Stridor and Upper Airway
Obstruction
Kevin R Schwartz
Massachusetts General Hospital
Department of Pediatrics
Stridor: Definition
Extrathoracic obstruction:
-Supraglottic: epiglottitis, retropharyngeal
abscess, diptheria, anaphylaxis
-Glottic/Subglottic: croup, laryngomalacia,
vocal cord paralysis
Intrathoracic obstruction:
-foreign body aspiration, compression by
lymph nodes or tumor, vascular wings/webs
Stridor: Differential Diagnosis
• State the main ideas you’ll be talking about
Viral Croup
• Pathophysiology: viral infection with measles,
parainfluenza type I and 3, influenza A/B, RSV or
metapneumovirus causeslaryngo tracheobronchitis.
Edema in the subglottic region, which is bound by
the cricoid cartilage causes upper airway narrowing.
• Epidemiology: Mainly affects children aged 6mos to
3yrs with peak incidence in second year of life.
Boys>girls.
Viral Croup
• Clinical Presentation:
Often antecedent URI symptoms x12-48 hours
followed by onset of “barky” characteristic cough,
hoarse voice, stridor and respiratory distress, may
be accompanied by fever as high as 40 C but
patient should NOT drool or appear toxic
• Physical Examination Findings: Observe pt’s
positioning (?sniffing position), mental status,
retractions/flaring, cyanosis, stridor at rest vs. w/
agitation, hydration status,
Viral Croup
• Labs/Studies:
Labs uneccessary for diagnsosis and
obtaining bloodwork may be distressing to
patient, worsening condition.
AP and lateral neck radiographs:
Viral Croup: Treatment
Viral Croup: Treatment
Viral
Croup:
Treatment
Bjornson, CL et al. Croup.
The Lancet 2008;371:329339
d/c home
admit
Diptheria: Pathophysiology and
Epidemiology
• Pathophysiology: Corynebacterium
diptheriae(gram-positive pleomorphic bacillus)
infects upper respiratory tract and, after 2-4 days
incubation, elaborates a toxin which causes
necrosis of mucous membranes and formation of
pseudomembranes. The toxin may also affect
heart, nerves and kidneys.
• Epidemiology: endemic in Africa, Asia, South
America. V. rare in immunized populations,
mostly affecting children <15y/o
Diptheria: Clinical Presentation
• Nasal Diptheria(most often in infants): mild
rhinorrhea which progresses to malodorous,
mucopurulent drainage
• Tonsillar/Pharyngeal Diptheria: begins w/ malaise,
low-grade fever and pharyngitis. Membrane
appears within 1-2 days with cervical
lymphadeneitis and edema
• Laryngeal Diptheria: often an extension of
pharyngeal infection, presents similar to croup.
• Complications:
- Neuro: paralysis of soft palate or diaphragm,
peripheral neuropathies, loss of DTRs.
-Cardiac: myocarditis may occur anywhere from 1st
to 6th week of illness, usually transient
Diptheria: Clinical Presentation
In general, attempts to remove the membrane result in
bleeding.
Diptheria: Treatment
Diptheria: Treatment
- If signs of incipient airway obstruction, tracheostomy should be performed.
Orotracheal intubation is an alternative BUT may dislodge the pseudomembrane and
fail to relieve the obstruction.
Diptheria: Complications and
Public Health Measures
Foreign Body
• Epidemiology: Seen in children > 6m/o,
with incidence peaking ~2-3 y/o
• Clinical Presentation: Acute onset of stridor
in the child with no antecedent illness or
fever of the appropriate age group.
• Labs/Studies: Radio opaque objects may be
visible on X ray.
Retropharyngeal Abscess:
Pathophysiology and
Epidemiology
• Usually an antecedent pharyngitis causes
suppuration of retropharyngeal lymph nodes with
subsequent abscess formation in the
retropharyngeal space.
• Occur most commonly in children aged 2 to 4y/o,
majority of cases occur in children <6y/o
• Microbiology includes: Strep pyogenes, Staph
aureus, Haemophilus, and respiratory anaerobes.
