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9/20/2010
DISCLAIMER
A Case of Stridor
By Melania Bochis
Chief Complaint
• 69 yo retired nurse practitioner presents to my office complaining of cough and “sinusitis”.
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ARISING FROM THIS WEBSITE AND ITS CONTENT.
History of Present Illness
• Patient first noted symptoms in January and following an office visit was diagnosed with tracheobronchitis. She was treated with Levaquin and improved.
• In March she had brochospasm episode due to sinusitis/bronchitis again and was given Mucinex and Advair and improved. A followup
appt. in April showed near normal exam.
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9/20/2010
History of Present Illness
(cont’d)
History of Present Illness
(cont’d)
• In June she again had cough and wheezing. She received Zithromax, Advair, Mucinex and Claritin. CXR was done and read normal.
• The morning of her Pulmonary consult appt. she came for an office visit and was noted to have markedly different breathing pattern consistent with stridor.
• Patient called office inquiring about sputum culture and upon reviewing the chart I recommended a Pulmonary consult for bronchoscopy, possibly CT scan of chest and office appt. with me.
– Onset/Timing: 3 weeks while still on vacation
– Frequency: constant
– Alleviated by: partially when using inhaler
– Exacerbated by: increased respiratory demand
– Associated with: weight loss, anorexia, anxiety
Review of Systems
• All pertinent complaints were described in the HPI.
• LLater, patient also described a constant i
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sensation that she had to clear her throat which she self explained as a chronic sinusitis.
Medical and Surgical Histories
Past Medical
• Enlarged thymus • Chorioretinitis
• Atypical histoplasmosis
• Osteoporosis
• Diverticulosis
• Episodic genital herpes
• Depression
• Anxiety
• Remote tobacco use
Past Surgical
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Tonsillectomy
Cholecystectomy
Appendectomy
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y
Bilateral breast implants
Hammertoe surgery
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9/20/2010
Social History
• Retired Nurse Practitioner
• Divorced since 1972
• Has 2 living daughters, one adopted son murdered in 2003
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• Drinks a glass of wine with dinner occasionally
• Smoked for 7 years, up to 1 ppd quit in 1978
• Never used illicit drugs Medications and Allergies
Medicatios
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Zoloft 75 mg PO QD
Fosamax 70 mg PO Qweek
Xanax 0.5 mg PO QHS PRN
g
Azathioprine 175 mg PO QD
Allergies
• Novocaine : swelling
• Penicillin : hives
• Horse serum : anaphylaxis
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Family History
• Father : former surgeon, died at 82 due to complications from prostate cancer
• Mother : homemaker, died at 81 from leukemia
• Brother : physician, died at 65 due to emphysema related complications
• Brother : 78 yo and healthy
• Daughters : healthy
Physical Exam
• Thin, pleasant female
• Moderate respiratory distress, gasping with breath and difficulty talking
Audible inspiratory high pitched sound
high pitched sound
• Audible inspiratory
VITALS : BP=110/62; HR=79 bpm; RR=18
Ht=5’8”; Weight=136.8 lbs
Ox. Sat. = 96%
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9/20/2010
Physical Exam (cont’d)
• Pertinent findings:
– No cyanosis
– No palpable lymphadenopathy
– No oro‐pharyngeal abnormalities
No oro pharyngeal abnormalities
– No palpable neck masses
– No sinus tenderness
– Diffuse inspiratory stridor with decreased sounds towards periphery
PFT
Accessory Data
• CXR : reading normal
• CMP: normal
• CBC: chronic macrocytosis, no leukocytosis or shift
• PFT: FEV1=2.28L (61%‐mild obstructive)
minimal improvement with Albuterol
DLCO normal
flattened inspiratory curve
Patient’s actual spirometry 4
9/20/2010
Radiology
• CXR: Interstitial pattern
• CT Chest: No significant abnormality
• CT Neck: Moderate flattening of distal trachea and mainstem
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bronchi which may represent hi hi h
some tracheomalacia
• CT Chest: Opacity paratracheally with some distal tracheal involvement
• PET: Hypermetabolic paratracheal lesion
Axial CT airway imaging in A) inspiration and B) expiration and C) dynamic expiration There is
expiration and C) dynamic expiration. There is excessive tracheal collapsibility on expiration. Note that in some cases the collapse can not be demonstrated on end‐ exhalation, but is much more prominent on dynamic imaging. Reliance on in‐ and expiratory imaging alone can be a source for false negative examinations. Courtesy of Dr. P. Boiselle.
