Browse the corpus

CHAPTER 126: Stridor and Drooling in Infants and Children 789  RHABDOMYOSARCOMA Rhabdomyosarcoma is a frequent malignancy of the head and neck in children. This tumor presents in the neck in 40% of cases, often as a large painless mass, rarely causing compression or infiltration of adja cent structures, most notably the airway. 44,45,56 Peak incidence is at 2 to 5 years old and again at 15 to 19 years old. Neck tumors may present with brachial plexus palsy.  NEUROBLASTOMA Neuroblastoma in the neck is a malignancy of the sympathetic chain, although the adrenal glands are the most common primary site. 37,57 Most present before the age of 5 years, and those arising in the neck (5%) have a better prognosis than tumors of adrenal origin. 35,58 Neuroblastoma may present with local compressive signs such as hoarseness, dysphagia, airway obstruction, Horner’s syndrome, or cranial nerve palsies.  THYROID CANCER Thyroid cancer accounts for 21% of pediatric head and neck cancers; however, its incidence is decreasing due to declining radiation exposure. Childhood thyroid cancer is usually papillary, presenting at a more advanced stage, with node, muscle, and metastatic involvement in 90% of cases; despite its advanced presentation, the prognosis is better than adult thyroid cancer. 59 Benign causes of diffuse thyroid enlarge ment include symptomatic thyrotoxicosis or Hashimoto’s thyroiditis, 60 although goiter is seen in some parts of the world.  METASTATIC DISEASE Metastatic disease may also present as cervical lymphadenopathy, accounting for 1% of childhood head and neck cancers. Tumors that metastasize to the neck include nasopharyngeal carcinoma and some thoracic/GI tumors. The location of the metastasis may give a hint to the origin of the primary tumor: posterior triangle nodes are often seen in nasopharyngeal carcinoma, whereas isolated supraclavicular nodes suggest a mediastinal or abdominal mass. REFERENCES The complete reference list is available online at www.TintinalliEM.com. FIGURE 125-10. Schematic of fibromatosis colli or pseudotumor of infancy. Shortened sternocleidomastoid muscle Pseudotumor of infancy laser or surgical excision. Hemangiomas compromising the airway result in biphasic stridor not responsive to nebulized epinephrine and may be associated with cutaneous lesions in a beard distribution.  NEUROFIBROMAS AND SCHWANNOMAS Neurofibromas and schwannomas are rare usually large tumors often involving the orbits, the skull base, or the parotid region, and are fre quently associated with neurofibromatosis type I, which may present with café-au-lait spots and other classic features.  FIBROMATOSIS COLLI Fibromatosis colli (also known as pseudotumor of infancy) presents in the neonatal period as a mass in the sternocleidomastoid muscle (Figure 125-10). Often due to birth trauma with forceps delivery, part of the involved muscle is replaced by dense fibrous tissue. 51,53 Parents will often notice a mass or limited range of motion of the neonate’s neck in the first weeks of life. Physical examination reveals a firm, solid, immobile mass located within the sternocleidomastoid muscle that is horizontally mobile, vertically fixed, and moves with the muscle when the head is turned. It is often associated with some degree of sternoclei domastoid contracture (torticollis). The diagnosis can often be made clinically, and imaging is not necessary.

mobile mass located within the sternocleidomastoid muscle that is horizontally mobile, vertically fixed, and moves with the muscle when the head is turned. It is often associated with some degree of sternoclei domastoid contracture (torticollis). The diagnosis can often be made clinically, and imaging is not necessary. Treatment involves stretching and physical therapy, resulting in spontaneous resolution over a period of 4 to 8 months. 37,51,53 MALIGNANT NEOPLASMS Malignant head and neck masses are rare, accounting for approximately 1% of all etiologies. However, assessment for worrying features is important in the ED (Table 125-4); management of a suspected malignant lesion should include urgent referral for definitive treatment. The more common childhood malignancies presenting as a neck mass are highlighted briefly (see also Chapter 145).  LYMPHOMA Lymphoma is the most common childhood malignancy of the head and neck. 35,46,51 Most lymphomas present as a large, firm mass that is often mobile, but can be fixed and is commonly located in the anterior triangle or the supraclavicular area. 1,44,46,54,55 One study found that 35% of childhood head and neck lymphomas presented as a supraclavicular mass. 1 Hodgkin’s lymphoma is more likely nodal, is more often found in the supraclavicular area, and is seen more often in teenagers, whereas non-Hodgkin’s lymphoma is primarily extranodal and has increasing incidence with age. Diagnosis requires excisional biopsy. Do not give steroids before biopsy because steroids interfere with staging. Stridor and Drooling in Infants and Children Rushi R. Parikh Craig J. Huang INTRODUCTION Stridor is characterized as a high-pitched, harsh, monophonic sound produced by turbulent airflow through a partially obstructed airway. 1 Both inspiratory and expiratory stridor are associated with airway obstruction. As air is forced through a narrow tube, it undergoes an increase in speed and a decrease in pressure (Bernoulli’s principle). The decrease in lateral pressure causes the walls of the airway to temporarily collapse and vibrate, generating this stridulous sound. Hagen-Poiseuille’s law shows that resistance to laminar airflow increases markedly with small decreases in the airway’s radius. 2 A small amount of inflammation can result in significant airway obstruction in children. R (resistance) = 8 •η (viscosity) • l (length)/π • r4 (radius) Immediately assess a child with stridor, as stridor indicates a dif ficult airway, and advanced airway management may be necessary CHAPTER Tintinalli_Sec12_p0669-0996.indd 789 8/2/19 7:52 PM