Retropharyngeal Abscess:
Clinical Presentation
• Clinical Presentation:
Fever, dysphagia, drooling, odynophagia,
stridor. Often with unwillingness to move
the neck, trismus is unusual. A fluctuant
mass may be palpable in posterior
pharyngeal wall.
Retropharyngeal Abscess: Imaging
• Lateral neck film:
Should be obtained
with neck in
extension during
inspiration.
• Retropharyngeal
space considered
widened if wider
than adjacent
vertebral body or
greater than 7mm at
C2 or 14mm at C6
Retropharyngeal Abscess: Management
• Antibiotics:
-Ampicillin/Sulbactam 50mg/kg IV q6 until
afebrile then Amox/Clav 45mg/kg PO q12
or clindamycin 13mg/kg q8 x 14days total.
• Surgery:
-indicated for large abscesses and those
which do not respond to antibiotics alone.
Peritonsillar Abscess:
Pathophysiology and Epidemiology
• Antecedent pharyngitis progresses to
abscess formation in superior pole of tonsil.
Microbiology is the same as that for
retropharyngeal abscess.
• May occur at any age but most common in
young teenagers
Peritonsillar Abscess: Clinical
Presentation
• Typical presentation is severe sore throat,
fever and a muffled “hot potato” voice.
Drooling may be present, trismus is
common
• Physical Examination: Unilateral tonsil
swelling or visible abscess in tonsil with
uvular deviation to the other side, exam
often limited by trismus.
Peritonsillar Abscess: Management
• Antibiotics: Same as for retropharyngeal abscess
• Surgery: Older more cooperative child may be
able to undergo needle aspiration or simple I and
D as an outpatient. Younger children unable to
cooperate require drainage in the OR.
• If there have been prior episodes of abscess or
recurrent pharyngitis, a quinsy tonsillectomy is
indicated.
• Antibiotics alone usually inadequate treatment,
however a 24 hour admission for antibiotics,
hydration and analgesia may be trialled if the
patient’s airway is not compromised.
Complications of Deep Neck
Infections
•
•
•
•
•
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Airway obstruction
Septicemia
Thrombosis of the internal jugular vein
Mediastinitis
Carotid artery rupture
Lemierre’s Syndrome (infection of vessels
of carotid sheath causing bacteremia and
metastatic spread of infection to lungs and
mediastinum.)
Epiglottitis: Epidemiology and
Pathophysiology
• Pathophysiology: Cellulitis of the epiglottis and
aryepiglottic folds with edema causing obtruction
of airflow during inspiration. Most cases 2/2 H.
flu type B, other pathogens include: H. flu other,
Strep pneumo, Staph aureus, Strep pyogenes
• Most cases occur in children 1-5y/o with a peak at
3y/o. Hib vaccine has dramatically reduced
incidence.
Epiglottitis
• Clinical Presentation:
ABRUPT onset of high fever(>38.8), severe sore
throat, dysphagia and drooling. Child generally
appears toxic and generally sits with neck
hyperextended and chin thrust forward.
• Physical Exam: stridor not generally present or not
prominent, increase WOB not apparent, but
inspiratory distress. Generally, direct visualization
of throat is contraindicated as this may cause
agitation precipitating complete airway
obstruction. Leukocytosis >20K generally present
on CBC with left shift.
Epiglottitis: Imaging
Lateral neck film
shows “thumb
sign”
Epiglottitis: Management
• 1) Airway – Patient should be
nasotracheally intubated in an OR setting
with a team standing by who can perform
tracheostomy. Usually patient remains
intubated x 2-3 days.
• 2) Antibiotics: Oxacillin/Nafcillin(50mg/kg
IV Q6) AND Ceftriaxone 50mg/kg IV QD
x7-10 days.
References
• Wald, E et al. Peritonsillar and Retropharyngeal
Abscess in Children. www.uptodate.com 2008
• Woods, C et al. Epiglottitis. www.uptodate.com
2008
• Quintero, D et al. Assesment of stridor in children.
www.uptodate.com 2008
• Pocket Book of Hospital Care for Children, WHO
2005
• Schwartz, W The 5-Minute Pediatric Consult.
Philadelphia: Lipincott William and Wilkins 2005