compound diaphyseal fractures of the tibia...introduction • stertor=snoring – caused by...
TRANSCRIPT
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Stridor/Snoring/OSAS
Adriaan Adriaan PentzPentzDivision of OtorhinolaryngologyDivision of Otorhinolaryngology
University of Stellenbosch and Tygerberg HospitalUniversity of Stellenbosch and Tygerberg Hospital
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Stridor/Stertor
• Noisy breathing = airway obstruction• ALWAYS THINK WHAT’S CAUSING
IT!
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Introduction
• Stertor=Snoring– Caused by obstruction of airway above the
larynx– Vibration in tissues of nasopharynx,
oropharynx or soft palate– Rough, unmusical
• Stridor– Due to obstruction in the larynx, trachea or
bronchi
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Stridor:
• Harsh, high-pitched, crowing noise during inspiration- larynx/ supraglottis obstruction
• Stridor of lower pitch with snoring + excessive secretions- pharynx/ nasopharynx
• Inspiratory+ expiratory stridor with prolonged low-pitched expiration- trachea/ brongi
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Grading of Stridor:
• Grade I : Inspiratory stridor• Grade II : Expiratory stridor• Grade III : Inspiratory + expiratory stridor
with pulsus paradoxsis• Grade IV : Respiratory arrest
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Associated signs and symptoms
• Dyspnoea– Severity of one reflects severity of the other– Signs of respiratory embarrassment
• Nasal flaring• Accessory muscles• Cyanosis• Indrawing of soft tissues• Tracheal tug
– Beware of signs in neonate and small infant
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Associated signs and symptoms (continued)
• Cough– Harsh and barking– Subglottic inflammation/tracheal compression
• Hoarseness– Speech or crying– Vocal cord pathology
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Associated signs and symptoms (continued)
• Deglutition and respiration– Share common pathway: oropharynx– Disorders of the one may interfere with the
other– Stridor/Stertor often increase during feeding– Infants often noted to be poor or slow feeders
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General features: Stridor
• Always a symptom or a sign; never a diagnosis or a disease
• History and physical examination will indicate problem areas
• Endoscopy will confirm final diagnosis
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History and physical examination (continued)
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Special investigations (continued)
• Endoscopy– Gold standard
• Evaluate nasal passages, nasopharynx, oropharynx, larynx and trachea
• General anaesthetic if required• Decide on treatment
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Special investigations (continued)
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Endoscopy
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Causes and classification
• Adult• Children• Neonatal
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Causes: Adult
• Malignancy– Nasopharynx, oropharynx, larynx
• Laryngeal trauma– Post intubation
• Acute laryngitis• Supraglottitis/epiglottitis
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Causes: Examples (continued)
• Malignancy– Usually slow in onset– Progressive– Associated symptoms
• Hoarseness• Dysphagia/odynophagia
– Associated signs• Neck mass
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Causes: Children (continued)
• Laryngotracheobronchitis (Croup)• Epiglottitis• Foreign body• Trauma
– Post intubation• Retropharyngeal abscess• Laryngeal papillomata
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Causes: Examples
• Laryngotracheobronchitis (Croup)– Viral infection– 6 months - 3 years– Pyrexia, barking cough– Stridor: Grade I-IV
• Treatment– Hospitilisation– Oxygen and adrenaline nebulisation– Intubation in severe cases
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Epiglotittis
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Causes: Examples (continued)
• Epiglottitis– Haemophilus influenza Group B– 3 years - 7 years– Pyrexia, severe sore throat– Stridor– Dribbling, breathing with raised chin, open
mouth– Cherry red epiglottitis
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Causes: Examples (continued)
• Treatment– Emergency
• IVI antibiotics
– Needs intubation• Small tube • Extubation within 48 hours
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Foreign body
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Prolonged intubation
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Causes: Children (continued)
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Causes: Children (continued)
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Causes: Neonatal
• Laryngomalacia• Congenital tumors, cysts• Webs• Subglottic stenosis• Vocal cord paralysis
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Laryngomalacia
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Causes: Examples (continued)
• Laryngomalacia– Weak supraglottic framework– Self-limiting; resolves at 3 years
• Subglottic stenosis– Congenital or acquired– Beware after intubation– May need tracheostomy
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Stenosis
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Laryngeal web
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Obstructive sleep apnoea syndrome (OSAS)
• Definitions– Apnoea
• Cessation of airflow at nostrils for 10 seconds or longer
– Apnoea index• Number of apnoeas per hour of sleep
– Hypopnoea• Reduction in airflow associated with desaturation
– Sleep apnoea syndrome• 5 or more apnoeic episodes during a hour sleep
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Risk factors of OSAS
• Obesity• Male + age• Anatomical facial abN –nasal obstruction
-adenotonsillar hypertrophy-macroglossia-micrognathia/retrognathia
• Family history• Sedatives + alcohol• Smoking
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Clinical features
• Sleep fragmentation• Daytime fatigue• Morning headache• Daytime somnolence• MVA• Poor job performance• Depression + family discord
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Complications of obstructive sleep apnoea
• Systemic hypertension• Pulmonary hypertension• Cor pulmonale• Coronary artery disease• Cardiac arrythmia• Cerebrovascular accidents• Polycythemia• Increased mortality
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Special investigations
• Sleep studies /polysomnography• Lateral X-ray neck• CXR, ECG• Nasal endoscopy• Elective intubation
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Special investigations (continued)
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Treatment (OSAS)
• Medical Rx:– Dietary modification– Nasopharyngeal airway– CPAP (continuous positive airway pressure)
• Surgical Rx:– Adenotonsillectomy– UPPP– Tracheostomy
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Summary
• Stridor is abnormal and should be investigated
• Stridor is an emergency!!!• Laryngeal evaluation has to be performed in
all patients with stridor• Snoring for longer than 6 months in a child
is abnormal