Differential Diagnosis: Infantile Stridor

Differential Diagnosis: Differential Diagnosis: Infantile Stridor Infantile Stridor

Amy Stinson

MS IV

KCUMB

StridorStridor

An expression of partial respiratory tract obstruction 2° to external compression or partial occlusion within the airway1

Character & Intensity:– Site & Degree of obstruction– Airflow velocity & Pressure gradient – Stridor

StridorStridor

Inspiratory – problem at or above vocal cords, usually high pitched at cords, low pitched above cords– Laryngomalacia, unilateral cord paralysis

Expiratory – problem is below cords – tracheobronchial tree, more prolonged– Vascular compression

Biphasic – usually subglottic– Subglottic stenosis, subglottic hemangioma, bilateral

cord paralysis

LaryngomalaciaLaryngomalacia

Most common cause of stridor Most common congenital laryngeal abnormality “Congenital flaccid larynx” or “Inspiratory

laryngeal collapse” Inspiration:

– Prolapse of supraglottic structures– Extreme infolding of “Omega-shaped” epiglottis and

aryepiglottic folds


Photographs show a case of laryngomalacia during expiration (A) and inspiration (B). Note the infolding of the aryepiglottic folds.

www.entjournal.com/htmlDocs/Images/ped-0209.jpg


Normal Vs Abnormal www.meei.harvard.edu/.../images/laryngomal.jpg


Signs & symptoms:– Inspiratory stridor within a few days of birth– Initially mild more pronounced with a peak at 6 –9

mo4

– Stridor is worse when supine and neck flexion: better when prone and neck extension1

– Symptoms worse when sleeping, feeding, or on exertion

– Most commonly – mild stridor that is self limited– Most cases spontaneously resolve by 2 yrs of age


More Severe:– Severe stridor, apneic episodes, feeding

problems, & FTT pulmonary HTN & cor pulmonale

Presumed etiologies:4

– Abnormally pliable supraglottic cartilage– Neuromuscular abnormalities– GER


DX:– Endoscopy under local anesthesia– Laryngotracheobronchoscopy to R/O other path– Polysomnography to detect desaturations w/hypoxia or

hypercapnia Treatment:

– OBSERVE– Temp trach in severe cases– Sx for 10% supraglottoplasty which reduces amount of

laryngeal mucosa– Anti-reflux meds


“State Dependent” Laryngomalacia6

– Neurogenic factors would cause at states of awareness – often paradoxical.

– Direct stimulation resolves

Discoordinate Pharyngolaryngomalacia6

– Assoc. with severe collapse and poor outcomes– Need CPAP & nasal stents and poss. trach

Vocal Cord ParalysisVocal Cord ParalysisSecond most common congenital

abnormality of larynx4

Congenital & Bilateral is most common presentation with stridor and is usually seen in males4

Unilateral paralysis on Left seems to be more common but less associated with stridor6

Check nucleus ambiguous & supranuclear tracts plus Vagus nerve & branches3

www.meei.harvard.edu/.../images/laryngomal.jpg

Vocal Cord ParalysisVocal Cord Paralysis

Etiology:– Idiopathic– CNS: Arnold-Chiari malformation– CV: Congenital abnormalities of heart & great vessels

of Sx correction of– Trauma: Repair of TE fistula, birth trauma, head injury– Inflammatory: Guillian-Barre– PNS: myotonic dystrophy, myasthenia gravis


Signs & Symptoms:– Asymp acute airway

obstruction– High pitched

inspiratory stridor, apnea, cyanosis

– Hoarse, breathy cry– Weak cough– All more common with

bilateral palsy– www.meei.harvard.edu/.../images/laryngomal.jpg


Dx:– Fiberoptic endoscopy– Laryngotracheobronchoscopy– MRI

Tx:– Unilateral: Observe, Speech therapy– Bilateral: Tracheotomy, frequent endoscopies,

no Sx for at least a year – maybe longer

Subglottic StenosisSubglottic Stenosis

3rd most common congenital cause of stridor

Subglottis is the narrowest part of airway & the only complete ring (cricoid cartilage)

Congenital & Acquired www.meei.harvard.edu/.../images/

laryngomal.jpg

Subglottic StenosisSubglottic Stenosis2,4,52,4,5

Congenital:– Soft tissue stenosis or cartilaginous stenosis– Severe: stridor at birth– Mild: intermittent stridor & resp tract infections

Acquired:– Neonatal intubations, external trauma, high trach,

infection, burns– Repeated failure of attempted extubation– Gradual onset of stridor after extubation

Subglottic StenosisSubglottic Stenosis1,21,2

Stenosis if < 4mm in full term infant; < 3mm in preterm infant

Meyer-Cotton Grading– I: 0-50%– II: 51-70%– III: 71-99%– IV: no detectable lumen– www.meei.harvard.edu/.../images/laryngomal.jpg

