This lecture will discus the approach to stridor / upper airway obstruction in children and paediatric age group. Topics to be discussed:- Upper Airway Obstruction (UAO):- eitiology, clinical features, invetigations, treatment Foreign Body Aspiration Choanal Stenosis (Atresia) Laryngomalacia (Floppy Larynx) Subglottic Stenosis Adenoidal and Tonsillar Hypertrophy Others causes of UAO

1. By
Jwan Ali Ahmed AlSofi

2. Contents:-
•Upper Airway Obstruction (UAO):- eitiology, clinical features,
invetigations, treatment
•Foreign Body Aspiration
• Choanal Stenosis (Atresia)
• Laryngomalacia (Floppy Larynx)
•Subglottic Stenosis
•Adenoidal andTonsillar Hypertrophy
•Others causes of UAO

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4. Upper Airway Obstruction (UAO)
•UAO, is defined as blockage of any part of the airway
located above the thoracic inlet, can range from
nasal obstruction due to the common cold to life-
threatening obstruction of the larynx or upper
trachea (subglottic space).

5. Upper airways obstruction:-
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• rapidly leads to respiratory failure and death.
• It may occur acutely as a result of an inhaled foreign body, or inhalation
burns.
Complete obstruction of the upper airway
• Leads to increased work of breathing
• Accompanied by additional noises on breathing.
• Variable upper airway obstruction leads to stertor (snoring when asleep)
• Fixed partial airway obstruction leads to stridor.
• By far the most common cause of stridor is viral laryngotracheobronchitis
(‘croup’).
Partial obstruction of the upper airway

6. ETIOLOGY
•The differential diagnosis of airway obstruction
varies with patient age
•Can also be subdivided anatomically into
1. Supraglottic
2. Glottic
3. Subglottic

7. Age-Related Differential Diagnosis of Upper
Airway Obstruction
NEWBORN
Congenital subglottic stenosis (uncommon)
Choanal atresia
Micrognathia (Pierre Robin syndrome, DiGeorge syndrome)
Macroglossia (Beckwith-Wiedemann syndrome, Down, hypothyroidism)
Laryngeal web, clefts, atresia
Laryngospasm (intubation, aspiration, transient)
Vocal cord paralysis/paresis
Pharyngeal collapse
Dislocated nasal cartilage

8. INFANCY
Laryngomalacia (most common etiologic disorder)
Subglottic stenosis (congenital, acquired, e.g., after intubation)
Airway hemangioma
Tongue (macroglossia, tumor (dermoid, teratoma, ectopic thyroid)
Laryngeal papillomatosis
Vascular rings/slings
Rhinitis

9. TODDLERS
Viral croup
Spasmodic/recurrent croup
Bacterial tracheitis (toxic, high fever)
Foreign body (airway or esophageal)
Laryngeal papillomatosis
Retropharyngeal abscess
Hypertrophied tonsils and adenoids

10. OLDER CHILDREN
Epiglottitis
Inhalation injury (burns, toxic gas, hydrocarbons)
Foreign bodies
Angioedema (familial history, cutaneous angioedema)
Anaphylaxis (allergic history, wheezing, hypotension)
Trauma (tracheal or laryngeal fracture)
Peritonsillar abscess (adolescents)
Mononucleosis

11. CLINICAL MANIFESTATIONS:-
• Upper airway obstruction is more pronounced during inspiration.
▫ Because the negative pressure generated collapses the upper airway, increasing resistance and turbulent
airflow that creates an inspiratory noise.
• Children with UAO may have increased inspiratory work of breathing
▫ manifested by suprasternal retractions.
• The respiratory noise most commonly associated with upper airway obstruction is stridor, a
harsh sound caused by the vibration of the airway structures mainly in inspiration. Occasionally
stridor may also be present on exhalation.
▫ Stridor often decreases during sleep due to lower inspiratory flow rates
▫ Increase during feeding , excitement, & agitation.
▫ Stertor (snoring when asleep) is a low-pitched sound like a snore and suggests implosion of pharyngeal
soft tissue structures. Is due to variable upper airway obstruction – causes:- adenoid hypertrophy,
obstructive sleep apnea, obesity and URTI.
•Hoarseness or aphonia with stridor suggests vocal cord involvement.

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• In normal breathing, during inspiration the negative intrapleural pressure dilates the intrathoracic airways but
collapses the extrathoracic airway (a);
• and on expiration positive intrapleural pressure does the opposite (b).
• This explains why extrathoracic obstruction causes difficulty in inspiration, whereas intrathoracic obstruction
causes problems on expiration.
• Numbers represent pressures at different points.

