STRIDORSTRIDOR

ANNE ASPIN 2010ANNE ASPIN 2010

Common causesCommon causes

• Laryngomalacia – 60%

• Congenital subglottic stenosis

• Vocal cord palsy - unilateral, birth trauma – temporary

• Bilateral vocal cord palsy assoc other congenital anomalies

Morimoto et al (2004)Morimoto et al (2004)

• 97 patients 1991-2001

• Laryngomalacia 32%

• Vocal cord palsy and laryngeal stenosis 22%, within 2/12, severe dyspnoea

• Haemangioma or papilloma 11%

• Cystic disease 7%

contcont

• 2 / 31 of laryngomalacia and 2 / 22 VCP had neuromuscular disorders

• 3 of VCP complicated by laryngeal stenosis

• 33 / 97 Tracheostomy

• Sometimes stridor is the only presenting symptom. Past history important

InvestigationInvestigation

• Rigid or direct microlaryngoscopy – general anaesthetic.

• Flexible fibre- optic laryngoscope, neonate awake (first line choice now)

Case historyCase history

• 6/12 girl• Fever, coughing• Inspiratory stridor• Palpable neck swelling, bulging

pharyngeal wall• Limited movement of neck• ? spasmodic croup, lymphadenitis coli• Found to be retro pharyngeal abscess

TreatmentTreatment

• Oral incision

• Drainage of abscess

• Antibiotics

Unilateral vocal cord paralysisUnilateral vocal cord paralysis

• Stridor

• Laryngospasm

• Dyspnoea

• Cause by abnormal innervation of nerve branches into adductor fibers

CasesCases

• Post Thyroid surgery

• Post cervical disc surgery

• After Herpes simplex virus with cranial nerve involvement

• Fire optic laryngoscopy showed affected vocal cord immobile

TreatmentTreatment

• Laryngeal electromyography showed evidence of reduced but intact voluntary motor conduction in thyroarytenoid muscle.

• Botox injections

ResearchResearch

Objective

• Determine stridor at rest after oral Prednisolone 1mg/kg

• And whether quick response after mild croup

MethodMethod

• Retrospective explicit chart review of children over 1 year of age admitted to a teaching hospital

• Patient demographics

• Croup scores at AE

• Duration of stridor at rest after steroids

ResultsResults

• 188 cases analysed

• Median duration at rest was 6.5 hrs, range 0.5 hrs- 82 hrs

• Patients with low score at AE recovered quicker in response to steroids, early discharge home.

Amphotericin induced stridorAmphotericin induced stridor

• Adverse effects reported Amphotericin B

• Dyspnoea

• Tachypnoea

• Bronchospasm

• Haemoptysis

• hypoxia

ObjectiveObjective

• To review mechanism of action and reports of respiratory adverse effects for Amphotericin B, the liposomal preparations for Amphotericin B and the differential diagnosis of stridor

• Medline search 1966 – 2002 looking for possible mechanisms and immunoregulatory effects of Ampho B

ResultsResults

• Amphotericin B shows increase in tumour necrosis factor alpha (TNF alpha) concentrations in macrophages.

• Induces prostaglandin E2 synthesis, increasing production of interleukin1 beta in mononuclear cells

ConclusionConclusion

• Amphotericin B induces production of TNF alpha, interferon gamma and interleukin 1 beta which have toxic effects.

Medicines for childrenMedicines for children

• Test dose infused over 30 mins – 100mcg

• Renal impairment

• Low serum pott, mag, phos

• Lft’s

• arrhythmias

• Pulmonary reactions if Amph and leucocyte Tx.

ReferencesReferences

• Bent J (2006). Pediatric laryngotracheal obstruction : current perspectives on Stridor. The Laryngoscope. 116 (7) : 1059 - 1070

• Berghout E, Peetsold M, Verboom A, Plotz F (2005). Inspiratory Stridor in a Child with a Retropharyngeal Abscess Instead of the Normally Expected Sublottic Laryngitis. Ned Tijdschr Geneeskd. 149(9):478-81 (Article in Dutch)

• Kavshal M, Upadhyay A, Aggarwal R, Deorari A (2005). Congenital Stridor Due to Bilateral Vocal Cord Palsy. Indian Journal of Paediatrics. 72(5): 443-4

• Lowery M, Greenberger P (2003) Amphotericin Induced Stridor: A Review of Stridor, Amphotericin Preparations, and their Immunoregulatory Effects. Annals of Allergy Asthma Immunology. 91(5): 460-6

References cont.References cont.• Majumdar S, Bateman N, Bull P (2006). Paediatric Stridor. Archives

of Disease in Childhood, Education Practice Edition. 91 : ep101 - ep105.

• doi 10.1136/adc.2001.066902• Morimoto N, Kawashiro N, Tsuchihashi N, Taiji H (2004). Congenital

Laryngeal Stridor. Nippon Jibinkoka Gakkai Kaiho. 107(7):690-4• Moumoulidis I, Gray R, Wilson T (2005). Outpatient Fibre-optic

Laryngscopy for Stridor in Children and Infants. European Archives Otorhinolaryngology. 262(3): 204-7

• Parker R, Powell C, Kelly A (2004). How Long Does Stridor At Rest Persist in Croup After The Administraton of Oral Prednisolone? Emergency Medicine. Vol 16, Iss 2, p135

• Tewfik T, Sobol S (2010). Congenital malformations, larynx. http://emedicine.medscape.com/article/867630-overview

• Woo P, Mangaro M (2004). Aberrant Recurrent Laryngeal Nerve Innervaton As A Cause of Stridor and Laryngospasm. Annals of Otology, Rhinology, Laryngology. 113(10): 805-8