A powerpoint slide showing how to approach a case of stridor and various pathologies in which stridor can be seen

1. An approach to a case of Stridor
Dr. Raghav Kakar
MD Paeds

2. Introduction
• Stridor is a harsh, high-pitched respiratory sound produced by
turbulent airflow through a partially obstructed airway at the
level of the supraglottis, glottis, subglottis, and/or trachea.
• It should be differentiated from stertor, which is a lower-
pitched, snoring-type sound generated at the level of the
nasopharynx, oropharynx, and, occasionally, supraglottis.
• Stridor is a symptom, not a diagnosis or disease, and the
underlying cause must be determined.

3. Mechanism
Stridor can occur at the
following places:
1. Nose and Mouth
2. Larynx (Epiglottis,
Supraglottis, Glottis
and Subglottis)
3. Trachea

4. Stridor may occur during the following
respiratory phases :
• Inspiratory phase = suggest airway
obstruction above glottis
• Expiratory phase = suggest obstruction in
lower trachea
• Biphasic (both inspiratory & expiratory) =
suggest glottic/subglottic lesion.

6. • An infant or child’s airway lumen is naturally narrower/smaller than adults.
• Therefore any minor reductions to this airway diameter ( such as
inflammation, mucosal edema, foreign object, collapsing epiglottis) can result
in further narrowing or obstruction of the airway.
• Due to this narrowing, it causes an exponential increase in airway resistance
which makes it significantly difficult for the child to breathe.

7. • The upper and lower airways are small, prone to
occlusion by secretions, and susceptible to oedema and
swelling.
• The support components of the airway are less
developed and more compliant than in the adult.
• The ribs are cartilaginous and perpendicular relative to
the vertebral column, reducing the effect of the ‘bucket
handle’ movement of the rib cage.
• In addition, the intercostal muscles and accessory
muscles of ventilation are immature.

8. • As a result, children are more reliant on the diaphragm
for inspiration.
• Increased respiratory effort causes subcostal and sternal
recession, and the mechanical efficiency of the chest
wall is reduced.
• Higher metabolic rate and increased oxygen demand
mean children with airway compromise can deteriorate
very quickly.
• Also, with a smaller functional residual capacity and
fewer fatigue-resistant fibres in the diaphragm, there is
little respiratory reserve at times of stress.

9. Causes according to the age and the onset
Neonates
Laryngomalacia 1st
Vocal cord dysfunction 2nd
Congenital tumours
Choanal atresia
Laryngeal webs
Chronic
Chronic
Chronic
Chronic
Chronic
Child
Infection -epiglottitis -Laryngitis
Croup : 1-2 days duration less severe
Foreign body
Laryngeal dyskinesia
Acute
Acute
Acute
Chronic
Adults
Infection -epiglottitis -Laryngitis
Trauma – acquired stenosis
Acute
Acute

10. Causes of Stridor: Anatomic Location, Sound, and Etiology
Features Supraglottis Glottis Subglottic
Trachea
Sounds
Sonorous
Gurgling
Coarse
Expiratory stridor
Biphasic stridor High-pitched stridor
Inspiratory stridor
E
T
I
O
L
O
G
Y
Congenital
Micrognathia
Pierre Robin syndrome
Macroglossia
Down syndrome
Storage diseases
Choanal atresia
Lingual thyroid
Thyroglossal cyst
Laryngomalacia
Vocal cord
paralysis
Laryngeal web
Laryngocele
Subglottic stenosis
Tracheomalacia
Tracheal stenosis
Vascular ring
Hemangioma cyst
Acquired
Adenopathy
Tonsillar hypertrophy
Foreign body
Pharyngeal abscess
Epiglottitis
Papillomas
Foreign body
Croup
Bacterial tracheitis
Subglottic stenosis
Foreign body

11. Precipitating factors
Worsening with straining or crying Laryngomalacia, subglottic
hemangioma
Worsening in a supine position Laryngomalacia, tracheomalacia,
macroglossia, micrognathia
Worsening at night Viral or spasmodic croup
Worsening with feeding Tracheoesophageal fistula,
tracheomalacia, neurologic disorder,
vascular compression
Antecedent upper respiratory tract
infection
Croup, bacterial tracheitis
Choking Foreign body aspiration,
tracheoesophageal fistula