Subglottic StenosisSubglottic Stenosis

Decrease risk:– Uncuffed,

polyvinylchloride tubes– Smaller tubes– Nasotracheal intubation

= less friction– www.meei.harvard.edu/.../images/laryngomal.jpg

Subglottic StenosisSubglottic Stenosis Treatment:

– Observe: Grade I, II, airway can increase with growth of child

– Tracheotomy: until reconstruction– Endoscopic: Laser can decrease granulation tissue,

can actually worsen with long term scarring– Laryngotracheal reconstruction: requires cartilage

grafts and stents, enlarges stenosed portion– Cricotracheal resection: excises stenosed portion,

higher success rate, but increased risk of recurrent laryngeal nerve damage

Subglottic HemangiomaSubglottic Hemangioma

A soft, compressible, bluish tumor below true vocal cords

Female > male 2:1 50% have cutaneous

hemanigioma Subglottis is most common

location – usually unilateral Tend to proliferate from birth

– 1 yr then involute. Usually resolved by 5 yrs.

www.childrensenthouston.com/images/laryngomal

Subglottic HemangiomaSubglottic Hemangioma Signs & Symptoms:

– Intermittent stridor that progresses to biphasic stridor with dyspnea and cyanosis

– Originally dx as croup


Subglottic HemangiomaSubglottic Hemangioma

Treatment– Observe: if small– Tracheotomy until involution– Steroids – possible estrogen receptor involution– Laser therapy – good for hemostasis– Surgical excision – becoming more common because of

stenosis from trach– Interferon – alfa-2a has antiangiogenic activity when

hemangioma in proliferate phase

Less Common Causes of Less Common Causes of StridorStridor

Dysphagia lusoriaLaryngeal cystsCongenital laryngeal websLaryngeal foreign bodiesRespiratory papillomatosis

Dysphagia LusoriaDysphagia Lusoria

“Dysphagia of unclear etiology” Congenital anomalies of aortic arch:

– Double aortic arch– Anomalous origin of R or L subclavian artery– Kommerell’s Diverticulum – saccular aneurysmal

dilation at of ARSA or ALSA – If LA or ductus present between subclavian and

pulmonary complete vascular tracheobronchial ring Presents as respiratory distress, dysphagia &

stridor

Dysphagia LusoriaDysphagia Lusoria

Dx:– CXR– Barium swallow w/

esophogram

Tx:– Sx repair through

lateral thoracotomy with lung separation

Laryngeal CystsLaryngeal Cysts2,42,4

Rare cause of Stridor More superficial Fluid filled Ductal: MC, originate

from obstruction of submucous gland

Saccular: in laryngeal ventricles, usually congenital


Congenital Laryngeal Congenital Laryngeal WebsWebs1,2,41,2,4

Embryology: Failure of complete recanalization

Most common in anterior glottis (fusion of ant portion of vocal cords)

Abnormal cry & stridor Incise thin webs Excise and stent severe

webs www.meei.harvard.edu/.../images/

laryngomal.jpg

Laryngeal Foreign BodiesLaryngeal Foreign Bodies44

MC in kids 1-3 yrsMost inhaled objects pass through larynx

and lodge distallyIf lodged in larynx & partially obstructed

– Stridor, hoarseness, and cough– Confirm w/X-ray– Remove in OR

Respiratory PapillomatosisRespiratory Papillomatosis1,2,41,2,4

Most common neoplasm of larynx in children Dx: most common btw 2 –5 yrs Increased risk:

– First born, vaginal delivery, teenage mother– HPV 6, 11

Gradual progression of dyspnea and stridor

Tx: surgical ablation w/CO2 laser webs & scarring

ReferencesReferences

1. Rowe, LD. Pediatric Airway Obstruction. Otolaryngology – Head and Neck Surgery. Current Surgery. Chap 38.

2. Kirby, GS. et al. Respiratory Tract and Mediastinum. Current Pediatrics. Chap 18. 3. Gormley, PK. et al. Congenital vascular anomalies and persistent respiratory

symptoms in children. International Pediatric Journal of Otorhinolaryngology. Nov 1999: 51:23-31.

4. Lange, et al. Current Opinion in Otolaryngology and Head and Neck Surgery. Lippincott, Wilkins and Williams. Dec 1999. p 349.

5. Mossad, E. et al. Diverticulum of Kommerell: A review of a Series and a Report of a Case with Tracheal Deviation Compromising Single Lung Ventilation. Anesth Analog. 2002:94:1462-4

6. Bent, J. Pediatric Laryngotracheal Obstruction: Current Perspectives on Stridor. Laryngoscope. 2006: 116: 1059-1070

7. Sisk, EA. et al. Tracheotomy in Very Low Birth Weight Neonates: Indications and Outcomes. Laryngoscope. 2006: 116: 928-933

Differential Diagnosis: Infantile Stridor

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