The child >6 months old with a relatively short duration of symptoms (hours
to days) characteristically has an acquired cause of stridor. Causes are
either inflammatory/infectious, such as croup or epiglottitis,
or noninflammatory, such as a foreign body aspiration. The remainder
of this chapter discusses the most common causes of acquired stridor
Croup (laryngotracheobronchitis) is the most common cause
of stridor outside the neonatal period. Children 6 months to 3 years
old are most commonly affected, with a peak in the second year of
life. The incidence of croup is highest in the fall and the
early winter months, but it may occur throughout the year. The most
common viruses detected in croup include parainfluenza, respiratory
syncytial virus, human bocavirus, and rhinovirus.1
Croup is acquired through inhalation of the virus. The clinical
course varies according to the underlying viral etiology, but typically
begins with 1 to 2 days of nasal congestion, rhinorrhea, cough,
and low-grade fever before the onset of classic croup symptoms.
These classic symptoms include a harsh cough often described as
barking or “like a seal,” hoarse voice, and stridor.
Parents may also report inadequate oral intake. Symptoms are often
perceived to be worse at night. The severity of symptoms is related
to the amount of edema and inflammation of the airway. Assess for
tachypnea, stridor at rest, nasal flaring, retractions, mental status
(lethargy or agitation), and oxygen desaturation. The “typical” duration
of symptoms ranges from 3 to 7 days. Children generally have
the most severe symptoms on the third and fourth days of illness and
subsequently begin to improve.
The diagnosis of croup is clinical. Laboratory tests are generally
unnecessary. Plain radiographs are not required in uncomplicated croup
and should be reserved for evaluating children with findings suggestive
of another diagnosis, such as epiglottitis, retropharyngeal abscess,
and aspirated foreign body. If obtained, radiographic findings on posteroanterior
chest radiograph in patients with croup may demonstrate subglottic
narrowing (“steeple sign”) (Figure
119-1). This finding is unreliable, however, and may be present
in normal children, and absent in up to 50% of children
Anteroposterior neck radiograph in patient with croup;
note presence of the “steeple sign” (arrow).
(Courtesy of W. McAlister, MD, Washington University School of Medicine,
St. Louis, MO.)
Croup is often classified as mild, moderate, or severe (Table 119-3), and treatment is directed primarily
at mitigating airway obstruction. Although numerous scoring systems
for croup have been published, in general, these are more useful
as research tools than for clinical practice. Their primary role
is to provide a semiobjective scale by which to classify patients
for comparative studies, and their usefulness as a tool for clinical
decision making with individual patients is much less clear.
The score, if calculated, should only be used as one piece of data
in the decision-making process.
119-3 Assessment of Croup Severity |Favorite Table|Download (.pdf)
119-3 Assessment of Croup Severity
|Occasional barking cough||Frequent barking cough||Frequent barking cough|
|No audible stridor at rest||Easily audible stridor at rest||Prominent inspiratory and occasionally expiratory stridor|
|Mild or no chest wall/subcostal retractions||Chest wall/subcostal retractions at rest||Marked sternal retractions|
|No agitation and distress||Little or no agitation and distress||Agitation and distress|
Most children with croup are not brought for medical attention.
Children with croup presenting to the ED should be placed in a position
of comfort, often in the lap of the caretaker. Assess respiratory
distress through observation, without disturbing the child. Agitation
and crying increase oxygen demand and may worsen airway compromise.
