ENT Flashcards
What is epiglottitis?
What is the most common causative organism?
Inflammation & swelling of the epiglottis caused by infection; epiglottis can swell to point of completely obstructing the airway within hours hence it is a life threatening emergency.
Most common causative organism was typically was Haemophilus influenza type B however since vaccination Streptococcus species predominate. Incidence has decrease since introduction of HiB vaccine.
Why are children at higher risk of acute airway obstruction?
Children are at higher risk of acute airway obstruction because of their anatomy:
- Child’s epiglottis is much more floppy, broader, longer and angled more obliquely to the trachea
- larger tongue
- anteriorly-angled vocal cords
… mean children find it more difficult to move air past even a partial obstruction.
State some risk factors for epiglottitis
- Children not vaccinated against Haemophilus influenza
- Immunosupression
Describe the clinical features of epiglottitis
Rapid onset of symptoms <12hrs:
- Drooling
- Dyspnoea
- Stridor
- Sat in tripod position (sat leaning forward on outstretched arms with neck extended and tongue out)
- Muffled voice/”hot potato voice”
- High fever
- Sore throat
- Difficulty or pain swallowing
- Toxic/septic/unwell appearance
*Can remember by 4D’s: dyspnoea, dysphagia, drooling & dysphonia
State some differential diagnoses for epiglottitis
- Croup
- Inhaled foreign body
- Retropharyngeal abscess
- Tonsillitis
- Peritonsillar abscess
If a child is acutely unwell and epiglottitis is suspected investigations should not be performed; however, if you were to do investigations what investigations would you do?
Children with epiglottitis have high risk of obstructing their airway if agitated hence they shouldn’t be examined or undergo unnecessary observations or investigations. Investigations you might do when child more stable:
- Throat swabs (both bacterial & viral)
- Bloods: FBC, blood cultures, CRP
- Lateral neck x-ray: shows characteristic thumbprint sign due to swollen epiglottis. Also useful for excluding foreign body
- Diagnosis made by direct visualisation should only be done by senior staff who are able to intubate if necessary
Discuss the management of epiglottitis
Emergency situation!! Management is centred around ensuring airway is secure. Most pts don’t require intubation but need to be prepared to perform at any time.
- Do NOT distress child (as could cause closure of airway)
- Alert a senior paediatrician, anaesthetist, ICU and ENT as endotracheal intubation or emergency tracheostomy may be necessary
- Oxygen (if parent can hold mask near child’s face)
- Nebulised adrenaline (temporary relief of oedema)
- IV antibiotics (Ceftriaxone/cefotaxime)
- IV steroids
- IV intravenous fluids
Discuss the prognosis and potential complications of epiglottitis
Prognosis
- Most patients do not need intubating
- Most patients who are intubated can be extubated after a few days and make a full recovery
- However death may occur if not diagnosed and managed in time
Potential complications
- Epiglottic abscess (collection of pubs around epiglottis which can also threaten airway and is managed in same way as epiglottitis)
- Deep neck space infection (e.g. retropharyngeal abscess)
- Mediastinitis (rare)
- Sepsis
- Meningitis
-
Pneumonia (particularly after extubation)
*
Compare epiglottitis & croup
What is laryngomalacia?
Congenital abnormality of the larynx cartilage that predisposes to dynamic supraglottic collapse during the inspiratory phase of respiration; resulting in intermittent upper airway obstruction and inspiratory stridor as larynx cartilage flops across the airway during inspiration. Most common laryngeal abnormality and cause of stridor in neonates.
Is laryngomalacia a serious condition?
- Most cases are not associated with respiratory distress and are self limiting over several months
- However some severe cases may be life-threatening and require surgical intervention
Discuss the natural progression of laryngomalacia, including:
- When it first presents
- When symptoms peak
- When it usually resolves by
- Usually presents in first few weeks of life
- Symptoms peak at 6-8 months (when respiratory function increases before larynx increases in size)
- Usually resolves in first 2 years (remember serious forms may require surgical intervention as they are life-threatening)
State four structural abnormalities in laryngomalacia
- Short aryepiglottic folds (these pull on epiglottis and change its shape)
- Long, curled ‘omega shaped’ epiglottis
- Redundant arytenoid mucosa making arytenoids bulky and prone to collapsing into airway
- Tissue around supraglottic larynx has less tone
Discuss the typical presentation of laryngomalacia
- Inspiratory stridor
- Stridor is intermittent, worse when: feeding, upset, lying on back or during respiratory tract infections
- Normal cry
*Rarely causes complete airway obstruction or other complications such as respiratory distress, obstructive sleep apnoea, poor weight gain
State some differential diagnoses for laryngomalacia
- Vocal cord paralysis
- Subglottic stenosis
- Epiglottitis
- Croup
What is the key investigation for laryngomalacia?
First line= flexible laryngoscopy
If need to view subglottic region would do rigid larygnoscopy
Discuss the management of laryngomalacia; think about management of mild, severe and life-threatening cases
Mild cases
- 90% cases are mild and don’t require treatment
- Educate parents about progression (e.g. peak at 6 months, exacerbated by infections, resolved by 2yrs)
- GORD can exacerbate so may consider anti-reflux medications if GORD is present
Severe cases
- Surgery to change shape of larynx e.g. endoscopic aryepiglottoplasty
Life-threatening
- Keep child calm
- Involve senior paediatrician, anaesthetist, ENT, HDU/ICU
- Steps to help maintain own airway:
- Humidified oxygen
- Nebulised adrenaline
- Oral or IV dexamethasone (don’t cannulate if will cause distress)
- Heliox (helium & oxygen- helium helps oxygen flow through narrower spaces)
- If fail to maintain own airway will need ventilatory support (could try laryngeal mask, endotracheal intubation). *NOTE: tracheostomy is rarely required.
- Surgical intervention
What is obstructive sleep apnoea
Episodes of complete or partial airway obstruction of upper (in particular pharyngeal) airway during sleep. Present in 1-3% children.
What investigation is used to diagnose OSA in children?
Polysomnography
Remind yourself of the structure of Waldeyer’s tonsillar ring and state which structure is most commonly infected in tonsillitis
Palatine are infected in tonsillitis
Describe clinical features of tonsillitis
- Fever
- Sore throat
- Odynophagia
- Erythematous, inflamed, enlarged tonsils +/- exudates
Presentation may be more non-specific in younger children:
- Headache
- Poor oral intake
- Vomiting
- Abdo pain
Describe typical presentation of otitis media
Infants may present with non-specific symptoms (irritability, poor feeding, fever, lethargy, vomiting).
Older children may present with:
- Otalgia
- Reduced hearing in affected ear
- Otorrhea
- Rubbing/tugging of ear
- URT infection symptoms (fever, cough, sore throat)
- Bulging, red, inflamed tympanic membrane (doughnut)
- Loss of light reflex
