++
It is important to recognize the differences between the pediatric
and adult upper airway to fully understand why even a relatively
minor obstruction can cause significant airway compromise in children
(Fig. 510-1). The pediatric airway is shorter
and narrower and the larynx is placed more anterior than in adults.1 The
narrowest portion of the pediatric airway is the subglottis, which
is below the vocal cords. Therefore, mild edema in this region can
result in a large reduction in the cross-sectional area of the airway.
The resistance is inversely proportional to the fourth power of
the radius of the airway (see Chapter 503).
Therefore, even a small decrease in airway diameter leads to a much larger
increase in resistance. Young children, and infants especially,
have a large tongue in relation to the small oropharynx.1 They
also have a larger epiglottis.1 Signs of partial
inspiratory obstruction include stridor (a high-pitched sound heard
on inhalation), hoarseness, and increased work of breathing (suprasternal and
intercostal retractions).2 Stridor can be inspiratory
or expiratory, depending on whether the obstruction is supraglottic
or subglottic respectively. If the obstruction is severe or near-complete, worsening
agitation, cyanosis, and respiratory failure will likely occur.
Although acute stridor is usually infectious in etiology, other disorders
may be present, especially when symptoms are severe or persistent.
This chapter discusses inspiratory airway obstruction of infectious
or noninfectious origin.
+++
Noninfectious Causes
of Upper Airway Obstruction
++
Disorders of the upper airway are also discussed in Chapter 371.
++
Laryngomalacia is the most common cause of noninfectious,
persistent stridor in infants. It is characterized by a long, curved
epiglottis that folds into an omega shape, with varying degrees
of prolapse of the arytenoids during inspiration.3The
flaccid supraglottic structures prolapse into the airway, leading to
obstruction while breathing in. The inspiratory noise can begin
in the first 2 months after birth, and it commonly presents as stridor
that worsens with crying and activity; improvement occurs when the
infant is placed in the prone position. Diagnosis is usually based
on the history and physical examination; however, airway endoscopy
is also helpful. The condition usually resolves spontaneously by
12 to 24 months. In more severe cases, surgery (supraglottoplasty)
may be necessary.4 Gastroesophageal reflux disease (GERD),
has been linked to laryngomalacia, and the possibility of concurrent
reflux should be considered and treated.5 GERD
can worsen the symptoms of laryngomalacia by contributing to further
inflammation and edema of the larynx.
++
Laryngeal cysts, webs, laryngoceles, and saccular
cysts are much less common conditions that can cause airway
obstruction.4 Depending on the degree of obstruction,
they can present soon after birth. Laryngeal cysts can present with
hoarseness and stridor. Saccular cysts are caused by obstruction
of the laryngeal saccule opening.4 The saccule
is a mucus membrane pouch located between the false vocal cords
and the inside of the thyroid cartilage.2 Its function
is to moisten the vocal cord surfaces with mucus. The saccular cyst
is full of mucus secretions and therefore causes airway obstruction
at the level of the vocal cords. Diagnosis is made via airway endoscopy,
and treatment requires marsupialization or surgical excision. Laryngoceles
are another abnormality of the laryngeal saccule. In this condition,
the saccule is filled with air and can compress the laryngeal airway.4 This
can cause a weak cry as well as other symptoms of airway obstruction.
