Pediatric Examination and Board Review by Robert Daum, Jason Canel

or druginduced angioedema.
    Diagnosis of viral laryngotracheobronchitis is usually made on clinical grounds. The typical child with croup is about 1-6 years of age, is in the midst of a URI, has stridor and cough, and is nontoxic in appearance. Under these circumstances, confirmation of the diagnosis can be made with neck radiographs (see Figure 8-1 ). Narrowing of the upper airway, commonly referred to as a steeple sign, is especially apparent on the anteroposterior (AP) radiograph. In epiglottitis, a lateral neck radiograph would show an enlarged epiglottis referred to as a thumb sign ( Figure 8-2 ), if a radiograph were obtained (see answer 1).
    For children with retropharyngeal or peritonsillar abscess there may be prominent swelling and erythema of the tonsillar bed or posterior pharyngeal wall, and inspection of the mouth can be diagnostic. The clinical presentation of diphtheria can also resemble epiglottitis. However, with the widespread use of DTaP vaccination, diphtheria is rare in the US. A child with maxillary sinusitis would present with facial pain, toothache, or headache. The physical examination would reveal the presence of pain on pressure applied to the area of the sinus. The patient who has purulent pansinusitis can appear toxic but does not have airway symptoms.

    FIGURE 8-2. Epiglottitis. Lateral soft-tissue x-ray of the neck demonstrating thickening of aryepiglottic folds and thumbprint sign of epiglottis. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AS, et al. Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010:437. Photo contributor: Richard M. Ruddy, MD . )
     
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    6. (A) The epidemiology of epiglottitis has changed. In the United States, this is no longer a disease of young children caused by Haemophilu s influenzae but rather a disease of teenagers and young adults. In these patients, the offending bacteriologic agent is usually S aureus . Streptococcus pneumoniae , betahemolytic streptococci, nontypeable H influenzae, and even fungi have occasionally been implicated. In teens and adults with symptoms of epiglottitis, it is important to verify human immunodeficiency virus (HIV) status because opportunistic infections of the larynx are not uncommon in these patients.
    7. (A) The primary cause of these deep neck infections is either S aureus or group A streptococcus. If there is concern for a diagnosis of deep neck abscess in a child, antimicrobial agents should be directed at these organisms. However, despite appropriate antibiotic therapy surgical drainage of a peritonsillar abscess is often necessary.
    8. (D) Evaluation of spinal fluid in the toxic child with sinusitis is important before a course of antibiotic therapy is initiated because meningitis is not uncommon in this setting and will alter therapy. A CT scan may help localize any central nervous system (CNS) extension and is generally performed before the lumbar puncture.
    9. (C) Epiglottitis is usually distinguishable from croup by the toxic appearance and the profound dysphagia seen in the child with epiglottitis. Patients with epiglottitis are 2-6 years old. Children with croup are 1-6 years of age and usually present amid an URI with prominent airway symptoms including stridor and a “barking” cough.
    10. (A) Infectious croup (laryngotracheobronchitis) is most often caused by parainfluenza virus types 1 or 2. There is currently no vaccine for the parainfluenza virus, and croup remains common in the United States and all over the world. As in epiglottitis, croup affects young children. Initially patients with croup present with low-grade fever, rhinorrhea, stridor, and cough. If the disease progresses to airway obstruction, the child will have severe stridor and shortness of breath. With respiratory efforts, suprasternal retractions are also observed in children with severe croup.
    11. (B) Most parainfluenza virus infections are mild with episodes of laryngotracheobronchitis lasting for 3-4 days, and