Humidified air or cool mist do not improve clinical symptoms.2,3 Current
standard treatment is the use of nebulized epinephrine and corticosteroids (Table 119-4). Nebulized epinephrine
is the mainstay of treatment for moderate to severe croup patients
with marked retractions and stridor at rest. Mild
croup generally does not require epinephrine. All
patients with croup benefit from the administration of oral steroids
as a one-time dose. Those with moderate or severe croup who require
nebulized epinephrine should be observed in the ED for 3 hours before considering
Table 119-4 Croup Pharmacotherapy |Favorite Table|Download (.pdf)
Table 119-4 Croup Pharmacotherapy
|Dexamethasone||0.15–0.6 milligrams/kg PO/IM
(10 milligrams maximum)||Give for mild, moderate, or severe croup. May crush pills and
mix in juice or applesauce.|
|May give IV solution PO without dilution.|
|Budesonide||2 milligrams nebulized||Consider if PO steroids vomited.|
|l-epinephrine (1:1000)||0.5 mL/kg nebulized (5 mL maximum)||Use for moderate or severe croup; may need repeat dose if
|Racemic epinephrine (2.25%)||0.05 mL/kg/dose nebulized (maximum 0.5
mL)||Use for moderate or severe croup; may need repeat dose if severe.|
Studies comparing l-epinephrine with racemic epinephrine
show no significant difference in response.5,6 Epinephrine
works by rapidly decreasing airway edema through vasoconstrictive
alpha effects. Clinical effects of epinephrine are seen in as few
as 10 minutes and last for more than 1 hour.7,8 Use
of epinephrine decreases the number of children with croup requiring
intubation, intensive care unit admission, and admission to the
hospital in general.
ED observation for about 3 hours is recommended. Ledwith’s
group monitored patients for 3 hours after epinephrine nebulization
and found that 38% of the patients who had a recurrence
requiring admission did so between the second and third hour.9 Prendergast
et al. also demonstrated that there was an upward trend in the croup
score between the second and third hours in those patients ultimately
β Agonists such as albuterol should not
be used for croup or when signs of upper airway obstruction from
edema are present (i.e., stridor). Vascular β-receptors
cause vasodilation that may worsen edema and exacerbate upper airway
Children with mild, moderate, and severe croup all benefit from
corticosteroids, which reduce both the severity and duration of
croup episodes.11,12 Corticosteroids improve symptoms
by anti-inflammatory effects in the upper airway. Studies demonstrating
the efficacy of steroids against placebo have used dexamethasone and nebulized
budesonide. Dexamethasone is equally effective if given parenterally
or orally. Most clinicians initially prescribe oral corticosteroids
because of ease of administration. Oral administration of the IV formulation
of dexamethasone has the advantage of lower volume due to increased
concentration when compared with the oral preparation, and may be
associated with less vomiting. Nebulized budesonide and IM dexamethasone are
alternatives to PO dexamethasone in children who are vomiting. Because
even patients with very mild croup symptoms can benefit from steroid
administration, most ED patients diagnosed with croup should be
treated with corticosteroids.
Heliox may be a treatment option in severe, refractory croup. Heliox
is a gaseous mixture of helium with oxygen. Replacing nitrogen with the less dense
helium decreases airway resistance and improves gas flow through
a compromised airway. Heliox is typically given in a 70% helium/30% oxygen
ratio. Studies of the use of heliox in croup show no definitive
advantage over conventional treatment.13–15
Most children with croup can be safely discharged to home (Table 119-5). Observe in the ED for 3 hours
after epinephrine administration. Children with persistent
stridor at rest, tachypnea, retractions, and hypoxia or those who
require more than two treatments of epinephrine should be admitted
to the hospital. Intubation is reserved for cases of severe
croup not responding to medical treatment. When intubation is necessary,
use endotracheal tubes smaller than recommended for patient size
and age to avoid traumatizing the inflamed mucosa.
Table 119-5 Criteria for
Discharge from ED in Patients with Croup |Favorite Table|Download (.pdf)
Table 119-5 Criteria for
Discharge from ED in Patients with Croup
|3 h since last epinephrine|
|Able to take fluids well|
|Caretaker able to recognize change in child’s condition
and has adequate transportation to return if necessary|
|Parents have a phone and no social issues for concern|
Epiglottitis, or supraglottitis, is an acute inflammatory condition
of the epiglottis that may progress rapidly to life-threatening
airway obstruction. The epiglottis is a leaf-shaped cartilaginous
structure with a thin epithelial layer. The epiglottis arises from
the base of the posterior tongue and covers the larynx during swallowing.
