1. Presented by : Anna

2. Stridor is :
•Harsh vibration sound,
•Different pitch (high, low)
•Produced by turbulent airflow through a
narrowed/obstructed airway
(upper respiratory tract – nose, larynx, trachea).
Stridor may occur during the following respiratory phases :
Inspiratory phase = suggest airway obstruction above glottis
Expiratory phase = suggest obstruction in lower trachea
Biphasic (both inspiratory & expiratory) = suggest glottic/subglottic
lesion.

3. •An infant or child’s airway lumen is naturally
narrower/smaller than adults.
•Therefore, any minor reductions to this airway
diameter (such as inflammation, mucosal edema,
Stridor can occur at the following places: foreign object, collapsing epiglottis) can result in
1. Nose & Mouth further narrowing or obstruction of the airway.
2. Larynx (Epiglottis, Supraglottis, •Due to this narrowing, it causes an exponential
Glottis,Subglottis) increase in airway resistance which makes it
3. Trachea. significantly difficult for the child to breathe.

4.  According to Site of Obstruction
 Nose and pharynx
Choanal atresia

 Lingual thyroid or thyroglossal cyst ACUTE
 Macroglossia


Micrognathia
Hypertrophic tonsils/adenoids
• Acute laryngo-
 Retropharyngeal or peritonsillar abscess
 Larynx tracheobronchitis (Croup)
 Laryngomalacia


Laryngeal web, cyst or laryngocele
Laryngotracheobronchitis (viral croup) • Acute epiglottitis
 Acute spasmodic laryngitis (spasmodic croup)


Epiglottitis
Vocal cord paralysis
• Foreign body inhalation
 Laryngotracheal stenosis


Intubation
Foreign body
• Retropharyngeal abscess
 Cystic hygroma
 Subglottic hemangioma
 Laryngeal papilloma
 Angioneurotic edema
 Laryngospasm (hypocalcemic tetany)


Psychogenic stridor
Trachea
CHRONIC
 Tracheomalacia


Bacterial tracheitis
External compression
Laryngomalacia

5.  Viral croup accounts for over 95% of laryngotracheal
infections.
 Occurs from 6 months – 6 years. (Peak incidence : 2nd
year of life)
 Viruses : Parainfluenza (most common).
: Respiratory Synctial Virus (RSV)
: Influenza
 Mucosal inflammation and increased secretions affect
the : : Larynx (glottic & subglottic regions),
: Trachea
: Bronchi.
 Potential danger because it causes critical narrowing
in the child’s airways (trachea).

6.  Previous upper respiratory tract infection prior to development of upper
airway obstruction.
 Child develops “Barking” cough
 Hoarseness of voice
 Inspiratory stridor (when excited, at rest or both)
 Symptoms worsen at night and often recur with decreasing intensity for
several days and resolve completely within a week.
 Agitation and crying greatly aggravate the symptoms and signs.
PHYSICAL EXAMINATION :
 Agitated child
 Normal to moderately inflamed pharynx
 Slightly increased respiratory rate
 Suprasternal, infrasternal, intercostal retractions in very severe cases.

7. Croup is a clinical diagnosis and does not necessarily require a
radiograph
of the neck.
Radiographs of the
neck can show the
typical subglottic
narrowing, or
steeple sign, of
croup on the
posteroanterior
view.

8. First --- Assess/Determine the severity
Clinical Assessment of Croup (Wagener)
 Severity :
1) Mild - Stridor with excitement or at rest, with no
respiratory distress.
2) Moderate – Stridor at rest with intercostal, subcostal or
sternal recession.
3) Severe – Stridor at rest with marked recession,
decreased air entry and altered level of
consiousness.
 Pulse oximetry : Helpful but not essential
 Arterial blood gas : Not so helpful as blood parameters may
remain normal to the late stage. Child may get distressed with
the blood taking procedure!

