Stridor Research Articles

Woman with Stridor

A 45-year-old woman who had undergone a remote thyroidectomy presented to the emergency department with 2 hours of nontraumatic dyspnea and dry cough. She was afebrile, her respiratory rate was 34 breaths/min, and her oxygen saturation was 98%. On physical examination, the patient had inspiratory stridor and wheezing. Point-of-care ultrasound was performed to assess the patient’s vocal cord movements (Figure and Video 1). Video 2 shows normal vocal cord movement.

Anaesthesia and laryngomalacia - A case report

Laryngomalacia is one of the commonest causes of congenital stridor in neonates. The treatment depends on the severity of the stridor. We present a case of 12 day old neonate with a history of stridor who was diagnosed to have laryngomalacia on clinical examination and confirmed by flexible fibreoptic bronchoscopy. The neonate underwent excision of excessive aryepiglottic fold under general endotracheal anaesthesia with controlled ventilation as the definitive surgery.

HEREDITARY ALPHA TRYPTASEMIA MASKED AS ASTHMA EXACERBATION

<h3>Introduction</h3> Clinical phenotypes of hereditary alpha tryptasemia (HAT) are variable and can range from asymptomatic to anaphylaxis. Due to this broad range of presentations, diagnosis can be challenging, particularly if only one organ system is involved. <h3>Case Description</h3> An 8-year-old male presented to the emergency department with hypoxemia and stridor. His exam was notable for inspiratory and expiratory stridor with increased work of breathing. He received nebulized racemic epinephrine without improvement, and then had resolution of symptoms with intramuscular epinephrine and oral corticosteroids. Spirometry was suggestive but not diagnostic of asthma. Due to symptoms localized only to the respiratory tract, asthma was initially suspected. However, mast cell disorders were also considered since he required epinephrine before symptom improvement. Serum tryptase was elevated on initial and repeat testing. Genetic testing demonstrated increased copies of <i>TPSAB1</i>, consistent with HAT. <h3>Discussion</h3> Hereditary alpha tryptasemia is an autosomal dominant disorder resulting from increased copies of <i>TPSAB1</i> which encodes alpha tryptase. Disease severity varies from asymptomatic to anaphylaxis. Higher tryptase levels and increased symptom severity parallels increased number of <i>TPSAB1</i> copies. Serum tryptase level is the initial screening test. If elevated, genetic testing for <i>TPSAB1</i> should be performed. Though presentations with single organ involvement are not normally concerning for systemic disease, severe presentations of atopic diseases, including asthma, should prompt consideration of HAT. Treatment is symptom directed and may include antihistamines, mast cell stabilizers, leukotriene inhibitors, and epinephrine.

Creation of salpingopharyngeal fistulae for the management of guttural pouch tympany and persistent guttural pouch empyema

SummaryCase 1, Guttural pouch tympanyAn 8‐month‐old Arabian filly presented with a history of longstanding bilateral fluctuant parotid region swelling and acute onset dyspnoea, tachypnoea, inspiratory stridor and right mucopurulent nasal discharge. Endoscopy and drainage (mucopus from the right, air from the left) of the GPs resulted in temporary reduction in the bilateral parotid region swelling. Marked dyspnoea recurred 48 h later, with accompanying external GP distention. A diagnosis of bilateral (R &gt; L) GP tympany with secondary guttural pouch empyema of the right GP was therefore made. An indwelling Foley catheter was positioned in the right GP, but the filly dislodged the catheter daily and after 5 days, surgery was performed.Case 2, Persistent guttural pouch empyemaAn 18‐year‐old pony gelding had chondroids found in the right GP 6 months previously and was diagnosed with a ‘strangles’ (Streptococcus equi var. equi) infection. Over subsequent months, multiple medical and surgical treatments were attempted but empyema kept recurring. After 6 months, it became difficult to introduce an endoscope into the right pouch, due to stenosis of the auditory tube. A laser salpingopharyngostomy procedure was recommended.Both horses underwent endoscopically guided salpingopharyngeal fistulation in the midline dorsal nasopharyngeal recess using a diode laser under standing sedation after topical application of local anaesthetic. A fistula approximately 1.5 × 2 cm was created (Figure 1) and then the median septum between the left and right pouches was resected caudally with the laser creating a large fenestration between the two pouches. No complications of surgery occurred.In Case 1, external GP distension resolved immediately following surgery. Re‐examination at 6 weeks post‐operatively showed continued patency of the fistula and resolution of secondary empyema. The foal remained asymptomatic thereafter until it was lost to follow‐up.Case 2 had resolution of nasal discharge. A final follow‐up endoscopy 3 months post‐operatively revealed both pouches to be clear, and the salpingopharyngeal fistula to still be patent. Telephone follow‐up 6 months post‐surgery revealed that the pony had no recurrence of clinical signs.