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9/20/2010
Bronchoscopy
• Dropped saturation during procedure
• “Hamburger‐like tissue” from mid trachea down
• Appearance c/w aggressive tumor, mucus A
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coated
• Severe airway compromise due to • No bronchoscopic biopsy performed
• BAL not diagnostic
Pathology
• BAL: macrophages, inflammation, no malignancy.
• Culture: Yeast (Candida spp.), MRSA
• Biopsy: Atypical squamos
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metaplasia
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background of necrosis and inflammation.
Stridor
• Definition: A harsh noise produced during breathing, typically heard as a high pitched inspiratory wheeze audible at a distance.
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• Commonly caused by obstruction affecting the larynx or extrathoracic trachea.
• Accentuated by inspiration
• Generated by wall vibration
• Pitch depends on speed and density of air (heliox)
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Causes of Stridor in Children
• 1. Congenital: Choanal atresia, Congenital laryngeal paralysis
• 2. Inhaled foreign body: peanuts, toys
• 3. Croup syndrome: Diphteria, 3 C
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laryngotracheobronchitis, epiglotitis, croup, upper airway burns, angioneurotic edema, mononucleosis
Causes Above the Larynx and Inside the larynx of trachea
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Retropharyngeal abscess
New growths of the pharynx
Lingual angioedema
Mucus plugs
Impaired cough or clearing mechanisms
Causes of Stridor in Adults
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Causes above the larynx
Causes inside the larynx or trachea
Causes in the wall of the larynx or trachea
External compression of larynx or trachea
Laryngeal nerve palsy
Narrowing of both main bronchi
Causes in the Walls of the Larynx and Trachea
• Inflammatory : acute diphteria, irritant laryngitis, Wegener’s, sarcoidosis, TB, syphyllis.
• Traumatic or post traumatic
• Neoplastic: malignant or benign tumors of larynx Neoplastic: malignant or benign tumors of larynx
or trachea
• Edema of glottis: burns, toxic gases, angioedema
• Rheumatoid arthritis
• Tracheopathia osteopatica
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External Compression
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Goiter
Thyroiditis
Carcinoma of thyroid
Aortic malformations: double aortic arch
Infections : bacterial and fungal
Ludwig’s angina
Mediastinal disease
Other Causes
• Laryngeal nerve palsy: bulbar or pseudobulbar
palsy, lesions of recurrent laryngeal nerves
• Narrowing of both main bronchi: bronchial i
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carcinoma, TB, sarcoidosis, amyloidosis, tracheomalacia
Tracheal Tumors
• Epidemiology: – Rare overall incidence, 0.1 per 100,000.
– Mean age 60 yo
– M>F
– Exceedingly rare in kids
Tracheal Tumors
• Pathology:
– Majority are malignant
– 1/2‐2/3 are squamos cell (SCC)
– Less than 10% are adenoid cystic carcinomas Less than 10% are adenoid cystic carcinomas
(ACC)
– Benign tumors include:
Hemangiomas
Hamartomas
Neurogenic tumors
Granular cell tumors
Squamous papillomas
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Pathology
• SCC (Squamous cell carcinima) : identical to SCC of lung
• ACC (Adenoid Cystic cacinoma): identical to ACC’ss of salivary glands
ACC
of salivary glands
• MEC (mucoepidermoid carcinoma) : histologically identical to MEC of the sallivary
glands
Mucoepidermoid Carcinoma
• Squamous cells, mucin secreting cells and intermediate cells
• Arise from bronchial glands in main airways
• More common in bronchi than in trachea
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• Well delineated polypoid masses
• Low grade < 5% rarely extend to local LN
• High grade regional and direct distant mets
Adenoid Cystic Carcinoma
• Typicaly polypoid lesions in trachea or mainstem bonchi
• Infiltrative plaques with longitudinal and circumferential extension
circumferential extension
• Extension along nerves and blood vessels common
• High rate positive surgical margins
• Multiple recurrences with late mets
Presentation and Diagnosis
• Presents usually with cough, hoarseness, dyspnea, hemoptysis (common with SCC), wheeze and stridor . • Diagnosis :
Diagnosis :
– CXR not diagnostic
– CT scan preferred
– PFT’s help
– Bronchoscopy needed for tissue biopsy
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Treatment
• Surgery
– Treatment of choice
– Underutilized
• Radiation therapy
Radiation therapy
– Postop radiation used with SCC and ACC especially in incomplete margin
– Not certain if it improves
– RT sometimes used alone as primary treatment
– Laser resection with the rigid bronchoscope
Prognosis
• Squamous cell carcinoma
– US : 47% 5 y survival, 36% 10 y survival
– Netherlands 12% survival (but only 12% had surgery
• Adenois cystic carcinoma
• Mucoepidermoid carcinoma
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