Also classified into supra glottis or subglottis obstruction ( presented as strider which is whistled sound This figure is related to WHO program NOT academic program - 1-
Air Way Obstruction upper air way ) )
Is defined as blockage of the portion of the air ways located above thoracic inlet , manifested during inspiration because the pressure within upper air way is negative relative to atmosphere ( negative pressure causing collapse of the air way ) Upper air way obstruction classified clinically into :- 1- congenital 2- acquired1-laryngomalacia ( commonest ) 2-sub-glotic stenosis 3- rhinitis 4-vascular ring 5- tongue tumor & ectopic thyroid
C-Toddler ( 1—3 years ):--- 1-viral croup ( commonest ) 2- spasmodic croup 3-F.B inhalation (foreign body ) 4-bacteria trachitis 5-tonsil & adenoid hyperatrophy 6- retropharyngial abscess 7- diphteria ( rare ) -2-
Upper air way obstruction classified according to cause :-
A- new born ( until one month of age ) :--- 1-foreign material( meconium and amniotic fluid ) 2-bilateral cho-anal atresia 3-cong. Sub-glottic stenosis 4-micrognathia as in pierr Robin syndrome and Digorgi syndrome . 5-macroglosia as in hypothyrodism &down syndrome 6-congenital Anomalies of the larynx , pharynx & trachea . 7-vocal cord paralysis 8-laryngospasm ( as in intubation and aspiration )B- infancy ( 1—12 month of age )D- above 3 years :--. 1- epiglotitis 2- F.B( foreign body ) 3- trauma 5-angio-edema 5-IMN ( infec. Mono nucleosis ) 6-anaphylaxasis 7- peritonsilar abscess in adolescent 8- diphtheria ( rare )
Cong. Anomalies :---- Laryngiomalacia :-is most common cause of chronic stridor in infancy in which the soft immature cartilage of upper larynx collapse inward during inhalation , also may be seen in older patients especially those with neuromuscular conditions resulting in weakness of muscle of throat it is defined by collapse or flabiness of supreglottis structures ( epiglotis or arytenoid cartilage) during inspiration resulting in air way obstruction which usually benign & self limited . The symptom usually appear in the first two weeks of life and severity increased for up to 6 months . Clinical features :--- strider is main presentation appear at birth or shortly after birth & become symptomatic during first year of life ( but may delay to several Years if infant has very large arytenoid stridor is loudest at :--- 1- feeding of child 2- quit relaxing 3- supine position or neck flexion ,4- crying and agitation stridor is deminished at :-- at sleep Stridor is exacerbated by viral infection Symptom usually begin within first 2 weeks of birth and increased symptoms within 4-8months, improved within 8-12 months and resolute by 12-18 month of age or may extend to 24 months Laryngoscope used in diagnosis of disease Treatment :--most infant are treated conservatively feeding modification like pacing , thickened liquid and food and upright posture , Many infant need anti reflux therapy infant has growth retarded or failure or hypoxia which needs tracheostomy or epiglotoplasty 3-.
A positive history must never be ignored ( a negative history may be misleading ) . Sudden chocking or coughing episode accompany by wheezing are highly suggestive of an air way F.b . F.B mostly lodged in a bronchus ( right bronchus in 58%) -4-
Subglottic stenosis :---- either cong. Or acquired ( which more common due to aggressive management in preterm baby with intubation or mechanical ventilation
resulting residual air way damage to larynx . stridor is main presentation ( recurrent or persistant croup ), occurred in both inspiration and expiration and worsen with age Treatment by tracheostomy or reconstructive surgery Foreign Body :--- most victims are older than infant and toddler ( children of less than 3 years of age account for 73% of cases , 33% of objects aspirate are nuts particularly peanuts .
Acquired causes of upper air way obstruction :- involved either supra or sup glottic structures
How to differentiated between them :---- Example supra glotic supglotic 1- epiglot., peritonsilar abscess croup, retro-pharangial abscess F.B, trachitis, angio-ed. 2-stridor 2- quit 2-Loud 3-voice 3-muffled 3-hoarse 4-dysphagia 4-yes 4-no 5-sitting up or arching posture 5-yes 5-no 6-barking cough 6- no 6- yes 7-fever 7-high 40 c 7-low 38-39 8-toxicity 8-yes very toxic 8-no unless trachitis. 9-trismus 9-yes 9-no 10-drooling 10-yes 10-no 11-facial edema 11- yes 11-no unless angio-edema . - 5-
Epiglottitis :--- is pediatric emergency , dramatic & potentially lethal condition because of inflamed air way may obstruct suddenly& totally leading to death infection lead to acute onset of inflammatory edema in lingual surface of epiglottis where submucosal surface is loosely attached the edema is rapidly progress to involve aryepiglottis fold , arytenoid and entire subglottis leading to frank air way obstruction .