ammation can result in significant airway obstruction in children. R (resistance) = 8 •η (viscosity) • l (length)/π • r4 (radius) Immediately assess a child with stridor, as stridor indicates a dif ficult airway, and advanced airway management may be necessary CHAPTER Tintinalli_Sec12_p0669-0996.indd 789 8/2/19 7:52 PM 790 SECTION 12: Pediatrics in childhood as recurrent or persistent croup. Prolonged endotracheal intubation in premature babies is the most common cause of acquired subglottic stenosis. 5 Treatment is based on the severity of the stenosis. Hemangiomas are benign congenital tumors of endothelial cells or vascular malformations that can occur anywhere on the body (80% are located above the clavicles), including the airway, where they can cause obstruction and stridor. Hemangiomas typically enlarge throughout the first year of life, may not be noticed at birth, and tend to spontane ously regress by age 5 years old. For infants <6 months old, thoroughly examine the skin, because cutaneous hemangiomas, especially in a beard distribution, may be a clue to the presence of an airway hemangioma. Consider airway hemangioma in new-onset stridor beginning after the first month of life without another explanation; definitive diag nosis requires airway visualization through endoscopy . Although most hemangiomas spontaneously regress, large malformations and those causing significant respiratory symptoms may require treatment with β-blockers, steroids, laser, or surgery. 6-9 Vascular rings and slings are rare congenital anomalies of the aortic arch and pulmonary artery in which anomalous vessels can compress the trachea or esophagus. Examples include a double- or right-sided aortic arch. Symptoms are often present from birth or early in the first month of life and may be progressive and exaggerated during inter current upper respiratory infections; difficulty with feeding may also occur if the esophagus is compressed. Chest radiograph may reveal subtle narrowing or anterior compression of the trachea on the lateral view or an abnormal (e.g., right-sided) aortic arch. Further evaluation includes bronchoscopy, CT angiography, and echocardiography to evaluate for associated congenital heart anomalies. Definitive treat ment is surgical.  STRIDOR IN CHILDREN >6 MONTHS OLD 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 (Table 126-2). CROUP Croup (viral laryngotracheobronchitis) is the most common cause of stridor outside the neonatal period, commonly affecting children 6 months to 3 years old. The incidence is highest in the fall and the early winter months, but sporadic cases can be seen year-round. The most common viruses are parainfluenza virus and rhinovirus, followed by various other respiratory viral pathogens including influenza, respi ratory syncytial virus, metapneumovirus, enterovirus, and coronavirus. In areas where measles remains prevalent, this is an important cause of croup. Coinfection by more than one virus is not uncommon, and bacterial superinfection, although rare, is also possible. 10,11  CLINICAL FEATURES The clinical course of croup varies, but symptoms typically begin after 1 to 3 days of nasal congestion, rhinorrhea, cough, and low-grade fever. Classic symptoms are a harsh barking cough, hoarse voice, and stridor. Symptoms are often 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, lethargy or agitation, and oxygen desaturation.

e fever. Classic symptoms are a harsh barking cough, hoarse voice, and stridor. Symptoms are often 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, lethargy or agitation, and oxygen desaturation. Most croup is self-limited and short in dura tion, resolving spontaneously within 3 days, although depending on the etiology, it may last longer.  DIAGNOSIS Diagnosis is clinical. Laboratory studies, viral tests, or radiographs are needed only in children who fail to respond to conventional therapy or if considering another diagnosis such as epiglottitis, retropharyngeal TABLE 126-1 Causes of Stridor Children <6 mo of age Children >6 mo of age Laryngotracheomalacia Croup Vocal cord paralysis Epiglottitis Subglottic stenosis Bacterial tracheitis Airway hemangioma Foreign body aspiration Vascular ring/sling Retropharyngeal abscess (see Chapter 113, “Intubation and Ventilation in Infants and Children”). A thorough history and examination will often lead to a “working diagnosis. ” Inquire about the time and events surrounding the onset of stridor, the presence of fever, known congenital anomalies, cardiac abnormalities, perinatal complications, prematurity, neonatal intensive care unit interventions, and previous endotracheal intubation or instrumentation. The level of obstruction can often be identified on examination. Partial obstruction of the upper airway at the nasopharynx and/or oro pharyngeal level produces sonorous sounds, called stertor. Obstruction above the true vocal cords is generally indicative of inspiratory stridor, whereas expiratory stridor is characterized by obstruction below the true vocal cords. Biphasic stridor suggests obstruction at the level of the true vocal cords. Consider airway foreign body until proven otherwise if there is marked variation in the pattern of stridor. The noise made by a child with stridor is often interpreted as wheezing by parents unfamiliar with stridor. Clarify what the parent means when the word “wheezing” is used—whether the sound occurs when the child breathes in or breathes out. The differential diagnosis of stridor depends on the child’s age (Table 126-1).  STRIDOR IN INFANTS <6 MONTHS OLD An infant <6 months old with a long duration of symptoms often has a congenital cause of stridor. The major causes are laryngomalacia, tra cheomalacia, vocal cord paralysis, and subglottic stenosis. Less common but important considerations include airway hemangiomas, vascular rings, and slings. Stridor presenting in the first 6 months of life will often require direct airway visualization through endoscopy or advanced imaging. The timing of this evaluation (emergent or outpatient) is dic tated by the severity of symptoms and clinical suspicion. Laryngomalacia accounts for 60% of all neonatal laryngeal problems and results from a developmentally weak larynx. Collapse occurs with each inspiration at the epiglottis, aryepiglottic folds, and arytenoids. Generally, stridor worsens with crying and agitation but often improves with neck extension and when the child is prone. Laryngomalacia usually manifests shortly after birth, which is a key diagnostic feature, and generally resolves by 18 months of age. In many cases, the tracheal support structures are similarly affected, resulting in laryngotracheomalacia. Symptom exacerbations may occur with upper respiratory infections or increased work of breathing from any cause. Definitive diagnosis can often be made with flexible fiberoptic laryngoscopy. Surgery may be required if a child suffers from failure to thrive, apnea, or pulmonary hypertension. Vocal cord paralysis can be congenital or acquired.

