Croup, also known as laryngotracheobronchitis, is an acute respiratory condition characterized by inflammation of the upper airway, particularly affecting the larynx, trachea, and bronchi. It is a common childhood illness that can cause significant respiratory distress.
Key points:
Most common in children 6 months to 3 years of age
Peak incidence occurs in the second year of life
More frequent in boys than girls (ratio approximately 3:2)
Typically occurs in fall and early winter
Can be mild to severe, with potential for airway obstruction in severe cases
Etiology of Croup in Children
Understanding the causes of croup is essential for effective management:
1. Viral Causes (Most Common):
Parainfluenza viruses (types 1 and 3 most common)
Respiratory syncytial virus (RSV)
Influenza A and B viruses
Human metapneumovirus
Adenoviruses
Coronaviruses (including SARS-CoV-2)
2. Bacterial Causes (Rare):
Mycoplasma pneumoniae
Bacterial tracheitis (a complication of viral croup)
3. Non-infectious Causes:
Allergic reactions
Inhaled irritants
Reflux-induced laryngitis
4. Pathophysiology:
Viral infection leads to inflammation and edema of the subglottic region
Narrowing of the airway results in the characteristic "seal-like" barking cough
Inspiratory stridor occurs due to turbulent airflow through the narrowed airway
Clinical Presentation of Croup in Children
The presentation of croup can range from mild to severe:
1. Common Symptoms:
Barking cough (often described as "seal-like")
Inspiratory stridor
Hoarseness
Respiratory distress (varying degrees)
Low-grade fever (usually <39°C)
2. Progression of Symptoms:
Often begins with mild upper respiratory symptoms (rhinorrhea, cough)
Typical croup symptoms develop over 12-48 hours
Symptoms often worsen at night
Peak severity usually on the second or third night of illness
3. Severity Assessment:
The Westley Croup Score is commonly used:
Mild (0-2 points): Barking cough, no stridor at rest
Moderate (3-5 points): Stridor at rest, mild retractions
Severe (6-11 points): Marked stridor, significant retractions
Consider intubation (preferably with an endotracheal tube 0.5-1.0 mm smaller than usual)
ICU admission
4. Follow-up and Discharge Criteria:
Observe for at least 2-4 hours after treatment
Ensure adequate oral intake and absence of stridor at rest
Provide caregiver education on warning signs and when to seek medical attention
Complications and Special Considerations
While most cases of croup resolve without sequelae, awareness of potential complications is important:
1. Potential Complications:
Respiratory failure
Pneumonia
Bacterial tracheitis
Pulmonary edema (post-extubation)
2. Recurrent Croup:
Consider underlying conditions:
Subglottic stenosis
Laryngomalacia
Tracheomalacia
Gastroesophageal reflux disease
Referral to ENT specialist may be warranted
3. Special Populations:
Premature infants: Higher risk of severe disease
Children with comorbidities: May require more aggressive management
4. Prevention Strategies:
Hand hygiene
Avoiding close contact with individuals with respiratory infections
Routine childhood vaccinations (may prevent some viral causes)
5. Prognosis:
Generally excellent with appropriate management
Most children improve within 3-7 days
Hospitalization rates are low (<5% of cases)
Introduction to Laryngitis in Children
Laryngitis in children refers to inflammation of the larynx, often resulting in hoarseness or loss of voice. While usually acute and self-limiting, it can sometimes indicate more serious underlying conditions, especially in pediatric populations.
Key points:
Most common in ages 3 months to 3 years
Can be viral, bacterial, or due to irritants
Often accompanies upper respiratory tract infections
May present differently in children compared to adults
Etiology of Pediatric Laryngitis
Understanding the various causes of laryngitis in children is crucial for effective management:
1. Infectious Causes:
Viral (most common):
Respiratory Syncytial Virus (RSV)
Parainfluenza viruses
Influenza viruses
Adenoviruses
Bacterial:
Group A Streptococcus
Haemophilus influenzae
Moraxella catarrhalis
2. Non-infectious Causes:
Allergies
Gastroesophageal reflux disease (GERD)
Vocal cord nodules or polyps
Inhaled irritants (e.g., smoke, chemical fumes)
Excessive voice use or shouting
3. Rare but Serious Causes:
Epiglottitis
Laryngeal diphtheria
Foreign body aspiration
Laryngeal papillomatosis
Clinical Presentation of Laryngitis in Children
The presentation of laryngitis in children can vary based on age and etiology:
Common Symptoms:
Hoarseness or changes in voice quality
Cough (often described as "barking" or "croupy")
Difficulty swallowing or painful swallowing (odynophagia)
Sore throat
Fever (usually low-grade)
Age-specific Presentations:
Infants:
Weak cry or inability to cry
Feeding difficulties
Inspiratory stridor
Toddlers and Older Children:
Hoarse voice
Throat clearing
Vocal fatigue
Associated Symptoms:
Runny nose or nasal congestion
Mild dyspnea
Fatigue
Mild chest discomfort
Note: Severe respiratory distress, high fever, or drooling may indicate more serious conditions like epiglottitis and warrant immediate attention.
