Stridor: An Alarming Sign in Emergency

A. Sivaranjini

Final year, Emergency Medicine Resident, Kauvery hospital, Chennai, India

Background

Stridor represents an emergency situation and may require urgent respiratory assessment or ENT opinion. We herein, present a case of 77-years-aged gentleman with supraglottic mass who came with stridor and hoarseness of voice. CT neck showed asymmetric circumferential thickening involving bilateral aryepiglottic folds, false & true vocal cords, paraglottic space, and anterior part of thyroid cartilage, with transglottic extension into the subglottis. Emergency tracheostomy was done under MAC. Under GA, direct laryngoscopy revealed ulceroproliferative growth which was debulked and sent for HPE. Biopsy revealed moderately differentiated cell carcinoma – Grade II. Patient was stridor free after the emergency tracheostomy and was advised to follow up in oncology OPD for further management.

Keywords:

Stridor, laryngeal growth on laryngoscopy, emergency tracheostomy.

Case Presentation

A 77- years- aged gentleman, known to have diabetes and coronary artery disease, presented to ER with complaints of breathing difficulty associated with noisy breathing for the last 4 months which was gradually progressive, and worsened over the last 1 month. He also gave a history of cough with greenish coloured sputum which was occasionally blood stained. There was associated hoarseness of voice along with significant weight loss (approx 8 kg in 1 month) associated with loss of appetite and decreased oral intake. He also gave history of coughing while consumption of food? aspiration.

Patient had consulted an ENT specialist 1 year ago for above-mentioned complaints. He was diagnosed to have a small lesion in the vocal cord and advised surgery, but the patient deferred the procedure and was lost to follow-up.

His past medical history indicated a diagnosis of adenocarcinoma stomach, and he had undergone total gastrectomy, esophagojejunostomy, and jejunojejunostomy in 2009.

On examination at the Emergency:

PR: 105/min, BP: 130/90mmhg, SpO2: 94% on room air, RR: 26/min, GCS: 15/15

CBG: 135mg/dl.

General & systemic examination

Conscious, confused, obeying commands. He was tachycardic, tachypnoeic, extremely diaphoretic, yet afebrile.

His respiratory system examination revealed an audible inspiratory stridor, bilateral wheeze and diffuse crepitations.

Other systemic examinations appeared normal.

Investigations and managment:

ABG showed Type I respiratory failure. So patient was started on high flow oxygen with 15 L of O2 with NRBM.

Patient was initially treated with IV steroids, nebulisation of steroids and IV Furosemide in view of crepitations in lungs.

ECG indicated sinus tachycardia with occasional ventricular premature complexes. Urea and electrolytes were normal.

After stabilising the airway and breathing, we obtained Urgent ENT opinion in view of pre-existing vocal cord lesion 1 year ago.

Flexible endoscopy showed ulceroproliferative growth occupying the supraglottic space; bilateral vocal cords not seen.

CT Neck showed asymmetric circumferential thickening involving bilateral aryepiglottic folds, false and true vocal cords, paraglottic space, anterior part of thyroid cartilage with involvement of both the inner and outer cortex and soft tissue extending anteriorly & showing transglottic extension into the subglottis.

Few subcentimetric nodes in the neck at level 2,3.

CT-Chest showed

(a). Patchy air space consolidation and ground glass opacification in the dependent portions of the basal segments of the bilateral lower lobes and the right middle lobe, likely aspiration pneumonia.

(b). Few scattered fibrotic bands in the right upper lobe and few scattered subpleural parenchymal bands in the left upper lobe.

An emergency tracheostomy was done under MAC with mild sedation, and patient was relieved of stridor. Direct laryngoscopy done under GA showed ulceroproliferative growth with necrotic areas seen involving the supraglottis false cords and anterior commissure, extending into the subglottis which was debulked & sent for HPE.

Patient extubated, was fully conscious after tracheostomy, and shifted to ICU for observation. He was hemodyanamically stable and shifted to ward.

Left vocal cord biopsy showed features of moderately differentiated cell carcinoma â€“ grade II.

Oncologist opinion obtained advised to do PET MR and decide further. Patient was stable/ambulant and asked to follow up in oncology OPD for further management.

Discussion

Laryngeal cancers represent one-third of all head and neck cancers and can be a significant source of morbidity and mortality due to airway obstruction. It can be at different levels of the larynx. Supraglottic, infraglottic, glottic, subglottic or even thyroid cancers infiltrating the trachea may lead to airway obstruction. Any cancers involving the larynx can cause airway obstruction and the only treatment to relieve the airway obstruction is emergency tracheostomy.

As in this case, the presence of hoarseness of voice and stridor should be given a priority attention. Our patient presented with symptoms of respiratory distress due to progressive increase in the size of supraglottic mass and superadded chest infection.

