factors would cause at states of awareness – often paradoxical. • Direct stimulation resolves • Discoordinate Pharyngolaryngomalacia6 • Assoc. with severe collapse and poor outcomes • Need CPAP & nasal stents and poss. trach

  11. Vocal Cord Paralysis Second most common congenital abnormality of larynx4 Congenital & Bilateral is most common presentation with stridor and is usually seen in males4 Unilateral paralysis on Left seems to be more common but less associated with stridor6 Check nucleus ambiguous & supranuclear tracts plus Vagus nerve & branches3 www.meei.harvard.edu/.../images/laryngomal.jpg

  12. Vocal Cord Paralysis • Etiology: • Idiopathic • CNS: Arnold-Chiari malformation • CV: Congenital abnormalities of heart & great vessels of Sx correction of • Trauma: Repair of TE fistula, birth trauma, head injury • Inflammatory: Guillian-Barre • PNS: myotonic dystrophy, myasthenia gravis

  13. Vocal Cord Paralysis • Signs & Symptoms: • Asymp  acute airway obstruction • High pitched inspiratory stridor, apnea, cyanosis • Hoarse, breathy cry • Weak cough • All more common with bilateral palsy • www.meei.harvard.edu/.../images/laryngomal.jpg

  14. Vocal Cord Paralysis • Dx: • Fiberoptic endoscopy • Laryngotracheobronchoscopy • MRI • Tx: • Unilateral: Observe, Speech therapy • Bilateral: Tracheotomy, frequent endoscopies, no Sx for at least a year – maybe longer

  15. Vocal Cord Paralysis www.meei.harvard.edu/.../images/laryngomal.jpg

  16. Subglottic Stenosis • 3rd most common congenital cause of stridor • Subglottis is the narrowest part of airway & the only complete ring (cricoid cartilage) • Congenital & Acquired • www.meei.harvard.edu/.../images/laryngomal.jpg

  17. Subglottic Stenosis2,4,5 • Congenital: • Soft tissue stenosis or cartilaginous stenosis • Severe: stridor at birth • Mild: intermittent stridor & resp tract infections • Acquired: • Neonatal intubations, external trauma, high trach, infection, burns • Repeated failure of attempted extubation • Gradual onset of stridor after extubation

  18. Subglottic Stenosis1,2 • Stenosis if < 4mm in full term infant; < 3mm in preterm infant • Meyer-Cotton Grading • I: 0-50% • II: 51-70% • III: 71-99% • IV: no detectable lumen • www.meei.harvard.edu/.../images/laryngomal.jpg

  19. Subglottic Stenosis • Decrease risk: • Uncuffed, polyvinylchloride tubes • Smaller tubes • Nasotracheal intubation = less friction • www.meei.harvard.edu/.../images/laryngomal.jpg

  20. Subglottic Stenosis • Treatment: • Observe: Grade I, II, airway can increase with growth of child • Tracheotomy: until reconstruction • Endoscopic: Laser can decrease granulation tissue, can actually worsen with long term scarring • Laryngotracheal reconstruction: requires cartilage grafts and stents, enlarges stenosed portion • Cricotracheal resection: excises stenosed portion, higher success rate, but increased risk of recurrent laryngeal nerve damage

  21. Subglottic Hemangioma • A soft, compressible, bluish tumor below true vocal cords • Female > male 2:1 • 50% have cutaneous hemanigioma • Subglottis is most common location – usually unilateral • Tend to proliferate from birth – 1 yr then involute. Usually resolved by 5 yrs. • www.childrensenthouston.com/images/laryngomal

  22. Subglottic Hemangioma • Signs & Symptoms: • Intermittent stridor that progresses to biphasic stridor with dyspnea and cyanosis • Originally dx as croup www.meei.harvard.edu/.../images/laryngomal.jpg

  23. Subglottic Hemangioma • Treatment • Observe: if small • Tracheotomy until involution • Steroids – possible estrogen receptor  involution • Laser therapy – good for hemostasis • Surgical excision – becoming more common because of stenosis from trach • Interferon – alfa-2a has antiangiogenic activity when hemangioma in proliferate phase

  24. Less Common Causes of Stridor • Dysphagia lusoria • Laryngeal cysts • Congenital laryngeal webs • Laryngeal foreign bodies • Respiratory papillomatosis

  25. Dysphagia Lusoria • “Dysphagia of unclear etiology” • Congenital anomalies of aortic arch: • Double aortic arch • Anomalous origin of R or L subclavian artery • Kommerell’s Diverticulum – saccular aneurysmal dilation at of ARSA or ALSA • If LA or ductus present between subclavian and pulmonary  complete vascular tracheobronchial ring • Presents as respiratory distress, dysphagia & stridor

  26. Dysphagia Lusoria • Dx: • CXR • Barium swallow w/ esophogram • Tx: • Sx repair through lateral thoracotomy with lung separation

  27. Laryngeal Cysts2,4 • Rare cause of Stridor • More superficial • Fluid filled • Ductal: MC, originate from obstruction of submucous gland • Saccular: in laryngeal ventricles, usually congenital • www.meei.harvard.edu/.../images/laryngomal.jpg

  28. Congenital Laryngeal Webs1,2,4 • Embryology: Failure of complete recanalization • Most common in anterior glottis (fusion of ant portion of vocal cords) • Abnormal cry & stridor • Incise thin webs • Excise and stent severe webs • www.meei.harvard.edu/.../images/laryngomal.jpg

  29. Laryngeal Foreign Bodies4 • MC in kids 1-3 yrs • Most inhaled objects pass through larynx and lodge distally • If lodged in larynx & partially obstructed • Stridor, hoarseness, and cough • Confirm w/X-ray • Remove in OR

  30. Respiratory Papillomatosis1,2,4 • Most common neoplasm of larynx in children • Dx: most common btw 2 –5 yrs • Increased risk: • First born, vaginal delivery, teenage mother • HPV 6, 11 Gradual progression of dyspnea and stridor Tx: surgical ablation w/CO2 laser  webs & scarring

  31. References • 1. Rowe, LD. Pediatric Airway Obstruction. Otolaryngology – Head and Neck Surgery. Current Surgery. Chap 38. • 2. Kirby, GS. et al. Respiratory Tract and Mediastinum. Current Pediatrics. Chap 18. • 3. Gormley, PK. et al. Congenital vascular anomalies and persistent respiratory symptoms in children. International Pediatric Journal of Otorhinolaryngology. Nov 1999: 51:23-31. • 4. Lange, et al. Current Opinion in Otolaryngology and Head and Neck Surgery. Lippincott, Wilkins and Williams. Dec 1999. p 349. • 5. Mossad, E. et al. Diverticulum of Kommerell: A review of a Series and a Report of a Case with Tracheal Deviation Compromising Single Lung Ventilation. Anesth Analog. 2002:94:1462-4 • 6. Bent, J. Pediatric Laryngotracheal Obstruction: Current Perspectives on Stridor. Laryngoscope. 2006: 116: 1059-1070 • 7. Sisk, EA. et al. Tracheotomy in Very Low Birth Weight Neonates: Indications and Outcomes. Laryngoscope. 2006: 116: 928-933

More Related