ay occur with upper respiratory infections or increased work of breathing from any cause. Definitive diagnosis can often be made with flexible fiberoptic laryngoscopy. Surgery may be required if a child suffers from failure to thrive, apnea, or pulmonary hypertension. Vocal cord paralysis can be congenital or acquired. Unilateral vocal cord paralysis is more common than bilateral and can present with feeding problems, stridor, hoarse voice, and changes to a child’s cry. Children with bilateral cord paralysis often have a normal voice associated with stridor and dyspnea, and symptoms can include cyanosis and apneic episodes. 5 Diagnosis is by flexible nasolaryngoscopy. Endotracheal intubation can be difficult with bilateral cord paralysis, and a surgical airway may be required to secure the airway. Subglottic stenosis may be congenital or acquired and is diagnosed when there is a narrowing of the laryngeal lumen. Congenital stenosis is usually diagnosed in the first few months of life when the child is noted to have persistent inspiratory stridor. Mild cases may present later Tintinalli_Sec12_p0669-0996.indd 790 8/2/19 7:52 PM

nosis may be congenital or acquired and is diagnosed when there is a narrowing of the laryngeal lumen. Congenital stenosis is usually diagnosed in the first few months of life when the child is noted to have persistent inspiratory stridor. Mild cases may present later Tintinalli_Sec12_p0669-0996.indd 790 8/2/19 7:52 PM CHAPTER 126: Stridor and Drooling in Infants and Children 791 TABLE 126-2 Common Acquired Causes of Stridor Viral Croup Epiglottitis Bacterial Tracheitis Foreign Body Aspiration Retropharyngeal Abscess Peritonsillar Abscess Etiology Parainfluenza viruses (occasionally influenza respiratory syncytial virus, rhinovirus, metapneumovirus, enterovirus, and coronavirus) Streptococcus pneumoniae Staphylococcus aureus (most) Variable Polymicrobial Polymicrobial Foods Streptococcus pyogenes S. pyogenes S. aureus S. pneumoniae Peanuts S. aureus S. aureus S. pyogenes Haemophilus influenzae H. influenzae Seeds Gram-negative rods Oral anaerobes Moraxella catarrhalis Balloons/other toys Oral anaerobes Age 6 mo–3 y old All ages 3 mo–13 y old Any 6 mo–4 y old 10–18 y old (most) Peak 1–2 y old Mean, 6–12 y old Mean, 1–6 y old 6 mo–5 y old most common Rare >4 y old 6 mo–5 y old (rare) 80% <3 y old Onset 1–3 d Rapid, hours 2–7 d viral upper respiratory infection (especially influenza) Immediate or delayed possible Insidious over 2–3 d after an upper respiratory infection or local trauma Antecedent pharyngitis Suddenly worse over 8–12 h Effect of positioning on symptoms None Worse supine None Usually none Neck stiffness and hyperextension Worse supine Prefer erect, chin forward Location dependent Trismus common Stridor Inspiratory and expiratory Inspiratory Inspiratory and expiratory Location dependent Inspiratory when severe Uncommon Cough Seal-like bark No Usually present Often transient or positional No No Possible thick sputum Voice Hoarse Muffled Usually normal Location dependent Often muffled Muffled Not muffled “Hot potato” Possibly raspy Primarily if at or above glottis “Hot potato” “Hot potato” Drooling No Yes Rare Rare—often if esophageal Yes Often Dysphagia Occasional Yes No Rare—typically if esophageal Yes Yes Radiologic appearance Subglottic narrowing “steeple sign” (no diagnostic value) Enlarged epiglottis; “thumbprint sign” Subglottic narrowing Often normal Thickened bulging retropharyngeal soft tissue May see enlarged tonsillar soft tissue Thickened aryepiglottic folds Irregular tracheal margins Possible radiopaque density Stranding across trachea Ball-valve effect Segmented atelectasis abscess, or aspirated foreign body. 10 If radiographs are ordered, provide close monitoring during the procedure, as agitation may worsen exist ing airway obstruction.11 Radiographs may demonstrate subglottic nar rowing (“steeple sign”) (Figure 126-1); however, the steeple sign may be present in normal children and can be absent in up to 50% of those with croup. Croup is often classified as mild, moderate, or severe, and treatment is directed primarily at decreasing airway obstruction. Croup scoring systems are more useful as research tools than in clinical practice. The score, if calculated, should be used as only one piece of data in the decision-making process. One of the commonly used scoring guidelines is the modified Westley Croup Score (Table 126-3). Place children in a position of comfort, often in the lap of the caretaker, and assess respiratory distress through observation, without disturbing the child. Agitation and crying increase oxygen demand, creating tur bulent airflow and resulting in greater airway resistance. Humidified air or cool mist does not appear to improve clinical symptoms. 14 However, anecdotally, exposing children with croup to cold air at home reduces the intensity of symptoms.