Diagnosis of Laryngitis in Children
Accurate diagnosis involves a combination of clinical assessment and, when necessary, additional tests:
1. Clinical Evaluation:
Detailed history:
Onset and duration of symptoms
Recent illnesses or exposures
Voice use patterns
Physical examination:
Assess overall appearance and respiratory status
Examine throat and neck
Listen for breath sounds and voice quality
2. Diagnostic Tests:
Laryngoscopy:
Flexible nasolaryngoscopy for detailed laryngeal examination
Particularly useful in persistent or recurrent cases
Imaging:
Neck X-ray: May be used to rule out epiglottitis or foreign body
CT or MRI: Reserved for suspected structural abnormalities or tumors
Laboratory Tests:
Throat culture: If bacterial infection is suspected
Viral PCR: To identify specific viral pathogens
3. Differential Diagnosis:
Croup
Epiglottitis
Bacterial tracheitis
Peritonsillar abscess
Vocal cord dysfunction
Anaphylaxis
Management of Pediatric Laryngitis
Treatment approach depends on the underlying cause and severity of symptoms:
1. Conservative Management:
Voice rest: Encourage quiet activities
Hydration: Increase fluid intake
Humidification: Use of cool mist humidifiers
Avoid irritants: Keep child away from smoke and other airborne irritants
2. Pharmacological Interventions:
Antipyretics/Analgesics:
Acetaminophen or Ibuprofen for fever and pain relief
Corticosteroids:
Oral dexamethasone or prednisone in moderate to severe cases
Can reduce inflammation and improve symptoms
Antibiotics:
Only if bacterial infection is confirmed or strongly suspected
Choice depends on local antibiotic resistance patterns
3. Specific Treatments:
For GERD-related laryngitis:
Proton pump inhibitors or H2 blockers
Dietary modifications
For allergic causes:
Antihistamines
Nasal corticosteroids
4. Monitoring and Follow-up:
Regular assessment of respiratory status
Follow-up in 1-2 weeks for persistent symptoms
Referral to ENT specialist for chronic or recurrent cases
Complications and Special Considerations
While most cases of pediatric laryngitis resolve without sequelae, awareness of potential complications is crucial:
1. Potential Complications:
Airway obstruction:
More common in infants and young children
May require immediate intervention
Secondary bacterial infections
Chronic laryngitis:
Can lead to permanent voice changes
May indicate underlying conditions like GERD or allergies
Psychological impact:
Voice changes can affect a child's social interactions and self-esteem
2. Red Flags Requiring Immediate Attention:
Severe respiratory distress
Inability to swallow saliva (drooling)
High fever with toxic appearance
Stridor at rest
Cyanosis
3. Long-term Management:
Voice therapy for chronic cases
Regular follow-ups for recurrent laryngitis
Management of underlying conditions (e.g., GERD, allergies)
Education on vocal hygiene
4. Prevention Strategies:
Proper hand hygiene
Avoiding close contact with individuals with respiratory infections
Promoting good vocal habits
Maintaining adequate hydration
Avoiding exposure to secondhand smoke and other irritants
Introduction
Epiglottitis is a potentially life-threatening condition characterized by inflammation and swelling of the epiglottis and surrounding tissues. It can lead to rapid airway obstruction, especially in children. Although the incidence has decreased significantly since the introduction of the Haemophilus influenzae type b (Hib) vaccine, it remains an important pediatric emergency that requires prompt recognition and management.
Etiology
The most common causative agents include:
Haemophilus influenzae type b (Hib): Historically the primary cause, now less common due to vaccination
Flexible nasopharyngolaryngoscopy: Only if airway is secure
Blood tests: Complete blood count, blood cultures
Epiglottic cultures: Once airway is secured
Caution: Avoid agitating the child or manipulating the airway unnecessarily, as this may precipitate complete airway obstruction.