Evaluation and treatment is similar to that of saccular cysts. Laryngeal
webs are rare congenital anomalies that can present in the newborn
period if the web is large and cause significant respiratory distress
and stridor. The most severe entity along the spectrum of laryngeal
webs is laryngeal atresia, which presents at birth and requires
immediate intervention with tracheotomyl.4 Treatment
includes surgical approaches such as laryngotracheal reconstruction. Infants
with congenital laryngeal anomalies should have a genetic and cardiovascular evaluation
to screen for other syndromes that may occur in conjunction.2
++
Thyroglossal duct cysts (originating from the thyroglossal duct) usually
present early in the neonatal period. They are most commonly found
in the neck but can also be seen at the base of the tongue in the
vallecula.4 Stridor, cough, and changes in voice
quality can occur. Laryngoscopy confirms the diagnosis, and treatment
is surgical.2
++
Congenital subglottic stenosis consists of narrowing of the airway
lumen at the cricoid region, not thought to be secondary to intubation,
trauma, or other acquired causes.4 Depending on
the severity, it is commonly diagnosed in the first few months of
life. Common presentations include inspiratory or biphasic stridor
(stridor that is both inspiratory and expiratory) and recurrent
croup. If the stenosis is mild, it may cause symptoms only during
times of upper respiratory tract infection.4 Differential
diagnosis includes hemangiomas or cysts in the subglottic region. Airway
endoscopy is necessary to evaluate the severity of the stenosis
and confirm the diagnosis. Surgical intervention such as laser excision
of scar tissue and laryngotracheal reconstruction,2 may
be necessary for extremely severe cases, but in most children, the
symptoms improve as the larynx grows.4 The milder
cases are therefore managed conservatively with observation and
follow-up.
++
Subglottic hemangiomas (congenital vascular lesions) are rare
but can be life threatening because of their location and size.
Symptoms can include recurrent croup, stridor, hoarseness, and cough.
Half of these children will also have hemangiomas on their skin.4 Infants
will often present prior to 6 months of age, and females are more
commonly affected. Diagnosis is confirmed by rigid airway endoscopy.2 Characteristically,
hemangiomas enlarge rapidly in the first few months of life, have
stable growth from 1 to 2 years of age, and involute by the time
the child is school age.2 Corticosteroids are helpful
in some, but not all, to hasten regression of the lesion; however,
they are not without several side effects. Some patients require
tracheotomy to adequately control the airway if the lesion is large,
obstructing, and growing.2 Surgical resection may
be required for large lesions.4
+++
Tumors of the
Upper Airway
++
Mass lesions and tumors of the upper airway are rare in childhood. Malignancies
that affect the head and neck (including the oropharynx) include
non-Hodgkin lymphoma, rhabdomyosarcoma, neuroblastoma, and teratoma.2 Airway
obstruction may result from external compression or by seeding the
oropharynx from another primary site in the head or neck. Management
is specific to the tumor type and may include a combination of surgery,
chemotherapy, and/or radiation therapy.2
+++
Gastroesophageal
Reflux Disease
++
GERD is associated with or can exacerbate several upper respiratory conditions,
including apnea, laryngospasm, spasmodic croup, hoarseness, throat
clearing, chronic cough, and stridor.5 Reflux of
gastric contents into the laryngopharyngeal region can lead to chronic
inflammation and edema. Respiratory symptoms from reflux can occur
without the classic regurgitation and irritability during feeds.
Parents report that the infant appears happier and has less stridor
when in the prone position. GERD often occurs in conjunction with
laryngomalacia, and stridor may improve with antireflux medication.5 Apneic
episodes in infants should be investigated for the possibility that reflux
has a role.5 Animal models have shown that GERD,
along with trauma and infection, can lead to subglottic stenosis, and
studies in children suggest at least an association between GERD and
subglottic stenosis.5 No studies have proven a
response to aggressive acid inhibitory therapy but this is often
prescribed. Diagnostic testing for GERD may include a pH probe,
gastric scintiscan, and esophageal biopsy6 as well
as management, are discussed in Chapters 394 and 511.
