1. Laryngo-tracheal Infections

2. Stridor
It is the noise caused by obstruction of airflow due to narrowing in respiratory tract
It may be inspiratory / biphasic /expiratory
Inspiratory stridor alone indicates that the lesion is at vocal cord level or above
An expiratory phase occurs when the tracheal lumen is also narrowed by oedema or inflammation

3. Acute Laryngeal infections in childhood
Acute Epiglottitis
Laryngotrachealbronchitis
Bacterial Laryngotrachealbronchitis
Diphtheria
Conditions which mimic laryngeal infections

4. Acute Epiglottitis Most frightening pediatric emergency
If unrecognized it can kill the child
Haemophilus influenzae type B , is the causative organism in most cases
The disease is concentrated maximally on the epiglottis but the inflammation may involve whole supraglottic compartment
Most cases seen between 1 and 6 years of age, peak incidence between ages 3 and 4

5. Clinical features
Sudden transformation of a fit child into one who is desperately ill, within a few hours
Classical features:
A fit child c/o sore throat which intensifies, with in half and hour dysphagia reported
Inspiratory stridor develops and within 2 hours child becomes critical
Child sits up and leans forward
Saliva is dribbling due to absolute dysphagia
Voice is muffled
As time goes child becomes quiet and respiratory distress appears to lessen.
An an ominous sign: respiratory & cardiac arrest imminent

7. Management It is a surgical emergency
Examination of throat by tongue depressor is particularly dangerous- sudden respiratory obstruction may occur
Lateral X-ray of neck may show classical ‘thumb’ sign of swollen epiglottis
If the clinical situation suggests that the diagnosis is epiglottitis , there is no point in confirming it what might turn out to be fatal X-ray

9. The child is shifted to OT and anesthetized in upright position
Laryngoscope inserted & diagnosis confirmed
An appropriate size orotracheal tube inserted
Otherwise rigid bronchoscope used to secure airway
Tracheostomy / nasotracheal tube
Culture swabs taken from epiglottis
Nasogastric tube inserted for feeding
I/V line established

10. Best Clinical Practice
Adults with suspected acute epiglottitis should be admitted and airway closely monitored
Patients should be treated with I/V second- or third-generation cephalosporins and 100% humidified oxygen
Airway obstruction should be treated early, ideally by intubation

11. Laryngotracheobronchitis (Croup)
As name suggests it involves larger proportion of respiratory tract
Area of maximum impact is sub-glottis
An acute illness with hoarseness, a barking cough, stridor and varying degree of respiratory distress
Affects young children (6 months to 3 years)

12. In most cases causative organism is paramyxovirus, para-infleunza virus type I and type II
In adults it may also occur from herpes simplex, cytomegalovirus & influenza virus
Adult croup is rare, more severe & impaired immunity should always be considered
The key feature is sub-glottic oedema

13. Investigations
Direct viral antigen detection by sampling mucus from nasopharynx
A plain neck radiograph may show narrowing of the subglottis (steeple sign) and ballooning of hypopharynx
Chest X-ray to exclude collapsed lobes or meditational shift

17. Management
Oxygen, steroids and nebulized epinephrine should be administered
Monitor airway and oxygen saturation, consider endotracheal intubation if necessary
Broad spectrum antibiotics to cover secondary infection
No evidence to support antiviral agents

18. Best Clinical Practice
Adult croup is rare but rapidly progressive
Once suspected patient should be admitted
Larynx inspected by flexible laryngoscope
Broad-spectrum ABx to prevent bacterial infection
If the airway deteriorates patient should be intubated and ventilated

19. Bacterial Laryngotrachealbronchitis
May be a separate disease or be caused by secondary bacterial infection of viral laryngotrachealbronchitis
Also called bacterial tracheitis since it involves trachea predominantly
Much more severe illness and much less common
More severe respiratory obstruction and artificial airway is often needed
Tracheostomy preferred over intubation

20. Diphtheria Caused by Corynebacterium diphtheriae
Spreads by droplet infection
Affects non-immunised children and susceptible adults particularly elderly
Usual site of infection is the tonsils and fauces but it can also occur in nasal cavities or spread to larynx

22. Clinical Features Severe sore throat, malaise, pyrexia
Examination of throat shows characteristic grey membrane in oropharynx which may spread to larynx
Enlarged tender cervical lymph nodes

23. Investigations A swab from throat for C/S
A sample of grey membrane for screening

24. Management Treat with benzyl penicillin and antitoxin
Acute obstruction should be managed with intubation
Complications:
The diffusible exotoxin has predilection for cardiac and renal tissues
Neurological complications soft palate paralysis, diaphragm & EOM

25. Conditions which mimic laryngeal infections in childhood
Foreign bodies
Peritonsillar abscess
Retropharyngeal Abscess
Infectious mononucleosis

26. Infectious mononucleosis
A common disease often sub-clinical or mild
Caused by Epstein-Barr virus
Spread is usually transfer of infected saliva during kissing

27. Clinical Features Acute sore throat with large infected tonsils
Cervical lymphadenopathy with grossly enlarged bilateral lymph nodes
Fever, Malaise
There may also be palatal petechiae, oral ulceration, splenomegaly and hepatomegaly

30. Complications
Gross swelling of tonsils and adenoids causes airway obstruction, but inflammation and ulceration can also extend to larynx
The severity of laryngeal involvement may be masked by upper airway obstruction
Splenic rupture
CNS complications like encephalitis, meningitis, CN palsies
Immune deficiency and HIV status be looked into

31. Investigations Full Blood count
Heterophil antibody test: Heterophil antibodies are antibodies that are stimulated by one antigen and react with an entirely unrelated surface antigen present on cells from different mammalian species
Specific EBV serology
HIV testing

32. Management I/V fluids Analgesia
In serious infections antibiotics, steroids and acyclovir should be considered
Ampicillin / amoxycillin are best avoided for fear of inducing a maculopapular rash