The patients with stridor are at high risk of respiratory failure and death and require initial stabilisation with ventilation & oxygenation. The degree of respiratory distress depends on whether partial airway obstruction has developed gradually (e.g. laryngeal tumour) or rapidly (e.g. acute epiglottitis).

Dysphonia may occur which can progress to breathing difficulty, aspiration pneumonia, stridor and acute airway emergencies necessitating tracheostomy like in our case.

Clinical presentation of stridor in emergency

The most common presenting symptom is loud, noisy breathing.

Depending upon the etiology, the presentation can be acute or chronic and may be accompanied by other symptoms.

A thorough history may provide helpful clues. A particular emphasis should be placed on the following:

(a). Age of onset, duration, severity and progression of stridor

(b). Precipitating events (crying or feeding) in paediatrics

(c). Positioning (prone, supine, or sitting)

(d). Quality and nature of crying in paediatrics

(e). Presence of aphonia

(f). Other associated symptoms (cough, aspiration, difficulty in feeding, drooling or sleep-disordered breathing)

Examination findings: There are different characteristics to the sound of stridor based on the anatomical location of the obstruction.

(a). Inspiratory

(b). Expiratory

(c). Biphasic

which can describe the timing in the respiratory cycle when it can best be heard.

Pathophysiological mechanisms

To understand the origin of stridor we need to define the anatomical regions of the airways. The supraglottis (extra thoracic region) consists of nasopharynx, epiglottis, larynx, aryepiglottic folds and false vocal cords. The glottic and subglottic region consists of the trachea prior to entering the thoracic cavity. So, the inspiratory stridor tends to suggest extrathoracic pathology, while expiratory stridor suggests intrathoracic pathology. Biphasic stridor is usually due to fixed obstruction such as foreign body.

Management of stridor in emergency

(a). All patients with stridor should be in the position whichever they are comfortable. The patient should be kept in nil per oral. Giving anything orally can worsen the airway obstruction.

(b). Stabilise the patient, start high-flow oxygen, and alert suitable senior specialists.

(c). Try to suction secretions or clear any foreign body from airway if obvious or visible

(d). Give adrenaline or steroids (IV or inhaled) as necessary.

(e). Take bloods including an ABG or cultures if indicated.

(f). If the clinical setting suggests the patient is stable but airway intervention will likely be needed shortly, the patient should be transported to OT for anaesthesia and ENT airway intervention.

(g). Unstable patients will require intubation in the ED. An endotracheal tube size less than the age calculated size is needed to account for the airway edema from the underlying illness. It is important to have someone call for anesthesia and ENT backup, if possible, in the unstable patient. Flexible fiberoptic tools are ideal as it more easily allows to attempt an intubation. A surgical airway kit should also be at the bedside in case of sudden complete airway collapse.

(h). Supraglottic airways may worsen the airway obstruction by the pressure they exert on an epiglottis. Preoxygenation is important to attempt any intubation.

(i). Emergent steps to secure an airway should precede any other intervention. The main airway management option are:

(j). Tracheostomy under local anaesthesia, and

(k). Inhalational induction of anesthesia and tracheal intubation or tracheostomy under general anaesthesia if anatomy is difficult to visualise and while the patient still maintains adequate spontaneous ventilation.

Patient education

Any patient who does have a supraglottic tumor needs to be counselled regarding symptoms of increased work of breathing or voice changes, and to present for re-evaluation immediately in order to minimize the risk of an emergent airway.

Patients who undergo tracheostomy will be extensively educated on caring for the stoma, suctioning and preventing mucus plugs, and what to do if the tracheostomy tube becomes occluded (immediately remove it and proceed to the nearest Emergency Room)

Conclusion

Laryngeal obstruction is a medical or surgical emergency. It can result in increased respiratory distress and can progress to fatal cardiopulmonary arrest.

The above mentioned symptoms and signs are the red flag signs and they should rush to emergency immediately for further management.

Rapid intervention should proceed diagnostic workup in the ill-appearing patient. Delay in the diagnosis may increase the risk of the patient to suffer from the complications of hypoxia such as cardiac arrest. The immediate goal of management is to provide prompt relief of airway obstruction with low morbidity & mortality.

Acknowledgement

I would like to thank, Dr, Niraj Joshi, Chief Consultant, Department of ENT, Dr. Aslesha Sheth, Consultant and Clinical lead, Department of Emergency Medicine, for guiding me to prepare this article.

References

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[5] Elfatihi M. Stridor: ED presentations, evaluation, and management. 2019. http://www.emdocs.net/stridor-ed-presentations-evaluation-and-management/

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Stridor: An Alarming Sign in Emergency