12. Associated symptoms
Barking cough Croup
Brassy cough Tracheal lesion
Drooling Epiglottitis, foreign body in esophagus,
retropharyngeal or peritonsillar abscess
Weak cry Laryngeal anomaly or neuromuscular disorder
Muffled cry Supraglottic lesion
Hoarseness Croup, vocal cord paralysis
Snoring Adenoidal or tonsillar hypertrophy
Dysphagia Supraglottic lesion

13. Past health
Endotracheal intubation Vocal cord paralysis, laryngotracheal
stenosis
Birth trauma, perinatal asphyxia,
cardiac problem
Vocal cord paralysis
Atopy Angioneurotic edema, spasmodic croup
Family history
Down syndrome
Hypothyroidism
Psychosocial history
Psychosocial stress Psychogenic stridor

14. Physical Examination Findings
in the evaluation of Stridor in Children
PHYSICAL FINDINGS POSSIBLE ETIOLOGY
General
Cyanosis Cardiac disorder, hypoventilation with
hypoxia
Fever Underlying infection
Toxicity Epiglottitis
Tachycardia Cardiac failure
Bradycardia Hypothyroidism
Position of the child
Hyperextension of the neck Extrinsic obstruction at or above larynx
Leaning over, drooling Epiglottitis
Lessening of stridor in prone position Laryngomalacia

15. Chest findings
Prolonged inspiratory phase Laryngeal obstruction
Prolonged expiratory phase Tracheal obstruction
Unilateral decreased air entry Foreign body in ipsilateral bronchus
Associated signs
Arrhythmias, significant heart
murmurs, abnormal heart sounds
Structural heart disease
Cutaneous hemangiomas Subglottic hemangioma
Peripheral neuropathy Vocal cord paralysis
Urticaria/angioneurotic edema Angioneurotic edema

16. Laryngotracheobronchitis (Croup)
• Viruses typically cause croup, the most common
form of acute upper respiratory tract obstruction.
• Age group involved is 3 months to 5 years with
the peak in the 2nd year of life.
• Male preponderance.
• 15% have strong family history.

17. Pathophysiology
• Virus invades epithelium of the nasopharynx with
local spread to larynx and trachea
• Epithelial damage causes mucous production and
loss of ciliary function
• Oedema of the subglottic larynx. A small amount
of oedema within the ring of the cricoid cartilage
leads to a large decrease in air flow
• Fibrinous exudates partially occludes the lumen
of trachea.

18. Clinical Presentation
• Previous upper respiratory tract infection prior to
development of upper airway obstruction.
• Child develops “Barking” cough
• Hoarseness of voice
• Inspiratory stridor (when excited, at rest or both)
• Symptoms worsen at night.
• Resolves completely within a week.
• Agitation and crying greatly aggravate the
symptoms and signs.

19. PHYSICAL EXAMINATION :
• Agitated child
• Normal to moderately inflamed pharynx
• Slightly increased respiratory rate
• Suprasternal, infrasternal, intercostal retractions
in very severe cases.
• Prefers to sit up in bed or held upright.

20. Investigations
Croup is a clinical diagnosis and does not necessarily require a
radiograph
of the neck.
Radiographs of the
neck can show the
typical subglottic
narrowing, or
steeple sign, of
croup on the
Postero anterior
view.

21. Management
Clinical Assessment of Croup
Westley Scoring System
0 1 2 3
Stridor None Only with
agitation
Mild at rest Severe at rest
Retraction None Mild Moderate Severe
Air entry Normal Mild decrease Mod. Decrease Marked
decrease
Colour Normal N/A N/A Cyanotic
Level of
consciousness
Normal Restless when
disturbed
Restless when
undisturbed
Lethargic

22. Westley Scoring System
Score Degree Management
0-2 Mild Mist therapy
3-7 Moderate Racemic epi, Steroids
>8 Severe Racemic epi, Steroids, Admit
Racemic epinephrine :
0.05 ml/kg/dose ( with a maximum of 0.5ml) of a 2.25% of
solution diluted to 3 ml total volume with normal saline. Given
via neb over 15 minutes.
L- epinephrine
0.5ml/kg/dose ( max. of 5 ml) of a 1:1000 dilution. Given via neb
over 15 minutes.

23. • Dexamethasone
0.6 mg/kg IV, IM or PO as a single dose
• Nebulized Budesonide (2mg/4cc) has proved
as effective as adrenaline nebulizer (4mg/4cc)
• Antibiotics are not indicated.
• Sedatives are contraindicated

24. EPIGLOTTITIS
• Acute epiglottitis is a life-threatening emergency due to
respiratory obstruction.
• Affects all children’s age group, but most common in 1- 6
years children.
• M/c organism : H. influenzae type b.
• Other: S.pyogenes, S. pneumoniae, Staph aureus
• There is intense swelling of the epiglottis and
surrounding tissues associated with septicaemia.