+++
Vocal Cord Abnormalities
+++
Vocal Cord Dysfunction
++
Vocal cord dysfunction (VCD), also known as
paradoxical vocal fold motion (PVFM), has gained recognition recently
as a cause of upper airway obstruction as a result of paradoxical
closure of the true vocal folds during inspiration.7 It
is most commonly seen in females and historically was thought to
be related only to psychiatric or psychogenic disorders.7 This
has since been shown not to be the case. VCD can occur over wide
range of ages from childhood to adulthood; however, in children,
it usually presents in early adolescence.8 A wide
spectrum of symptoms can occur, including throat tightness, chest
tightness and pain, hoarseness, difficulty getting air “in,” cough,
inspiratory stridor, dysphonia, dyspnea, and air hunger.7,8 Patients
may experience anxiety and panic during these acute episodes. Triggers
are numerous, including emotional stressors, reflux, and exercise.7 Asthma
and GERD exist as comorbid conditions with VCD and should be considered
and treated if necessary. VCD may be mismanaged, with a false diagnosis
of asthma, and patients are placed on unnecessary medications such
as corticosteroids. Exposure to irritants, such as cleaning solutions, perfumes,
or chlorine in swimming pools has also been associated with VCD.7 Careful
history and physical examination, spirometry with inspiratory loops,
and documentation of normal oxygen saturation during episodes are
the keys to diagnosis of VCD.7,8 Spirometry may
reveal attenuation of inspiratory flow, indicating extrathoracic
airway obstruction, whereas asthma causes intrathoracic airway obstruction.
Laryngoscopy after exercise challenge can also document paradoxical
vocal cord motion in those patients whose symptoms are related to
activity. Treatment of VCD is best carried out via a multidisciplinary approach.
It involves the patient’s physician as well as a speech
therapist who can focus on breathing exercises.8 Patient
education and their understanding of the condition are also extremely
important.
++
Causes of vocal fold paralysis are further discussed in Chapter 371 and are shown in Table 371-5. Neonates
can present with stridor caused by unilateral (often with a hoarse
cry) or bilateral (often with a normal or high-pitched cry) vocal
cord paralysis. This can be secondary to birth trauma, neurological
disease, or following heart or thoracic surgery (eg, patent ductus
arteriosus surgery), and it can also be idiopathic.2 Congenital
vocal cord paralysis usually presents in the first month of life,
and the possibility of other congenital anomalies should be investigated.
Central neurologic disease, such as brainstem compression with an
Arnold-Chiari malformation, can cause bilateral vocal cord paralysis.2 Airway
obstruction, apnea, and cyanosis are more severe with bilateral
paralysis, and many of these infants need tracheotomy. Diagnosis
is confirmed with airway endoscopy to observe the motion and position
of the vocal cords. Over time, paralysis may resolve spontaneously,
but until then, the infant is at risk for aspiration with feeding.2 A
modified barium swallow with a feeding evaluation is helpful in assessing
aspiration and swallowing problems in these patients. Surgical intervention,
such as arytenoidectomy, may also be necessary.
+++
Recurrent Respiratory Papillomatosis
++
Recurrent respiratory papillomatosis (RRP), caused
by human papilloma virus (HPV), commonly affects the vocal folds.
HPV types 6 and 11 may cause these lesions, but HPV type 11 causes
more aggressive disease in children.9 Patients
can present with hoarseness, dysphagia, a weak or hoarse cry, and
with advanced lesions, stridor, and shortness of breath. The virus
can be transmitted to the infant from the mother with genital HPV
infection during vaginal delivery. Risk factors for the juvenile
onset of RRP include being the firstborn child, being born by vaginal
delivery, and being born to a teenage mother.9 Evaluation
includes history and physical examination, followed by nasopharyngolaryngoscopy
or direct laryngoscopy for visualization. The diagnosis is made
on gross appearance of the lesions as well as pathology.9 Treatment
includes surgical therapies such as carbon dioxide laser ablation,
pulsed dye laser ablation, as well as adjuvant treatments such as
cidofovir and α-interferon.9 Unfortunately,
papillomas commonly recur, and some patients require multiple procedures
over their lifetime. There is a very low risk of malignant transformation, but
progression to squamous cell carcinoma has been reported.2
+++
Foreign Bodies
in the Throat
++
Foreign body aspiration is discussed in detail in Chapter 118.
