Stridor <6 months
Other stuff
Croup
Board Questions
Epiglottitis
100
What etiology of stridor presents after the first month of life without another explanation?
Airway hemangioma
100
Cause of ludwig's angina
Odontogenic source, often from the spread of periapical abscesses of mandibular molar
100
What is croup?
Viral laryngotracheobronchitis
100
A 4-year-old from Guatemala presents to the emergency room with a fever, drooling, and inspiratory stridor. Dad states that the child appeared well the day prior to presentation. The child is sitting with his neck extended. Which of the following is the most likely diagnosis?
Croup
Epiglottitis
Laryngomalacia
Tracheitis
Epiglottitis
100
A 5-year-old unvaccinated boy presents to the emergency department with fever and sore throat since this morning. He is in moderate respiratory distress, sitting upright, and drooling. He is awake and alert. What is the most appropriate next step?
Establish peripheral intravenous access
Obtain a soft tissue neck radiograph
Position the patient to optimize physical examination
Transfer to the operating room for intubation
Transfer to the operating room for intubation
200
What is the presentation of an infant with vocal cord paralysis? Unilateral and bilateral
Unilateral → feeding problems, stridor, hoarse voice, and changes to a child’s cry
Bilateral → normal voice associated with stridor, dyspnea, cyanosis and apneic episode
200
Describe presentation of bacterial tracheitis
History of upper respiratory infection symptoms followed by sudden worsening with high fever, stridor (often biphasic), and cough (which may be productive with thick sputum)
Toxic appearance
200
What is the cause of croup?
Parainfluenza virus and rhinovirus
Other respiratory viral pathogens: influenza, respiratory syncytial virus, metapneumovirus, enterovirus, and coronavirus
200
A 2-year-old boy is brought into the ED by his parent for a 2-day history of cough, post-tussive emesis, and diminished food intake, although he has been taking liquids. The coughing began after eating some popcorn. The other parent reports that he has no fever or rhinorrhea. He had bronchiolitis at 3 months of age but has been otherwise healthy. In the ED, his vital signs include T 37°C, HR 100 bpm, RR 24/min, and SpO2 of 94%. On exam, he has mild nasal flaring, diffuse rhonchi, and wheezing noted to be louder on the left side of the chest. Which of the following is the best modality to confirm the diagnosis?
- Arterial blood gas test
- Bronchoscopy
- CT scan of the chest
- Inspiratory and expiratory chest radiographs
Bronchoscopy
200
Name 4 causes of epiglottitis
Bacterial infection - streptococcal and staphylococcal species, HiB
Candida - immunocompromised
Thermal injury
Caustic burns
Direct trauma
300
What is subglottic stenosis and what type of stridor do they present with?
Narrowing of the laryngeal lumen
Persistent inspiratory stridor
300
Treatment for bacterial tracheitis
Operating room for sedation, intubation, and bronchoscopy
Administer empiric antibiotics in the ED to cover likely pathogens (staph aureus)
300
Subglottic stenosis = "steeple sign"
300
A 5-year-old boy presents to the emergency department with fever, sore throat, and difficulty swallowing. He has been complaining of a mild sore throat for the last one week. He refuses to extend his neck or turn his head from side to side, however, he is not currently experiencing respiratory distress. A soft tissue radiograph of the neck reveals widening of the space anterior to cervical vertebral bodies. Which of the following is the most likely diagnosis?
Bacterial tracheitis
Epiglottitis
Peritonsillar abscess
Retropharyngeal abscess
Retropharyngeal abscess
300
"Thumb sign" - enlarged epiglottis protruding from the anterior wall of the hypopharynx and thickened aryepiglottic fold
400
What is the cause and classic presentation for laryngomalacia?
Caused by a developmentally weak larynx leading to collapse at the epiglottis, aryepiglottic folds, and arytenoids
Symptoms manifest shortly after birth
Stridor worsens with crying and agitation but often improves with neck extension and when the child is prone
400
Describe the presentation for PTA and describe physical exam findings.
Sore throat (often unilateral), fever, chills, trismus, and voice change (“hot potato voice”)
Bulging of the affected tonsil and deviation of the uvula away from the involved tonsil are evident
400
When would you admit a patient with croup?
Persistent stridor at rest, tachypnea, retractions, and hypoxia or those who require more than two treatments of epinephrine
400
An 18-month-old previously healthy female is brought in by her parents with concerns of fever and cough. She started with a runny nose two days ago and this evening developed a fever to 102°F and a barky cough. On examination she has mild inspiratory stridor with crying, but no stridor when she is resting comfortably in her mother’s arms. No retractions are present. In addition to antipyretics and corticosteroids, which of the following treatments is indicated?
Ceftriaxone
Nebulized albuterol
Nebulized racemic epinephrine
No additional treatments needed
No additional treatments needed
400
Treatment for epiglottitis
Keep patient calm
Administer nebulized l-epinephrine to decrease airway edema
Consult ENT and anesthesiology ASAP
Intubation → Awake, fiberoptic nasotracheal intubation under conscious sedation
Antibiotics to cover Streptococcus pneumoniae, Staphylococcus aureus, and H. influenza - Ceftriaxone and vancomycin
Steroids
500
Name 6 causes of stridor in infants <6 months old
Laryngomalacia
Tracheomalacia
Vocal cord paralysis
Subglottic stenosis
Hemangiomas
Vascular rings and slings
500
Neck xray findings for retropharyngeal abscess
Retropharyngeal space at C2 is twice the diameter of the vertebral body or greater than one half the width of the C4 vertebral body
500
What are the two mainstay medications in treatment for croup and when do you give them?
Steroids - always!
Nebulized epinephrine → moderate to severe croup, respiratory distress, stridor at rest
500
A 3-year-old boy presents in severe respiratory distress. His mother informs you that he has been ill for the last 5 days, initially with a low-grade fever and “barky cough.” He was seen at an urgent care facility 4 days ago and given a “breathing treatment” and discharged on steroids. He has become progressively worse despite compliance with the steroid regimen, which prompted his mother to call an ambulance this morning. He is otherwise healthy and up-to-date on his immunizations. On examination, the child is toxic in appearance and febrile. His oropharynx is clear. You hear both inspiratory and expiratory stridor. What is the most likely diagnosis?
Bacterial tracheitis
CroupYour Answer
Epiglottitis
Peritonsillar abscess
Bacterial tracheitis
500
Describe the presentation of a child with epiglottitis
Abrupt onset of fever, stridor, drooling, sore throat, muffled voice
Progress rapidly, with inability to handle oral secretions followed by stridor and respiratory distress
Tripod or sniffing position with the neck hyperextended and the chin forward to maintain the airway