isturbing the child. Agitation and crying increase oxygen demand, creating tur bulent airflow and resulting in greater airway resistance. Humidified air or cool mist does not appear to improve clinical symptoms. 14 However, anecdotally, exposing children with croup to cold air at home reduces the intensity of symptoms. The primary treatments for croup include nebulized epinephrine and corticosteroids (Table 126-4). Give nebulized epinephrine for moder ate to severe croup, primarily those with stridor at rest; mild croup generally does not require epinephrine. Epinephrine decreases airway edema through its vasoconstrictive α-receptor effects. Clinical effects of epinephrine are seen in as few as 10 minutes. Use of epinephrine decreases the number of children with croup requiring hospitalization, intensive care unit stay, or intubation. Studies comparing l-epinephrine with racemic epinephrine show no significant difference in response initially; however, at 2 hours after administration, patients receiving l-epinephrine displayed lower croup scores. 15,16 Administration of nebulized intermittent positive-pressure breathing has no benefit over simple nebulization. 16 ED observation for at least 3 hours is recommended when epinephrine is required because an increase in croup scores can occur between the second and third hours after epinephrine in patients ultimately requiring admission. All patients with croup, whether mild, moderate, or severe, ben efit from the administration of oral steroids as a one-time dose. Steroid administration reduces the severity and duration of symptoms Tintinalli_Sec12_p0669-0996.indd 791 8/2/19 7:52 PM

d hours after epinephrine in patients ultimately requiring admission. All patients with croup, whether mild, moderate, or severe, ben efit from the administration of oral steroids as a one-time dose. Steroid administration reduces the severity and duration of symptoms Tintinalli_Sec12_p0669-0996.indd 791 8/2/19 7:52 PM 792 SECTION 12: Pediatrics FIGURE 126-1. Anteroposterior neck radiograph in a patient with croup; note presence of “steeple sign” ( arrow). [Photo used with permission of W. McAlister, MD, Washington University School of Medicine, St. Louis, MO.] TABLE 126-3 The modified Westley Croup Score Inspiratory stridor None = 0 points With agitation only = 1 point At rest = 2 points Intercostal retractions Mild = 1 point Moderate = 2 points Severe = 3 points Air entry Normal = 0 points Slightly decreased = 1 point Severely decreased = 2 points Cyanosis None = 0 points With agitation only = 4 points At rest = 5 points Level of consciousness Normal = 0 points Altered = 5 points 0–17 points total <4 points = mild croup 4–6 points = moderate croup >6 points = severe croup and results in a decrease in return visits to the ED or hospital length of stay.10,18 A one-time dose of dexamethasone has become the steroid of choice given ease of administration, cost, and medication half-life. Dexamethasone is equally effective given parenterally or orally. Currently, a single dose of 0.6 milligram/kg PO of the oral dexamethasone preparation is recommended. 14 The onset of action for oral dexametha sone is generally 4 to 6 hours after oral administration, but effects can be seen within 1 hour. 10 Most clinicians initially prescribe oral corticoste roids because of ease of administration. Using injectable dexamethasone formulation (4 milligrams/mL) for oral administration provides less volume than commercially available oral products (0.1 milligram/mL or 1 milligram/mL) and can improve tolerability and minimize risk of emesis. 19 Nebulized budesonide and IM dexamethasone are alternatives to oral dexamethasone in children who are vomiting. For severe croup with respiratory failure despite medical therapy, endotracheal intubation may be necessary. When possible, intubation should be performed in a controlled setting such as the operative room or intensive care unit by the most experienced person available. Intu bation should be performed using an endotracheal tube 0.5 to 1 mm smaller than normally used for the patient’s size given the upper airway edema. Heliox, in a 70% helium/30% oxygen ratio, has theoretical treatment benefits for severe, refractory croup. Replacing nitrogen with the less dense helium decreases airway resistance and may improve gas flow through a compromised airway. An important limitation is the low fractional concentration of inspired oxygen in the gas mixture. Despite its theoretical benefits, studies show no definitive advantage of heliox over conventional treatment. In certain clinical scenarios, it may still hold some short-term clinical benefit. 20,21 Although historically used in children with mild to moderate croup, the use of humidified air is also likely ineffective. There are insufficient data to determine whether nebulized β-agonists are beneficial in children with croup.10,22 In addition, there is theoretical risk of worsening upper airway obstruction with β-agonist use in croup, as β-receptors in the vasculature cause vasodilation (as compared to the vasoconstrictive α effects of epinephrine), which may worsen upper airway edema in croup. Therefore, β-agonists are not recommended for treatment of croup.  DISPOSITION AND FOLLOW-UP Most children with croup can be safely discharged to home (Table 126-5). Children who have received nebulized epinephrine should be observed in the ED for 3 to 4 hours after administration.

