THÔNG TIN TÀI LIỆU
complaints of hoarseness and stridor Neoplastic processes causing tracheal compression can also lead to stridor in the older child Psychogenic or functional stridor (also called vocal cord dysfunction or paradoxical vocal cord movement) is an uncommon cause of stridor, and presents in older children, typically adolescents The diagnosis is three times more common in females than males More than 50% of patients meet diagnostic criteria for a psychiatric disorder This diagnosis can be challenging as many of these patients have asthma as a comorbid condition, and may present with apparent distress and poor aeration Characteristically, stridor improves when the patient is unaware that he or she is being observed, and it may clear with cough The diagnosis can be confirmed by nasopharyngoscopy in the symptomatic patient when the vocal cords are noted to be adducted during inspiration EVALUATION AND DECISION The first priority is to ensure that the airway is adequate by assessing the level of consciousness, color, perfusion, air entry, breath sounds, and work of breathing, including respiratory rate, nasal flaring, and retractions Oxygen saturation should be obtained, although a normal saturation does not rule out severe disease Conversely, a low saturation with upper airway obstruction as the only etiology of illness is an ominous sign If possible, the child should be allowed to assume a position of comfort to minimize agitation and distress and maximize airway patency Immediate resuscitative measures should be instituted as necessary (see Chapter Airway ) The child may then be evaluated systematically In the child with acute onset of stridor, history should focus on associated symptoms such as fever, duration of illness, drooling, rhinorrhea, and history of choking or trauma ( Fig 75.1 ) Immunization status should be verified, particularly H influenzae vaccination In the case of a child with chronic stridor, important historical points include age at onset and progression of stridor, as well as ameliorating and aggravating factors Physical examination should include careful inspection of the nares and oropharynx, with particular attention to trismus, increased secretions or drooling, visible mass, and abnormal phonation Of note, the examination and manipulation of the oropharynx of any child with suspected supraglottitis should be deferred until a secure airway can be established Quality of the voice or cry should be noted as normal, hoarse (e.g., with croup, vocal cord paralysis, papilloma), weak (e.g., with neuromuscular disorder), or aphonic (e.g., with laryngeal obstruction) Regional findings such as adenopathy, neck masses, meningismus, trauma, or bruising should also be sought Position of comfort should be noted Children
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