9.  Indications for hospital admission :
o Moderate and severe viral croup
o Toxic looking
o Age : < 6 months
o Poor oral intake
o Family lives a long distance from hospital/lacks
realiable transportation
o Lacks reliable caregiver at home

10. MILD MODERATE SEVERE
(Outpatient) (Inpatient) (Inpatient)
Dexamethasone Dexamethasone Nebulised
Oral/Parenteral Oral/Parenteral adrenaline
0.15 kg/single dose 0.3-0.6mg/kg single 0.5mg/kg 1:1000
may repeat at 12, and
24 hours. And/or Dexamethasone
Prednisolone Oral/Parenteral
1-2 mg/kg/stat Nebulised 0.3-0.6mg/kg
Budesonide Nebulised
Or if vomitting : 2mg stat Budesonide
Nebulised And 1 mg 12 hrly 2mg stat, 1 mg 12
Budesonide hrly
2mg single dose If no improvement :
And
only Nebulised adrenaline
OXYGEN
Intubate & Ventilate

11.  Acute epiglottitis is a life-threatening emergency due to respiratory
obstruction.
 Affects all children’s age group, but most common in 1- 6 years children.
 It is caused by H. influenzae type b. The introduction of universal Hib
immunisation in many countries during infancy has led to a decrease of
over 99% in the incidence of epiglottitis and other invasive H. influenzae
type b infections.
 There is intense swelling of the
epiglottis and surrounding tissues
associated with septicaemia.

13. Often, an otherwise healthy child suddenly
develops :
- Sore throat
- Fever
Within a few hours, patient appears :
- Toxic,
- Difficulty in swallowing
- Labored breathing
- Drooling usually present (as patient finds it painful to swallow).
- Neck hyperextended to attempt to maintain airway.
- Child may assume tripod position – sitting upright & leaning forward
with chin up and mouth open while bracing on the arms.
- Brief period of air hunger with restlessness may be followed by
rapidly increasing cyanosis and coma.
- Stridor – usually is a late finding and suggest that airways maybe
almost completely blocked!

14.  Laryngoscope
- Performed immediately
in a controlled environment
(O.T. or ICU).
 Lateral radiographs of the
upper airway (in cases where
epiglottis is thought to be the
cause, but not certain).
- Classic radiograph will show
the “Thumb” sign.
- Proper positioning of the patient
crucial to avoid misinterpretation. of the film.
Attempts to lie the child down or examine the throat with a spatula must not be
undertaken as they can precipitate total airway obstruction and death.

15.  Once the diagnosis of epiglottis is suspected, urgent
hospitalization is required (ICU or OT or Anaesthetic room with
resuscitation facilities).
 Treatment should be started immediately with a team of senior
anaesthetist, paediatrician and ENT surgeon. (compulsory for
senior experienced staff to be present!)
 Intubate child under general anaesthesia.
 Urgent tracheostomy (very rare) if intubation impossible.
 Take blood samples for culture (Only after airway is secured!).
 Start patient on antibiotics immediately (e.g. cefuroximine) for 3-5
days as most patients might have concomitant bacteremia.
 Tracheal tube can be removed usually within 24 hours (Depending
on patient’s progress).
 Most children recover fully within 2-3 days.
MINUTES COUNT IN ACUTE EPIGLOTTIS!

16. Children age 1 to 3 are most like to swallow or breathe in a foreign object,
such as a coin, marble, pencil eraser, buttons, beads, or other small items or
foods as they are always very
intrigued and interested in their
surroudings.

17.  Choking & Coughing (common)
(is present in 95% of patients presenting with foreign body aspiration)
 Stridor is commonly present with upper airway or upper tracheal foreign
bodies.
- Indicates prompt intervention required!
- Approximately 50% of children have inspiratory stridor or expiratory
wheezing, with prolongation of the expiratory phase, and medium-to-
coarse rhonchi.
Patients may present with (depending on location/degree of obstruction) :
1) Larynx - Hoarseness / aphonia
- Stridor
2) Trachea - Wheezing (can mimic asthma)
3) Bronchial - Cough
- Unilateral wheezing
- Decreased breath sounds

18. RADIOGRAPHY
 Neck - AP view of neck
- Lateral view of soft tissues
 Chest - PA view (take both during inspiration & expiration)
- Lateral view
Some points to remember about radiography investigation :
 Obtaining 2 views of the foreign body helps to determining its location and excludes the
presence of superimposed multiple foreign bodies.
 Most foreign bodies are radiolucent
 Radiolucent tracheal foreign bodies may show signs of an infraglottic opacity or of
swelling from airway inflammation on PA and lateral neck radiographs.

19. BRONCHOSCOPY (FLEXIBLE) :
 If the clinical suspicion is high for foreign body aspiration,
flexible bronchoscopy should be performed for definitive
diagnosis and
treatment.
COMPUTER TOMOGRAPHY (CT SCAN)
 As a result of its greater contrast resolution
 In addition to providing plain radiographic findings, such as
hyperlucency, atelectasis, and lobar consolidation, CT scans can
depict the foreign body within the lumen of the tracheobronchial
tree and the 3-dimensional position of the foreign body within the
thorax.