Management
Epiglottitis is a medical emergency requiring prompt intervention:
Airway management:
Maintain a calm environment
Allow child to assume position of comfort
Prepare for potential intubation or emergency tracheostomy
Avoid agitating the child or examining the throat
Oxygen therapy: Provide supplemental oxygen as needed
Intravenous access: Establish for fluid resuscitation and medication administration
Antibiotics: Empiric broad-spectrum antibiotics (e.g., ceftriaxone plus vancomycin)
Corticosteroids: To reduce inflammation (e.g., dexamethasone)
Intubation: Often necessary; should be performed by the most experienced practitioner available
Intensive care: Close monitoring in PICU setting
Complications
Potential complications of epiglottitis include:
Complete airway obstruction
Respiratory failure
Pneumonia
Sepsis
Epiglottic abscess
Pulmonary edema
Neurological sequelae due to hypoxia
Prevention
Preventive measures include:
Haemophilus influenzae type b (Hib) vaccination: Key to preventing most cases
Antibiotic prophylaxis for household contacts of Hib epiglottitis cases
General hygiene measures to prevent respiratory infections
Pneumococcal vaccination may also help reduce risk
Introduction to Pediatric Tracheitis
Tracheitis is an inflammation of the trachea, which can be particularly severe in pediatric patients. It is a rare but potentially life-threatening condition that requires prompt recognition and treatment. In children, bacterial tracheitis often occurs as a complication of a viral upper respiratory tract infection, leading to bacterial superinfection of the trachea.
The incidence of bacterial tracheitis is estimated to be around 0.1 cases per 100,000 children per year, with a peak incidence in children aged 3-8 years. It is more common in the fall and winter months, coinciding with the higher prevalence of viral respiratory infections during these seasons.
Etiology of Pediatric Tracheitis
Tracheitis in children is typically caused by bacterial infection, often following a viral upper respiratory infection. The most common causative organisms include:
Staphylococcus aureus: The most frequent pathogen, accounting for approximately 50-65% of cases
Streptococcus pneumoniae: Responsible for about 20-25% of cases
Haemophilus influenzae: Seen in 10-15% of cases, particularly in unvaccinated children
Moraxella catarrhalis: Less common but still significant
Group A Streptococcus: Occasionally implicated
Viral infections, particularly influenza, parainfluenza, and respiratory syncytial virus (RSV), often precede bacterial tracheitis by damaging the tracheal mucosa and predisposing it to bacterial invasion.
Clinical Presentation of Pediatric Tracheitis
The clinical presentation of tracheitis in children can be dramatic and may initially resemble other upper airway obstructions. Key features include:
Rapid onset of symptoms, often within 24-48 hours
High fever (typically >39°C or 102.2°F)
Toxic appearance with lethargy and ill appearance
Stridor (both inspiratory and expiratory)
Barking or brassy cough
Respiratory distress with increased work of breathing
Hoarseness or dysphonia
Tachycardia and tachypnea
Difficulty swallowing and drooling
It's important to note that tracheitis can rapidly progress to complete airway obstruction, making early recognition crucial.
Diagnosis of Pediatric Tracheitis
Diagnosis of tracheitis in children requires a high index of suspicion and can be challenging due to its similarity to other upper airway conditions. The diagnostic approach includes:
Clinical Assessment: Thorough history and physical examination
Imaging Studies:
Neck and chest X-rays: May show subglottic narrowing, irregular tracheal contour, or haziness of the tracheal air column
CT scan: Can provide detailed images of the trachea and surrounding structures
Laryngoscopy and Bronchoscopy: Gold standard for diagnosis, revealing:
Erythema and edema of the tracheal mucosa
Thick, purulent secretions adhering to the tracheal wall
Pseudomembranes or sloughing of tracheal mucosa
Microbiological Studies:
Tracheal aspirates for culture and sensitivity
Blood cultures (though often negative)
Laboratory Tests:
Complete blood count (CBC) showing leukocytosis
Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Differential diagnosis includes croup, epiglottitis, retropharyngeal abscess, and foreign body aspiration.
Treatment of Pediatric Tracheitis
Treatment of tracheitis in children requires aggressive management and often necessitates admission to a pediatric intensive care unit (PICU). The key components of treatment include:
Airway Management:
Close monitoring of respiratory status
Intubation may be necessary in severe cases
Avoid racemic epinephrine or corticosteroids, as they are ineffective in bacterial tracheitis
Antibiotic Therapy:
Empiric broad-spectrum antibiotics should be started immediately
Initial regimen often includes vancomycin plus a third-generation cephalosporin (e.g., ceftriaxone)
Adjust antibiotics based on culture and sensitivity results
Typical duration is 10-14 days
Supportive Care:
Intravenous fluids for hydration
Oxygen therapy as needed
Antipyretics for fever control
Frequent Suctioning: To remove thick secretions and maintain airway patency
Mechanical Ventilation: May be required in severe cases or respiratory failure
Continuous monitoring and reassessment are crucial throughout the treatment course.
