Evaluation and Management of Pediatric Stridor

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1 Evaluation and Management of Pediatric Stridor Pamela Nicklaus, MD FACS Associate Professor Fellowship Director Pediatric Otolaryngology Children s Mercy Hospital and Clinics 2013 Children's 2013 Mercy Children's Hospitals Mercy and Hospitals Clinics. All and Rights Clinics. Reserved. All Rights 03/13 Reserved. 03/13

2 Overview Definitions Case presentations of stridor by location Evaluation Treatment 2

3 Anatomy review: 3

4 Anatomy review: real time Video: Behold, the human larynx! 4

5 Child vs. adult airway 1. A child s larynx is located HIGHER in the neck than the adult 5

6 Child vs. adult airway 2. A child s airway is narrower and more conical Cricoid (subglottis) considered narrowest portion of child s larynx 6

7 Remember college Physics? Poiseuille s (pwaa-zuhee) Law: Resistance inversely proportional to radius to 4 th power Bernoulli s Law: Pressure decreases as velocity increases, causing tendency to collapse Resistance 16x 3x 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

8 Child vs. adult airway 3. A child s laryngeal and tracheal cartilages are softer, more dynamic, cause of malacia Over time, both growth and mineralization of the cartilages make these structures more rigid On the plus side, laryngeal fractures are less common in children. 8

Biphasic Stertor: Low-pitched inspiratory sound from nose/pharynx (like

9 Stridor: Definitions Stridor: Harsh, high-pitched, musical sound produced by turbulent airflow through partially obstructed airway Inspiratory Expiratory Biphasic Stertor: Low-pitched inspiratory sound from nose/pharynx (like snoring) 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

10 This 2 month old patient presents to your office Video: 10

12 Assessment strategies 1. Assess acuity! Is this evolving rapidly? Fever Drooling (new onset) Rapid change in cry or voice New food aversion New retractions/nasal flaring Body position (arching) Fatigue 12

13 Assessment strategies 2. Obtain Airway History/chronicity Acute? Progressive? Prior respiratory problems? ALTEs aspiration pneumonias croup like episodes History of prematurity History of intubation Difficult intubation? #? Length of time intubated? 13

14 Assessment strategies 3. Review associated symptoms Feeding adequacy and diet Failure to thrive Choking episodes Consistency of food? Liquids vs. solids? Frequent spitting up/reflux history Apneas Perioral cyanosis or blue spells 14

15 Assessment strategies 4. Exam Vitals with continuous pulse oximetry Assess work of breathing Accessory muscle use, retractions Quality of stridor Describe Pitch, intensity Inspiratory/biphasic/expiratory Improve with prone or side positioning? Worsen with crying/agitation/feeding? 15

16 Laryngomalacia Video: Laryngeal collapse during breathing 16

LARYNGOMALACIA- common Most common cause of inspiratory stridor in the newborn Typically begins after several weeks of life Increases with feeding, exertion Feeding problems common GERD common

17 LARYNGOMALACIA- common Most common cause of inspiratory stridor in the newborn Typically begins after several weeks of life Increases with feeding, exertion Feeding problems common GERD common due to negative intrathoracic pressures required for breathing Respiratory distress, apnea, and cyanosis may occur 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

18 Laryngopharyngeal reflux : signs Erythema Cobblestoning Pretreatment Severe Edema Edema + Erythema Normal After 6 months PPI Image from

Indicated for failure to thrive, prolonged feeding, recurrent ER visits, or cyanosis/severe apnea,

19 LARYNGOMALACIA Self limited disorder- parents can be counseled that 90% of cases resolve by age 2. Lots of assurance Reflux therapy Supraglottoplasty or temporary tracheostomy required in ~10% Indicated for failure to thrive, prolonged feeding, recurrent ER visits, or cyanosis/severe apnea, and rarely parental anxiety Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

20 This 2 month old patient presents to your office Video: Note: Biphasic stridor with lower pitch Difficulty feeding 20

21 Assessment: Localization of stridor Biphasic stridor: intermediate pitch Fixed lesion Glottis & Subglottis Extrathoracic (proximal) trachea 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