Foreign bodies may lodge just below the vocal cords or in the upper
esophagus and produce symptoms similar to croup or asthma. There
is often not a witnessed choking episode or clear history of foreign
body aspiration. Physicians should have a high suspicion (of foreign body)
in a toddler, for example, who presents with sudden onset of stridor,
cough, and hoarseness without other signs of an upper respiratory tract
infection (such as fever, rhinorrhea, or other viral prodrome).
Common foreign bodies include seeds, bones, coins, and pieces of
plastic.10
++
Upper airway and chest radiography is recommended when there
is an abrupt onset of symptoms of upper airway obstruction. Radiography of
the neck/upper airway can be helpful if the inhaled object
is radiopaque (coins, batteries) but not if the object is radiolucent.11 Endoscopic
inspection and removal of the foreign body in the upper airway is
performed by otolaryngology.
++
Airway management is the first concern in a child who has sustained
a burn injury. Scald burns can affect the airway if there is significant
face and/or neck involvement. Inhalation injuries should
be considered after a child has been exposed to a flame injury,
especially in a closed space.12 Clinical signs
include singed nasal or facial hairs, stridor, wheezing, respiratory
distress, hoarseness, oral blisters, as well as edema and blisters
of the tongue.12 Flexible bronchoscopy can be used
to evaluate the extent of airway involvement. Smoke inhalation can
also lead to acute lung injury, affecting lung parenchyma and also
result in carbon monoxide intoxication.12 Endotracheal
intubation in the acute setting may be necessary, since worsening
airway edema may progress rapidly and complicate airway management.12 Management
includes obtaining appropriate control of the airway, fluid resuscitation,
and other supportive measures of care.12
+++
Angioedema and Angioneurotic
Edema
++
Angioedema and hereditary angioedema are discussed further in
Chapters 189 and 193. Angioedema consists of localized swelling
that is distinct from urticaria, which can occur to several triggers,
and most commonly is seen in vascular areas of the body such as
the face, eyes, mouth, and oropharynx. Angioedema occurs in tissues
deeper than the dermis and lasts for 24 to 48 hours, while urticaria
occurs in the dermis and usually lasts for shorter periods.13 Both
entities can coexist in patients. Angioedema can be allergic and
can be seen with anaphylaxis (immunoglobulin E [IgE] mediated
to foods, insects, or certain medications). It can also be nonallergic,
such as is seen when angiotensin-converting enzyme (ACE) inhibitors
and aspirin cause angioedema (non-IgE mediated).13 It
can occur in autoimmune and lymphoproliferative diseases as well
as in trauma and certain infections. It can affect the upper airway,
causing obstruction with symptoms of stridor and respiratory distress.
Acute management involves use of subcutaneous epinephrine and airway
control as necessary. Antihistamines and steroids may be necessary
for long-term management.
++
Hereditary angioneurotic edema is a disorder secondary to low
levels of, or defective, C1 inhibitor,14 a protein
that inactivates targets (such as C1 esterase) specifically in the
complement system as well as in the clotting and kinin pathways.
Unchecked activation of these mediators leads to edema formation
(via vascular permeability). It is inherited via an autosomal dominant
pattern, although there have been cases of de novo mutations in
patients whose parents do not have hereditary angioneurotic edema.14 The
clinical manifestations are subcutaneous edema, abdominal/intestinal
edema, and laryngeal edema. Episodes of larynx edema are rare but
extremely concerning because of its serious consequences. Symptoms
include stridor, hoarseness, a feeling that something is stuck in
the throat (globus sensation), and respiratory distress.14 Acute
management includes control of the airway with intubation if necessary
and replacement with intravenous C1-inhibitor concentrate. Prophylactic,
long-term treatment involves avoiding known triggers and using antifibrinolytics
and attenuated androgens.14
+++
Airway Obstruction
in Children with Down Syndrome
++
Children with Down syndrome are particularly at risk for upper
airway obstruction secondary to anatomical abnormalities in addition
to hypotonia. They have macroglossia and midface hypoplasia combined
with a softer supraglottis.15 As a result, there
is a higher prevalence of laryngomalacia in these infants.16 GERD
is commonly seen alongside laryngomalacia. Obstructive sleep apnea
has been found more frequently in children with Down syndrome than
in the general population.15 This is also secondary
to hypotonia, mandibular hypoplasia, and large adenoids, which all
lead to collapse of the upper airway at inspiration while asleep.
