Stridor

Question 1

Define stridor and explain what its presence indicates

Answer 1

Stridor is a noise heard during the inspiratory phase of breathing.
It indicates either dynamic or fixed extrathoracic airway obstruction.

Question 2

List the causes of stridor

Answer 2

1. Nose and Nasopharynx:
   - Congenital obstruction (choanal atresia)
   - Inflammation (rhinitis, sinusitis)
2. Mouth, oropharynx and hypopharynx:
   - Congenital obstruction (macroglossia, glossoptosis)
   - Inflammation (tonsils)
   - Masses (cystic hygroma)
   - Foreign body
3. Larynx:
   - Congenital obstruction
   - Inflammation
   - Infection (epiglottitis)
   - Masses (haemangioma, abscess)
   - Trauma (subglottic stenosis, foreign body inhalation)
4. Trachea:
   - Congenital obstruction (tracheomalacia, fistula)
   - Infection

Question 3

In what age group is foreign body inhalation most common?

Answer 3

Toddlers and infants

Question 4

List the symptoms of foreign body obstruction in the larynx

Answer 4

1. Hoarseness
2. Cough
3. Dysphonia
4. Haemoptysis
5. Stridor
6. Wheezing
7. Dyspnoea
8. Cyanosis or apnoea

Question 5

List the symptoms of foreign body obstruction in the trachea and bronchus

Answer 5

1. Chest pain
2. Asymptomatic period after initial symptoms
3. Followed by features of pneumonia

Question 6

List the symptoms of foreign body obstruction in the oesophagus

Answer 6

1. Drooling
2. Dysphagia
3. Vomiting
4. Dyspnoea
5. Stridor
6. Respiratory failure
7. Apnoea
   (4 - 7 only if trachea compressed)

Question 7

How can we diagnose foreign body inhalation?

Answer 7

1. Monophonic wheeze or absent breath sounds on one side
2. Chest and neck radiographs, with lateral views; inspiratory and expiratory films
3. ABG if in severe distress

Question 8

How is foreign body inhalation managed?

Answer 8

1. ABC
2. Removal of foreign body in controlled environment if child calm with good air exchange
3. Can use paediatric choking protocol
4. Unconscious child with poor air entry given 100% O2 via face mask
5. Rigid bronchoscopy and object removal (if needed)

Question 9

List the differentiating features of croup

Answer 9

1. Time course = days
2. Coryzal prodrome
3. Barking cough
4. Can drink
5. Closed mouth
6. Not toxic
7. Fever <38.5
8. Rasping stridor
9. Hoarse voice

Question 10

List the differentiating features of epiglottitis

Answer 10

1. Time course = hours
2. No prodrome
3. Slight cough, if any
4. Not eating or drinking
5. Drooling saliva
6. Toxic
7. Fever >38.5
8. Soft stridor
9. Weak or silent voice

Question 11

What is the most likely causative organism in viral croup?

Answer 11

Parainfluenza virus

Question 12

What is the causative organism in acute epiglottitis?

Answer 12

Haemophilus influenza type b

Question 13

What is the approach to examination in children with stridor?

Answer 13

1. DO NOT EXAMINE THE THROAT
2. Assess severity:
   - Degree of stridor and subcostal recession
   - RR
   - HR
   - LOC, tiredness and exhaustion
   - Pulse oximetry

Question 14

How is viral croup managed?

Answer 14

1. Moist or humidified air (benefits unproven)
2. Steroids - oral predinisolone or oral dexamethasone or nebulised budesonide (reduces severity and duration)
3. Nebulised adrenaline - can provide transient relief from symptoms

Question 15

How is acute epiglottitis managed?

Answer 15

1. ABC call for senior help - anaesthetist, ENT surgeon and senior paediatrician
2. Endotracheal intubation
3. Manage in ICU
4. Take blood cultures
5. Start IV antibiotics
   - 2nd or 3rd gen cephalosporin (e.g cefuroxime, ceftriaxome, cefotaxime) IV for 7-10 days
6. Rifampicin prophylaxis to close contacts