RAPID GROWTH OF GRANULATION TISSUE: A RARE CAUSE OF STRIDOR

RAPID GROWTH OF GRANULATION TISSUE: A RARE CAUSE OF STRIDOR

Management of Stridor in Severe Laryngomalacia: A Review Article.

Laryngomalacia is the term most broadly used to portray the "internal breakdown of structures of supraglottis of the larynx at the time of inspiration. It is often associated with stridor during inspiration, which is of a high pitch at the time of birth and comes into notice by 14 days. When there is an increase in breathing, stridor worsens, and it is usually position-dependent. Laryngomalacia means the weakening of the larynx resulting in a collapse of the laryngeal cartilages, especially the epiglottis, into the airway. This partially occludes the upper airway during inspiration and causes inspiratory stridor. The exact etiology of the condition is not known. It is a well-known cause of noisy breathing in neonates and infants. The common presentation is a neonate with flushing and high-pitched inspiratory stridor that is usually noticed before 14 days of age. This worsens with breathing and supine positioning and improves in a prone position. Less commonly, it can present with hypoxia, feeding problems, aspiration, and failure to thrive. The condition may increase in severity during early lifebut usually self-resolves by two years of age. The hiccup-like squeak of laryngomalacia during inspiration is due to unsettled air flowing through the laryngeal passage. The condition is diagnosed with laryngoscopy, and the treatment varies with presentation and severity. Neonates with the uncomplicated disease can be treated expectantly. Those presenting with feeding problemsand gastroesophageal reflux will require acid suppression. Severe complications like aspiration, severe airway obstruction, and hypoxia will require surgical treatment, including supraglottoplasty.In cases where the surgical treatment failed, noninvasive ventilation can be advised. The article reviews the various medical and surgical interventions and the management of severe laryngomalacia.

Supraglottoplasty- cold technique

Supraglottoplasty is the mainstay surgical treatment for severe laryngomalacia. The decision to operate is based on the severity of patient symptoms. High-pitched inspiratory stridor is the classic finding, but severity of symptoms is based on a spectrum of feeding and respiratory findings. The cold-steel technique was first described in the 1980s and has remained the primary technique for many pediatric otolaryngologists. This article reviews etiology of laryngomalacia, indications for operation, and cold-steel technique for the treatment of laryngomalacia.

Case Report: Bilateral peritonsillar abscess with complications of upper airway obstruction

Background: Peritonsillar abscess is a collection of pus between the tonsillar fibrous capsule and the pharyngeal constrictor muscle. Unilateral peritonsillar abscess is a common complication of acute tonsillitis, whereas bilateral peritonsillar abscess is rare. The incidence of bilateral peritonsillar abscess remains unknown but is estimated to be 4.9% of all peritonsillar abscess cases. Case report: A 20-year-old man came to the emergency room with bilateral peritonsillar abscess and complained of shortness of breath for two weeks. Physical examination showed muffled voice, 82% oxygen saturation, and inspiratory stridor. The isthmus faucium was narrow, with approximately 30% remaining. Peritonsillar puncture revealed pus mixed with blood. The treatment for this patient included bilateral peritonsillar incision and drainage and intravenous antibiotics of levofloxacin and metronidazole. The patient came to the Ear, Nose, Throat, Head, and Neck (ENTHN) Outpatient Unit eight days after the procedure for a control checkup and was in good condition. Conclusion: We have reported a bilateral peritonsillar abscess with complications of upper airway obstruction, in which we performed incision and drainage. Prompt and appropriate management is needed to avoid unwanted morbidity and mortality.

