Sneak peek 2 Integrated handbook of family medicine

                     Approach to case of   Stridor

Ø Harsh & high pitched sound produced by turbulent airflow through a partially obstructed airway is called as stridor.

Ø It can be inspiratory, expiratory or biphasic.

1. Inspiratory stridor:

It occurs due to  obstruction at the level of supraglottis.

E.g. laryngeal, nasal, pharyngeal.

2. Expiratory stridor:

It occurs at level of obstruction is below the sub glottis i.e. at trachea/bronchi.

3. Biphasic stridor:

This type has obstruction at the level of glottis and sub glottis.

Causes of stridor:

Larynx	Glottis	Sub glottis	Trachea & Bronchi	others
Supraglottis Laryngomalacia Webs Saccular cysts Laryngocoele Diphtheria Tetanus Prolonged intubation	Webs VC Paralysis	Webs Stenosis Haemangioma	Webs Stenosis Tracheomalacia Vascular compression Cysts Mediastinal tumours Foreign body tracheobronchitis	Choanal atresia Macroglossia Tracheo osophageal fistula

Evaluation:

This helps to determine the Level of obstruction and type of lesion.

History:

Ø Age of onset.( congenital /acquired).

Ø Onset and progression.

ü Sudden- Forign body,edema.

ü Gradual & progressive- laryngomalacia,juvenile papilloma.

Ø Nature of the sound and timing of the sound.

Ø Severity.

Physical Examination:

Ø Maintain a calm, quiet, reassuring attitude.

Ø It need to be fast yet detail.

Ø It should not be overdone.

Ø Make the patient comfortable & use Minimum instruments.

Ø Check for lesion at larynx or trachea.

Ø Look for respiratory distress, recession in suprasternal notch, sternum.

Ø Note the character of the stridor.

ü Snoring indicates nasopharyngeal origin.

ü Gurging & muffled sound suggest pharyngeal origin.

ü Hoarse voice suggest laryngeal cause.

Ø Fever suggestive of infection or inflammation.

Ø Sequential auscultation with unaided ear and with stethoscope over nose, open mouth, neck and chest helps to localize probable site of origin.

Ø Stridor of laryngomalacia, micrognathia, macroglossia disappears when baby lies in prone position.

Investigations:

Ø X-ray like lateral view of the neck  is helpful for above the glottis lesion.

Ø PA View of the chest helps t o find the sub glottis and the central airway lesion.

Ø CT and MRI has limited role because of Motion artifacts and Lack of fat plane in the region especially in children.

Ø Echo cardiography helps to rule out vascular compression, congenital cardiac disease.

Ø Flexible endoscopy: Good optics, paediatric sizes tubes are  available.

This is excellent for dynamic lesions like Laryngomalacia, Vocal Cord  Palsy .Sub glottis structures are poorly visualised.

Ø Laryngoscopy

Ø Bronchoscopy

Treatment:

Medical treatment:

Ø Oxygen inhalation with 40 – 60% concentration can help.

Ø Steroids therapy like IV Dexamethasone (0.15 – 0.6 mg/kg) or nebulised Budesonide (2 mg) may relive spasm. It helps to decreases the inflammation and oedema.

Ø Epinephrine inhalation helpful in mucosal oedema reduction as they act as topical decongestants.

Ø However the effect is temporary and definitive management is required. Rebound effect may be dangerous.

Ø Oropharyngeal airway mainatainace with endotracheal intubation require in severe stridor cases.

Surgical Treatment:

1.     Cricothyroidotomy.

2.     Tracheostomy.