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STRIDOR

STRIDOR. ANNE ASPIN 2010. Common 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). 97 patients 1991-2001 Laryngomalacia 32%

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STRIDOR

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  1. STRIDOR ANNE ASPIN 2010

  2. Common causes • Laryngomalacia – 60% • Congenital subglottic stenosis • Vocal cord palsy - unilateral, birth trauma – temporary • Bilateral vocal cord palsy assoc other congenital anomalies

  3. 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%

  4. cont • 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

  5. Investigation • Rigid or direct microlaryngoscopy – general anaesthetic. • Flexible fibre- optic laryngoscope, neonate awake (first line choice now)

  6. Case 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

  7. Treatment • Oral incision • Drainage of abscess • Antibiotics

  8. Unilateral vocal cord paralysis • Stridor • Laryngospasm • Dyspnoea • Cause by abnormal innervation of nerve branches into adductor fibers

  9. Cases • Post Thyroid surgery • Post cervical disc surgery • After Herpes simplex virus with cranial nerve involvement • Fire optic laryngoscopy showed affected vocal cord immobile

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

  11. Research Objective • Determine stridor at rest after oral Prednisolone 1mg/kg • And whether quick response after mild croup

  12. Method • 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

  13. Results • 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.

  14. Amphotericin induced stridor • Adverse effects reported Amphotericin B • Dyspnoea • Tachypnoea • Bronchospasm • Haemoptysis • hypoxia

  15. Objective • 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

  16. Results • 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

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

  18. Medicines 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.

  19. References • 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

  20. 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 ArchivesOtorhinolaryngology. 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

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