A novel phenotype in an Italian family with a rare progranulin mutation

IntroductionProgranulin (PGRN) is a secreted glycoprotein encoded in humans by the GRN gene, located on chromosome 17q21. Several nonsense and missense pathogenetic GRN mutations have been described.ObjectiveWe herein describe two sisters carrying a rare GRN mutation with extremely different clinical features and family history of dementia and behavioral disorders, with a novel presentation with stridor and dysphonia.MethodsPatients underwent a multidimensional assessment including neurological and neuropsychological evaluation, structural and functional imaging, and genetic screening.ResultsThe younger sister presented at the age of 64 with inspiratory stridor, dysphonia and exercise-induced dyspnea. Transnasal fiberoptic laryngoscopy showed bilateral adduction of the vocal cords at rest and paradoxical further adduction of the vocal cords during forced inspiration, suggesting the hypothesis of an adductor laryngeal dystonia. The older sister presented at the age of 63 with a rapidly progressive corticobasal syndrome. The only clinical feature common to both sisters was a dysexecutive syndrome. The c.893G > A mutation in exon 9 of GRN was found in heterozygosis in both sisters, causing a missense Arginine to Histidine substitution in position 298 of the protein (p.R298H).ConclusionsOur report supports the pathogenicity of the GRN p.R298H mutation, which is first detected in two members from the same family, showing an extremely different phenotypes. Moreover, we report the first case of an FTD-associated mutation presenting with inspiratory stridor and dysphonia linked to adductor laryngeal dystonia, thus expanding the clinical spectrum of GRN-related disorders.

Tracheal resection and anastomosis in a dog with an osteochondroma

AbstractA 2‐month‐old golden retriever was presented with a history of intermittent wheezing and inspiratory stridor. Previous thoracic radiographs revealed the presence of a discrete opacity partially obscuring the trachea at the level of the thoracic inlet. Through tracheoscopy, a smooth, broad‐based intratracheal mass was visualised just past the thoracic inlet that made up about 80% of the tracheal diameter. Histological examination of biopsies obtained during this procedure was consistent with tracheal osteochondroma. The mass was removed by resection and anastomosis of the trachea through a cervical approach. Histopathology of the excised mass confirmed the prior diagnosis of osteochondroma. Re‐evaluation and repeat thoracic radiographs 6 months postoperatively showed complete resolution of clinical signs and no evidence of recurrent disease. This case demonstrates that tracheal resection and anastomosis can be a viable and curative surgical procedure for some masses, including osteochondromas, within the trachea.

Ectopic thymic carcinoma in the nasopharynx of a Golden Retriever

An eleven-year-old, male, neutered Golden Retriever was referred for a chronic history of stertorous breathing, inspiratory stridor and mucopurulent discharge from the left nostril. A computed tomographic (CT) scan of the head, neck and thorax revealed a nasopharyngeal mass causing bone lysis of the hard palate. There were no signs of local or distant metastatic disease. Nasopharyngoscopy confirmed a large mass, occluding the entire nasopharynx. Histopathologi cal analysis of the biopsies was indicative of a chronic inflammatory polyp. The mass was surgi cally removed through a ventral approach to the nasopharynx. Histopathological examination of the mass identified it as a thymic carcinoma arising from ectopic thymic tissue. The dog recov ered well but died of unknown causes one year later.

Ring-sling complex association with pig bronchus: a pediatric case report

The ring-sling complex is an association between pulmonary artery sling and congenital tracheal stenosis. Pulmonary artery sling is a rare form of vascular ring in congenital heart disease. The clinical case of a child with inspiratory laryngeal stridor associated with respiratory distress is presented, evaluated in another center where respiratory endoscopy was performed, observing extrinsic tracheal compression. Given the clinical suspicion of a vascular ring, CT angiography was requested, confirming the diagnosis of pulmonary artery sling. He was referred to our hospital and during the surgical intervention a new respiratory endoscopy and tracheobronchography were performed, reaching the diagnosis of congenital tracheal stenosis, right accessory bronchus (pig bronchus) and complete vascular rings, both repaired in the same surgical act.

Algorithm for the management of laryngeal obstruction in pediatrics

The larynx is at the aerodigestive crossroads; any pathology that involves it will have an impact on breathing, swallowing and/or the voice. It`s divided into three regions: supraglottis (includes epiglottis, ventricular bands and laryngeal ventricles), glottis (space limited by the vocal cords) and subglottis (narrowest area of pediatric airway and the only point of larynx completely surrounded by cartilage: the cricoid ring). Laryngeal obstruction can present as a potentially fatal acute condition or as a chronic process. The main symptom is inspiratory or biphasic stridor. The etiology varies widely according to age and it may be of congenital, inflammatory, infectious, traumatic, neoplastic or iatrogenic origin. We describe the pathologies that cause laryngeal obstruction, either those that occur very often or those which are important for their severity, their guiding symptoms to the presumptive diagnosis, additional studies and treatment.

