Throat Swelling in Children: Clinical Evaluation Learning App

Clinical History Assessment

Systematic approach to history taking for a child presenting with throat swelling

Physical Examination Guide

Systematic approach to examining a child with throat swelling

Diagnostic Approach

Initial Assessment

Upon presenting with throat swelling, immediate evaluation should include:

• Airway assessment including patency and respiratory effort
• Vital signs including respiratory rate, heart rate, temperature, and oxygen saturation
• Level of distress and ability to swallow or speak
• Assessment for signs of systemic involvement (rash, joint pain)

Laboratory Studies

Investigation	Clinical Utility	Key Findings
Complete Blood Count	Assess for infection or inflammation	Leukocytosis in bacterial infections; lymphocytosis in viral infections
C-Reactive Protein (CRP) / ESR	Evaluate degree of inflammation	Elevated in bacterial infections and inflammatory conditions
Throat Culture	Identify bacterial pathogens	Group A Streptococcus, other bacterial pathogens
Rapid Strep Test	Rapid identification of Group A Streptococcus	Positive in streptococcal pharyngitis
Blood Culture	Identify bacteremia in severe cases	Positive in epiglottitis, retropharyngeal abscess
Mononucleosis Spot Test	Diagnose Epstein-Barr virus infection	Positive in infectious mononucleosis

Imaging Studies

Investigation	Clinical Utility	Key Findings
Lateral Neck X-ray	Evaluate airway and surrounding soft tissues	Thumb sign (epiglottitis), thickened retropharyngeal space (abscess)
Neck Ultrasound	Evaluate soft tissue and lymph nodes	Lymphadenopathy, abscess formation, vascular anomalies
CT Scan with Contrast	Detailed evaluation of deep neck spaces	Abscess localization, extent of infection, vascular anomalies
MRI	Detailed soft tissue and vascular assessment	Neoplasms, vascular malformations, inflammation patterns

Specialized Tests

Investigation	Clinical Utility	Key Findings
Nasopharyngolaryngoscopy	Direct visualization of upper airway	Epiglottic swelling, laryngeal pathology, vocal cord function
Allergen Testing	Identify potential allergens in angioedema	Specific IgE antibodies to triggers
Complement Levels (C1-INH)	Diagnose hereditary angioedema	Reduced C1 esterase inhibitor levels or function
PCR Testing	Identify viral pathogens	EBV, CMV, adenovirus, HSV, COVID-19

Diagnostic Algorithm

A stepwise approach to diagnosing the cause of throat swelling:

1. Assess airway compromise risk - Stridor, voice change, drooling, tripod positioning
2. Determine acuity - Acute vs. chronic presentation
3. Localize - Identify anatomical location (tonsils, pharynx, larynx, neck)
4. Basic testing - CBC, CRP, rapid strep test as indicated
5. Imaging - Based on clinical suspicion:
   • Lateral neck X-ray if epiglottitis or retropharyngeal abscess suspected
   • Ultrasound for suspected lymphadenopathy or superficial abscess
   • CT with contrast for deep space infection concerns
6. Consider advanced testing based on initial findings
7. Specialist consultation - ENT, infectious disease, allergy/immunology as needed

Management Strategies

Emergency Management

Immediate interventions for acute throat swelling with airway compromise:

• Airway management: Position of comfort, avoid distressing examinations
• Supplemental oxygen: Provide as needed with minimal disturbance
• Preparation for advanced airway: Immediate ENT/anesthesia consultation
• Emergency medications: Epinephrine for anaphylaxis (0.01 mg/kg IM; max 0.3 mg)
• IV access: Establish for medication administration
• Monitoring: Continuous cardiorespiratory monitoring

Specific Management Approaches

Condition	Medical Management	Surgical/Interventional Approach
Acute Tonsillitis/Pharyngitis	- Analgesics for pain control - Antibiotics if bacterial (Penicillin/Amoxicillin) - Adequate hydration	- Rarely needed acutely - Tonsillectomy for recurrent cases (>7 episodes in 1 year)
Peritonsillar Abscess	- IV antibiotics (Ampicillin/sulbactam or Clindamycin) - Hydration and pain control	- Needle aspiration - Incision and drainage - Consider tonsillectomy for recurrent cases
Retropharyngeal Abscess	- IV antibiotics (covering anaerobes) - NPO status - Steroid consideration	- Surgical drainage in OR setting - Airway management priority
Epiglottitis	- Minimize examination/disturbance - IV antibiotics (3rd gen cephalosporin) - Humidified oxygen	- Controlled intubation in OR - Potential tracheostomy standby
Allergic Angioedema	- Epinephrine for severe cases - Antihistamines (H1 and H2 blockers) - Corticosteroids - Trigger avoidance	- Rarely needed - Emergency airway if progressive despite medication
Hereditary Angioedema	- C1 esterase inhibitor concentrate - Icatibant (bradykinin receptor antagonist) - Danazol for prophylaxis	- Emergency airway if needed - Not responsive to standard allergy treatments
Infectious Mononucleosis	- Supportive care - Corticosteroids if severe airway obstruction - Avoid contact sports	- Rarely required - Emergency tonsillectomy for severe obstruction
Ludwig's Angina	- Broad-spectrum IV antibiotics - Airway monitoring - Dental consultation	- Surgical decompression of floor of mouth - Source control (dental extraction if needed)

Long-term Management

Considerations for ongoing care:

• Follow-up imaging: For complicated infections to ensure resolution
• ENT referral: For recurrent tonsillitis, sleep-disordered breathing
• Allergist referral: For recurrent allergic reactions or suspected hereditary angioedema
• Dental care: For prevention of deep space infections of dental origin
• Immunology referral: For recurrent infections suggesting immunodeficiency
• Speech and swallowing evaluation: After severe infections or interventions

Family Support and Education

• Education about warning signs requiring emergency care
• Proper medication administration techniques
• Hydration importance and strategies
• Allergen avoidance for allergic reactions
• Genetic counseling for hereditary conditions
• Proper hygiene to prevent spread of infectious causes