25. Clinical presentation
Often, an otherwise healthy child suddenly develops :
• Sore throat
• Fever
Within a few hours, patient appears :
• Toxic,
• Difficulty in swallowing
• Labored breathing
• Drooling usually present (as patient finds it painful to swallow).
• Neck hyperextended to attempt to maintain airway.
• Child may assume tripod position – sitting upright & leaning
forward with chin up and mouth open while bracing on the arms.

26. • Brief period of air hunger with restlessness may be
followed by rapidly increasing cyanosis and coma.
• Stridor – usually is a late finding and suggest that
airways maybe almost completely blocked!
• Estabilishing an airway by endotracheal intubation or
less often, by tracheostomy is indicated in patients
with epiglottitis regardless of the degree of apparent
respiratory distress.
• In general, children with acute epiglottitis are
intubated for 2-3 days, as the response to antibiotics is
usually rapid

27. Investigations
• Laryngoscope
- Performed immediately in a controlled environment
(O.T. or ICU).

28. • Lateral radiographs of
the upper airway (in
cases where epiglottis is
thought to be the
cause, but not certain).
- Classic radiograph will
show the “Thumb”
sign.
- Proper positioning of
the patient crucial to
avoid misinterpretation

29. Management
• Once the diagnosis of epiglottis is suspected, urgent
hospitalization is required (ICU or OT or Anaesthetic
room with resuscitation facilities).
• Intubate child under general anaesthesia.
• Urgent tracheostomy (very rare) if intubation
impossible.
• Culture for blood, and epiglottic surface should be
collected. (Only after airway is secured!).

30. • Start patient on antibiotics immediately (e.g. cefotaxime,
ceftriaxone, or meropenem) for at least 10 days as most
patients might have concomitant bacteremia.
• Tracheal tube can be removed usually within 24 hours
(Depending on patient’s progress).
• Most children recover fully within 2-3 days.
• Indication for Rifampicin prophylaxis(20mg/kg X 4d) for all
house members include a child <4yr of age and
incompletely immunized, younger than 12 months of age
and hasn’t completed the primary vaccination, or
immunocompromised.
MINUTES COUNT IN ACUTE EPIGLOTTIS!

31. FOREIGN BODY ASPIRATION
• Children age 1 to 3 are most like to swallow or breathe in a
foreign object, such as a coin, marble, pencil eraser,
buttons, beads, or other small items or foods as they are
always very intrigued and interested in their surroudings.

32. • Despite a strong gag reflex, a young child’s
airway is more prone to obstruction than an
adult’s airway.
• The most serious complication of foreign body
aspiration is complete obstruction of the
airway.
• Which can be recognized in the conscious
child as sudden respiratory distress followed
by inability to speak or cough.

33. Clinical presentation
• 3 stages of symptoms may result :
1. Initial event : Violent paroxysms of coughing,
choking, gagging and possible airway obstruction
occurs immediately when the foreign body is
aspirated.
2. Asymptomatic interval: The foreign body becomes
lodged, reflexes fatigue, and the irritating symptoms
subside. This stage is most treacherous. It is during
this stage , when the child is first seen, that the
possibility of a foreign body aspiration is minimized,
the physician being reassured by the absence of
symptoms that no foreign body is present.

34. 3. Complications: Obstruction, erosion, or
infection develops to direct attention again to
presence of foreign body. Complications include:
Fever, cough , haemoptysis, pneumonia and
atelectasis.
• Stridor is commonly present with upper airway
or upper tracheal foreign bodies.
- Indicates prompt intervention required!
- Approximately 50% of children have
inspiratory stridor or expiratory wheezing, with
prolongation of the expiratory phase, and
medium-to-coarse rhonchi.

35. Patients may present with (depending on
location) :
1) Larynx - Hoarseness / aphonia
- Stridor
2) Trachea - Wheezing (can mimic asthma)
3) Bronchial - Cough
- Unilateral wheezing
- Decreased breath sounds

36. Investigations
RADIOGRAPHY
• Neck - AP view of neck
- Lateral view of soft tissues
• Chest - PA view (take both during inspiration & expiration)
- Lateral view
Some points to remember about radiography investigation :
• Obtaining 2 views of the foreign body helps to determining its location and
excludes the presence of superimposed multiple foreign bodies.
• Most foreign bodies are radiolucent
• Radiolucent tracheal foreign bodies may show signs of an infraglottic
opacity or of swelling from airway inflammation on PA and lateral neck
radiographs.