Case Report: Bilateral peritonsillar abscess with complications of upper airway obstruction

Background: Peritonsillar abscess is a collection of pus between the tonsillar fibrous capsule and the pharyngeal constrictor muscle. Unilateral peritonsillar abscess is a common complication of acute tonsillitis, whereas bilateral peritonsillar abscess is rare. The incidence of bilateral peritonsillar abscess remains unknown but is estimated to be 4.9% of all peritonsillar abscess cases. Case report: A 20-year-old man came to the emergency room with bilateral peritonsillar abscess and complaining of shortness of breath for two weeks. Physical examination showed muffled voice, 82% oxygen saturation, and inspiratory stridor. The isthmus faucium was narrow, with approximately 30% remaining. Peritonsillar puncture revealed pus mixed with blood. The treatment for this patient included bilateral peritonsillar incision and drainage and intravenous antibiotics of levofloxacin and metronidazole. The patient came to the Ear, Nose, Throat, Head, and Neck (ENTHN) Outpatient Unit eight days after the procedure for a control checkup and was in good condition. Conclusion: We have reported a bilateral peritonsillar abscess with complications of upper airway obstruction, in which we performed incision and drainage. Prompt and appropriate management is needed to avoid unwanted morbidity and mortality.

COVID-19-Associated Croup in Children.

As SARS-CoV-2 has evolved, so has its effects on the pediatric population.1 While early variants typically resulted in lower respiratory infections, the recently identified Omicron variant may exhibit a predilection for the upper airways.2 The relatively smaller upper respiratory tract in children compared to adults has been thought to predispose them to more severe clinical presentations resembling laryngotracheobronchitis, or croup. Caused by viral-induced subglottic airway inflammation, croup is classically characterized by sudden onset "barking cough", inspiratory stridor, and respiratory distress. Endemic coronaviruses have been linked to croup, however only sparse case reports have described croup specifically associated with SARS-CoV-2 and it remains unclear if croup cases constitute a causative relationship or result of co-infection with another virus.3-6 To address this knowledge gap, we performed a retrospective analysis of the incidence and clinical characteristics of croup associated with SARS-CoV-2 infection at a large freestanding children's hospital.

Clinical, Radiographic And Bronchoscopic Findings of Tracheal Collapse in A Calf

A six-day-old calf was presented to the XXX University Veterinary Teaching Hospital with a history of wheezing (noisy respiration), dyspnea that worsens with exercise and drinking. The calf shown upper respiratory tract symptoms including extended head and neck, dilated nostrils, severe inspiratory stridor with characteristic “honking” sound, and exophthalmos. Upon these findings, we suspected upper airway obstruction and decided to perform cervical-thoracal radiography and bronchoscopy to obtain detailed visualization of the upper respiratory tract. On the thorax radiograph, significant tracheal narrowing was visible at the thoracic inlet, and it was beginning at the caudal cervical region (C5) and extending to the cranial thorax (T1). Also, severe dorsoventrally narrowing was displayed approximately 15 cm after entering the trachea using bronchoscopy. The tracheal collapse was diagnosed in this case based on clinical, radiographical, and bronchoscopy findings. It is important to remember that tracheal collapse should be considered in the differential diagnosis in calves that show upper respiratory tract symptoms such as extended head and neck, dilated nostrils, severe inspiratory stridor with characteristic “honking” sound.

Un pianto stridulo che confonde: non è sempre laringomalacia

The case of a young infant with congenital stridor eventually diagnosed as unilateral idiopathic paralysis of vocal cords is described. The differential diagnosis of congenital stridor is discussed.