Complications of Pediatric Tracheitis
While prompt treatment often leads to good outcomes, several complications can occur in pediatric tracheitis:
Airway Obstruction: The most immediate and life-threatening complication
Respiratory Failure: May require mechanical ventilation
Sepsis: Due to systemic spread of infection
Toxic Shock Syndrome: Particularly with Staphylococcus aureus infections
Pulmonary Edema: Can occur post-extubation
Tracheal Stenosis: A long-term complication due to scarring
Pneumothorax: Rare but possible, especially in mechanically ventilated patients
Cardiopulmonary Arrest: In severe, untreated cases
Close monitoring and early intervention are key to preventing these complications.
Prognosis of Pediatric Tracheitis
With appropriate and timely treatment, the prognosis for pediatric tracheitis is generally good. Key points regarding prognosis include:
Most children recover completely within 3-5 days of starting treatment
Mortality rates have significantly decreased with modern management, now less than 5%
Full recovery without long-term sequelae is the norm
Recurrence is rare but possible
Long-term follow-up may be necessary to monitor for tracheal stenosis
Factors influencing prognosis include the speed of diagnosis, appropriateness of initial treatment, and any complications that may have occurred during the course of illness.
Croup (Laryngo-tracheo-bronchitis)
What is the typical age range for children affected by croup?
6 months to 3 years
Which virus is the most common cause of croup?
Parainfluenza virus
What is the characteristic sound of croup?
Barking cough
In croup, which part of the airway becomes inflamed and narrowed?
Subglottic region
What time of day do croup symptoms typically worsen?
Night
Which of the following is NOT a common symptom of croup?
High fever (>104°F/40°C)
What is the Westley Croup Score used to assess?
Severity of croup
Which medication is commonly used to reduce airway inflammation in croup?
Dexamethasone
What is the primary goal of croup management?
Maintaining airway patency
How is mild croup typically managed?
Supportive care at home
What environmental factor can help alleviate croup symptoms?
Cool mist or humidified air
Which of the following is a potential complication of severe croup?
Respiratory failure
What is the typical duration of croup symptoms?
3-7 days
In which season is croup most commonly seen?
Fall and early winter
What imaging study may be used to diagnose croup?
Neck X-ray (steeple sign)
Which of the following is contraindicated in croup management?
Sedatives
What is the role of antibiotics in most cases of croup?
No role (viral etiology)
How does croup affect the voice?
Hoarseness
What is the appropriate oxygen saturation target for children with croup?
>92%
Which of the following is a sign of severe croup?
Stridor at rest
What is the mechanism of action of racemic epinephrine in croup?
Vasoconstriction and mucosal decongestion
How quickly does dexamethasone typically improve croup symptoms?
Within 6 hours
What is the recommended dose of dexamethasone for croup?
0.15-0.6 mg/kg
Which of the following is NOT a risk factor for croup?
Female gender
What is the role of heliox in croup management?
Reduces work of breathing in severe cases
How does positioning affect a child with croup?
Upright position may improve symptoms
What is the primary difference between viral and spasmodic croup?
Presence of prodromal symptoms in viral croup
Which of the following is a contraindication to home management of croup?
Toxic appearance
What is the appropriate route of administration for dexamethasone in croup?
Oral or intramuscular
How does croup affect the child's ability to swallow?
Usually not affected
Laryngitis
What is the primary symptom of laryngitis?
Hoarseness or loss of voice
Which of the following is the most common cause of acute laryngitis?
Viral infection
How long does acute laryngitis typically last?
1-3 weeks
What is the definition of chronic laryngitis?
Symptoms lasting more than 3 weeks
Which of the following is NOT a common cause of chronic laryngitis?
Viral infection
What is the primary treatment for viral laryngitis?
Voice rest and supportive care
Which of the following professions is at higher risk for developing laryngitis?
Teachers
What is the role of antibiotics in most cases of acute laryngitis?
No role (usually viral etiology)
Which diagnostic test is most useful in evaluating chronic laryngitis?
Laryngoscopy
What is the recommended duration of voice rest for acute laryngitis?
3-7 days
Which of the following is a risk factor for laryngitis?