22 Tracheomalacia Primary Congenitally weak/insufficient tracheal cartilage Secondary Tracheal compression or weakening caused by Esophageal atresia Vascular rings/slings External Mass lesions Prior surgery (tracheostomy, TEF repair) 22

23 Management of tracheomalacia Primary: Similar to laryngomalacia will generally improve with time. Often associated with concurrent laryngomalacia Positive pressure ventilation/cpap Severe malacia may require temporary tracheostomy Secondary: depending on etiology may improve or worsen with time. Removal of mass lesions Vascular surgery Resection and reanastomosis of weak segment if isolated. (I.e. esophageal atresia site) 23

24 Tracheal compression 24

25 This infant presents to your office with recurrent croup, but no other URI symptoms: Video: recurrent croup patient 25

Often responds to nebulized epinephrine and oral/iv steroids Higher

26 Subglottic hemangioma biphasic stridor Looks, sounds, and acts like croup. Progressive symptoms starting in first few weeks of life. Often responds to nebulized epinephrine and oral/iv steroids Higher likelihood in patients with cutaneous hemangiomas but not always! Esp beard distribution hemangiomas 26

Subglottic Hemangioma: management Capillary proliferate rapidly then involute around age 5 Medical management: Propranolol (oral) New gold standard, typically begins working within days.

27 Subglottic Hemangioma: management Capillary proliferate rapidly then involute around age 5 Medical management: Propranolol (oral) New gold standard, typically begins working within days. Corticosteroids useful if propranolol contraindicated or in acute situations Surgical management: Intubation and/or tracheostomy may be required in severe cases. Intralesional injections of steroid Endoscopic or open Excision becoming less common 27

28 Same Patient History of prematurity and intubation History of intubation and RSV History of cardiac surgery and prolonged intubation Even have a history of no intubation Flexible endoscopy and see nothing 28

29 Subglottic stenosis biphasic stridor Congenital ( shelves / elliptical cricoid ) Acquired 29

30 Subglottic stenosis Cotton Myer Grading system: based on percentage luminal obstruction Grade I % Grade II % Grade III % Grade IV - 100% 30

31 Subglottic Stenosis: Management Depends on type of stricture and location Membranous (thin) acquired strictures Dilation CO2 laser or sharp excision + dilation Thick strictures, +/- cartilaginous component Bypass: Tracheostomy (bypass obstruction) Resect: Cricotracheal resection with primary anastomosis Augment: Laryngotracheal reconstruction with cartilage grafting 31

32 Balloon dilation 32

33 Open Surgical Management Augmentation 33

34 Open Surgical Management Bypass Resect 34

Other Causes of Biphasic Stridor 2013 Children's

36 Bilateral Vocal Fold Paralysis biphasic stridor Unilateral vocal fold paralysis does not commonly cause stridor evaluate for other causes! Bilateral vocal fold paralysis: progressive stridor as vocal cords migrate to a paramedian position Causes: Idiopathic, birth trauma, neurologic, hypoxemia at birth, iatrogenic Rule out arnold chiari malformation and hydrocephalus with MRI 36

37 Laryngeal Web biphasic stridor Rare Associated w/ Chromosome 22q11 deletion in 50% Often discovered or lysed with intubation. Thin webs : endoscopic repair Thicker webs: open surgery 37

38 Recurrent Respiratory Papillomatosis biphasic stridor 38

39 Other acquired lesions: biphasic stridor Laryngeal granuloma Subglottic cysts 39

40 1 year old presents with a funny wheeze Mom state that he is just not right Growing well Eats just fine On exam he appears healthy He has no inspiratory stridor He does have an expiratory noise, not quite a wheeze When he gets a cold it seems his mucous gets stuck and he can t cough it out 40

Tracheal Stenosis Congenital Acquired High

43 Other causes of expiratory stridor Foreign Body Distal tracheomalacia Bronchomalacia 43

44 2 year old present to the ED with stridor and barky cough and looks like this Note features: Biphasic stridor Often louder with inspiratory phase barky cough Viral Croup Video 44

of age Narrowest part of airway is at cricoid cartilage In children 1 mm of airway edema may