20. 1) Most cases of inhalation events are not witnessed, hence
diagnosis usually depends on high index of suspicion.
2) Bring child to hospital
3) Immediately do a lateral neck X-ray, AP-Chest X-ray (but
hard to detect at times).
4) Endoscopy under general anaesthesia is usually the
preferred choice of investigation as it also allows
removal of the foreign body.
5) Children with foreign body inhalation are usually
comfortable despite some stridor and chest recession.
6) Most interventions can be organised semi-urgently.
7) However, immediate attention is required if the child
decompensates.

21. Retropharyngeal abscesses are deep neck space infections that
can pose an immediate life-threatening emergency, with
potential for airway compromise and other catastrophic
complications

22.  The retropharyngeal space can become infected
in two ways :
1) Infection spreads from a contiguous area
2) Penetrating trauma (can directly inoculate
the space)
The "classic" retropharyngeal abscess observed
in pediatric patients occurs when an upper
respiratory tract infection (URTI) spreads to
retropharyngeal lymph nodes, forming chains in
the retropharyngeal space on either side of the
superior constrictor muscle.

23.  Common complaints :
 Sore throat
 Fever
 Neck pain
 Neck stiffness (torticollis)
 Jaw stiffness (trismus)
 Stridor
 Drooling of saliva
 Muffled voice
 Sensation of lump in the throat
 Breathing difficulties
 Sometimes an upper respiratory illness can precede
symptoms by weeks.

24. 1) Laboratory Studies (Non-specific)
- WBC counts can be elevated
- Culture and sensitivity test (Gram stain can help direct with
empiric antibiotic treatment).
2) Imaging Studies
(Lateral plain X-ray)
- May also demonstrate gas or
a foreign body in the
retropharyngeal space.
- Perform the study during
inspiration with the neck
held in normal extension

25. Medical Care
 ABC - Determining airway stability remains a top priority.
 Allow patients to remain in a position of comfort, which is usually supine with their necks
extended. Neck flexion or forcing a child to sit up can occlude the airway.
 Only experienced physician in airway management should attempt a definitive procedure.
 Remember that sedatives and paralytics can cause relaxation of airway muscles with
subsequent complete occlusion!
 Start empiric antibiotic therapy without delay (After obtaining blood culture results) Broad-
spectrum coverage is indicated. Clindamycin is first-line treatment. Because of the
increasing frequency of resistant bacteria, treatment may be initiated alone or in
combination with cefoxitin or a beta-lactamase–resistant penicillin, such as
ticarcillin/clavulanate, piperacillin/tazobactam, or ampicillin/sulbactam.
 Patients with cellulitis can be treated with parenteral antibiotics alone.
 Closely observe these patients for development of an abscess. Some authors advocate the
use of antibiotics alone for small abscesses. These patients need to be closely monitored for
improvement.

26. SURGICAL INTERVENTION
 Needle aspiration of an abscess can be performed both to assist in
diagnosis and to treat an abscess. This should only be performed
by a qualified surgeon in the operating suite. Definitive airway
management should be immediately available.
 A small retropharyngeal abscess can be aspirated with an 18-gauge
needle by the intraoral route. Larger abscesses require incision and
drainage using either an intraoral or transcervical approach or
both, depending on the location of the carotid sheath in
relationship to the abscess.
 Completely evacuate pus from the abscess. Obtain a specimen for
Gram stain, culture, and sensitivity. Abscesses in the
parapharyngeal space isolated lateral to the carotid sheath can be
aspirated by an external approach.
 CT scanning or ultrasonography may be used to help guide the
aspiration.

27. - Diphtheria is an infectious disease caused by
the bacteriumCorynebacterium diphtheriae.
- This disease primarily affects the mucous
membranes of the respiratory tract
(respiratory diphtheria), although it may also
affect the skin (cutaneous diphtheria) and
lining tissues in the ear, eye, and the genital
areas.

28.  The symptoms usually begin after a two- to five-day incubation period. Symptoms of respiratory
diphtheria may include the following:
 sore throat,
 fever,
 malaise,
 hoarseness,
 difficulty swallowing,
 stridor
 difficulty breathing.
 With the progression of respiratory diphtheria, the infected individual may also develop an
adherent gray membrane (pseudomembrane) forming over the lining tissues of the tonsils and/or
nasopharynx.
 Individuals with severe disease may also develop neck swelling and enlarged neck lymph nodes,
leading to a "bull-neck" appearance.
 Extension of the pseudomembrane (which consists of fibrin, bacteria, and inflammatory cells, no
lipid) into the larynx and trachea can lead to obstruction of the airway with subsequent
suffocation and death. (stridor and respiratory difficulty).
 The dissemination of diphtheria toxin can also lead to systemic disease, causing complications
such as inflammation of the heart (myocarditis) and neurologic problems such as paralysis of the
soft palate, vision problems, and muscle weakness.

