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Stridor

In newborns, laryngomalacia is probably the most common cause of stridor in newborns. Key to this diagnosis is that it improves when the child is prone. Lay the child on their back, they are going to have much more stridor, lay them on their stomach and they are going to seem better. Also tends to worsen when a child is agitated. The vast majority of cases will improve spontaneously over the course of the first year without any intervention at all. Subglottic stenosis can be either congenital or acquired. Unlike laryngomalacia there is no change with position and sometimes can be severe enough that it requires tracheostomy. Vocal cord paralysis: unilateral, usually not a big deal. You have mild symptoms, maybe some mild stridor with a hoarse cry. Bilateral vocal cord paralysis presents very early on, even in the delivery room, with much more severe evidence of obstruction. Extrinsic compression, any kind of mass, can press on the larynx. Things like hemangioma, cystic hygromas, vascular rings, goiters, mediastinal masses, a whole bunch.

Older kids: acute illnesses are much more likely, especially croup. Again, pattern recognition is key here. You should be able to diagnose this without any tests. Barky cough, worse at night. Usually peaks on the second or third night and resolves within 5-7 days. And usually a low grade fever. Diagnosis is usually clinical but if you are going to do x-rays you should see something which is called the steeple sign, where rather than having folding out of the epiglottic folds and upper trachea, it has a straightened pattern which suggests a church steeple. Treatment: cool mist, racemic epinephrine.

I think more and more people are starting to use Decadron. Certainly seems to be helpful in some cases, although his caution about indiscriminate use of steroids is also reasonable to say. Epiglottitis, H. flu type B, very rare these days. I gave a talk at a family medicine course a couple of months ago and asked, when was the last time anybody there (there were 250 people in the room) had seen a case of H. flu disease? Had anybody seen any cases in the last five years? None. Last ten years? None. It’s because of our aggressive immunization with H. flu, it’s still disappearing, but you still have to watch out for it obviously. Clinical manifestations here, sudden onset, high fever, toxicity, stridor, respiratory distress. The thing I think to emphasize, in addition to what Dr. Cherry said, is you do not … if you suspect this, you do not want to do anything to these kids. This is the kind of Board question where one of the things they want to test is when you know when not to do something. It’s as important sometimes to know when not to do something as it is to know when to do something. So you don’t want to examine the oropharynx, you don’t want to draw blood, do x-rays, anything like that. You want to get an urgent ENT consult, take the child to the OR for intubation.

Foreign body aspiration: peak incidence is younger ages, six months to four years and clinical manifestation is sudden onset - and that’s key - sudden onset of coughing, gagging, choking, dyspnea, afebrile. And also an object that was previously visible is no longer visible. It’s very suggestive. If it is extrathoracic you are likely to hear stridor and a croupy cough. If it has gone down intrathoracic you are going to see more cough and wheezing. Diagnosis: extrathoracic, x-rays are helpful if it is radiopaque and one key link that I think is relatively likely to show up on exams is what happens if you see a coin? And what you will see is that coins in the sagittal plane are in the larynx or trachea. The way you can remember that is the tracheal rings have an opening in front so that if a coin is going to slide down into the trachea it’s going to be pointed in this direction. So when you do an x-ray you are going to see it on end, whereas if it’s in the esophagus it’s going to be in the coronal plane.