Case (82)

[Dr.Habiib]

Farhan is child 4 years old presented to emergency room of the hospital at 3:00 AM because of severe respiratory distress of one hours duration. His mother stated that he was awoken from sleep with cough, hoarse voice and respiratory distress.

Examination:

- Temperature: 39°C
- Pulse: 110/min
- Respiratory rate: 30/min
- The child had noise breathing more during inspiration,
- He had working alae nose and supraclavicular recession.
- He was not cyanosis.

Questions:
1. What is the most probably diagnosis?
2. Why is it more common in child?
3. Mention other differential causes in children?
4. How to treat this patient?

[drabdoo]

Croup or acute laryngotracheobronchitis
parainfluenza is common at this age
epiglottitis acute tracheitis
Adrenaline nebulizer steroid im or nebulizer

[Dr.Habiib]

Answers:

1. The most probably diagnosis is: Acute non-specific laryngitis causing stridor.
         Reasons:
              •   The stridor is laryngeal because it`s inspiratory.
              •   Hoarseness of voice & cough indicates laryngitis.
              •   Laryngitis in children usually present with obstruction.

NB:
        Acute non-specific laryngitis is acute inflammation in laryngeal mucosa.
        It is associated with upper respiratory infection (mostly common cold).
        It starts viral infection then secondary bacterial infection.
        The most predisposing factor is low general resistance and pollution, but in adult may be due to vault use of voice.
        The main symptom in children is stridor.



2. Acute non-specific laryngitis in children more dangerous as it causes stridor, this is due to the following factors:
     a)    The larynx is small in children (easy obstruction).
     b)   The submucosa of larynx in children is loose (easy for oedema).
     c)    The larynx in children is funnel-shaped with narrow subglotic area (easy for obstruction).
     d)   The laryngeal cartilage in children are softer (easy for collapse).



3. Differential diagnosis:
     a)   Laryngeal diphtheria:
                 •   Gradual onset of low grade fever 38?C
                 •   Pulse is not proportionate to the fever.
                 •   Marked enlarged lymph node( bull neck)
                 •   Diphtheric memberane: unilateral, not limited to tonsillar margin.
     b)  Acute epiglottitis:
                 •   Inflammation starts by severe sore throat & child can`t swallow his own saliva leadind to drooling.
                 •   High fever 40?C.
                 •   Muffled voice then severe stridor.
                 •   The epiglottis is markedly swollen & congested.
                 •   X-ray lateral view of the neck showing swollen epiglottis.


4. Treatment:

 HOSPITILIZATION and take the following measurements:
                 A)   Systemic antibiotic by injection.
                 B)   Steroid: to decrease inflammatory oedema in laryngeal mucosa.
                 C)   Supply oxygen by inhalation.
                 D)   Steam inhalation with tincture benzoine.
                 E)   If all that failure, save the airway by:
                    •   Endotracheal intubation.
                    •   Tracheostomy in severe stridor.