Stridor



Stridor


Christopher M. Walker, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Tracheobronchomalacia


  • Saber-Sheath Trachea


  • Laryngeal/Pharyngeal Tumor


  • Thyroid Mass


Less Common



  • Trauma


  • Tracheal Stenosis


  • Foreign Body


  • Wegener Granulomatosis


Rare but Important



  • Tracheopathia Osteochondroplastica


  • Infection


  • Tracheal Neoplasm


  • Tracheobronchial Amyloidosis


  • Relapsing Polychondritis


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Review focuses on stridor in adults


  • Stridor



    • High pitched sound secondary to turbulent flow in upper airway


    • Indicates pathology in trachea or larynx


  • Radiography and CT



    • Primary imaging modalities used in directing differential diagnosis


  • Final diagnosis may require bronchoscopy with biopsy


Helpful Clues for Common Diagnoses



  • Tracheobronchomalacia



    • Abnormal tracheal or bronchial cartilage



      • ≥50% decrease in cross-sectional area with expiration


      • Trachea may appear normal on inspiratory images


    • Congenital or acquired causes secondary to



      • Intubation, external mass or vessel causing compression, infections, or COPD


  • Saber-Sheath Trachea



    • Strong association with COPD


    • Cartilage damage through repeated coughing


    • Coronal tracheal diameter ≤2/3 sagittal diameter


    • Normal tracheal wall thickness


  • Laryngeal/Pharyngeal Tumor



    • Squamous cell carcinoma most common etiology


    • Document extent of disease, as it influences surgical and therapeutic plan


  • Thyroid Mass



    • Goiter or malignancy may externally compress trachea


Helpful Clues for Less Common Diagnoses



  • Trauma



    • Hematoma compressing airway


    • Secondary tracheal stenosis from remote trauma


  • Tracheal Stenosis



    • Focal stricture with circumferential wall thickening


    • ± cartilage damage with resulting tracheomalacia


    • Prolonged endotracheal intubation



      • Subglottic tracheal stenosis at cuff site


      • Reduced incidence with low-pressure balloon cuffs


    • Tracheostomy tube placement



      • Stenosis at stoma site


    • Other etiologies



      • Complete cartilaginous tracheal ring and sarcoidosis


    • Treat with mechanical dilation or stenting


  • Foreign Body



    • History essential for diagnosis


    • Foreign body rarely radiopaque


  • Wegener Granulomatosis



    • Circumferential subglottic tracheal wall thickening with luminal narrowing


    • ± cavitary lung nodules


    • ± pansinus disease


    • Laboratory evidence of glomerulonephritis (microscopic hematuria and proteinuria)


Helpful Clues for Rare Diagnoses



  • Tracheopathia Osteochondroplastica



    • Benign disease occurring in older men


    • Often incidental at bronchoscopy


    • Rarely leads to symptoms


    • Small and irregularly shaped calcified nodules arising from cartilage


    • Spares noncartilaginous posterior tracheal membrane


  • Infection



    • Tuberculosis



      • Circumferential wall thickening with tracheal narrowing



      • Mediastinal lymphadenopathy


    • Epiglottitis



      • More indolent than pediatric epiglottitis, secondary to larger hypopharynx


    • Rhinoscleroma



      • Chronic granulomatous infection by Klebsiella rhinoscleromatis


      • Central America, Africa, and India


      • Nasal cavity involved in 95% with polyps and soft tissue thickening


      • Spares paranasal sinuses


      • 25% have subglottic tracheal involvement with concentric or nodular narrowing


      • Air-filled crypts in tracheal lumen nearly diagnostic


  • Tracheal Neoplasm



    • 3 different forms



      • Primary malignant, metastatic disease, and primary benign tumors


    • 3 growth patterns



      • Sessile, polypoid, and circumferential growth


    • CT documents extent of disease and trachea distal to lesion


    • Squamous cell carcinoma



      • Most common primary malignant disease of trachea


      • Strong association with smoking


      • 10% multifocal at presentation


    • Adenoid cystic carcinoma



      • Posterolateral tracheal wall


      • ± growth along airways


    • Metastatic disease



      • Invasion or compression from bronchogenic or esophageal carcinoma


      • Hematogenous metastases from melanoma, breast, colon, and renal cell carcinoma


      • ± single or multiple endotracheal lesions


    • Tracheobronchial papillomatosis



      • HPV infection of tracheal and bronchial tree


      • Small well-circumscribed noncalcified tracheal nodules


      • ± cystic lung lesions


  • Tracheobronchial Amyloidosis



    • Nodular or concentric wall thickening of trachea and mainstem bronchi



      • ± nodular calcification


    • ± atelectasis or lobar collapse


    • Usually no lung nodules


    • Treatment with stenting or resection


  • Relapsing Polychondritis



    • Systemic disorder associated with repeated bouts of cartilaginous inflammation


    • Trachea and bronchi affected late in disease course


    • Also affects cartilage of



      • Ears, nose, and joints


    • CT shows



      • Tracheobronchial wall thickening with sparing of noncartilaginous posterior wall


      • Severe disease may affect posterior wall


    • Stenosis leads to recurrent pneumonia


    • Treat with stents and corticosteroids







Image Gallery









Axial NECT shows diffuse intrathoracic tracheal narrowing image with more than 50% reduction in cross-sectional area when compared to inspiratory images, which is diagnostic of tracheomalacia.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Tracheal Mass
  2. Unilateral Pulmonary Consolidation
  3. Eggshell Calcification, Hilum
  4. Unilateral Pleural Effusion

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 8, 2016 | Posted by in CARDIOLOGY | Comments Off on Stridor

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access