worsen upper airway edema in croup. Therefore, β-agonists are not recommended for treatment of croup.  DISPOSITION AND FOLLOW-UP Most children with croup can be safely discharged to home (Table 126-5). Children who have received nebulized epinephrine should be observed in the ED for 3 to 4 hours after 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. 10,11,22 Admit children with respiratory failure and those requiring intubation to intensive care. EPIGLOTTITIS Epiglottitis, or supraglottitis, is an acute inflammatory condition of the epiglottis that may progress rapidly to life-threatening airway obstruc tion. Widespread administration of Haemophilus influenzae type B vaccine has significantly reduced the number of cases of childhood epi glottitis and shifted the epidemiology toward older children (mean age 6 to 12 years). In the postvaccine era, most cases of infectious epiglottitis are caused by streptococcal and staphylococcal species, whereas Candida species can cause epiglottitis in the immunocompromised patient. Noninfectious causes, such as thermal injury, caustic burns, and direct trauma, can cause swelling and inflammation of the epiglottis with a similar clinical picture.  CLINICAL FEATURES Infection typically presents with the abrupt onset of fever, stridor, drooling, and sore throat. Symptoms may progress rapidly, with inability to handle oral secretions followed by stridor and respiratory distress. Cough is often absent, and the voice may be muffled. Most children appear toxic and anxious and may assume a tripod or sniffing position with the neck hyperextended and the chin forward to maintain the airway. Tintinalli_Sec12_p0669-0996.indd 792 8/2/19 7:52 PM

l secretions followed by stridor and respiratory distress. Cough is often absent, and the voice may be muffled. Most children appear toxic and anxious and may assume a tripod or sniffing position with the neck hyperextended and the chin forward to maintain the airway. Tintinalli_Sec12_p0669-0996.indd 792 8/2/19 7:52 PM CHAPTER 126: Stridor and Drooling in Infants and Children 793  DIAGNOSIS The ideal approach to the diagnosis of epiglottitis varies depending on the practice and the environment. Each institution should have a written protocol for suspected epiglottitis management. Important components of all protocols are listed in Table 126-6. 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. 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 23,24 (Figure 126-2). If suspicion for the diagnosis still exists despite normal-appearing radio graphs, direct visualization of the epiglottis is necessary to exclude the diagnosis (Figure 126-3).  TREATMENT Keep the child seated and upright in a position of comfort. Provide oxygen only if this does not further agitate the child. Administer nebulized 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. The most skilled individual avail able should perform intubation as soon as the diagnosis is made. Awake, fiberoptic nasotracheal intubation under conscious sedation should be considered in the spontaneously breathing patient. Use paralytics and vagolytics as needed. 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. Supraglottic devices are not effective in children with upper airway obstruction; if endotracheal intubation is unsuccessful, an emergent surgical airway is required. Antibiotic coverage should target Streptococcus pneumoniae, Staphylococcus aureus, and H. influenzae, with consideration for methicillin-resistant S. aureus (e.g., ceftriaxone and vancomycin). Antibiotics are typically continued for 7 to 10 days. Steroids are often used to decrease mucosal edema of the epiglottis. Admit all children with suspected or confirmed epiglot titis to an intensive care unit setting. BACTERIAL TRACHEITIS Bacterial tracheitis, also known as membranous laryngotracheobronchitis or bacterial croup, is an uncommon infection that can cause life-threat ening 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. 25,26 The most commonly isolated pathogen obtained from culture at bronchoscopy is S. aureus. Other organisms implicated in bacterial tracheitis include S. pneumoniae, Streptococcus pyogenes, Moraxella catarrhalis, H. influenzae, and oral anaerobes.

