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OT44 Otolaryngology
Pediatric Otolaryngology
Toronto Notes 2019
Signs of Croup
The3Ss
Stridor
Subglottic swelling Seal bark cough
Feeding Difficulty and Aspiration
• supraglotticlesion
• laryngomalacia
• vocalcordparalysis
• laryngealcleft→aspirationpneumonia • TEF
Acute Laryngotracheobronchitis (Croup)
Definition
• inflammationoftissuesinsubglotticspace±tracheobronchialtree
• swellingofmucosalliningandassociatedwiththick,viscous,mucopurulentexudatewhich
compromises upper airway (subglottic space is narrowest portion of upper airway)
• normalfunctionofciliatedmucousmembraneimpaired
Etiology
• viral:parainfluenzaeI(mostcommon),II,III,influenzaAB,RSV
Clinical Features
• age:4mo-5yr
• precededbyURTIsymptoms
• generallyoccursatnight
• biphasicstridorandcroupycough(loud,sea-lionbark) • appearlesstoxicthanepiglottitis
• supraglotticareanormal
• ruleoutforeignbodyandsubglotticstenosis
• “steeple-sign”onAPX-rayofneck
• ifrecurrentcroup,thinksubglotticstenosis
Treatment
• racemicepinephrineviametered-doseinhalerq1-2hprn(onlyifinrespiratorydistress) • systemiccorticosteroids(e.g.dexamethasone0.5mg/kg,prednisone)
• adequatehydration
• closeobservationfor3-4h
• intubationifsevere(usesmallerendotrachealtubethanexpectedforage)
• hospitalizeifpoorresponsetosteroidsafter4handpersistentstridoratrest
• consideralternatediagnosisifpoorresponsetotherapy(e.g.bacterialtracheitis)
• ifrecurrentepisodesofcroup-likesymptoms,performhighkVcroupseriesX-ray(APandlat)when
well to rule out underlying subglottic stenosis and consider bronchoscopy for definitive diagnosis
Acute Epiglottitis
Definition
• acuteinflammationcausingswellingofsupraglotticstructuresofthelarynxwithoutinvolvementof vocal cords
Etiology
• H.influenzaetypeb
• relativelyuncommonconditionduetoHiBvaccine
Clinical Features
• anyage,mostcommonly1-4yr
• rapidonset
• toxic-looking, fever, anorexia, restlessness
• cyanotic/pale,inspiratorystridor,slowbreathing,lungsclearwithdecreasedairentry
• preferssittingup(“tripod”posture),openmouth,drooling,tongueprotruding,sorethroat,dysphagia
Investigations and Management
• investigationsandphysicalexammayleadtocompleteobstruction,thuspreparationsforintubationor tracheotomy must be made prior to any manipulation
• stat ENT/anesthesia consult(s)
• WBC(elevated),bloodandpharyngealculturesafterintubation • lateralneckradiograph(onlydoneifpatientstable)
Treatment
• secureairway
• IVaccesswithhydration
• antibiotics:IVcefuroxime,cefotaxime,orceftriaxone • moistair
• extubatewhenleakaroundtubeoccursandafebrile
• watchformeningitis
Acute epiglottitis is a medical emergency
When managing epiglottitis, it is important not to agitate the child, as this may precipitate complete obstruction
Thumb sign: cherry-shaped epiglottic swelling seen on lateral neck radiograph