| An acute inflammation of the
supraglottic larynx characterized by stridor and acute upper airway
obstruction and considered a medical emergency.
Incidence
is decreasing due to H. flu immunization, with an
age of onset if 2-7 years of age with a peak at 3.5 years. Risk factors
are sporadic, with a male to female preponderance (3:2). Bacterial
pathogens H. influenzae type b (rare) and Group A beta-hemolytic
Streptococcus. An intense inflammation of the supraglottic region occurs
with aswelling of the epiglottis, aryepiglottic folds, arytenoid
cartilages and ventricular bands, leading to acute upper airway
obstruction.
Clinical features
include an upper respiratory tract infection with
sore throat, dysphagia, high fever, toxic in appearance. Inspiratory
stridor is worse in the supine position and placing the patient in the
supine position is contraindicated. The child will generally sit erect
and lean forward with his chin thrust forward (neck hyperextended),
tongue protruding, and drooling. 4 "D's" - dysphagia, dysphonia,
drooling, and distress. The acute upper airway obstruction may range
from mild inspiratory and expiratory stridor to severe respiratory
distress and arrest. Therefore, do not agitate the patient, do not
attempt to place in the supine position, examination of the throat is
contraindicated (may lead to a reflex laryngospasm), and do not attempt
blood work or x-rays.
Complications
include meningitis, otitis media, cervical
adenitis, pneumonia, and septic arthritis. Investigations are
contraindicated until the patient is stabilized with a secure airway.
Direct laryngoscopy
should be performed in the OR, with a swollen,
cherry-red epiglottis visualized. Blood cultures and CBC (leukocytosis
with left shift) should be obtained once the airway is stabilized.
Management
includes keeping the child
calm. Contact ENT or anesthesia stat. A physician should accompany the
patient continually. Short-term controlled endotracheal intubation
usually lasts for 2-3 days. Severe or life-threatening upper airway
obstruction may require an emergency trachestomy.
IV Cefuroxime for the acute
phase then oral Septra for a total antibiotic course of 7-10 days may be
administered. Rifampin prophylaxis for patient and family members may be
indicated. Corticosteroids and racemic epinephrine are contraindicated.
Prognosis
is excellent if managed appropriately. Mortality
is 25% in untreated cases.
Edited version of
Dr. Gandy
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