compared with the 4 years of age that has been classically described. 25,26 The most commonly isolated pathogen obtained from culture at bronchoscopy is S. aureus. Other organisms implicated in bacterial tracheitis include S. pneumoniae, Streptococcus pyogenes, Moraxella catarrhalis, H. influenzae, and oral anaerobes. 25-29  CLINICAL FEATURES Bacterial tracheitis often develops secondarily after a viral upper respiratory tract infection, particularly influenza A. A history of upper respiratory infection symptoms followed by sudden worsening with high fever, stridor (often biphasic), and cough (which may be productive with thick sputum) and a toxic appearance suggest the diagnosis. Thick mucopu rulent secretions of the trachea can result in upper airway obstruction. Children with tracheitis often complain of sore throat and will point to TABLE 126-5 Criteria for Discharge From ED in Patients With Croup •  No  stridor at rest and 3 h since last epinephrine (if given) •  Normal  color, pulse oximetry, and mental status •  Able  to tolerate oral fluids •  Caretaker  can recognize worsening symptoms and return to ED if necessary TABLE 126-6 Suspected Epiglottitis Management Protocol •   Immediate recognition and triage to a resuscitation area •   Continuous monitoring by someone trained in the management of a difficult airway •   Rapid consultation with appropriate colleagues from otolaryngology and anesthesiology •   Consideration and risk-benefit analysis of patient transfer with appropriate personnel present during the transfer •   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 FIGURE 126-2. Lateral neck view of a child with epiglottitis. Note the swollen epiglottis (arrow) resembling a “thumb.” TABLE 126-4 Croup Treatment Medication Dose Notes Dexamethasone 0.15–0.6 milligram/ kg PO/IM (10 milligrams maximum) Give for mild, moderate, or severe croup. May crush pills and mix in juice or applesauce or administer the IV formulation orally. 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 severe. Tintinalli_Sec12_p0669-0996.indd 793 8/2/19 7:52 PM

pills and mix in juice or applesauce or administer the IV formulation orally. 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 severe. Tintinalli_Sec12_p0669-0996.indd 793 8/2/19 7:52 PM 794 SECTION 12: Pediatrics FIGURE 126-3. Epiglottitis at laryngoscopy. [Reproduced with permission from Knoop K, Stack L, Storrow A: Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, Inc., New York. Part 2 Specialty Areas, Chapter 14, Pediatric Conditions, Figure 14-38.] FIGURE 126-4. Membranous tracheitis. Lateral soft tissue radiograph of the neck in a 13-year-old girl with the acute onset of stridor after 3 days of sore throat. Membranes (arrows) are visible in the subglottic region. [Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine, 4th ed. McGraw-Hill Education, Inc. © 2016. Fig 14.87, page 478. Photo contributor: Matthew R. Mittiga, MD.] their trachea when asked where it hurts. There is often tenderness with palpation of the trachea.  DIAGNOSIS Laboratory studies other than tracheal cultures (typically obtained dur ing bronchoscopy) 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 nar rowing of the trachea and irregular tracheal margins in patients with tracheitis (Figure 126-4). Because no single clinical or radiographic feature can definitively make a diagnosis, bronchoscopy is the diagnostic method of choice in bacterial tracheitis.  TREATMENT The management of tracheitis is similar to that of epiglottitis, with patients ideally going to the operating room for sedation, intubation, and bronchoscopy. There is no clear benefit from β-agonists or gluco corticoids in bacterial tracheitis. Administer empiric antibiotics in the ED to cover likely pathogens. In children with tracheostomies, prior lower respiratory cultures may also guide initial antibiotic choices. Appropriate choices include vancomycin or clindamycin plus a thirdgeneration cephalosporin. Definitive antibiotic choices depend on cultures and Gram stain of the mucopurulent secretions obtained at the time of bronchoscopy. Bronchoscopy may be therapeutic because the removal of purulent pseudomembranes improves tracheal toilet and may lessen upper airway obstruction. For continued management, most patients with bacterial tracheitis require a definitive airway and ventila tory support.  AIRWAY FOREIGN BODY 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. Suspect foreign body aspiration with a history of sudden coughing and choking in the child; this is the most predictive of all signs and symptoms in foreign body aspiration. 30-32 In many cases, the choking episode is not witnessed by a caregiver. Consider foreign body aspira tion 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 imple ment a protocol for obstructed airway management (see Chapter 109, “Resuscitation of Children”).

less 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 imple ment a protocol for obstructed airway management (see Chapter 109, “Resuscitation of Children”).  CLINICAL FEATURES A history of witnessed choking (sudden onset of cough, shortness of breath) is highly suggestive of airway foreign body, although not always observed. 33 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. A large majority of airway foreign bodies are found in the bronchi. Children can develop severe immediate-onset stridor or even cardiopulmonary arrest, but there are a proportion of patients who will remain minimally symptomatic. The most important factor in reducing mortality from an airway foreign body is recognition of the child in acute airway distress.  DIAGNOSIS Radiographs are helpful to confirm the diagnosis of airway foreign body but should not be used to exclude the diagnosis. Plain chest radiographs are normal in >50% of tracheal foreign bodies and 25% of bronchial foreign bodies. 34 More than 75% of airway foreign bodies in children <3 years of age are radiolucent. 34,35 Laryngeal and tracheal foreign bodies often constitute an acute emergency, and radiography is omitted. If performed, posteroanterior and lateral neck radiographs are the radiographic examinations of choice. Foreign bodies lodged in the proximal esophagus may also present with airway compression. Tracheal Tintinalli_Sec12_p0669-0996.indd 794 8/2/19 7:52 PM