45 Viral Croup (laryngotracheobronchitis) Most common cause of stridor after neonatal period Most affected are children 6 mo.- 3 y.o Peak incidence 1-2 yrs. of age Narrowest part of airway is at cricoid cartilage In children 1 mm of airway edema may crosssectional area 50-60% Most cases occur late fall or early winter Para influenza 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

46 VIRAL CROUP Diagnosis- typically made clinically X-rays: If atypical or prolonged cases Obtain lateral neck films and PA CXR PA CXR in croup steeple sign 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

47 Management: Isolated Croup Typically supportive Oral/IV Corticosteroids and nebulized epinephrine can be helpful for severe symptoms 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 01/13 03/13

2 year old present to ED with croup symptoms for several days, but now with high fever, listless, elevated heart and respiratory rate Parents say that he scared them when he was trying to cough and

48 2 year old present to ED with croup symptoms for several days, but now with high fever, listless, elevated heart and respiratory rate Parents say that he scared them when he was trying to cough and could not seem to breath at all Bacterial tracheitis Often Staph superimposed after viral infection Humidification and antibiotics May need bronch,debridement and intubation especially younger children 48

49 More about recurrent croup. My child gets croup every time he gets a cold! Suspect Structural or functional ENT abnormality Subglottic lesion or stenosis Intubation history Hemangioma, foreign body, tumor Chronic laryngopharyngeal reflux Chronic aspiration- laryngeal cleft, vocal fold weakness Allergic/Spasmodic Research says everyone should be bronched and other saying only high risk need bronch 49

50 Child with one day history of sore throat, decreased oral intake, difficulty breathing, listless, fever, elevated heart rate. Video: Note: child looks very ill. stridor is variable; may be absent. Expiratory noises due to difficulty controlling secretions. 50

Epiglottitis/Supraglottitis Clinical Picture Less likely in infants, more common in older children and adults Decreased incidence in children secondary to HIB vaccine Onset

51 Epiglottitis/Supraglottitis Clinical Picture Less likely in infants, more common in older children and adults Decreased incidence in children secondary to HIB vaccine Onset rapid, patients look toxic Patients prefer to sit upright muffled voice, dysphagia, drooling, restlessness 2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

EPIGLOTTITIS: lateral neck film Normal Epiglottis 2013 Children's Mercy

Management of supraglottitis If losing airway, prepare for intubation Choose ETT one size smaller than usual Otherwise, start O2, obtain detailed history, IV

53 Management of supraglottitis If losing airway, prepare for intubation Choose ETT one size smaller than usual Otherwise, start O2, obtain detailed history, IV access. Do not try to examine or anesthetize the nose or throat in patient with symptomatic stridor as this may induce panic, laryngospasm and total airway obstruction 53

54 Stridor by location: Supraglottic Inspiratory stridor High pitched typically increases with exertion. (bernoulli s law) Differential laryngomalacia or supraglottic lesion Infectious- supraglotitis 54

55 Biphasic stridor Stridor by location: Glottic/Subglottic typically increases with exertion. Ddx: Child Foreign body obstruction Vocal fold paralysis Subglottic/glottic stenosis Cyst or granuloma Tracheomalacia Tumors: papilloma, hemangioma Infectious - croup 55

56 Low biphasic or expiratory stridor Stridor by location: typically increases with exertion. Ddx: Tracheomalacia Vascular ring Tracheal stricture Complete tracheal rings Foreign body Trachea 56

57 Key points Paying attention to quality of stridor can help point to the source Most common cause of stridor in infants is laryngomalacia but few will require surgery Flexible fiberoptic scope exam can help determine etiology from level of vocal cords and up. 57

Disclosure Statement The Squeaky Baby

Disclosure Statement The Squeaky Baby A Pediatric Provider s Guide to Stridor in the Young Child I have no actual or potential conflict of interest in relation to this program. Daniel Jensen, MD Assistant