Pediatrics Answers 431influenzaetype b as the classic and most common etiology prior to the
introduction of the H influenzaetype b vaccination. Most cases now appear
inadultsandnonimmunized childrenand are seen most commonly as
secondary infections following viral illnesses (the most notorious was pri-
mary varicella prior to the widespread use of that vaccine). Signs and
symptoms include a prodromal period of 1 to 2 days with high fever, dys-
phagia, secretion pooling, and dyspnea. Patients usually sit in an erect or
“tripod” position, leaning forward with neck extended to give maximum
airway opening, to improve their symptoms. Radiographs of the neck may
show the classic thumbprint signof an enlarged, inflamed epiglottis,
although a CT scan of the neck may delineate the condition further. How-
ever, these are typically difficult to obtain because of the fact that patients
are not stable enough to leave the ED and need continuous monitoring in
case of airway compromise; so no radiographic studies are typically per-
formed. The classic approach to a patient with suspected epiglottitis is to
leave them in their caretaker’s arms, try to avoid agitating them, and call
immediately for ear, nose, throat (ENT) and anesthesia assistance in the
ED. Direct laryngoscopy is contraindicated because it may induce laryn-
gospasm. These patients require direct visualization, often only in the OR,
with the appropriate services prepared for the need to place a surgical air-
way emergently. IV antibiotics and steroids are indicated to help treat the
infection and decrease swelling.
Retropharyngeal abscesses (b)may present somewhat similarly, but
not typically in the same level of extremis as this patient. The classic phys-
ical examination finding is an inability to extend the neck because this
stretches the inflamed prevertebral soft tissue area. Retropharyngeal
abscess is suspected on the basis of a lateral neck film that demonstrates a
widened prevertebral soft tissue stripe. EBV pharyngitis (c)may present
with erythema or exudate of the tonsils, dysphagia, fever, and cough. In
addition, patients may be very uncomfortable and moderately ill appear-
ing, but will typically not present with airway compromise and hypoxia. In
addition, clinical mononucleosis is usually a condition of older children
and adolescents. Ludwig angina (d)is an infection of the submandibular
space.(e)Peritonsillar abscess is often a secondary infection of strep throat
and will present with trismus, difficulty swallowing, and fever.
390.The answer is d.(Fleischer and Ludwig, pp 813-814.)RSVis a com-
mon cause of respiratory distress in infants, especially under 6 months of
age, and the most common cause of the clinical condition known as