+++
Airway Obstruction
in Children with Charge Syndrome
++
CHARGE syndrome represents the following associated malformations:
C, coloboma; H, heart defects; A, atresia of choanae; R, retardation
of growth and/or development; G, genital anomalies; and
E, ear abnormalities.17 It is extremely common
for these infants to suffer from laryngopharyngeal airway obstruction,
and some require tracheotomy.17 Studies have shown
that contributing factors include laryngomalacia and supraglottic
obstruction due to hypotonia of this region. Infants with CHARGE
syndrome can also have swallowing problems and general laryngeal
dyscoordination due to cranial neuropathies (cranial nerves VII, IX,
X).17 There tends to be a high frequency of GERD
in these infants.
+++
Infectious Causes
of Upper Airway Obstruction
+++
Croup (Laryngotracheobronchitis)
++
Croup is the most common infectious cause of acute stridor and
upper airway obstruction seen in children (see also Chapter 241).18 It is seen in the early fall and winter
months, when viral upper respiratory tract infections reach their peak.
The age group most frequently affected is between 6 months and 4
years of age, and it is seen in males more than in females.18 Several
viruses can cause croup; however, parainfluenza type I is the most
common organism. Parainfluenza types II and III, respiratory syncytial
virus, adenovirus, and influenza can also cause croup. Mycoplasma
pneumoniae has also been implicated in croup.19 Many
children have a 1- to 3-day history of viral prodrome consisting
of nasal symptoms such as congestion or rhinorrhea and possibly
fever.20 Subsequently, there is development of
a harsh, barky cough that is often described to be similar to “a
barking seal or dog.” They may also have inspiratory stridor
as well as respiratory distress indicated by nasal flaring and suprasternal
and subcostal retractions. Stridor is often worsened with activity,
crying, and increased anxiety or agitation. Typically, the course
of illness lasts for no more than 1 week.18 The
viral infection causes inflammation and edema of the airway, especially
in the subglottic region.20 Croup is diagnosed
clinically by history and physical examination.18 An
x-ray of the upper airway can be useful to distinguish croup from other
entities such as a retropharyngeal abscess or foreign body. In croup,
a “steeple sign,” which is the tapering of the
subglottic airway, may be seen, but many patients will also have
normal x-rays.19 The differential diagnosis of croup
includes retropharyngeal abscess, epiglottis, foreign body, angioedema,
and structural abnormalities such as laryngomalacia or subglottic
stenosis. Obtaining a thorough and careful history greatly helps
to differentiate croup from these other conditions. Children who
have recurrent croup should be investigated for other problems beyond
simply recurring viral infections, such as anatomic abnormalities
or GERD.
++
Most children with croup do not require hospitalization; however,
many will need to be evaluated in an acute care setting if they
are having worsening stridor and respiratory distress. Some physicians
continue to recommend treatments such as mist therapy (air humidification),
but current studies available do not show evidence that this is
effective.20 Exposing children to steam from hot
showers or baths at home can put them at risk for scald injuries.20 Fever
reduction and avoidance of agitation are useful, both at home and
in the hospital setting. Obtaining blood work such as blood gas measurements
is rarely necessary and can certainly lead to further agitation,
increasing a child’s stridor and dyspnea. Oxygenation should
be monitored by pulse oximetry.
