Differentials
Bacterial tracheitis
SIGNS / SYMPTOMS
May or may not have antecedent symptoms consistent with croup; sudden deterioration following 2 to 7 days of a mild to moderate croup or other mild viral illness;[14] fever, toxic appearance (child appears systemically ill and does not interact normally with his/her surroundings) may be present; painful cough; poor response to treatment with nebulized epinephrine.[24][25][26][27]
INVESTIGATIONS
Radiologic studies are contraindicated if there is clinical suspicion of bacterial tracheitis, as manipulation of the neck region and agitation may precipitate further airway obstruction.
Bronchoscopy, performed at the time of intubation, shows erythematous tracheal mucosa, with thick, purulent tracheal secretions.[28]
The most frequently isolated pathogens from tracheal secretions include Staphylococcus aureus, group A streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae, and anaerobic organisms.[14][25][26][29][30][31]
Epiglottitis
SIGNS / SYMPTOMS
Rarely seen since widespread immunization against Haemophilus influenzae B; sudden onset of high fever, dysphagia, drooling, and anxiety; preferred posture: sitting upright with head extended; nonbarky cough.[14][32][33][34]
INVESTIGATIONS
Radiologic studies are contraindicated if there is clinical suspicion of epiglottitis, as manipulation of the neck region and agitation may precipitate further airway obstruction.
Visualization of the airway (prior to controlled endotracheal intubation) confirms the diagnosis showing an edematous, erythematous epiglottis, often obstructing the view of the vocal cords.
Foreign body in the upper airway
SIGNS / SYMPTOMS
Sudden onset of dyspnea and stridor; usually a clear history of foreign body inhalation or ingestion;[14] no prodrome or symptoms of viral illness; no fever (unless secondary infection).[35]
INVESTIGATIONS
Many foreign bodies are not radiopaque, thus x-rays may not confirm the diagnosis.
Direct visualization and removal of foreign body in the operating room confirms the diagnosis.
Retropharyngeal abscess
SIGNS / SYMPTOMS
Dysphagia, drooling, occasionally stridor, dyspnea, tachypnea, neck stiffness, unilateral cervical adenopathy; onset is typically more gradual, often accompanied by fever.[35]
INVESTIGATIONS
Lateral neck radiograph may demonstrate retroflexion of cervical vertebrae and posterior pharyngeal edema.[36]
Peritonsillar abscess
SIGNS / SYMPTOMS
Dysphagia, drooling, occasionally stridor, dyspnea, tachypnea, neck stiffness, unilateral cervical adenopathy; onset is typically more gradual, often accompanied by fever.[35]
INVESTIGATIONS
No differentiating tests.
Angioneurotic edema
SIGNS / SYMPTOMS
May present at any age; acute swelling of the upper airway may cause dyspnea and stridor; fever uncommon. Swelling of face, tongue, or pharynx may be present.
INVESTIGATIONS
No differentiating tests.
Allergic reaction
SIGNS / SYMPTOMS
May present at any age; rapid onset of dysphagia, stridor, and possible cutaneous manifestations (urticarial rash); often personal or family history of prior episodes or allergy.
INVESTIGATIONS
Allergy testing (skin prick or RAST) may determine underlying allergen.
Laryngeal diphtheria
SIGNS / SYMPTOMS
Extremely rare clinical emergency. May present at any age; history of inadequate immunization; prodrome with symptoms of pharyngitis for 2 to 3 days; low-grade fever, voice hoarseness, potentially barky cough; dysphagia, inspiratory stridor; characteristic membranous pharyngitis on examination.[35]
INVESTIGATIONS
No differentiating tests.
Congenital or acquired tracheal or laryngeal abnormalities
SIGNS / SYMPTOMS
Extremely rare. Usually presents at <3 months of age.
Abnormally prolonged or recurrent stridor. Poor response to croup treatment.
INVESTIGATIONS
Upper airway endoscopy or bronchoscopy will allow direct visualization of the underlying abnormality. However, these tests should be delayed until after the acute illness.
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