often constitute an acute emergency, and radiography is omitted. If performed, posteroanterior and lateral neck radiographs are the radiographic examinations of choice. Foreign bodies lodged in the proximal esophagus may also present with airway compression. Tracheal Tintinalli_Sec12_p0669-0996.indd 794 8/2/19 7:52 PM CHAPTER 126: Stridor and Drooling in Infants and Children 795 FIGURE 126-5. (A) Posteroanterior and (B ) lateral chest radiographs showing radi opaque bronchial foreign body. [Photos used with permission of W. McAlister, MD, Washington University School of Medicine, St. Louis, MO.] FIGURE 126-6. (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. [Photos used with permission of W. McAlister, MD, Washington University School of Medicine, St. Louis, MO.] and esophageal foreign bodies can be differentiated on neck radio graphs: foreign bodies typically lodge in the trachea in profile and in the esophagus en face. Suspected bronchial foreign bodies can be evaluated with the use of posteroanterior and lateral chest films ( Figure 126-5, A and B). Indirect radiologic signs of a radiolucent airway foreign body include unilateral obstructive emphysema, atelectasis, and consolida tion. Unilateral obstructive emphysema is seen when a foreign body obstructs airflow, mainly on expiration. This generates a check-valve obstruction that results in hyperinflation of the affected side and potential mediastinal shift to the opposite side. 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 in cooperative patients ( Figure 126-6, A and B ). Bilateral decubitus chest films have been used to demonstrate air trapping; however, they increase false positives without increasing true positives, suggesting a lack of clinical benefit. 34,36-38 A clinically suspected foreign body aspiration should ultimately be ruled out by bronchoscopy, regardless of the chest radiograph findings.34,36,37  TREATMENT Children with complete airway obstruction are typically unable to breathe or speak and require emergency basic life support measures to relieve airway obstruction. For detailed discussion, see Chapter 108, “Resuscitation of Neonates, ” and Chapter 109, “Resuscitation of Children. ” If basic life support maneuvers fail, perform direct laryngoscopy and foreign body extraction with Magill forceps. When the foreign body is not vis ible or able to be removed, orotracheal intubation with dislodgment of the foreign body more distally (often into the right mainstem bronchus) may relieve complete obstruction and be lifesaving. If the foreign body cannot be removed and ventilation cannot be provided through an endotracheal tube, attempt a surgical airway (needle cricothyroidotomy Tintinalli_Sec12_p0669-0996.indd 795 8/2/19 7:52 PM

n body more distally (often into the right mainstem bronchus) may relieve complete obstruction and be lifesaving. If the foreign body cannot be removed and ventilation cannot be provided through an endotracheal tube, attempt a surgical airway (needle cricothyroidotomy Tintinalli_Sec12_p0669-0996.indd 795 8/2/19 7:52 PM 796 SECTION 12: Pediatrics or emergency tracheostomy). For children with partial airway obstruc tion, monitor respiratory status closely and arrange for bronchoscopic removal under general anesthesia. RETROPHARYNGEAL ABSCESS 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. An important potential complica tion is caudal spread into this potential space leading to mediastinitis. These lymph nodes tend to regress by age 4 years old, obliterating this potential space, which explains the decreasing frequency of retropha ryngeal abscess in older 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 pen etrating 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 instru mentation or ventral extension of vertebral osteomyelitis. Retropha ryngeal infection typically progresses from an organized phlegmon to a mature abscess.  CLINICAL FEATURES Most cases of retropharyngeal abscess evolve insidiously over a few days after a relatively minor upper respiratory infection or pharyngitis. Fever is typically present but may be absent in >10% of patients. 39-41 Additional signs and symptoms include neck pain, odynophagia, dysphagia, trismus, excessive drooling, and neck swelling. The child may maintain the neck in an unusual position, with stiffness, torticollis, and hyperextension. The voice may be muffled, and anterior cervical lymphadenopathy is common. A unique finding is bulging of the posterior oropharynx. The diagnosis should be considered in any child who will not fully extend his or her neck to look up (Bolte’s sign). 41 Abscess progression can lead to stridor and respiratory distress. Pleuritic chest pain is an ominous sign, indicating extension of the infection into the mediastinum.  DIAGNOSIS 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 126-7). Rarely, gas may be seen within the collection. Contrast-enhanced CT scan may demonstrate necrotic nodes, inflammatory phlegmon, or fluid collection within a ring-enhancing abscess ( Figure 126-8). CT is helpful for diagnosing and defining the extent of the infection and surgical planning. However, CT scans are limited in their ability to differentiate between abscess and cellulitis/phlegmon. Therefore, imaging results should be correlated to clinical findings when guiding the decision of conservative versus surgical treatment. 39-47 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 pres ent.

s should be correlated to clinical findings when guiding the decision of conservative versus surgical treatment. 39-47 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 pres ent. A provider accustomed to managing the difficult pediatric airway should escort patients without airway compromise to radiology, and appropriate equipment should accompany the patient.  TREATMENT Carefully monitor and stabilize the airway. Obtain IV or IO access to administer fluids, antibiotics, and CT contrast. Most retropharyngeal abscesses are found to contain mixed flora when cultured. 39,40 Common organisms include S. aureus, S. pyogenes, Streptococcus viridans , and β-lactamase–producing gram-negative rods. Oral anaerobes are also FIGURE 126-7. Lateral soft tissue neck radiograph demonstrating retropharyngeal swelling (arrow). FIGURE 126-8. Contrast-enhanced neck CT showing a retropharyngeal fluid collection (arrow). frequently seen. 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. Initiate empiric antibiotic therapy in the ED with clindamycin (15 milligrams/kg per dose every 8 hours IV) or ampicillin-sulbactam (50 milligrams/kg per dose every 6 hours IV). Unusual complications Tintinalli_Sec12_p0669-0996.indd 796 8/2/19 7:52 PM