Widespread implementation of an effective Haemophilus influenzae type
B vaccine has significantly reduced the number of cases of childhood
epiglottitis. In the postvaccine era, most cases of infectious epiglottitis
are caused by streptococcal and staphylococcal species. Candida species
can cause epiglottitis in the immunocompromised patient. Noninfectious
causes, such as thermal injury, caustic burns, and direct trauma,
may cause swelling and inflammation of the epiglottis with a clinical
picture identical to that of infectious epiglottitis in the absence
Infection typically presents with the abrupt onset of fever,
drooling, and sore throat. Symptoms may progress rapidly, such that
the child may be unable to handle oral secretions and develops stridor
and respiratory distress. Cough is often absent, but the voice may
be muffled. Most children appear toxic and anxious and may assume
a tripod or sniffing position with the neck hyper-extended and the
chin forward to maintain the airway.
The ideal approach to the diagnosis of epiglottitis varies, depending
on the practice and the environment. Each institution should have
a written “suspected epiglottitis management protocol.” Important components
of all protocols are listed in Table 119-6.
Table 119-6 Suspected Epiglottitis
Management Protocol |Favorite Table|Download (.pdf)
Table 119-6 Suspected Epiglottitis
|1. Immediate recognition and triage to a resuscitation area|
|2. Continuous monitoring by someone trained in the management
of a difficult airway|
|3. Rapid consultation with appropriate colleagues from otolaryngology
|4. Consideration and risk-benefit analysis of patient transfer
with appropriate personnel present during the transfer|
|5. Bedside radiology without disturbing the patient or, if
moved to the x-ray suite, constant monitoring by a physician with
appropriate airway equipment and skills|
In older children and those with mild respiratory distress, gentle
direct visualization of the epiglottis may be attempted. Despite concerns that
such maneuvers could trigger worsening distress, no documented reports
show this to be unsafe. Patients with suspected epiglottitis who
are initially seen in an office or clinic without pediatric or otolaryngologic
subspecialty support should be transported to a referral center
accompanied by personnel who can manage the airway.
Lateral neck radiographs are usually unnecessary in patients
with the classic presentation of epiglottitis. When the diagnosis
is uncertain, obtain soft tissue neck radiographs with the neck
extended during inspiration. Affected children typically hold their
heads in a sniffing position and have prolonged inspiration already,
making it quite simple to obtain radiographs. Lateral neck radiographs
may show an enlarged epiglottis protruding from the anterior wall
of the hypopharynx (often called the “thumb sign”)
and thickened aryepiglottic folds (Figure 119-2).
If suspicion for the diagnosis still exists despite normal-appearing
radiographs, direct visualization of the epiglottis is necessary
to exclude the diagnosis (Figure 119-3).
Lateral neck view of a child with epiglottitis. (Courtesy of
W. McAlister, MD, Washington University School of Medicine, St. Louis,
Epiglottitis at laryngoscopy. (Reproduced with permission
from Knoop K, Stack L, Storrow A: Atlas of Emergency Medicine, 3rd
ed. McGraw-Hill, New York. Part 2 Specialty Areas, Chapter 14, Pediatric Conditions, Figure 14-38.)
Keep the child seated and upright in a position of comfort. Provide
oxygen. Administer nebulized racemic or l-epinephrine
to decrease airway edema. Alert the referral center or pediatric
otolaryngologist as soon as possible so decisions concerning intubation
or tracheotomy can be made in concert with consultants and support
personnel can be mobilized. Intubation should be done by the most
skilled individual available as soon as the diagnosis is
made. Sedation, paralytics, and vagolytics are used as indicated.
For a child who is able to maintain an airway, the decision to administer
paralytics must be accompanied by absolute certainty that intubation
will be successful. Have
multiple endotracheal tube sizes immediately available. If endotracheal
intubation is unsuccessful, an emergent surgical airway is required (see Chapter 29, Pediatric Airway Management).
Administer a second- or third-generation cephalosporin, such as cefuroxime or ceftriaxone, to ensure
adequate coverage of the most common infectious pathogens. With
the increasing incidence of Staphylococcus aureus and
highly resistant Streptococcus pneumoniae as a
cause of epiglottitis, one may also empirically add vancomycin to
the antibiotic regimen. Antibiotics are typically continued for
7 to 10 days. Steroids are often employed to decrease mucosal edema
of the epiglottis.
