Clinical Manifestations Acute Epiglottitis

Acute epiglottitis is a disease of relatively abrupt onset and rapid progression which, if untreated, results in death due to airway obstruction. Illness is characterized by fever, severe sore throat, dysphasia, and drooling. Airway obstruction is rapidly progressive and is associated with inspiratory distress, a choking sensation, irritability, restlessness, and anxiety. In contrast to viral croup, the patient is not hoarse and does not have the typical "croupy cough," but the speech is muffled or thick-sounding. The child with epiglottitis insists on sitting up and will become worse and exhibit great anxiety if forced to lie down.

Patients with epiglottitis will have leukocytosis with neutrophilia and positive blood cultures for H. influenzae type B. The epiglottis is swollen and cherry red. Therapy depends upon rapid diagnosis, the establishment of an airway, and the administration of antibiotics appropriate for the treatment of H. influenzae type B.

Acute Laryngotracheitis

In this section, only viral causes of croup are discussed. Initial symptoms in laryngotracheitis are usually not alarming and include nasal dryness, irritation, and coryza (profuse nasal discharge). Cough, sore throat, and fever occur. After 12 to 48 hours, signs and symptoms of upper-airway obstruction develop. The cough becomes "croupy" (sounding like a sea lion), and there is increasing respiratory stridor (difficulty associated with inspiration). The degree of airway obstruction is variable. Most severe disease is manifested by marked respiratory distress with supra- and infraclavicular and sternal retractions, cyanosis, and apprehension. Hypoxia can occur, and if there is no intervention, asphyxial death will occur in some children.

In laryngotracheitis the walls of the trachea just below the vocal cords are red and swollen. As the disease progresses, the tracheal lumen will contain fibrinous exudate, and its surface will be covered by pseudomembranes made up of exudative material. Because the subglottic trachea is surrounded by a firm cartilaginous ring, the inflammatory swelling results in encroachment on the size of the airway; it is often reduced to a slit 1 to 2 millimeters in diameter.

The treatment of laryngotracheitis includes the following: oxygen for hypoxia, fluids (locally via aerosol and systemically) to liquefy secretions, racemic epinephrine by aerosol to decrease inflammatory edema, and rarely the establishment of the mechanical airway. Corticosteroids are also frequently administered to decrease inflammation, but their use is controversial.

Spasmodic Croup

This croup is a distinct clinical syndrome, which in some instances is difficult to distinguish from mild laryngotracheitis. In contrast to laryngotracheitis in which the obstruction is due to inflammatory exudate and cellular damage, the obstruction in spasmodic croup is due to noninflammatory edema. Illness always has its onset at night, and it occurs in children thought to be well or to have a mild cold with coryza. The child awakens from sleep with sudden dyspnea, croupy cough, and inspiratory stridor. There is no fever.

Spasmodic croup tends to run in families, and affected children often have repeated attacks. Treatment relies upon the administration of moist air and reassurance by the parents.

Acute Laryngotracheobronchitis and Laryngotracbeobronchiopneumonitis

These illnesses are less common than laryngo-tracheitis and spasmodic croup but are more serious. Initial symptoms and signs are similar to those of laryngotracheitis. Usually the signs of lower respiratory involvement develop 2 to 7 days into the illness; occasionally both upper- and lower-airway obstructions occur simultaneously. In addition to the usual findings in croup, patients with laryngotracheo-bronchiopneumonitis will have rales, air trapping, wheezing, and an increased respiratory rate.

The illness is due to a more generalized infection with parainfluenza or influenza viruses or to secondary bacterial infection of the trachea, bronchi, and lungs. Exudate, pseudomembrane, and respiratory epithelial damage occur. Care involves appropriate antibiotics in addition to conventional treatment for laryngotracheitis.

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