The tumor, as it grows, may cause tracheal compression and stridor. Subglottic Hemangioma. A subglottic hemangioma occurs more commonly in girls, with a female-to-male ratio of No color change or, at most, a slight bluish discoloration is evident.
It is frequently associated with hemangiomas elsewhere on the body. The stridor is biphasic and exaggerated by crying or straining as the lesion tends to become engorged. Laryngeal Papilloma. This is the most common laryngeal neoplasm in children and usually results from vertical transmission of human papillomavirus at birth.
Usually multiple, papillomas most commonly occur in the vocal cords and ventricular bands but can involve any part of the larynx. They are most common in children between two and four years of age. The usual presenting symptom is hoarseness, but some patients have stridor and other signs of laryngeal obstruction. Angioneurotic Edema. Angioneurotic edema may result in acute swelling of the upper airway with resultant stridor and dyspnea.
Swelling of the face, tongue or pharynx may also be present. Laryngospasm Hypocalcemic Tetany. Hypocalcemia may rarely cause laryngospasm and stridor. Psychogenic Stridor. Stridor may be caused by emotional stress or it may be a manifestation of a conversion disorder. Vocal cord malfunction associated with emotional stress may result in inspiratory or expiratory stridor. Characteristically, the onset of stridor is sudden but without the expected amount of distress. The neck is often held in a flexed position rather than in an extended position.
Tracheomalacia is characterized by abnormal tracheal collapse secondary to inadequate cartilaginous and myoelastic elements supporting the trachea. Tracheal narrowing occurs with expiration and causes stridor.
The stridor is usually aggravated by respiratory tract infections and agitation. Bacterial Tracheitis. Bacterial tracheitis is usually caused by Staphylococcus aureus , although it can also be caused by H. Most patients are younger than three years of age. Bacterial tracheitis usually follows an upper respiratory tract infection.
The patient then becomes seriously ill with high fever, toxicity and respiratory distress. External Compression. Tracheal compression may result from vascular anomalies such as double aortic arch, right aortic arch with left ligamentum arteriosum, anomalous innominate artery, anomalous left common carotid artery, anomalous left pulmonary artery or aberrant subclavian artery. The child may prefer to keep the neck hyperextended. The stridor resulting from tracheal compression is often aggravated by feeding.
A thorough history Table 2 and physical examination Table 3 are important in the evaluation of children with stridor. Figure 3 presents an algorithm helpful in evaluating stridor in children. Vocal cord paralysis, congenital lesions such as choanal atresia, laryngeal web and vascular ring. Structural lesion such as laryngomalacia, laryngeal web or larynogotracheal stenosis. Tracheoesophageal fistula, tracheomalacia, neurologic disorder, vascular compression.
Epiglottitis, foreign body in esophagus, retropharyngeal or peritonsillar abscess. Glottic or subglottic lesion Extrinsic obstruction at or above larynx Information from references 12 and Adapted with permission from Handler SD.
Textbook of pediatric emergency medicine. Anteroposterior and lateral radiographic views of the neck are useful in the assessment of adenoidal and tonsillar size, epiglottic size and shape, retropharyngeal profile and subglottic and tracheal anatomy. The lateral neck radiograph must be taken with good extension of the neck and during inspiration so that the pharyngeal soft tissues are not mistaken for a retropharyngeal mass.
If foreign body aspiration is suspected and the preliminary films are negative, inspiratory and expiratory films should be obtained to look for air trapping behind the foreign body, producing a hyperlucent lung field in the ipsilateral side and a shift of the mediastinum to the opposite side.
A barium swallow is a useful method if vascular compression or gastroesophageal reflux is suspected. Gastrografin should be used as the contrast medium if tracheoesophageal fistula is suspected.
Videofluoroscopy is useful in the diagnosis of tracheomalacia, foreign body aspiration and vocal cord dysfunction. Computed tomographic CT scan and magnetic resonance imaging MRI may be obtained to visualize the airway and the surrounding soft tissue structures, including any evidence of vascular compression.
