© Borgis - New Medicine 3/2004, s. 80-82
Lidia Zawadzka-Glos, Beata Zając, Anna Kaczmarczyk
Causes of laryngeal stridor in children
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik MD, PhD
Summary
Laryngeal stridor may pose a diagnostic and treatment problem. Congenital anomalies of the cricoid cartilage, postintubation stenosis, subglottic haemangioma, laryngomalacia, congenital malformations such as: laryngeal webs and cysts, inflammatory lesions and foreign bodies should be considered in differential diagnoses. Laryngeal stridor occurring in children with subglottic stenosis has to be differentiated with vocal cord paralysis.
Laryngeal stridor is always a symptom, not a disease. It is a sound which is produced by tissue vibration and a turbulent flow of the air through the obstructed lumen of air passages. Stridor never occurs in health; it is a pathological symptom, evidence of an impaired patency of the respiratory tract. The assessment of stridor characteristics such as its loudness, sound pitch, respiration phase, allows establishing a likely localization of stenosis. Stridor may be described as inspiratory, biphasic, i.e. inspiratory – expiratory, or expiratory, dry or wet; sound pitch may be low or high. Stenosis of the air passage under the rima of the glottis causes an inspiratory stridor, stenosis at the level of the glottis and the subglottic portion produces an inspiratory-expiratory stridor with inspiratory prevalence. Stenosis of the trachea and lower respiratory tract leads to stridor with a prolonged expiratory phase. Impaired patency of the upper respiratory tract at the level of the nose or nasopharynx produces a characteristic anterior or posterior nasal stridor. An obstruction at the level of the middle and inferior pharynx results in a hoarse and wet inspiratory stridor.
Laryngeal stridor may be a symptom which occurs rapidly and causes acute laryngeal dyspnoea; it also may be chronic, usually present since the child´s birth and causing progressive restriction in respiratory tract patency. Slowly increasing stenosis of the laryngeal lumen results in adaptation to deteriorating breathing. In such cases, mild mucosal oedema in the course of infection may give rise to a rapid laryngeal obstruction, may exceed the patient´s adaptation possibilities, which may result in severe respiratory distress.The most frequent causes of laryngeal dyspnoea are caused by:
1. inflammatory diseases of the larynx
2. internal and external trauma to the larynx, postintubation stenosis
3. congenital abnormalities
4. papillomatosis of the larynx
5. haemangioma of the larynx
6. endogenous and exogenous foreign bodies
7. congenital and acquired paralysis of the vocal cords
8. laryngospasm
– tetanus
– irritation of the laryngeal vestibule mucosa
– epileptic seizures
– episodes of hysteria
9. non-inflammatory oedema
– allergic oedema
– lymphatic oedema
– Quincke´s oedema
– oedema associated with venostasis (superior vena caval syndrome, circulatory insufficiency, status post cardiosurgery)
10. oedema due to a diminished oncotic pressure (hypoalbuminaemia in nephrotic syndrome, cirrhosis of the liver).
Inflammatory disease of the larynx is the most frequent cause of laryngeal stridor. Acute laryngeal inflammation in paediatric patients has a different course than that in adults because of a specific anatomical structure of the larynx in a young child and a high predisposition of the laryngeal mucosa and loose connective tissue of the submucosal layer to develop oedema. Among many types of acute laryngitis, acute subglottic laryngitis is the most frequent. Laryngeal stridor in this condition is characteristically harsh, inspiratory or inspiratory-expira-tory with inspiratory prevalence; the associated cough is dry and barking. The symptoms are pathognomonic for acute subglottic laryngitis. The inflammation of the laryngeal mucous with specific symmetrical oedema at the subglottic portion, constricts the lumen of the air passages to a few millimeters. Subglottic laryngitis is typical in infants and young children. If the symptoms of laryngitis occur in children under 6 months of age, and are refractory to conventional treatment, or the episodes of laryngitis develop a few times in the first year of life, another concomitant pathology of the larynx should be considered.
Among different types of acute laryngitis, epiglottitis deserves special attention. The disease has been known for ages, but it still carries a high risk of fatalities. The risk is often due to a late diagnosis (lack of prodromal symptoms, the patient´s late presentation to the phy-sician), inadequate treatment procedures on diagnosing acute epiglottitis (not restoring the patency of the respiratory passages), or high virulence of Haemophilus influenzae, sepsis or multiorgan insufficiency. Stridor in epiglottitis is inspiratory, damp and low-pitched. It is a late-stage symptom which indicates obstruction of the inferior pharynx and laryngeal vestibule by a large oedematous epiglottis.
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