Bacterial tracheitis, also known as membranous laryngotracheobronchitis or bacterial
croup, is an uncommon infection that can cause life-threatening
upper airway obstruction. It can be a primary or secondary infection.
The mean age of presentation is now 5 to 8 years of age compared with
the 4 years of age that has been classically described.16,17
Bacterial tracheitis is often a secondary infection after a viral
upper respiratory tract infection. A history of URI symptoms followed
by sudden worsening with high fever, stridor, and cough (which may
be productive of thick sputum), and a toxic appearance suggest the diagnosis.
Increasing upper airway obstruction occurs from thick mucopurulent
secretions of the trachea. Management is similar to that of epiglottitis,
with patients ideally going to the operating room for sedation,
intubation, and bronchoscopy. Cultures and Gram stain of the mucopurulent
secretions should be obtained at this time, as Gram stain findings
may help guide the antibiotic therapy. Bronchoscopy may be therapeutic,
as the removal of purulent pseudomembranes improves tracheal toilet
and may lessen upper airway obstruction. For continued management,
most patients with bacterial tracheitis require intubation and ventilatory
The most commonly isolated pathogen obtained from culture at
bronchoscopy is S. aureus. Other organisms implicated
in bacterial tracheitis include S. pneumoniae, S.
pyogenes, Moraxella catarrhalis, H.
influenzae, and anaerobes.18,19 Initial
antibiotic choices include ampicillin/sulbactam or the
combination of a third-generation cephalosporin and clindamycin.
Consider the addition of vancomycin in areas of increasing methicillin-resistant S.
aureus. Laboratory studies other than tracheal cultures
are of limited use in the diagnosis. Neck radiographs are not needed
to make the diagnosis. When obtained to evaluate for other potential
diagnostic entities, neck films may show subglottic narrowing of the
trachea and irregular tracheal margins in patients with tracheitis (Figure 119-4). Because no single clinical
or radiographic feature can definitively make a diagnosis, bronchoscopy
is the diagnostic method of choice in bacterial tracheitis.
Lateral neck view of patient with bacterial tracheitis. Note
presence of irregular tracheal margins (arrows).
(Courtesy of W. McAlister, MD, Washington University School of Medicine,
St. Louis, MO.)
Foreign body aspiration can be a life-threatening emergency that
requires immediate intervention. Airway foreign body aspiration
occurs most commonly in children between 1 and 3 years old as a
result of increasing mobility and oral exploration. Foreign
body aspiration in children <6 months old often involves a well-meaning
sibling who places an object in the infant’s mouth. The
most common objects aspirated fall into two groups: food and toys.
Commonly aspirated foods include peanuts, sunflower seeds, carrots,
raisins, grapes, and hot dogs.
A high index of suspicion is needed to diagnose foreign body
aspiration. Consider foreign body aspiration in a young child
with respiratory symptoms, regardless of the duration of symptoms,
because many children may present >24 hours after foreign body aspiration. If
the clinical scenario clearly indicates the presence of a foreign
body or airway obstruction, immediately implement a protocol for
obstructed airway management. A foreign body aspiration should
be highly suspected when there is a history of sudden coughing and
choking in the child. This is the most predictive of all signs and
symptoms in foreign body aspiration.20,21 In
many cases, the choking episode is not witnessed by a caregiver.
Although the location of the aspirated foreign body plays a role
in determining the symptoms and signs on presentation, there is
great overlap between groups, and some children may be asymptomatic
on presentation. “Classic dogma” is that laryngotracheal
foreign bodies cause stridor and hoarseness, whereas bronchial foreign
bodies cause unilateral wheezing and decreased breath sounds. Eighty
percent to 90% of airway foreign bodies are found in the
bronchi. Patients may present with severe immediate onset stridor
or even cardiopulmonary arrest, but a significant proportion will
have no cough, wheeze, or stridor. The most important factor in
reducing mortality from an airway foreign body is the recognition
of the child in acute airway distress.
