A 20-month old girl is brought to the emergency department for difficulty breathing. The patient has had rhinorrhea and nasal congestion for the past 2 days. She developed a cough and noisy breathing this evening. Medical history is otherwise negative. She is growing well, meeting milestones, and up-to-date on immunizations. On examination, the patient has suprasternal and intercostal retractions, inspiratory stridor, and a barking cough. Inflammation and edema of which of the following sites is most likely causing this patient's stridor?

Question

A 20-month old girl is brought to the emergency department for difficulty breathing.  The patient has had rhinorrhea and nasal congestion for the past 2 days.  She developed a cough and noisy breathing this evening.  Medical history is otherwise negative.  She is growing well, meeting milestones, and up-to-date on immunizations.  On examination, the patient has suprasternal and intercostal retractions, inspiratory stridor, and a barking cough.  Inflammation and edema of which of the following sites is most likely causing this patient's stridor?

Quizplus · Accepted Answer

11ec160b_356d_4f27_9249_d1499cea360a_MD0001_00 This patient with upper respiratory symptoms (eg, rhinorrhea, nasal congestion) now has a barking cough, retractions, and inspiratory stridor, symptoms suggestive of croup. Croup is a viral infection caused by the parainfluenza virus most commonly seen in children age 6 months to 3 years. The virus spreads from the nasopharyngeal mucosa to the larynx and trachea, causing inflammation and edema of the proximal trachea (ie, subglottis). Narrowing at this area creates a partial airway obstruction, which results in inspiratory stridor, hoarseness, and a barking cough. X-ray may reveal subglottic narrowing (ie, steeple sign). (Choice A) The nasal mucosa is likely inflamed and edematous in this patient, leading to nasal congestion and rhinorrhea. However, edema of the nasal mucosa does not lead to stridor or a barking cough. (Choice B) The tonsils are located in the oropharynx and can become inflamed and edematous in conditions such as mononucleosis or a peritonsillar abscess. Although severe swelling in the oropharynx can lead to airway obstruction, it classically presents with voice changes (ie, hot potato voice) but not a barking cough. (Choice C) Inflammation and edema of the submandibular and sublingual spaces is characteristic of Ludwig angina, a rapidly progressive cellulitis that can lead to airway obstruction due to displacement of the tongue posteriorly. However, this typically occurs in adults due to an infection in the mandibular molars and presents with a firm, elevated floor of mouth, "woody" induration of the neck, drooling, and tripod positioning. (Choice D) Epiglottitis is a severe infection that can lead to stridor and respiratory distress. However, it does not cause a barking cough. In addition, it typically occurs in unimmunized children and patients typically appear very ill, anxious, and have high fever, difficulty swallowing, drooling, and tripod positioning. In contrast, children with croup are generally comfortable, even in the supine position; if visualized, they would have a normal-appearing epiglottis. (Choice E) Esophagitis can cause dysphagia, odynophagia, and chest pain. It does not lead to airway obstruction. Educational objective: Croup is a viral infection in which edema and narrowing of the proximal trachea (ie, subglottis) result in a barky cough and inspiratory stridor.

A 20-Month Old Girl Is Brought to the Emergency Department