38. Anterior-posterior (A) and lateral (B) radiographs
demonstrating tracheal radiopaque foreign body (arrow).

39. BRONCHOSCOPY (FLEXIBLE) :
• If the clinical suspicion is high for foreign body
aspiration, flexible bronchoscopy should be
performed for definitive diagnosis and treatment.
COMPUTER TOMOGRAPHY (CT SCAN)
• Detects hyperlucency, atelectasis, and lobar
consolidations better than X-rays.
• CT scans can depict the foreign body within the
lumen of the tracheobronchial tree and the 3-
dimensional position of the foreign body within
the thorax.

40. Management
• Most cases of inhalation events are not witnessed,
hence diagnosis usually depends on high index of
suspicion.
• Immediately do a lateral neck X-ray, AP-Chest X-ray
(but hard to detect at times).
• Prompt endoscopic removal of foreign object with
rigid instruments is the treatment of choice.
• Bronchoscopy is deferred only until pre-op studies
have been abtained and the patient has been prepared
by adequate hydration and emptying of stomach.

41. RETROPHARYNGEAL ABSCESS
 Retropharyngeal abscesses are deep neck space infections
that can pose an immediate life-threatening emergency, with
potential for airway compromise and other catastrophic
Complications

42. • The retropharyngeal space can become infected in two
ways :
1) Infection spreads from a contiguous area
2) Penetrating trauma (can directly inoculate
the space)
• Once Infected, the nodes may progress through 3
stages: cellulitis, phlegmon and abscess.
The "classic" retropharyngeal abscess observed in
pediatric patients occurs when an upper respiratory
tract infection (URTI) spreads to retropharyngeal
lymph nodes, forming chains in the retropharyngeal
space on either side of the superior constrictor muscle.

43. Clinical Presentation
Common complaints :
• Sore throat
• Fever
• Neck pain
• Neck stiffness (torticollis)
• Jaw stiffness (trismus)
• Stridor
• Drooling of saliva
• Muffled voice
• Sensation of lump in the throat
• Breathing difficulties
• Sometimes an upper respiratory illness can precede symptoms by
weeks.

44. Investigation
1) Laboratory Studies (Non-specific)
- WBC counts can be elevated
- Culture and sensitivity test (Gram stain can help direct with empiric
antibiotic treatment).
2) Imaging Studies
(Lateral plain X-ray)
- May also demonstrate gas or
a foreign body in the
retropharyngeal space.
- Perform the study during
inspiration with the neck
held in normal extension

45. CT scan
• It can be useful in identifying
rertropharyngeal, parapharyngeal or lateral
pharyngeal abscess.
• Deep neck infections can be easily identified.
• With contrast, it can reveal central lucency or
scalloping of the walls of lymph node, which
is thought to predict abscess formation

46. Management
• ABC - Determining airway stability remains a top
priority.
• Allow patients to remain in a position of comfort, which is
usually supine with their necks extended. Neck flexion or
forcing a child to sit up can occlude the airway.
• Remember that sedatives and paralytics can cause
relaxation of airway muscles with subsequent complete
occlusion!
• Start empiric antibiotic therapy without delay (After
obtaining blood culture results) Broad-spectrum coverage
is indicated.

47. • A 3rd generation cephalosporin combined with
ampicillin-sulbactum or clindamycin is effective.
• CT scanning or ultrasonography may be used to
help guide the aspiration.
• Drainage is necessary in patients with respiratory
distress or failure to improve with IV antibiotics.
• Some authors advocate the use of antibiotics
alone for small abscesses. These patients need to
be closely monitored for improvement.

48. DIPHTERIA
- Diphtheria is an infectious disease caused by
the bacterium Corynebacterium diphtheriae.
- This disease primarily affects the mucous
membranes of the respiratory tract
(respiratory diphtheria), although it may also
affect the skin (cutaneous diphtheria) and
lining tissues in the ear, eye, and the genital
areas.

49. CLINICAL MANIFESTATION
• The symptoms usually begin after a two- to five-
day incubation period. Symptoms of respiratory
diphtheria may include the following:
• sore throat,
• fever,
• malaise,
• hoarseness,
• difficulty swallowing,
• stridor
• difficulty breathing.