Radiographs are helpful to confirm the
diagnosis of airway foreign body but should not be used to exclude
the diagnosis, as plain chest radiographs are normal in >50% of
tracheal foreign bodies and one fourth of bronchial foreign bodies.22 Anteroposterior
and lateral neck radiographs are the radiographic examinations of
choice to identify laryngeal and tracheal foreign bodies. Suspected
bronchial foreign bodies can be evaluated with the use of posteroanterior
and lateral chest films (Figure 119-5). More
than 75% of airway foreign bodies in children <3 years
of age are radiolucent.20,23–25 Indirect
radiologic signs of a radiolucent airway foreign body include unilateral
obstructive emphysema, atelectasis, and consolidation. Unilateral
obstructive emphysema is seen when a foreign body obstructs air
flow, mainly on expiration. This generates a check-valve obstruction
that results in hyperinflation of the affected side and mediastinal
shift to the opposite side (Figure 119-6).
A foreign body that obstructs a bronchus may produce focal atelectasis
and consolidation visible on chest films. Inspiratory and expiratory
chest radiographs can aid in the diagnosis by showing hyperinflation
(air trapping) on expiratory films. Bilateral decubitus chest films
may also be used to demonstrate air trapping: on lateral decubitus
films, the dependent lung should collapse normally, but it remains
inflated in bronchial obstruction (Figures 119-7 and 119-8). It is important to note again that
a clinically suspected foreign body aspiration should ultimately
be ruled out by bronchoscopy.
A. Posteroanterior and (B)
lateral chest radiographs showing radiopaque bronchial foreign body.
(Courtesy of W. McAlister, MD, Washington University School of Medicine,
St. Louis, MO.)
A. Inspiratory and (B) expiratory
chest radiographs showing air trapping on the left with shift of
the mediastinum to the right caused by a peanut in the left mainstem
bronchus. (Courtesy of W. McAlister, MD, Washington University School
of Medicine, St. Louis, MO.)
Normal decubitus film with left side down.
Decubitus film, right side down, with foreign-body aspiration
on the right side.
Children with complete airway obstruction require immediate medical
attention. They are typically unable to breathe or speak and require
emergency implementation of BLS measures to relieve airway obstruction.
For detailed discussion of management of airway obstruction in children,
see Chapter 14, Resuscitation of Neonates,
and Chapter 15, Resuscitation of Children.
If BLS maneuvers fail, direct laryngoscopy and foreign body extraction
with Magill forceps should be attempted. When the foreign body is
not visible or able to be removed, orotracheal intubation with dislodgment
of the foreign body more distally (often into the right mainstem
bronchus) can relieve the complete obstruction and may be life saving.
If the foreign body cannot be removed and ventilation cannot be
provided through an endotracheal tube, needle cricothyroidotomy
or emergency tracheostomy should be performed (see Chapter 29, Pediatric Airway Management). Those patients who do not have
complete airway obstruction should have their respiratory status closely
monitored while preparations are made for bronchoscopic removal
under general anesthesia.
The retropharyngeal space occupies the space between the posterior pharyngeal
wall and the prevertebral fascia and extends from the base of the
skull to approximately the level of the second thoracic vertebrae.
This space is fused down the midline and contains two chains of
lymph nodes extending down each side. These lymph nodes tend to
regress by age 4 years old, thereby explaining the greater frequency
of retropharyngeal abscess in young children. The formation of a
retropharyngeal abscess is believed to be secondary to suppuration
of these lymph nodes that have been seeded from a distant infection.
Localized penetrating trauma with subsequent invasion of this space
by bacteria is another cause of retropharyngeal infection. This
most commonly occurs in children who fall with a stick or other
similar object in their mouth. Infection
can also occur from traumatic esophageal instrumentation or ventral
extension of vertebral osteomyelitis. Retropharyngeal infection typically
progresses from an organized phlegmon to a mature abscess.
Most cases of retropharyngeal abscess evolve insidiously over
a few days after a relatively minor upper respiratory infection. Fever
is typically present but may be absent in >10% of patients.26–29 Signs
and symptoms include neck pain, fever, dysphagia, excessive drooling,
and neck swelling. The child may maintain the neck in an unusual
position, with stiffness, torticollis, and hyperextension. A unique finding
is bulging of the posterior oropharynx. Abscess progression can lead
to stridor and respiratory distress. Pleuritic chest pain is an
ominous sign, indicating extension of the infection into the mediastinum.
