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