1. بسم الله الرحمن الرحيم الدكتور سعد يونس سليمان

2. Stridor Stridor is noisy respiration produced by turbulent airflow through the narrowed air passages...

3. 1- Laryngeal stridor: Congenital Traumatic Inflammatory Neoplastic Neuromuscular 2- Extra-laryngeal stridor: Retropharyngeal Abscess Parapharyngeal Abscess, Tumors of Thyroid Gland…

4. Laryngomalacia The most common congenital abnormality of the larynx. It is characterized by excessive flaccidity of supraglottic larynx which is sucked in during inspiration producing stridor and sometimes cyanosis. Stridor is increased on crying but subsides on placing the child in prone position; cry is normal (i.e. voice is unchanged).

5. manifests at birth or soon after and usually disappears by 2 years of age. Direct laryngoscopy shows: 1- elongated epiglottis, curled upon itself (omega-shaped  ) 2- floppy aryepiglottic folds 3- prominent arytenoids. Flexible laryngoscopy is very useful to make the diagnosis. Treatment: conservative and reassurance.

6. Laryngeal web It is due to incomplete recanalisation of the larynx. Web between the vocal cords in the anterior half of the glottis. The presenting features are= Airway obstruction + weak cry or aphonia dating from birth. Treatment: depends on the thickness of the web. Thin webs can be cut with a knife or CO2 laser. Thick ones may require excision via laryngofissure.

7. Traumatic conditions of the larynx Aetiology  External trauma  Internal trauma Pathology 1. Haematoma and oedema of supraglottic or subglottic region. 2. Tear of mucosa leading to subcutaneous emphysema. 3. Fracture of the hyoid bone, thyroid cartilage, or cricoid cartilage (the latter is fatal). 4. Dislocation of cricoarytenoid or cricothyroid joints. 5. There may be associated injury to the great vessels.

8. Clinical features SYMPTOMS Respiratory distress Hoarseness Painful and difficult swallowing Laryngeal pain marked on speaking or swallowing Haemoptysis when there is tear of mucosa. SIGNS Bruises Tenderness Surgical Emphysema INVESTIGATIONS X-ray soft tissue of the neck and CT scan is required.

9. Treatment: Conservative: Hospital admission and observation Voice rest. Humidification of inspired air. Steroid in full dose to resolve oedema and prevent scarring and stenosis. Analgesics. Antibiotics to prevent perichondritis and cartilage necrosis. Surgical: Tracheostomy and open reduction.

10. Acute Epiglottitis It is a serious condition Age: (2-7 years) Bacterial infection (H. influenzae). Dyspnoea and stridor  rapidly progressive and fatal Intense sore throat, difficulty in swallowing Drooling Fever may go up to 40°C. Sits up, leans forward, extends neck slightly One-third present unconscious, in shock Depressing the tongue should be avoided Respiratory distress+ Sore throat+Drooling = Epiglottitis

11. Investigation: Lateral soft tissue x-ray of neck may show swollen epiglottis (thumb sign).

12. Treatment: (1) Hospitalization, (2) Antibiotics (ampicillin or 3rd generation cephalosporin) (3) Steroid (4) I.V. fluid (5) Humidification and oxygen. (6) Intubation or tracheostomy may be required.

13. Inhaled Foreign Bodies F.B in the larynx is a rare condition but a sharp F.B. such as pin or glass may be impacted in the larynx. Large F.B. such as a bolus of food is almost immediately fatal when impacted in the larynx.

14. Clinical features: Three stages: Initial period of chocking, gagging and wheezing: * short time. * FB may be coughed out or it may lodge in the larynx Symptomless interval: Why? the respiratory mucosa adapts to the presence of FB. This interval varies with the size and nature of FB. Later symptoms: Large F.B.:  sudden death. Partially obstructive FB will cause discomfort or pain hoarseness cough dyspnoea wheezing and haemoptysis.

15. Treatment: Removal by direct laryngoscopy as soon as possible. Emergency tracheostomy may be necessary.

16. Intubation injury Aetiology 1.Rough intubation with inadequate muscle relaxant. 2.Prolonged period of intubation. 3.The use of too large tubes. 4.Inadequate fixation of the tube, so the tube moves up and down leading to mucosal abrasion.

17. Pathology Superficial mucosal abrasion. Granuloma formation which is commoner in women 4:1 Subglottic oedema more in children. Clinical features Hoarseness and sometimes dyspnoea. Treatment Voice rest. Endoscopic removal of granuloma.

18. الدكتور سعد يونس سليمان

19. Stridor is a physical sign not a disease. Attempt should always be made to discover the cause. 80% of pediatric cardiopulmonary arrest are primarily due to respiratory distress Majority of cardiopulmonary arrest occur at <1 year old

21. History It is important to elicit: Time of onset --congenital or acquired. Mode of onset. Sudden onset (FB, oedema) Gradual and progressive (laryngomalacia, juvenile papilloma). Duration. Short (FB, oedema), Long ( laryngomalacia). Relation to feeding. Aspiration in laryngeal paralysis. Cyanotic spells. Indicate needs for airway maintenance. Aspiration of a FB. Laryngeal trauma.

22. Physical examination: Stridor is always associated with respiratory distress  Recession of suprasternal notch, intercostal spaces and epigastrium during inspiratory efforts. Note the type of stridor. Inspiratory---larynx. Expiratory--- below the larynx. Mixed: (laryngotracheobronchitis).

23. Physical examination Associated fever  infection. Stridor of laryngomalacia disappears when the baby lies in prone position. Full ENT examination to exclude local pathology. Fiberoptic laryngoscopy and direct laryngoscopy under general anesthesia are required.

24. Radiography: X-ray of chest and soft tissue neck both AP and lateral view. CT scan/MRI. Treatment Once the diagnosis has been made, treatment of exact cause can be planned.