STRIDOR ent

Stridor

Definition: Noisy respiration produced by turbulent airflow through narrowed air passages.

Note: Stridor is a physical sign, not a disease. Always attempt to discover the cause.

Types & Site of Obstruction

Type Site of Lesion Examples
Inspiratory Supraglottis or Pharynx Laryngomalacia, Retropharyngeal abscess.
Expiratory Thoracic Trachea, Bronchi Bronchial foreign body, Tracheal stenosis.
Biphasic Glottis, Subglottis, Cervical Trachea Laryngeal papillomas, Vocal cord paralysis, Subglottic stenosis.

Aetiology

Common causes in infants and children:

1. Head & Neck Sites

  • Nose: Choanal atresia (Newborn).
  • Tongue: Macroglossia (Cretinism, Haemangioma), Lingual thyroid.
  • Mandible: Micrognathia (Pierre-Robin syndrome) → Tongue falls back.
  • Pharynx: Adenotonsillar hypertrophy, Retropharyngeal abscess, Dermoid.

2. Larynx

  • Congenital: Laryngeal web, Laryngomalacia, Cysts, Subglottic stenosis.
  • Inflammatory: Epiglottitis, Laryngotracheitis (Croup), Diphtheria.
  • Neoplastic: Haemangioma, Juvenile multiple papillomas.
  • Traumatic: Foreign bodies, Intubation oedema.
  • Neurogenic: Vocal cord paralysis.
  • Misc: Laryngismus stridulus, Tetany.

3. Trachea & Bronchi

  • Congenital: Atresia, Stenosis, Tracheomalacia.
  • Traumatic/Inflammatory: Foreign body, Tracheobronchitis, Post-intubation stenosis.

4. Lesions Outside Respiratory Tract

  • Congenital: Vascular rings (Double aortic arch), Oesophageal atresia, Cystic hygroma.
  • Inflammatory: Retro-oesophageal abscess.
  • Traumatic: Foreign body in Oesophagus (Secondary tracheal compression).

Management: History

Crucial points to elicit:

  • Time of Onset: Congenital vs. Acquired.
  • Mode of Onset:
    • Sudden: Foreign body, Oedema.
    • Gradual: Laryngomalacia, Papillomas, Hemangioma.
  • Duration: Short (Infection/FB) vs. Long (Anomalies).
  • Relation to Feeding: Aspiration suggests Laryngeal paralysis, TE fistula, or Vascular ring.
  • Cyanotic Spells: Urgent airway maintenance needed.

Physical Examination

1. Respiratory Distress: Look for recession in suprasternal notch, sternum, epigastrium.

2. Character of Sound (Localizing Value):

  • Snoring/Snorting: Nasal or Nasopharyngeal cause.
  • Gurgling + Muffled voice: Pharyngeal cause.
  • Hoarse cry/voice: Laryngeal cause (Vocal cords).
    *Note: Cry is normal in Laryngomalacia & Subglottic stenosis.
  • Expiratory Wheeze: Bronchial obstruction.

3. Positional Variation:

Stridor disappears in Prone Position
↓
Suggests: Laryngomalacia, Micrognathia, Macroglossia

4. Flexible Fibreoptic Laryngoscopy:

  • Outdoor procedure; Topical anaesthesia.
  • Diagnoses: Laryngomalacia, VC paralysis, Papillomas, Webs.

Investigations

  1. X-ray Neck/Chest (PA & Lateral): For foreign bodies.
  2. Fluoroscopy: For radiolucent foreign bodies (Inspiratory/Expiratory phases).
  3. CT Scan (with contrast): Mediastinal masses, Vascular anomalies (e.g., Sling left pulmonary artery).
  4. Angiography: Pre-op for vascular rings.
  5. Oesophagogram: For TE fistula or aberrant vessels.

Direct Laryngoscopy & Bronchoscopy

Setting: Operation Theatre (General Anaesthesia).

Procedure Steps:
  1. Preparation: Monitor O2 saturation, ECG. Expert anaesthetist required.
  2. Induction: Insufflation. Patient kept on Spontaneous Respiration.
  3. Examination:
    • Quick Direct Laryngoscopy.
    • Insert Bronchoscope (Subglottis → Bronchi).
    • Remove crusts/Foreign bodies; Collect secretions.
  4. Microlaryngoscopy: Can be done without intubation (Oxygen via catheter) to visualize larynx with magnification.

Treatment

Treat the exact cause once diagnosis is established.

📚 Source: Dhingra ENT | Chapter 59

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