Classically, with suspected retropharyngeal abscess, initial imaging
includes a soft tissue lateral neck radiograph. The radiograph should
be taken during inspiration with the neck extended to limit false positive
results. The diagnosis of retropharyngeal abscess/cellulitis
is suggested when the retropharyngeal space at C2 is twice the diameter of
the vertebral body or greater than one half the width of the C4
vertebral body (Figure 119-9). Rarely,
gas may be seen within the mass. Definitive diagnosis is based on
CT scan with IV contrast, which can differentiate cellulitis from
abscess, identify the anatomic spaces involved, and help with planning
a surgical approach to treatment. CT sensitivity for retropharyngeal
abscess is thought to be near 100%. A CT scan may demonstrate
necrotic nodes, inflammatory phlegmon, or fluid collection within
a ring-enhancing abscess (Figure 119-10).
Unstable patients should be intubated before going to the radiology
suite for CT scan. Patients requiring sedation to obtain a scan
may require presedation intubation if airway obstruction is present.
Patients without airway compromise should be escorted to radiology
by a physician accustomed to managing the difficult pediatric airway,
and appropriate equipment should accompany the patient.
Lateral soft tissue neck radiograph demonstrating retropharyngeal
Contrast-enhanced neck CT showing a retropharyngeal fluid
Carefully monitor and stabilize the airway. Obtain IV access to
administer fluids, antibiotics, and CT contrast. Retropharyngeal
cellulitis and small localized abscesses may be treated successfully
with antibiotic therapy alone. All other cases should undergo operative
incision and drainage, usually by an otolaryngologist. Steroids
can reduce airway edema, inflammation, and the progression of cellulitis
into an abscess. Most retropharyngeal abscesses are found to contain
mixed flora when cultured.30 Common organisms include S.
aureus, S. pyogenes, S. viridans,
and β-lactamase producing gram-negative rods.
Oral anaerobes are also frequently seen. Single-agent antimicrobial therapy
includes ampicillin/sulbactam or clindamycin. Unusual complications
of retropharyngeal abscess include airway obstruction, spontaneous
abscess perforation, mediastinitis, sepsis, aspiration, and jugular venous
Peritonsillar abscess is a deep oropharyngeal infection. It can
occur in patients of any age, but most commonly occurs in adolescents
and young adults. The disease typically begins as a superficial
infection that progresses to an accumulation of pus in a space between
the tonsillar capsule and the superior constrictor muscle. Most
are unilateral, and <10% are bilateral at the time of
Patients with peritonsillar abscess typically present with sore
throat, fever, chills, trismus, and voice change (“hot
potato voice”). Patients will often complain of “the
worst sore throat” of their life and may drool due to difficulty
swallowing their saliva. Ipsilateral ear pain and torticollis may
be present. Visualization of the oral cavity on physical examination
in patients with peritonsillar abscess may show bulging of the affected
tonsil and deviation of the uvula away from the involved tonsil
Peritonsillar abscess. (Reproduced with permission from
Knoop K, Stack L, Storrow A: Atlas of Emergency Medicine,
3rd ed. McGraw-Hill, New York. Part 1 Regional Anatomy,
Chapter 5, Ear, Nose & Throat Conditions, Figure 5-27.)
Differentiating peritonsillar cellulitis from peritonsillar abscess
can be difficult. If the child is toxic, consider a peritonsillar
abscess until proven otherwise. Imaging with US or CT scan may be
required to differentiate tonsillitis from abscess.
In nontoxic-appearing adolescents with good follow-up and with
findings most consistent with peritonsillar cellulitis, a trial
of oral antibiotics may be the best choice for treatment. Most cases
of peritonsillar abscess are managed as outpatients with prompt
aspiration or incision and drainage using local anesthetics in the
ED. Young and uncooperative children may require procedural sedation
to facilitate adequate evaluation and drainage. Complications of
needle aspiration and incision and drainage include hemorrhage,
puncture of the carotid artery, and airway aspiration of purulent
material. CT with IV contrast is the imaging modality of choice
for assessment of suspected infection in patients who have failed
incision and drainage and whom trismus or lack of cooperation prevents
a thorough intraoral examination.