29. LABARATORY TEST
 Confirmed by isolation of the bacterium Corynebacterium
diphtheriae. Diagnostic tests to isolate the bacterium
involve obtaining cultures from the nose and throat in any
individual suspected of having diphtheria, as well as their
close contacts.
 It is also important to determine whether or not the isolate
is capable of producing diphtheria toxin, and this can be
accomplished by testing in specialized laboratories.
ECG
 To see if there are any signs of myocarditis development.

30.  Diphtheria antitoxin
- is the mainstay of therapy. It neutralizes circulating diphtheria toxin and reduces the
progression of the disease. The effectiveness of diphtheria antitoxin is greatest if it is
administered early in the course of the disease.
 Antibiotics
- administered as soon as possible to patients with suspected diphtheria. Antibiotics help
eradicate the bacteria, thereby stopping toxin production, and they also help to prevent
transmission of diphtheria to close contacts.
Penicillin and erythromycin are the recommended antibiotics. Asymptomatic
carriers, as well as all close contacts potentially exposed to diphtheria, also
require antibiotic treatment.
 Supportive measures
- inserting a breathing tube (intubation), may be necessary if the patient cannot breathe on
their own or if there is the potential for airway obstruction.
Potential cardiac and neurologic complications also need to be closely followed and
addressed in consultation with the proper specialist.

31. •Most common congenital laryngeal anomaly in children.
•Most common cause of stridor (approximately 60% of cases)
•Stridor characteristics :
- Inspiratory
- Low pitched
-Exacerbated by any exertion, crying, feeding.
-Stridor happens due to the collapse of supraglottic structures inwards
during inspiration.
•Symptoms usually appear within the first 2 weeks of life
•They increase in severity up to 6 months (although gradual improvement
can begin at any time).
•Laryngopharyngeal reflux is common.

33.  FLEXIBLE LARYNGOSCOPE
 CHEST X-RAYS (when the breathing is
moderate to severe)
 BARIUM CONTRAST X-RAY (dysphagia
present)
 COMPLETE BRONCHOSCOPY (patients with
moderate to severe obstruction – because 15-
60% of infants with laryngomalacia have
synchronous airway anomalies).

34.  EXPECTANT OBSERVATION (as most
symptoms resolve spontaneously as the child
and airway grows).
 SURGICAL INTERVENTION – Endoscopic
Supraglottoplasty for patients with severe
obstruction (Especially when there are other
life-threatening events associated together
e.g. cor pulmonale, cyanosis, failure to
thrive).

36. ACUTE STRIDOR
CROUP ACUTE EPIGLOTTITIS INHALED FOREIGN BODY RETRO-PHARYNGEAL DIPHTERIA
Laryngotracheobronchitis ABCESS
•The most common cause •Acute onset •Common especially in • Common (under age 6  Insidious onset
of acute stridor •Is intensely painful children aged 1 to 2 years. years).  Exudate spreads
(Inspiratory) in children. Prevents the child from •Preceded by choking or • Present with high within 2-3 days and
•Usually age 6 months to speaking or swallowing; coughing. fever and difficulty may form adherent
2 years. •Saliva drools down the •Stridor (inspiratory) swallowing.
membrane
•Barking, chin happens depending on • Retropharyngeal
•seal-like cough, low fever •Soft inspiratory stridor location of foreign object abscesses present  Serious cause of
and worse at night. •High fever in an ill, toxic- and usually indicates with pain on stridor, but rare.
looking child almost fully blocked swallowing and  Stridor can occur.
•Respiratory difficulty over airways. hyperextension of the
hours neck.
•Child sits immobile, • Peritonsillar
upright, with an open abscess presents
mouth to optimise the with trismus, difficulty
airway. with swallowing and
difficulty with
speaking.
• Stridor of low pitch
can occur.

37. References :
Paediatric Protocols for Malaysian Hospitals – 2nd Edition
Illustrated Textbook of Paediatrics, - 3rd Edition
Nelson’s Textbook of Pediatrics – 19th Edition.