++
Corticosteroids continue to be one mainstay of therapy, even
for more mild cases of croup. Dexamethasone, either oral or intramuscular,
is effective in decreasing symptom severity, decreasing hospitalization
rates, and increasing symptom resolution.1819 The
standard use of dexamethasone is a 1-time dose of 0.6 mg/kg; however,
smaller doses have been shown to be effective.20 Prednisolone
has also been shown to be efficacious compared with placebo for
treatment of croup, as is nebulized budesonide at a dose of 2 mg.1819 Nebulized
racemic epinephrine is often used to acutely relieve upper airway
obstruction by decreasing edema via vasoconstriction and possibly
preventing further progression and need for intubation.18 It
will not alter the course of the illness as corticosteroids do.
It is classically used in patients with more moderate to severe
croup. Heliox, which is a helium and oxygen mixture (eg, 80:20)
and therefore a gas of much lower density than air (but similar
viscosity to air), can improve air flow in severe croup (as well
as in asthma and bronchiolitis).20 It
is used when a child is in severe respiratory distress and there
is concern of potential respiratory failure.
++
Spasmodic croup consists of episodes of inspiratory stridor that
occur mostly at night, without the classic viral prodrome.21 The
child may have had symptoms of a mild upper respiratory infection,
but fever is usually absent. The symptoms present quite suddenly,
in a well appearing child. Children are older than those who have
viral croup, and their symptoms usually resolve within 24 to 48
hours.20 The child awakens with a barking, harsh
cough and inspiratory stridor. Many will have recurrent episodes.
The etiology is not completely known, but both viral illness and
atopic disease is associated with spasmodic croup.20 Gastroesophageal
reflux (GER) has also been associated with recurrent croup.21 Parents
can attempt supportive care at home, such as exposure to cool night
air to improve symptoms. Treatment with racemic epinephrine and
steroids is helpful, as in viral croup. If symptoms are frequent
and recurrent, structural abnormalities of the airway should also
be considered.
++
Acute epiglottitis (also known as supraglottitis) is an infection
leading to inflammation and swelling of the epiglottis, which can
progress quickly to becoming a life-threatening emergency (see also Chapters 240, 241).
Prior to the standard use of Haemophilus influenzae b
(Hib) vaccine, this organism was the most common cause of epiglottitis.
Currently, Streptococcus pneumoniae, Staphylococcus aureus, and
group A β-hemolytic streptococci are among the
most common pathogens that cause this infection.19 It
is now rarely seen in childhood but must be considered when an ill-appearing
child presents with acute-onset of stridor. There have still been
cases of epiglottitis caused by Hib in immunized children, indicating
the possibility of vaccination failure.19 Children
affected are usually between 2 and 8 years old, although most recently
the age appears to be increasing. It presents quite suddenly (over
6–24 hours) with high fever, irritability, throat pain,
stridor, and what is known as a “hot potato” or
muffled voice.18 Unlike croup, there is usually
no preceding viral prodrome or cough, and the child has an extremely
ill appearance. The child will prefer to sit in the “tripod” position,
leaning forward and extending the neck to open the airway and increase
air entry.18 Eventually it becomes hard for the patient
to handle secretions and saliva, and therefore drooling will occur.18 Cyanosis,
stridor, and drooling all point to advanced, severe airway swelling
and impending respiratory failure due to airway obstruction.
++
Airway management is the first priority if epiglottitis is suspected.
