Stridor and Drooling

Stridor <6 months

100

What etiology of stridor presents after the first month of life without another explanation?

Airway hemangioma

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

300

What is subglottic stenosis and what type of stridor do they present with?

• Narrowing of the laryngeal lumen

• Persistent inspiratory stridor

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

500

Name 6 causes of stridor in infants <6 months old

1. Laryngomalacia

2. Tracheomalacia

3. Vocal cord paralysis

4. Subglottic stenosis

5. Hemangiomas

6. Vascular rings and slings

Other stuff

100

Cause of ludwig's angina

Odontogenic source, often from the spread of periapical abscesses of mandibular molar

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 

300

Treatment for bacterial tracheitis

• Operating room for sedation, intubation, and bronchoscopy

• Administer empiric antibiotics in the ED to cover likely pathogens (staph aureus) 

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

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

Croup

100

What is croup?

Viral laryngotracheobronchitis

200

What is the cause of croup?

• Parainfluenza virus and rhinovirus

• Other respiratory viral pathogens: influenza, respiratory syncytial virus, metapneumovirus, enterovirus, and coronavirus

300

Subglottic stenosis = "steeple sign"

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

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

Board Questions

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?

1. Croup

2. Epiglottitis

3. Laryngomalacia

4. Tracheitis

Epiglottitis

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

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

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

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

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?

1. Establish peripheral intravenous access

2. Obtain a soft tissue neck radiograph

3. Position the patient to optimize physical examination

4. Transfer to the operating room for intubation

Transfer to the operating room for intubation

200

Name 4 causes of epiglottitis

• Bacterial infection - streptococcal and staphylococcal species, HiB

• Candida - immunocompromised

• Thermal injury

• Caustic burns

• Direct trauma

300

"Thumb sign" - enlarged epiglottis protruding from the anterior wall of the hypopharynx and thickened aryepiglottic fold

400

Treatment for epiglottitis

1. Keep patient calm

2. Administer nebulized l-epinephrine to decrease airway edema

3. Consult ENT and anesthesiology ASAP

4. Intubation → Awake, fiberoptic nasotracheal intubation under conscious sedation

5. Antibiotics to cover Streptococcus pneumoniae, Staphylococcus aureus, and H. influenza - Ceftriaxone and vancomycin

6. Steroids 

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