13. The severity of upper airways obstruction is best assessed
clinically by:-
1. The characteristics of the stridor (none, only on crying, at rest, or biphasic)
2. The degree of accompanying chest retraction (none, only on crying, at rest).
3. Severe obstruction also leads to increasing respiratory rate, heart rate, and
agitation.
4. Pulse oximetry can reliably detect hypoxaemia but, in contrast to
parenchymal lung disease, it is a late feature in upper airways obstruction.
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14. Features suggest impending complete airway
obstruction and the need for intubation:-
1. Central cyanosis,
2. Drooling of saliva from inability to swallow it
3. Reduced level of consciousness.
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16. DIAGNOSTIC STUDIES:-
• Radiographic evaluation of a child with stridor may not be helpful. However,
▫ Lateral views of the neck and nasopharynx can assess for adenoid hypertrophy & airway swelling.
▫ AP views of the neck taken with the head in extension, the subglottic space should be symmetrical and
the lateral walls of the airway should fall away steeply. Asymmetry suggests subglottic stenosis or a
mass lesion, while tapering suggests subglottic edema. However, these findings may be subtle.
• Computed tomography (CT) scans of the upper airway can help delineate the site of the obstruction
but may require sedation in younger children.
• Flexible nasopharyngoscopy/laryngoscopy, which can be done without sedation, is extremely
useful in assessing airway patency, the presence of adenoid tissue, vocal cord, laryngomalacia and other
airway lesions,.
• Bronchoscopy can be useful in assessing the subglottic space and intrathoracic large airways, but this
procedure requires deep sedation.

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18. Basic management of acute upper airways obstruction is:-
• reduce anxiety by being calm, confident, and well organized
• observe carefully for signs of hypoxia or deterioration – agitation or fatigue or
drowsiness or cyanosis.
• Provide oxygen if required and tolerated
• Do not examine the throat with a spatula! It may precipitate upper airway
obstruction
• Oral, nebulized or intravenous steroids are beneficial in croup and have similar
speed of onset (90–120 min). If severe, administer nebulized epinephrine (adrenaline)
and contact an anaesthetist
• If respiratory failure develops from increasing airways obstruction, exhaustion or
secretions blocking the airway, urgent tracheal intubation is required.
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19. Foreign Body Aspiration

20. Epidemiology:-
• Aspiration of foreign bodies into the trachea and bronchi is relatively common.
• The majority of children who aspirate foreign bodies are under 4 years of age.
• Because the right mainstem bronchus takes off at a less acute angle than the left mainstem
bronchus, foreign bodies tend to lodge in right-sided airways.
• Some foreign bodies, especially nuts, can also lodge more proximally in the larynx or
subglottic space totally occluding the airway.
• Many foreign bodies are not radiopaque, which makes them difficult to detect radiographically.
• The most common foreign bodies aspirated by young children are food (especially nuts) and small
toys.
• Coins more often lodge in the esophagus than in the airways.
• Older children have been known to aspirate rubber balloons, which can be life-threatening.

21. Clinical Manifestations:-
Many children who aspirate foreign bodies have
- clear histories of choking,
- witnessed aspiration,
- physical or radiographic evidence of foreign body aspiration.
However, a small percentage of patients have a negative history because the
aspiration went unrecognized.

22. Physical findings observed
with acute foreign body
aspiration include:
• Cough
• Localized wheezing
• Unilateral absence of breath
sounds
• Stridor
• Rarely, bloody sputum.
Most foreign bodies are small
and quickly expelled, but
some may remain in the lung
for long periods of time
and presented as:
• Persistent cough with
sputum production
• Persistent wheezing
unresponsive to
bronchodilator therapy
• Recurrent or persistent
unilateral pneumonia.
• persistent atelectasis

23. Diagnostic Studies:
• Expiratory or lateral decubitus CXR :, reveal
▫ the presence of radiopaque objects
▫ focal air trapping – hyperlucency
• Bronchoscopy. – is both diagnostic and therapeutic.
Treatment:
• Foreign body removal via rigid bronchoscopy.

26. Expiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing
demonstrates continued hyperlucency and hyperexpansion of the right hemithorax.

27. The choking child from a foreign body
airway obstruction (FBAO):-
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28. (a) Abdominal thrusts (Heimlich manoeuvre) in older children – place a fist against the child’s
upper abdomen in the midline and grasp with the other hand. Pull backwards and upwards to
expel air from the lungs. In infants, back blows
(b) and chest thrusts
(c) are recommended, avoiding abdominal thrusts due to the risk of injury to the liver and
spleen.
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30. Choanal Stenosis (Atresia)
• Choanal stenosis/atresia is a congenital problem that presents in the neonatal
period.
• It may be bilateral or unilateral
• Is a relatively rare cause of respiratory distress in newborns.
• Neonates are generally obligate nose breathers, so obstruction of nasal passages can
cause significant respiratory distress, especially when feeding.
• Crying bypasses the obstruction because crying infants breathe through their
mouths.
• Inability to easily pass a small catheter through the nostrils should raise the
suspicion of choanal atresia.
• The diagnosis is confirmed by CT scan and by inspecting the area directly with a
flexible nasopharyngoscope.
• An oral airway may be useful in the short term, but the definitive treatment is
surgery

31. Laryngomalacia (Floppy Larynx)
• Laryngomalacia is most common cause of stridor in infants.
• It is due to exaggerated collapse of the glottic structures,
especially the epiglottis and arytenoid cartilages, during inspiration.
• Its precise cause is not known. It may be due to
▫ Decreased muscular tone of the larynx and surrounding structures
▫ Immature cartilaginous structures.
• Inspiratory stridor beginning at or shortly after birth should
raise the suspicion of laryngomalacia.
• It usually does not result in much respiratory distress.
• Occasionally it is severe enough to cause
▫ hypoventilation (CO2 retention), hypoxemia,
▫ Difficulty with feeding.