A large anterior mediastinal mass in a young infant

Abstract Funding Acknowledgements Type of funding sources: None. TITLE A large anterior mediastinal mass in a young infant Case Report A 4 week old male neonate, KS was referred to the emergency department with a 24 hour history of increased work of breathing, two brief episodes of apnoeas and inspiratory stridor. There was no infective symptoms or changes to his usual feeding pattern. There was no significant past medical history and he was on no regular medications. A chest x-ray demonstrated a large mediastinal mass and suspicion of cardiomegaly. A transthoracic echocardiogram demonstrated a structurally and functionally normal heart. However, there was a large anterior homogenous soft tissue mass extending to the left ventricular apex which was separate from the pericardium. This mass did not cause any heart chamber compression or compromise. Further cross-sectional imaging with cardiac computed tomography (CT) showed a non-enhancing uniform soft tissue mass occupying the superior and anterior mediastinum without evidence of calcification or fatty components. The lesion was seen to be extending from the root of the neck down to the left cardiac apex region with the total dimensions of the mass being 5.2 x 3.5 x 5cm. There was no compression of the great arteries or the airway. Parasternal ultrasound of the chest showed a starry sky appearance compatible with normal thymic tissue. Overall, the appearances were felt to be compatible with a prominent normal thymus. Discussion The differential diagnosis of an anterior mediastinal mass in young infants includes germ cell tumours (mainly teratomas), congenital thymic cysts and true thymic hyperplasia(1). These can be difficult to distinguish from the normal large neonatal thymus. The normal thymus can take on a variety of shapes and sizes and still be considered normal. One of the most important features of a normal thymus is the lack of mass effect or compression on the airway or vascular structures(2). True thymic hyperplasia is characterised by an increase in the size and shape of the thymus while preserving thymic architecture. If the anterior mass has a bipyramidal morphology with the presence of gross intercalated fat on CT, these findings are pathognomonic for thymic hyperplasia(3). Thymomas are rare in children and appear as well-defined, rounded or lobulated soft tissue density mass with mild enhancement on CT. It can demonstrate irregular borders with extension into adjacent structures and approximately 30% will have necrosis and internal cystic foci(4). The most common germ cell tumour in the mediastinum is a teratoma with the hallmark being fat, fluid and calcified components on CT(2). Lymphomas are the most common anterior mediastinal mass in children but are usually seen in children older than 5 years. They often cause mass effect with displacement of the trachea. CT scan demonstrates larger nodal areas with hypodense and cystic areas suggestive of necrosis(1). Abstract Figure 1 Abstract Figure 2

Inspiratory laryngeal stridor as the main feature of progressive encephalomyelitis with rigidity and myoclonus: a case report and literature review

BackgroundProgressive encephalomyelitis with rigidity and myoclonus (PERM) is an acute, potentially life-threatening, yet curable neuro-immunological disease characterized by spasms, muscular rigidity, and brainstem and autonomic dysfunction. The clinical features of glycine receptor (GlyR) antibody-positive PERM may be overlooked, particularly with some unusual symptoms.Case presentationA 52-year-old man was admitted to the hospital for evaluation of tension headache for 20 days and mild dysarthria. These symptoms were followed by panic, profuse sweating, severe dysarthria, dizziness, unsteady gait, and paroxysmal muscle spasms. Brain magnetic resonance imaging and cerebrospinal fluid analysis were normal. The patient’s condition steadily deteriorated. He repeatedly presented with rigidity, panic attacks, severe anxiety, paroxysmal inspiratory laryngeal stridor, cyanosis of the lips, and intractable epilepsy. Electromyography showed multiple myoclonic seizures, a single generalized tonic-clonic seizure, and a single generalized tonic seizure. Screening for autoimmune encephalitis antibodies revealed anti-GlyR antibodies in his cerebrospinal fluid. Immunomodulatory pulse therapy with steroids and immunoglobulin resulted in expeditious improvement of the symptoms within 2 weeks, and a follow-up at 5 weeks showed consistent clinical improvement.ConclusionOur case highlights that inspiratory laryngeal stridor is an important symptom of PERM. Our observation widens the spectrum of the clinical presentation of anti-GlyR antibody-positive PERM, where early identification is a key to improving prognosis.

Recognizing New-Onset Sleep Disorders in Autoimmune Encephalitis Often Prompt Earlier Diagnosis.

Sleep/wake disorders are common in patients with autoimmune encephalitis, sometimes the most prominent or sole initial symptom, then delaying diagnosis. Sleep/wake disorders in autoimmune encephalitis vary and include severe sleeplessness, hypersomnia, central and/or obstructive sleep apnea, rapid eye movement sleep behavior disorder, indeterminate sleep/wake states, and loss of circadian sleep/wake rhythms. N-methyl- d aspartate receptor encephalitis (NMDAR) is often associated with insomnia, then hypersomnia and sleep-related central hypoventilation. Profound sleeplessness and rapid eye movement sleep behavior disorder are seen in patients with voltage-gated potassium channel-complex antibodies. Fragmented sleep and hypersomnia are common in paraneoplastic syndromes associated with anti-MA protein encephalitis; rapid eye movement sleep behavior disorder in those with antibodies against leucine-rich glioma inactivated protein (LGI1) or contactin-associated protein 2 (CASPR2) antibodies. Antibodies against a cell adhesion protein IGLON5 may result in obstructive sleep apnea, inspiratory stridor, disorganized nonrapid eye movement sleep, and excessive movements and parasomnias fragmenting nonrapid and rapid eye movement sleep. Recognizing a particular sleep/wake disorder is often a presenting or prominent feature in certain autoimmune encephalitis permit for earlier diagnosis. This is important because reduced morbidity and better short- and long-term outcomes are associated with earlier diagnosis and immunotherapies.