50. • With the progression of respiratory diphtheria, the infected
individual may also develop an adherent gray membrane
(pseudomembrane) forming over the lining tissues of the tonsils
and/or nasopharynx.
• Individuals with severe disease may also develop neck swelling and
enlarged neck lymph nodes, leading to a "bull-neck" appearance.
• Extension of the pseudomembrane (which consists of fibrin,
bacteria, and inflammatory cells, no lipid) into the larynx and
trachea can lead to obstruction of the airway with subsequent
suffocation and death. (stridor and respiratory difficulty).
• The dissemination of diphtheria toxin can also lead to systemic
disease, causing complications such as inflammation of the heart
(myocarditis) and neurologic problems such as paralysis of the soft
palate, vision problems, and muscle weakness.

51. INVESTIGATIONS
LABARATORY TEST
• Confirmed by isolation of the bacterium Corynebacterium
diphtheriae. Diagnostic tests to isolate the bacterium
involve obtaining cultures from the nose and throat in any
individual suspected of having diphtheria, as well as their
close contacts.
• It is also important to determine whether or not the isolate
is capable of producing diphtheria toxin, and this can be
accomplished by testing in specialized laboratories.
ECG
• To see if there are any signs of myocarditis development.

52. MANAGEMENT
• Diphtheria antitoxin
- is the mainstay of therapy. It neutralizes circulating diphtheria toxin and
reduces the progression of the disease. The effectiveness of diphtheria
antitoxin is greatest if it is administered early in the course of the disease.
• Antibiotics
- administered as soon as possible to patients with suspected diphtheria.
Antibiotics help eradicate the bacteria, thereby stopping toxin production,
and they also help to prevent transmission of diphtheria to close
contacts. Penicillin and erythromycin are the recommended antibiotics.
Asymptomatic carriers, as well as all close contacts potentially exposed to
diphtheria, also require antibiotic treatment.

53. • Supportive measures
- inserting a breathing tube (intubation), may be
necessary if the patient cannot breathe on their
own or if there is the potential for airway
obstruction.
Potential cardiac and neurologic complications
also need to be closely followed and addressed in
consultation with the proper specialist.

54. LARYNGOMALACIA
• Most common congenital laryngeal anomaly in children.
• Most common cause of stridor (approximately 60% of
cases)
• Stridor characteristics :
• - Inspiratory
- Low pitched
- Exacerbated by any exertion, crying, feeding.
• -Stridor happens due to the collapse of supraglottic
structures inwards during inspiration.
• Symptoms usually appear within the first 2 weeks of life
• They increase in severity up to 6 months (although gradual
improvement can begin at any time).
• Laryngopharyngeal reflux is common.

57. Investigations
• FLEXIBLE LARYNGOSCOPE
• CHEST X-RAYS (when the breathing is
moderate to severe)
• BARIUM CONTRAST X-RAY (dysphagia present)
• COMPLETE BRONCHOSCOPY (patients with
moderate to severe obstruction – because 15-
60% of infants with laryngomalacia have
synchronous airway anomalies).

58. Management
• EXPECTANT OBSERVATION (as most symptoms
resolve spontaneously as the child and airway
grows).
• SURGICAL INTERVENTION – Endoscopic
Supraglottoplasty for patients with severe
obstruction (Especially when there are other
life-threatening events associated together
e.g. cor pulmonale, cyanosis, failure to thrive).

59. SUBGLOTTIC STENOSIS
• Develops after intubation or manipulation of
airways.
• May be continuous.
• Predominantly inspiratory but often biphasic.
• Flat inspiratory and expiratory loop on
spirometry
• Subglottic narrowing on neck radiograph and
direct laryngoscopy.

60. Haemangioma
• Worsening stridor.
• History of cutaneous Haemangiomas.
• Subglottic obstruction on neck radiograph
• Haemangioma seen on direct laryngoscopy

62. Vocal cord palsy
• History of injury to both recurrent laryngeal
nerves
• Arnold-Chiari malformation or increased
intracranial pressure.
• No movement of vocal cords during
laryngoscopy.

63. Vocal cord cyst
• Hoarse voice
• Chronic irritation to vocal cords or airway
instrumentation.
• Cysts visible on Laryngoscopy.

64. Laryngeal Papillomatoses
• Maternal history of human papilloma-virus
infection.
• Hoarse voice
• Can develop in the early years of life
• Papillomas visible on laryngoscopy.

65. Laryngeal Web
• Develops shortly after birth. (congenital)
• Or may develop after instrumentisation.
(acquired)
• Web visualised on laryngoscopy

66. Thank you