Direct examination of the airway is often necessary to confirm the diagnosis and is essential in children with persistent stridor. Flexible fiberoptic bronchoscopy is widely used in the evaluation of airways in children. However, rigid bronchoscopy performed under general anesthesia gives a better view of the airway, especially the part below the level of the vocal cords.
Rigid bronchoscopy also allows tissue biopsy and removal of foreign bodies using forceps. A complete blood count is useful if an infection is suspected.
Determination of the erythrocyte sedimentation rate is helpful in assessing for the presence of an infection. Depending on the degree of respiratory distress, arterial blood gas determination may be necessary to assess the degree of hypoxia and ventilatory status. An electrocardiogram and echocardiogram are indicated if significant heart murmurs are present or when structural heart disease is suspected.
The airway should be established immediately in children with severe respiratory distress or actual airway obstruction. This can be done by endotracheal intubation. After adequate ventilation is achieved by intubation, tracheostomy can be performed if deemed necessary. Supportive measures may include oxygen, humidified air, intravenous fluids, suction and aerosol treatments with steroids and beta-adrenergic drugs.
Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. He completed a residency in pediatrics at the University of Calgary.
Cho graduated from the University of Alberta in Edmonton, Alberta, and completed a residency in family medicine at the Royal Alexandra Hospital, also in Edmonton.
Address correspondence to Alexander K. Leung, M. Reprints are not available from the authors. The authors thank Dianne Leung for expert secretarial assistance and Sulakhan Chopra of the University of Calgary Medical Library for assistance in the preparation of the manuscript.
Simon NP. Evaluation and management of stridor in the newborn. Clin Pediatr. Clough J. Managing stridor in children. Stridor in the infant and child. Assessment, treatment. AORN J. Skolnik N. J Fam Pract.
Leung AK, Jadavji T. Polysaccharide vaccine for prevention of Haemophilus influenzae type b disease. J Roy Soc Health. Orenstein DM. Acute inflammatory upper airway obstruction. Berg E. Sobol S. The role of airway fluoroscopy in the evaluation of children with stridor.
Arch Otolaryngol Head Neck Surg. Stridor Noisy Breathing. Contact Us. Contact Us Online. International Patients. The timing and the sound of your child's noisy breathing provides clues to the type of airway disorder: Inspiratory stridor occurs when your child breathes in and it indicates a collapse of tissue above the vocal cords.
Expiratory stridor occurs when your child breathes out and it indicates a problem further down the windpipe. Biphasic stridor occurs when your child breathes in and out, and it indicates a narrowing of the subglottis, the cartilage right below the vocal cords.
The airway doctor may recommend one or more of these diagnostic tests: Flexible laryngoscopy — A test in which the doctor passes a tiny tube with a camera and light at the end through the nose and into the airway to look for problems.
Plain X-ray, airway fluoroscopy, barium swallow, and CT scan of the chest — Films that can help the doctor further evaluate the noisy breathing.
Children with bacterial tracheitis will usually require intravenous antibiotics. Around 80 percent of children will also require a breathing tube and 94 percent will need to stay in an intensive care unit.
A bacterial infection causing inflammation of the epiglottis, or soft tissue that closes off the windpipe, can be life-threatening. Though rare now, children between 2 and 6 years of age are most often affected by epiglottitis. In most cases, a child with epiglottitis will require oxygen and a breathing tube and will need to stay in a hospital. Doctors may also need to give them antibiotics, anti-inflammatory medications, and intravenous fluids.
To make a diagnosis, a doctor will begin by performing a physical exam and taking a detailed medical history. Treatment for stridor involves identifying and treating the underlying cause of the airway obstruction. A family doctor may also refer someone to an ear, nose, and throat or ENT specialist for further evaluation.
Some causes of stridor can lead to respiratory failure if treatment is delayed, so it is vital for a person with stridor to visit a doctor quickly for a diagnosis.
In many cases, a doctor can treat an airway obstruction that is responsible for stridor with medication or surgery. Vocal cord paralysis occurs when one or both vocal cords cannot move. It is often the result of nerve damage, and it can cause various complications….
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