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Morning Report Tuesday, November 8th, 2011

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1 Morning Report Tuesday, November 8th, 2011
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 Inspiratory stridor 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 Subglottis is the narrowest part 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
Extrathoracic: Left, during forced expiration, intratracheal pressure (Ptr) exceeds the pressure around the airway (Patm), lessening the obstruction. Right, during forced inspiration, when intratracheal pressure falls below the atmospheric pressure, the obstruction worsens resulting in flow limitation. Intrathoracic: Left panel, during forced expiration, the intrathoracic intratracheal pressure (Ptr) is less than the pressure in the pleural pressure (Ppl), worsening the obstruction. Right, during forced inspiration, intratracheal pressure exceeds the pleural pressure, lessening the degree of obstruction.

7 Anatomic Differential Diagnosis
Inspiratory Stridor Immobile cords Noid (adenoid) and tonsil enlargement Soft cartilage (laryngomalacia) Pharyngeal and hypopharyngeal masses Expiratory Stridor Tracheomalacia Bronchomalacia Vascular ring/ sling I/S: Laryngomalacia is most common cause of stridor in infants, followed by vocal cord paralysis (usually due to CNS lesions or traction on the recurrent laryngeal n. (birth complication), complication of PDA ligation/cardiac/ neck surgery) When comparing stridor from laryngomalacia with that of vocal cord paralysis, stridor wth laryngomalacia “wet with variable pitch;” vocal cord paralysis more high-pitched N: Stertor (low pitch) P: Peritonsillar, retropharyngeal abscess; epiglottitis, bacterial tracheitis, croup

8 Anatomic Differential Diagnosis
Biphasic Stridor Subglottic stenosis Critical fixed airway obstruction Vocal cord lesions* Croup* With subglottic stenosis, inspiratory component is louder **Don’t forget foreign body; type of stridor will depend on where the object is lodged**

9 Historical Pearls Age:
Laryngomalacia, subglottic stenosis, 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 Insidious Recurrent
FB aspiration Allergic reactions Infectious processes (epiglottitis, tracheitis, etc…) Insidious Viral croup Delayed airway burns Recurrent FB Subglottic stenosis 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 *place the bell over the child’s mouth and neck to determine to location of the stridor

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
Croup: (lateral view): hypopharynx is distended and there is subglottic haziness, normal epiglottis; diagnostic value of steeple sign is limited

15 Imaging CXR Airway fluoroscopy CT/MRI
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 **Biggest disadvantage of CT is not being able to image across the long axis of the trachea MRI better; gives a good evaluation of the mediastinum and estimates the length and degree of tracheal obstruction/ stenosis**

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 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… Epiglottitis: edematous epiglottis with the thumb sign, enlarged aryepiglottic folds, ballooned hypopharyngeal airway (BUT 70% of patients have normal neck films!)

19 Questions…Case #1 Diagnosis? Inspiratory or expiratory stridor?
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 inspiratory noise 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? Inspiratory or expiratory stridor?
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? Inspiratory or expiratory stridor?
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? Inspiratory or expiratory stridor?
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

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