Most peritonsillar abscesses are polymicrobial infections. Predominant organisms
include: anaerobes, group A β-hemolytic streptococci, S. aureus,
and H. influenzae.30 The fluid
obtained from needle aspiration should be sent for Gram stain and culture.
IV antimicrobial therapy may include ampicillin-sulbactam or clindamycin.
Outpatient management antibiotic choices include clindamycin and
amoxicillin/clavulanate. Single high-dose steroid administration
may improve symptoms in patients with peritonsillar abscess.31
Ludwig angina is a potentially life-threatening, rapidly expanding
infection of the submandibular space. The submandibular space is
composed of two spaces subdivided by the mylohyoid muscle into the
sublingual and submylohyoid space (submaxillary space) and extends
from the floor of the mouth to muscular attachments at the hyoid
bone. Infectious expansion into this space spreads superiorly and
posteriorly and often involves the entire submandibular space (Figure 119-12). Eighty-five percent
of cases arise from an odontogenic source, often from the spread
of periapical abscesses of mandibular molars.
Spread of infection within the submandibular space of
Ludwig angina usually begins with a mild infection that progresses
rapidly to severe mouth pain, drooling, trismus, tongue protrusion,
and brawny neck swelling. The child may lean forward to maximize
airway diameter. Stridor may develop with subsequent progressive
airway obstruction. Control the airway early, as intubation can be
extremely difficult late in the clinical course of the disease.
One case series reports that 11 out of 20 patients had an unsuccessful
attempt at intubation resulting in emergent tracheotomy.32 Treatment
is antibiotics and oral surgery to remove the dental abscess that
is the source of the infection. IV antibiotics should cover β-lactamase–producing
aerobic or anaerobic gram-positive cocci and gram-negative bacilli.
Consideration must be given to including coverage of community-acquired
methicillin-resistant S. aureus as well.
Traumatic oropharyngeal injuries in children typically occur
during a fall with an object in the mouth. Such injuries are often
referred to as “pencil injuries” and most commonly
occur in patients between 2 and 4 years of age. When evaluating
these injuries, ask if a foreign body was removed intact, or if
part of the object may have broken off into the soft tissue. If
there is suspicion of retained foreign body, imaging is required.
Children with oropharyngeal trauma may present with bleeding,
drooling, or dysphagia. Most wounds do not require surgical intervention
and closure, but large gaping wounds and those with persistent
bleeding may require closure under sedation or anesthesia. Prophylactic
antibiotics play an inconclusive role in the treatment of intraoral
wounds.33 There are rare but well-known complications
of penetrating pharyngeal injury. Entrance of free air into the neck
or chest can result in stridor and acute airway obstruction. Subsequent
retropharyngeal infection from introduction of bacteria into the penetrating
wound can occur. A more severe complication of oropharyngeal trauma
is carotid artery injury. The carotid artery is closely
associated with the lateral oropharynx and is at risk of injury
from penetrating and blunt impact forces. Penetrating injury results
in massive hemorrhage, whereas blunt injuries can cause compression
of the carotid artery between the object and upper cervical vertebrae.
The resultant shearing effect can cause an intimal tear in the vessel
with subsequent thrombosis formation. Symptoms may evolve over hours
to days and can result in significant neurologic sequelae (stroke
in the distribution of the common carotid territory).
Neither mechanism nor degree of injury is helpful in determining
the possibility of neurovascular compromise. Soft tissue lateral
neck films can assist in the evaluation of air in soft tissues, radiopaque
foreign bodies, and evaluating for abscess. Normal retropharyngeal
soft tissue in airway films is no more than one half of the width of
the adjacent vertebral body. An increase in the width and the presence of
air in the retropharyngeal space indicates pharyngeal injury and
may warrant further investigation. CT is superior to plain radiographs
for the detection of free air, inflammation, or abscess. CT angiography
is needed if carotid injury is suspected and should be considered
for patients who are unstable, who cannot be adequately assessed,
and for those in whom lateral pharyngeal trauma raises concern for
vascular injury.34 Treatment is specific for the
complication and involves consultation with surgery or otolaryngology.