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Paediatric Upper Airway Obstruction 281

has been used, do not remove them but continue anaesthesia via the The diagnosis is made by examining the throat and sending a piece
bronchoscope and carry out a tracheostomy onto the rigid bronchoscope. of membrane for urgent gram stain. The management is to deal with the
Once the airway is secure, blood cultures and a throat swab are toxins and support the airway:
carried out and IV chloamphenicol (50mg/kg body weight) is given, • Benzylpenicillin (50 mg/kg body weight, IV, 4-hourly). Once
followed by 25mg/kg every 6 hours. drinking is established and the child is less toxic, a change is made
The next step is to transfer the child to an ICU where the alternative to oral penicillin. Erythromycin is an alternative.
airway can be managed. Rapid response to treatment is usual, and
extubation is possible within 24–72 hours. • Dexamethasone (0.6 mg/kg, twice daily, IV) if there is stridor or
gross neck swelling.
Retropharyngeal Abscess
Retropharyngeal abscess is a condition most often seen in infants • Antitoxin is essential (60,000 units IM/IV). A test dose should be
and young children and may mimic epiglottitis in that the symptoms given first to ensure there is no reaction (0.1 ml of 1 in 1000 in
of inspiratory stridor, drooling, and a muffled voice are similar, but saline intradermally).
there is always a long period of fever and general debility prior to the • Consider tracheostomy if airway compromised.
diagnosis. It is due to the breakdown of a retropharyngeal adenitis into • Oxygen.
an abscess and is frequently associated with tonsillitis. The child will
usually have a stiff, painful neck, which is held to one side because the • Cardiac monitoring.
midline raphe attached to the anterior cervical spine pushes the abscess • Bed rest for 2 weeks.
to one side. The organisms are usually Streptococcus haemolyticus,
Staphylococcus aureus, or anaerobes. This condition is sometimes seen • Nasogastric feeding if there is palatal palsy.
in cases of tuberculosis (TB) where the cervical spine is involved and • Immunisation of patient and close contacts before discharge.
caseous breakdown occurs.
Due to the long history of preceding URTI symptoms, unlike for Glandular Fever
epiglottitis, it is permissible to examine the throat where an asymmetric Glandular fever (infectious mononucleosis) is a viral infection due to
pharyngeal swelling is seen. The next stage is a lateral neck x-ray, the Epstein-Barr virus, which may cause airway obstruction due to
which shows a lack of the normal lordosis and a widened space between massive tonsillar enlargement. Stertor rather than stridor is evident,
the spine and the pharyngeal airway. If the organism is anaerobic, a gas examination of the neck shows large cervical glands, and the tonsils are
bubble may be seen in the soft tissue swelling. covered with a white membrane. The other main symptom is extreme
The management involves urgent surgical drainage and culture of tiredness and lethargy. The liver and spleen may be enlarged and a
the drained pus. If GA and intubation are difficult, then a No 11 blade general lymphadenopathy may be present.
wrapped in tape (except for its point) can be used to lance the abscess. Treatment is mainly symptomatic with bed rest, fluids and analgesia.
A large IV cannula could also be tried. IV antibiotics depending on the Ampicillin should not be given since a widespread rash may occur.
gram stain of the organism are necessary in large doses. Mediastinitis is If the airway obstruction is present large doses of IV steroids will
the most serious complication, with a mortality rate of 40–50%. usually relieve the obstruction and intubation or tracheostomy is
Diphtheria rarely necessary.
Diphtheria is seen only where low immunisation levels are present. Bacterial Tracheitis
Infants are often protected by maternal antibodies, and the usual age Bacterial tracheitis is a rare but nasty condition in which the tracheal
group for diphtheria is 2–4 year olds. mucosa sloughs off to form thick crusts in the airway that are difficult
The disease nearly always affects the pharynx, and a thick white/ to remove. Measles is not infrequently complicated by this bacte-
gray membrane caused by the toxin covers the tonsils and pharyngeal rial infection, often due to Streptococcus pneumoniae or Haemophilus
walls and bleeds if it is separated from the underlying structures. The influenza B.
membrane may extend to the larynx, causing stridor. Frequently, large Children with bacterial tracheitis frequently require intubation and
cervical lymph nodes give the appearance of a “bull neck.” ICU management if only to clear the thick secretions. The child is
Toxaemia, which may vary from mild to severe, is the other main much more toxic with this bacterial infection than in viral LTB and
feature of diphtheria apart from the respiratory symptoms. Severe the absence of swallowing and drooling problems distinguish it from
toxaemia may result in cardiovascular collapse and neuropathy and epiglottitis. Bronchial complications are common, and prolonged
include myocarditis and palatal palsy. treatment with antibiotics, humidification, and physiotherapy are
necessary once the acute airway management has been completed.

Key Summary Points

1. If epiglottitis is suspected, do not examine the throat except at 6. Immunisation against H. influenzae should be administered.
the time of resuscitation. 7. In recurrent croup, suspect subglottic stenosis.
2. Hypoxaemia and cynanosis are very late signs. 8. Antibiotics chloramphenicol, cefuroxime, and ampicillin should be
3. Dexamethasone (0.6 mgm/kg body weight orally) should be available.
given early. (The oral form is as effective as injected if the child 9. Oxygen must be available.
is able to swallow.)
10. If intubation is considered, make sure personnel are available to
4. Nebulised epinephrine (1 ml in 1/1000 in 3 ml of 0.9% saline) carry out tracheostomy in case intubation fails.
should be available.
5. History taking and resuscitation should take place at the same time.