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33. Clinical Manifestations:-
•The primary sign of laryngomalacia is inspiratory stridor with
little to no expiratory component. The stridor is typically:-
▫Loudest when the infant is feeding or active
▫Decreases when the infant is relaxed, supine, or the neck is
flexed.
▫Exacerbated by viral respiratory infections & GERD.
•Laryngomalacia normally peaks by 3 to 5 months of age and
resolves between 6 and 12 months of age.

34. Diagnostic Studies:-
•In typical cases, no need for investigation.
•In severe or atypical cases, the patient should undergo
flexible nasopharyngoscopy/laryngoscopy to assess the
patency and dynamic movement (collapse) of the larynx
and surrounding structures.

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36. Treatment:-
•In most cases, no therapy is required for laryngomalacia.
▫ The infant should be observed closely during times of respiratory
infection for evidence of respiratory compromise, although most
infants with laryngomalacia tolerate infections fairly well.
•Infants with severe laryngomalacia that results in hypoventilation,
hypoxia, or growth failure may benefit from a surgical procedure
(aryoepiglottoplasty) or, in extreme cases, a tracheostomy to
bypass the upper airway.

37. Subglottic Stenosis
•Subglottic stenosis is the narrowing of trachea
immediately below the vocal cords.
•It may be:
▫Congenital
▫Acquired: due to prolonged or repeated endotracheal
intubation – intubation  inflammation  scarring of the subglottic space

38. Clinical Manifestations
• Subglottic stenosis can present as stridor that is frequently biphasic (on both
expiration and inspiration). However, the stridor is usually more prominent on
inspiration.
• Subglottic stenosis may also be associated with a barky cough similar to that noted
with croup.
• Respiratory infections can cause subglottic edema, exacerbating the clinical
manifestations of subglottic stenosis.

39. •Diagnostic studies:-
▫ Definitive diagnosis requires endoscopic evaluation, either by
flexible or rigid bronchoscopy.
Treatment
• Mild subglottic stenosis can be managed conservatively and may improve sufficiently
with airway growth alone.
• Severe cases require surgical intervention.

40. Adenoidal and Tonsillar Hypertrophy
•The most common cause of chronic upper airway
obstruction in children is hypertrophy of the adenoids
and tonsils.
•The adenoids are lymphoid tissue arising from the
posterior and superior walls of the nasopharynx in the
region of the choanae.
•Adenoid and tonsillar hyperplasia may be aggravated by
▫recurrent infection,
▫Allergy
▫inhaled irritants.

41. Clinical Manifestations:-
▫ Mouth breathing.
▫ Snoring.
▫ In some patients, obstructive sleep apnea.
▫ Recurrent or persistent otitis media, because the eustachian tubes
enter the nasopharynx at the choanae and can be obstructed by
enlarged adenoids.
Diagnostic Studies:
▫ Adenoidal hypertrophy is assessed by
a lateral radiograph of the nasopharynx
flexible nasopharyngoscopy.

42. Treatment:-
• If the adenoids or tonsils are large and thought to be significantly contributing to upper
airway obstruction, then the most effective treatment is removal.
• Because the adenoids are not a discrete organ but rather consist of lymphoid tissue,
regrowth after adenoidectomy is possible.
• If the tonsils are large and the obstruction is severe, then removing the tonsils in addition
to the adenoids may be necessary.

43. Other causes of UAO
• usually presents before 6 months of age.
• The treatment of hemangiomas is controversial
• laser therapy and corticosteroids (both direct injection and systemic) have been used with
moderate success.
• If the obstruction is severe, tracheostomy tube is needed.
Hemangioma,
Juvenile laryngeal papillomatosis .
• Paralysis may be unilateral or bilateral and
• is more often caused by damage to the recurrent laryngeal nerve than by a central lesion.
• Peripheral nerve injury can be caused by trauma (neck traction during delivery of infants or thoracic
surgical procedures).
• Central causes as hydrocephalus.
Vocal Cord Paralysis,
• should considered in any infant or child capable of ingesting small objects who develops acute
onset of stridor.
Foreign body,

44. Differentiating Supraglottic from Subglottic Causes of
Airway Obstruction

45. THANKYOU