STRIDOR
ANNE ASPIN 2010
Common causes
• Laryngomalacia – 60%
• Congenital subglottic stenosis
• Vocal cord palsy - unilateral, birth trauma
– temporary
• Bilateral vocal cord palsy assoc other
congenital anomalies
Morimoto et al (2004)
• 97 patients 1991-2001
• Laryngomalacia 32%
• Vocal cord palsy and laryngeal stenosis
22%, within 2/12, severe dyspnoea
• Haemangioma or papilloma 11%
• Cystic disease 7%
cont
• 2 / 31 of laryngomalacia and 2 / 22 VCP
had neuromuscular disorders
• 3 of VCP complicated by laryngeal
stenosis
• 33 / 97 Tracheostomy
• Sometimes stridor is the only presenting
symptom. Past history important
Investigation
• Rigid or direct microlaryngoscopy –
general anaesthetic.
• Flexible fibre- optic laryngoscope, neonate
awake (first line choice now)
Case history
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6/12 girl
Fever, coughing
Inspiratory stridor
Palpable neck swelling, bulging
pharyngeal wall
• Limited movement of neck
• ? spasmodic croup, lymphadenitis coli
• Found to be retro pharyngeal abscess
Treatment
• Oral incision
• Drainage of abscess
• Antibiotics
Unilateral vocal cord paralysis
• Stridor
• Laryngospasm
• Dyspnoea
• Cause by abnormal innervation of nerve
branches into adductor fibers
Cases
• Post Thyroid surgery
• Post cervical disc surgery
• After Herpes simplex virus with cranial
nerve involvement
• Fire optic laryngoscopy showed affected
vocal cord immobile
Treatment
• Laryngeal electromyography showed
evidence of reduced but intact voluntary
motor conduction in thyroarytenoid
muscle.
• Botox injections
Research
Objective
• Determine stridor at rest after oral
Prednisolone 1mg/kg
• And whether quick response after mild
croup
Method
• Retrospective explicit chart review of
children over 1 year of age admitted to a
teaching hospital
• Patient demographics
• Croup scores at AE
• Duration of stridor at rest after steroids
Results
• 188 cases analysed
• Median duration at rest was 6.5 hrs, range
0.5 hrs- 82 hrs
• Patients with low score at AE recovered
quicker in response to steroids, early
discharge home.
Amphotericin induced stridor
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Adverse effects reported Amphotericin B
Dyspnoea
Tachypnoea
Bronchospasm
Haemoptysis
hypoxia
Objective
• To review mechanism of action and
reports of respiratory adverse effects for
Amphotericin B, the liposomal
preparations for Amphotericin B and the
differential diagnosis of stridor
• Medline search 1966 – 2002 looking for
possible mechanisms and
immunoregulatory effects of Ampho B
Results
• Amphotericin B shows increase in tumour
necrosis factor alpha (TNF alpha)
concentrations in macrophages.
• Induces prostaglandin E2 synthesis,
increasing production of interleukin1 beta
in mononuclear cells
Conclusion
• Amphotericin B induces production of TNF
alpha, interferon gamma and interleukin 1
beta which have toxic effects.
Medicines for children
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Test dose infused over 30 mins – 100mcg
Renal impairment
Low serum pott, mag, phos
Lft’s
arrhythmias
Pulmonary reactions if Amph and
leucocyte Tx.
References
• Bent J (2006). Pediatric laryngotracheal obstruction : current
perspectives on Stridor. The Laryngoscope. 116 (7) : 1059 - 1070
• Berghout E, Peetsold M, Verboom A, Plotz F (2005). Inspiratory
Stridor in a Child with a Retropharyngeal Abscess Instead of the
Normally Expected Sublottic Laryngitis. Ned Tijdschr Geneeskd.
149(9):478-81 (Article in Dutch)
• Kavshal M, Upadhyay A, Aggarwal R, Deorari A (2005). Congenital
Stridor Due to Bilateral Vocal Cord Palsy. Indian Journal of
Paediatrics. 72(5): 443-4
• Lowery M, Greenberger P (2003) Amphotericin Induced Stridor: A
Review of Stridor, Amphotericin Preparations, and their
Immunoregulatory Effects. Annals of Allergy Asthma Immunology.
91(5): 460-6
References cont.
• Majumdar S, Bateman N, Bull P (2006). Paediatric Stridor. Archives
of Disease in Childhood, Education Practice Edition. 91 : ep101 ep105.
• doi 10.1136/adc.2001.066902
• Morimoto N, Kawashiro N, Tsuchihashi N, Taiji H (2004). Congenital
Laryngeal Stridor. Nippon Jibinkoka Gakkai Kaiho. 107(7):690-4
• Moumoulidis I, Gray R, Wilson T (2005). Outpatient Fibre-optic
Laryngscopy for Stridor in Children and Infants. European Archives
Otorhinolaryngology. 262(3): 204-7
• Parker R, Powell C, Kelly A (2004). How Long Does Stridor At Rest
Persist in Croup After The Administraton of Oral Prednisolone?
Emergency Medicine. Vol 16, Iss 2, p135
• Tewfik T, Sobol S (2010). Congenital malformations, larynx.
http://emedicine.medscape.com/article/867630-overview
• Woo P, Mangaro M (2004). Aberrant Recurrent Laryngeal Nerve
Innervaton As A Cause of Stridor and Laryngospasm. Annals of
Otology, Rhinology, Laryngology. 113(10): 805-8