Laryngo-tracheal Infections

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Laryngo-tracheal Infections
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Stridor

• It is the noise caused by obstruction of airflow
  due to narrowing in respiratory tract
• It may be inspiratory / biphasic /expiratory
• Inspiratory stridor alone indicates that the
  lesion is at vocal cord level or above
• An expiratory phase occurs when the tracheal
  lumen is also narrowed by oedema or inflammation

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Acute Laryngeal infections in childhood

• Acute Epiglottitis
• Laryngotrachealbronchitis
• Bacterial Laryngotrachealbronchitis
• Diphtheria
• Conditions which mimic laryngeal infections

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Acute Epiglottitis

• Most frightening pediatric emergency
• If unrecognized it can kill the child
• Haemophilus influenzae type B , is the causative
  organism in most cases
• The disease is concentrated maximally on the
  epiglottis but the inflammation may involve whole
  supraglottic compartment
• Most cases seen between 1 and 6 years of age,
  peak incidence between ages 3 and 4

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Clinical features

• Sudden transformation of a fit child into one who
  is desperately ill, within a few hours
• Classical features
• A fit child c/o sore throat which intensifies,
  with in half and hour dysphagia reported
• Inspiratory stridor develops and within 2 hours
  child becomes critical
• Child sits up and leans forward
• Saliva is dribbling due to absolute dysphagia
• Voice is muffled
• As time goes child becomes quiet and respiratory
  distress appears to lessen.
• An an ominous sign respiratory cardiac arrest
  imminent

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http//www.aic.cuhk.edu.hk/web8/supraglottitis.htm
http//www.aic.cuhk.edu.hk/web8/epiglottitis20pic
ture.htm
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Management

• It is a surgical emergency
• Examination of throat by tongue depressor is
  particularly dangerous- sudden respiratory
  obstruction may occur
• Lateral X-ray of neck may show classical thumb
  sign of swollen epiglottis
• If the clinical situation suggests that the
  diagnosis is epiglottitis , there is no point in
  confirming it what might turn out to be fatal
  X-ray

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www.learningradiology.com/archives04/COW2010...
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• The child is shifted to OT and anesthetized in
  upright position
• Laryngoscope inserted diagnosis confirmed
• An appropriate size orotracheal tube inserted
• Otherwise rigid bronchoscope used to secure
  airway
• Tracheostomy / nasotracheal tube
• Culture swabs taken from epiglottis
• Nasogastric tube inserted for feeding
• I/V line established

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Best Clinical Practice

• Adults with suspected acute epiglottitis should
  be admitted and airway closely monitored
• Patients should be treated with I/V second- or
  third-generation cephalosporins and 100
  humidified oxygen
• Airway obstruction should be treated early,
  ideally by intubation

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Laryngotracheobronchitis (Croup)

• As name suggests it involves larger proportion of
  respiratory tract
• Area of maximum impact is sub-glottis
• An acute illness with hoarseness, a barking
  cough, stridor and varying degree of respiratory
  distress
• Affects young children (6 months to 3 years)

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• In most cases causative organism is
  paramyxovirus, para-infleunza virus type I and
  type II
• In adults it may also occur from herpes simplex,
  cytomegalovirus influenza virus
• Adult croup is rare, more severe impaired
  immunity should always be considered
• The key feature is sub-glottic oedema

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Investigations

• Direct viral antigen detection by sampling mucus
  from nasopharynx
• A plain neck radiograph may show narrowing of the
  subglottis (steeple sign) and ballooning of
  hypopharynx
• Chest X-ray to exclude collapsed lobes or
  meditational shift

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Management

• Oxygen, steroids and nebulized epinephrine should
  be administered
• Monitor airway and oxygen saturation, consider
  endotracheal intubation if necessary
• Broad spectrum antibiotics to cover secondary
  infection
• No evidence to support antiviral agents

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Best Clinical Practice

• Adult croup is rare but rapidly progressive
• Once suspected patient should be admitted
• Larynx inspected by flexible laryngoscope
• Broad-spectrum ABx to prevent bacterial infection
• If the airway deteriorates patient should be
  intubated and ventilated

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Bacterial Laryngotrachealbronchitis

• May be a separate disease or be caused by
  secondary bacterial infection of viral
  laryngotrachealbronchitis
• Also called bacterial tracheitis since it
  involves trachea predominantly
• Much more severe illness and much less common
• More severe respiratory obstruction and
  artificial airway is often needed
• Tracheostomy preferred over intubation

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Diphtheria

• Caused by Corynebacterium diphtheriae
• Spreads by droplet infection
• Affects non-immunised children and susceptible
  adults particularly elderly
• Usual site of infection is the tonsils and fauces
  but it can also occur in nasal cavities or spread
  to larynx

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Clinical Features

• Severe sore throat, malaise, pyrexia
• Examination of throat shows characteristic grey
  membrane in oropharynx which may spread to larynx
• Enlarged tender cervical lymph nodes

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Investigations

• A swab from throat for C/S
• A sample of grey membrane for screening

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Management

• Treat with benzyl penicillin and antitoxin
• Acute obstruction should be managed with
  intubation
• Complications
• The diffusible exotoxin has predilection for
  cardiac and renal tissues
• Neurological complications soft palate paralysis,
  diaphragm EOM

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Conditions which mimic laryngeal infections in
childhood

• Foreign bodies
• Peritonsillar abscess
• Retropharyngeal Abscess
• Infectious mononucleosis

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Infectious mononucleosis

• A common disease often sub-clinical or mild
• Caused by Epstein-Barr virus
• Spread is usually transfer of infected saliva
  during kissing

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Clinical Features

• Acute sore throat with large infected tonsils
• Cervical lymphadenopathy with grossly enlarged
  bilateral lymph nodes
• Fever, Malaise
• There may also be palatal petechiae, oral
  ulceration, splenomegaly and hepatomegaly

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www.answers.com/topic/diphtheria
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Complications

• Gross swelling of tonsils and adenoids causes
  airway obstruction, but inflammation and
  ulceration can also extend to larynx
• The severity of laryngeal involvement may be
  masked by upper airway obstruction
• Splenic rupture
• CNS complications like encephalitis, meningitis,
  CN palsies
• Immune deficiency and HIV status be looked into

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Investigations

• Full Blood count
• Heterophil antibody test Heterophil antibodies
  are antibodies that are stimulated by one antigen
  and react with an entirely unrelated surface
  antigen present on cells from different mammalian
  species
• Specific EBV serology
• HIV testing

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Management

• I/V fluids
• Analgesia
• In serious infections antibiotics, steroids and
  acyclovir should be considered
• Ampicillin / amoxycillin are best avoided for
  fear of inducing a maculopapular rash