Caused by H. influenza type B which recovered from surface of epiglotitis or from blood culture in more than 90% and may be caused by other micro organism like streptococcal pneumonia , group A and C ( B hemolytic ) strepto cocci , staph , moraxella catarrhalis , klebseilla pneumonia and pseudomonus .while viral infection does not caused .Age of incidence is 2—7 years ( peak age 3.5 year )ClF :---usually no prodromal symptoms ( fever is first symptom followed by strider , labored breathing , dysphagia and sore throat ) 1- no other family members are ill . 2- is fulminating course of high fever , sore throat , dysphagia, dyspnea, stridor, drooling , more progress to total obstruction & prostration unless adequate treatment are given( strider is late finding& suggest near complete air way obstruction ). 3- moderate to severe respiratory distress( S.T. fulminating pulmonary edema may present ) 4- cynosis occurs in severe cases. 5- cherry red enlarged epiglotis by laryngoscope 6-X-ray of lateral film of neck showing thumb sign as swollen epiglotis 7- in young patient ---- neck is hyper-extended, while in older patients prefer sitting up position ,learning forward , mouth open &tongue protruded Classical triad symptoms ( dysphagia , drooling and distress ). --6--
Thumb sign
8-most pts have concomitant bacteremia occasionally ( other infection are present like pneumonia , O.M , cervical LAP , while meningitis , arthritis are rare blood culture is positive in 12-15% to 90% culture from epiglottis surface is positive in 50-75% CXR with consolidation in 15% ( because may associated with pneumonia ) . DD :-- 1- croup 2- bacherial trachitis 3- F.B aspiration 4- ludwig angina 5- retropharyngial & peritonsilar abscessTreatment :-- Aims of treatment :- 1- relieving of air way obstruction 2-eradication of infection agent 3-avoid any procedures that lead to anxiety like blood aspiration unless secure airway .Never place the child in supine position as it may lead to resp. arrest 1- admission for any suspicion of disease where close observation should be done . 2-endotrachial intubation is currently preferred method of treatment ( 6% of children die without artificial airway , compared to less than 1% of those with artificial airway .) 3-Antibiotic – ceftrixone or cefotaxime or combination of ampiciline + chlormphenicol or ampiciline + sublactum duration of treatment is 7—10 days ( most patients safely extubated within 2—3 days ) . Prevention :--- by H. infl. Vaccine . -10-
Complication of epiglottitis :- 1- other focci of infection may involved during bacteremic phase like pneumonia which most common followed by otitis media while meningitis has been reported
2- respiratory obstruction and arrest due to aspiration , extubation , pneumothorax and pneumo mediastinum , epiglotitis abscess , cervical cellulitis , pulmonary edema , cerebral hypoxia and death from asphyxia . Prognosis :-- is good and mortality is less than 1% but it is increased to 10% with those not protected by endotracheal intubation .
Croup :---is defined as term referred to a heterogeneous group of mainly acute & infectious process that are characterized by bark like or brassy cough , may be associated with inspiratory. stridor
Is caused by viral infection mostly Commonly occur in late fall & early winter . Has 2 types --- 1- infectious type . 2- spasmodic type( recurrent type ) Etiology :-- 75% by PIV , can be caused by adeno, measles, influnza, and RSV , Can be caused in 3.6% by mycoplasma . Pathology :-- 1- inflammatory edema 2-destructed ciliated epithilia 3-exudate ClF :---- 1- age is between 6 month to 3 years ( now age is 3 month to 5years ) with peak age in second year --11--
2- most patients proceeded by URTI of several days of less than 5 days 3-at first mild brassy cough with intermittent stridor & if obstruction is ( resp. distress is increased , the stridor become continuous ass. with resp.distress unusual except in young infant ) .
4-infection going down to reach bronchi & bronchiols leading to resp. distress with elevation of temperature with reach to 40 .5- if croup is suspected , examination is deferred & O2 is administered until patient is transferred to place of hospital where Optimal management possible 6- X-ray reveals steeple sign ( mean narrow subglotic space) & is not assoc. with disease severity . duration of illness ranged from several days to rarely several wKs Spasmodic croup :----( recurrent croup ):--- clinically is similar to infectious croup except that finding of infection in a patients & family are absent . Age of presentation is 1—3 years precipitating factors are :-- 1- viral infection in some cases only . 2-allergic & psychological factors 3- G.E.R which may role important Pathology :-- normal epithilium & pale watery edema --12-
ClF :---1- most frequently occurs at night or evening . 2-occurred in sudden onset that may proceed mild to moderate coryza .
Note :- croup may be early sign of asthma . The child may be awaken with barking cough , noisy inspiration & respiratory distress and may be appeared anxious & frightened . 3- a febrile 4-distress may be exacerbated by excitation & usually diminished within several hours & following days . Such episode usually several times . DD :--- 1- epiglotitis 2- trachititis 3- diphtheria ( present gray white appearances on pharyangial examination) . 4-measles croup 5-F.B aspiration 6- angio-edema 7-retropharangial & peritonsilar abscess 8- hypocalcaemia with laryngeal tetany 9-extrensic compression of air way like hematoma , or mass
CX :-- occurs in 15% with viral croup . 1- commonest cx.:- is extension of infection to involve other region of resp. tract like middle ear , bronchial & pul. Parenchyma .
2- trachitis 3- interstial pneumonia 4-broncho pneum.( is unusual unless aspiration of gastric contents occurred during period of resp. distress although 2nd bacterial infection is rare ) 5-pneumothorax & pneumomediastinum ( common CX. Of tracheostomy ) .Causes of death in croup :--- 1- laryngial obstruction 2- tracheostomy Cx like pneumo thorax & mediastinal emphysema . -14— -
How differentiate clinically between laryngomalacia and subglttic stenosis :--
Clinical laryngomalacia subglottic stenosis 1-age of onset first month &increased upto at birth 6 month 2-stridor inspiratory both inspiratory expiratory 3-fate improved with age worse with age 4- position of patient yes no including arching or sitting upHow differentiate clinically between epiglotitis and croup
Factors epiglotitis croup 1-age 2-7years( 3.5years) 3months-5years 2-onset sudden gradual 3-other member no yes of family 4-stridor quit loud 5- voice muffled hoarse 5-dysphagia yes no 6-fever & toxicity yes no 7-barking cough no yes