rgo operative incision and drainage, usually by an otolaryngologist. Initiate empiric antibiotic therapy in the ED with clindamycin (15 milligrams/kg per dose every 8 hours IV) or ampicillin-sulbactam (50 milligrams/kg per dose every 6 hours IV). Unusual complications Tintinalli_Sec12_p0669-0996.indd 796 8/2/19 7:52 PM CHAPTER 126: Stridor and Drooling in Infants and Children 797 FIGURE 126-9. Examination of the oropharynx illustrating unilateral bulging palate and erythema of the left peritonsillar fossa with the uvula mildly deviated to the contralateral side. [Reproduced with permission from Goldman L, Ausiello D: Cecil Medicine, 23rd ed. Philadelphia, PA: Saunders Elsevier; 2008.] aspiration and incision and drainage include hemorrhage, puncture of the carotid artery, and airway aspiration of purulent material. Y ounger children with few prior episodes of tonsillitis and small abscesses may respond to oral antibiotics without the need for drainage. 49 In non–toxicappearing adolescents with good follow-up and findings most consistent with peritonsillar cellulitis, a trial of oral antibiotics is also reasonable. Empiric coverage includes amoxicillin-clavulanate (45 milligrams/kg per dose every 12 hours to a maximum of 875 milligrams per dose) or clindamycin (10 milligrams/kg per dose every 8 hours). Adjunct therapy with single high-dose steroid administration seems to improve symptoms in patients with peritonsillar abscess after drainage. LUDWIG’S ANGINA Ludwig’s 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 (Figures 126-10 and 126-11). Most cases arise from an odontogenic source, often from the spread of periapical abscesses of mandibular molars. Infection is typically polymicrobial involving oral flora. Ludwig’s angina usually begins with a mild infection that progresses rapidly to include fever, chills, severe mouth pain, drooling, trismus, tongue protrusion, and brawny neck swelling. The child may maximize airway diameter by assuming a “sniffing position. ” Stridor may develop with subsequent progressive airway obstruction. Control the airway early, because intubation can be extremely difficult late in the clinical course of the disease. 51 Treatment includes empiric 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 (e.g., ampicillin-sulbactam or clindamycin or penicillin G). Consider additional coverage for community-acquired methicillin-resistant S. aureus in those at risk for colonization. 51,52 DIPHTHERIA Diphtheria is an acute toxin-mediated disease caused by Corynebacterium diphtheria, a gram-positive non–spore-forming bacillus, and has largely been eradicated in developed nations through widespread vac cination. It is transmitted from person to person through respiratory of retropharyngeal abscess include airway obstruction, spontaneous abscess perforation, mediastinitis, sepsis, aspiration, and jugular venous thrombophlebitis/thrombosis, also known as Lemierre’s syndrome. PERITONSILLAR ABSCESS Peritonsillar abscess, also known as a quinsy, is a posterior oropharyn geal infection. It can occur in patients of any age, but most commonly occurs in adolescents and young adults.

diastinitis, sepsis, aspiration, and jugular venous thrombophlebitis/thrombosis, also known as Lemierre’s syndrome. PERITONSILLAR ABSCESS Peritonsillar abscess, also known as a quinsy, is a posterior oropharyn geal 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, whereas <10% are bilateral at the time of diagnosis. Most peritonsillar abscesses are polymicrobial infections. Predominant organisms include anaerobes, group A β-hemolytic streptococci, S. aureus, and H. influenzae.  CLINICAL FEATURES Patients with peritonsillar abscess typically present with sore throat (often unilateral), 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. On examination, bulging of the affected tonsil and deviation of the uvula away from the involved tonsil are evident ( Figure 126-9). Differentiating peritonsillar cellulitis from peritonsillar abscess can be difficult. If the child is toxic, consider a peritonsillar abscess until proven otherwise.  DIAGNOSIS Peritonsillar abscess is typically a clinical diagnosis, and routine labora tory or imaging studies are not needed. If drainage is performed in the ED, send purulent material for Gram stain and culture. Cases without typical exam findings may require imaging to distinguish cellulitis from abscess. US (intraoral or submandibular) may be helpful in cooperative children. For cases in which deep space neck infection is a consideration, imaging with CT using IV contrast is often helpful. As mentioned earlier, lateral radiographs of the neck may identify retropharyngeal abscess.  TREATMENT Most cases of peritonsillar abscess are managed as outpatients with prompt aspiration or incision and drainage using local anesthetics in the ED. Y oung and uncooperative children may require procedural sedation to facilitate adequate evaluation and drainage. Complications of needle Geniohyoid muscle Sublingual space Submandibular space: Mylohyoid muscle Superficial fascial layer Submaxillary space FIGURE 126-10. Spread of infection within the submandibular space of the neck. Tintinalli_Sec12_p0669-0996.indd 797 8/2/19 7:52 PM