Therefore, obtaining blood work and aggressive attempts at visualization
of the oropharynx should be avoided. Only in a child who appears
stable should a cautious examination of the posterior pharynx (without
the use of a tongue depressor) be attempted.18 Manipulating
or touching the oropharynx with a tongue depressor can cause complete
obstruction. The examination may reveal a grossly swollen, erythematous epiglottis,
projecting beyond the base of the tongue.18 A definitive
diagnosis of epiglottitis should occur in a controlled situation
(such as the operating room) with appropriate personnel (anesthesiologist
and otolaryngologist) who are trained to manage difficult airways
and are able to secure the airway surgically if necessary. A lateral
neck radiograph can be helpful but should not delay treatment. A “thumbprint
sign,” which describes a round and thickened epiglottis,
can be seen on the x-ray.19 Once the child has
a secured airway and is out of danger of progressing to total airway obstruction,
a complete blood count (CBC) and blood culture can be done and intravenous
antibiotics can be started. Patients will often have positive blood
cultures. High-dose, broad-spectrum antibiotics such as ceftriaxone
or ampicillin-sulbactam should be used.1819 Complications
seen with epiglottitis can include complete airway obstruction,
pulmonary edema postintubation, pulmonary infiltrates and pneumonia,
and respiratory arrest.18
+++
Bacterial Tracheitis (Pseudomembranous
Croup or Bacterial Croup)
++
Bacterial tracheitis is an uncommon entity but an important cause
of severe upper airway obstruction. It is commonly caused by Staphylococcus
aureus; however, Moraxella catarrhalis,Streptococcus
pneumoniae, and H influenzae are also
seen (see also Chapter 240).18 Children
present with symptoms similar to epiglottitis and croup. After this
initial presentation, they can progress to having respiratory distress
with high fever and become very ill appearing. Lateral neck radiographs
can show subglottic narrowing (steeple sign, as can be seen in viral
croup) and irregularity of the tracheal air column (indicating sloughing
of pseudomembranous material from the tracheal wall).18 They
can also develop pulmonary infiltrates consistent with pneumonia.
Airway endoscopy reveals large amounts of mucopurulent secretions
and subglottic edema. These secretions are thick and can occlude
the airway. They should be suctioned and sent for Gram stain and
culture. Treatment includes appropriate intravenous antibiotics
as well as airway management such as endotracheal intubation if
necessary.18
+++
Retropharyngeal
and Peritonsillar Abscess
++
The retropharyngeal space refers to the area between the anterior
cervical vertebrae and the posterior pharyngeal region.2 A
retropharyngeal abscess occurs in this space either by spread of
an upper respiratory tract infection (such as pharyngitis) to the
retropharyngeal lymph nodes or by a penetrating oropharyngeal injury. Group
A Streptococcus, anaerobic organisms, and Staphylococcus
aureus commonly cause this disease.18 This
infection is not common, but it needs to be diagnosed correctly and
treated without delay. It is mostly seen in children under 6 years
of age, especially in toddlers. This is explained by the fact that
the lymphatics that drain the retropharyngeal space atrophy by this
age.19 Clinical presentation includes fever, dysphagia,
drooling, neck stiffness, and pain. As the infection progresses
and pus collects, forming the abscess, stridor and respiratory distress
can develop from compression of the pharynx. The differential diagnosis
includes meningitis, epiglottitis, and croup. Physical examination
can reveal bulging of the posterior wall of the pharynx. Obtaining
a lateral neck radiograph is helpful in these cases in order to
specifically examine the retropharyngeal space for soft tissue swelling.
Widening of this potential space (> 7 mm at the
level of the second cervical vertebrae) may indicate a retropharyngeal
abnormality.18 Computed tomography (CT) scan of
the neck is necessary to distinguish between a true abscess and cellulitis
and is often used in evaluation of this deep neck infection.18 Treatment
requires the use of appropriate intravenous antibiotics; however,
surgical drainage is performed in those cases in which medical management
fails. Complications can include respiratory failure, aspiration
pneumonia (from abscess rupture), and spread of infection to other
areas in the deep neck.19
++
Peritonsillar infections and abscesses occur as a result of spread
from an infection in the tonsils. They are most common in adolescents
who have recurrent tonsillitis.19 Fever, throat
pain, decreased oral intake, and drooling are some of the symptoms
seen. Both anaerobic and aerobic organisms cause this infection.
Physical examination can reveal displacement of the uvula.19 CT
scan is often used to aid in the diagnosis of abscess.19 Treatment
includes intravenous antibiotics and may include surgical drainage.
Airway obstruction is a potential complication of peritonsillar
abscess.19