Smoking
What is the primary difference between laryngitis and epiglottitis?
Severity and potential for airway compromise
How does laryngitis affect swallowing?
Usually does not affect swallowing
Which of the following is NOT a recommended home remedy for laryngitis?
Gargling with hot water
What is the role of corticosteroids in the treatment of acute laryngitis?
Limited; may be used in severe cases or when rapid voice recovery is needed
Which of the following is a potential complication of chronic laryngitis?
Vocal cord lesions
What is the appropriate management for laryngitis caused by vocal cord nodules?
Voice therapy and possible surgical removal
How does reflux contribute to laryngitis?
Irritation of vocal cords by stomach acid
What is the role of humidification in managing laryngitis?
Helps moisturize and soothe the larynx
Which of the following is NOT a typical symptom of laryngitis?
High fever
What is the primary difference between laryngitis in adults and children?
Children are at higher risk for airway obstruction
How does alcohol consumption affect laryngitis?
Can exacerbate symptoms and delay healing
What is the appropriate fluid intake recommendation for patients with laryngitis?
Increased fluid intake
Which of the following medications may contribute to laryngitis?
Inhaled corticosteroids
What is the role of voice amplification devices in managing chronic laryngitis?
Can reduce vocal strain in susceptible individuals
How does laryngitis affect singing voice?
Reduced range and altered quality
What is the primary cause of laryngitis in professional singers?
Vocal overuse or misuse
Which of the following is a sign of potentially serious underlying pathology in laryngitis?
Unilateral vocal cord paralysis
What is the role of antiviral medications in treating laryngitis?
Generally not indicated
How does laryngitis affect breathing?
Usually does not affect breathing in adults
Epoglottitis
What is the correct spelling of the condition often misnamed as "epoglottitis"?
Epiglottitis
Which bacteria was historically the most common cause of epiglottitis in children?
Haemophilus influenzae type b (Hib)
What age group is most commonly affected by epiglottitis in the post-Hib vaccine era?
Adults
Which of the following is NOT a classic symptom of epiglottitis?
Barking cough
What is the characteristic posture of a patient with epiglottitis?
Tripod position (leaning forward with neck extended)
Which diagnostic test is considered the gold standard for diagnosing epiglottitis?
Direct visualization of the epiglottis
What is the thumb sign on lateral neck X-ray indicative of in epiglottitis?
Swollen epiglottis
Which of the following is the most appropriate initial management step for suspected epiglottitis?
Secure the airway
What is the role of nebulized epinephrine in epiglottitis management?
Temporary reduction of airway edema
Which antibiotic is commonly used as empiric therapy for epiglottitis?
Third-generation cephalosporin
What is the typical duration of antibiotic treatment for epiglottitis?
7-10 days
Which of the following is a potential complication of epiglottitis?
Complete airway obstruction
What is the mortality rate of epiglottitis with proper treatment?
<1%
How has the incidence of pediatric epiglottitis changed since the introduction of the Hib vaccine?
Significantly decreased
Which of the following is NOT a risk factor for adult epiglottitis?
Obesity
What is the role of corticosteroids in epiglottitis management?
Reduce inflammation and edema
Which imaging study is preferred in stable patients with suspected epiglottitis?
Lateral neck X-ray
What is the appropriate positioning for a child with suspected epiglottitis during transport?
Allow child to assume position of comfort
Which of the following procedures is contraindicated in initial management of epiglottitis?
Blind nasopharyngeal intubation
What is the role of blood cultures in epiglottitis management?
Identify causative organism
How does epiglottitis affect swallowing?
Severe odynophagia (painful swallowing)
Which of the following is a sign of impending respiratory failure in epiglottitis?
Drooling
What is the appropriate management of the airway in severe epiglottitis?
Endotracheal intubation or tracheostomy
How does epiglottitis differ from croup in terms of onset?
Epiglottitis has a more rapid onset
What is the role of fiber-optic nasolaryngoscopy in epiglottitis diagnosis?
Allows visualization of the epiglottis without disturbing the airway
Which of the following organisms is an increasing cause of epiglottitis in adults?
Streptococcus pneumoniae
What is the appropriate disposition for a patient diagnosed with epiglottitis?
ICU admission
How does vaccination status affect the management of suspected epiglottitis?
Lower suspicion in fully vaccinated individuals, but does not rule out the condition
What is the role of throat examination in suspected epiglottitis?
Should be avoided due to risk of precipitating complete airway obstruction
Which of the following is NOT typically elevated in the blood tests of patients with epiglottitis?
Eosinophil count