Pediatric emergency medicine trisk 1385 1385
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obstruction, upper airway anomalies (particularly laryngotracheomalacia), and
congenital or postintubation subglottic stenosis. Common causes for upper airway
obstruction in infants and children include adenotonsillar hypertrophy, croup,
foreign body, retropharyngeal abscess, and tracheitis. Airway edema can be
secondary to trauma, thermal or chemical burn, or anaphylaxis. Epiglottitis or
supraglotittis, although less common, can be one of the most life-threatening
causes of respiratory distress and is a true emergency. The incidence of
epiglottitis has declined significantly since routine immunization against
Haemophilus influenzae type b , the pathogen that once caused at least 75% of
cases. Streptococcus pneumoniae , group A streptococcus, Staphylococcus aureus
, and nontypeable and other strains of Haemophilus influenza now account for
most cases of bacterial epiglottitis. Epiglottitis should be suspected in children
who have abrupt onset of fever, sore throat, dysphagia, drooling, muffled voice,
labored respirations, and/or stridor. Young children appear toxic and anxious and
assume a sniffing position with protruding jaw and extended neck. These children
are at risk of abrupt onset of respiratory arrest from obstruction. Older children
and adolescents may present with just severe sore throat, often with a less rapid
progression, without oropharyngeal abnormalities. Peritonsillar and
retropharyngeal abscess may present with symptoms similar to epiglottitis but are
less likely to have stridor and the onset is more gradual. Croup or
laryngotracheobronchitis is the most common cause of upper airway obstruction
in children 6 months to 3 years of age. Croup causes subglottic narrowing and is
characterized by a barky cough, inspiratory stridor, and hoarseness that are worse
at night. Viral croup is most often caused by parainfluenza virus, frequently with
preceding upper respiratory infection symptoms, which may or may not be
accompanied by fever. Respiratory distress often occurs with wakening during the
night in a child who was relatively well before going to sleep. Children with
croup-like symptoms that are recurrent or prolonged may have an underlying
fixed or functional airway abnormality, most commonly subglottic stenosis or
hemangioma. Children with chronic stridor, particularly those younger than 2
years, may also have an underlying congenital anomaly. Tracheitis, an infection
of the trachea, may occur as a primary infection with abrupt onset, high fever
similar to epiglottitis. More commonly, it presents as a secondary infection in a
child with an initial croup-like illness but with a worsening clinical course.
Although tracheitis is usually due to bacteria, most commonly streptococcus or
staphylococcus, cases in which only viruses or no pathogen is identified are not
uncommon. Foreign-body aspiration, which has a peak age of occurrence of 1 to
5 years, may cause obstruction of the upper or lower airway and is a leading
