Approach to upper airway obstruction (pediatrics): Clinical sciences

Upper airway obstruction occurs when any part of the airway above the thoracic inlet is blocked. 

Based on the site of obstruction, upper airway obstruction can be subdivided into nasopharyngeal, supraglottic, glottic, subglottic, and tracheal.

If your patient presents with a chief concern suggesting upper airway obstruction, first perform an ABCDE assessment to determine if your patient is unstable or stable.

If unstable, stabilize their airway, breathing, and circulation. In some cases, you might need to intubate your patient or even place a surgical airway emergently. Next, obtain IV access and put your patient on continuous vital sign monitoring, including respiratory rate, pulse oximetry, and cardiac monitoring. Finally, if needed, don’t forget to provide supplemental oxygen.

Once you stabilize the patient, obtain a focused history and physical exam to determine the underlying cause.

First, let’s start with epiglottitis. In this case, your patient’s caregiver will usually report a rapid onset of high fever, as well as difficulty breathing and swallowing, with drooling and the absence of a cough. The physical exam typically reveals an anxious-appearing child sitting upright with their neck extended in a tripod position, with the chin pushed forward. Additionally, your patient may have a muffled voice, audible stridor with labored breathing, and a cherry-red epiglottis! These findings are highly suggestive of epiglottitis.

Here’s a clinical pearl! If the findings don’t clearly point to epiglottitis, you can order a lateral neck X-ray. If imaging reveals a “thumb sign” and swelling of the aryepiglottic folds, you can confirm the diagnosis of epiglottitis.

Next up is bacterial tracheitis.

These patients might have a recent history of a viral upper respiratory infection, with rapid onset of high fever, hoarseness, progressive stridor, and respiratory distress that’s not responsive to nebulized racemic epinephrine. 

Additionally, physical exam reveals a toxic-appearing child with a biphasic stridor. These findings are highly suggestive of bacterial tracheitis.

Finally, let’s go over anaphylaxis!

In this case, your patient’s caregiver will typically report a rapid onset of facial swelling and dyspnea, without a fever. They may also have a known allergy with exposure to a specific food or another allergen, such as insect venom. Meanwhile, the physical exam may reveal hypotension as well as audible stridor and wheezing. Additionally, you may notice facial edema and a diffuse urticarial rash. Based on these findings, you can diagnose anaphylaxis.

Now, let’s return to the ABCDE assessment and discuss stable patients.

First, obtain a focused history and physical examination. Patients usually have a history of dyspnea, with or without a cough, while physical exam might reveal signs of respiratory distress, like suprasternal, intercostal, and subcostal retractions. Additionally, you might notice audible stertor, stridor, or monophonic or localized wheezing.

With these findings, you should consider upper airway obstruction.

Next, assess for signs and symptoms of nasopharyngeal obstruction, such as audible stertor and visible tonsillar or pharyngeal swelling. If these are present, consider nasopharyngeal causes of upper airway obstruction, including retropharyngeal abscess, peritonsillar abscess, tonsillitis, and adenotonsillar hypertrophy.

First, let’s discuss retropharyngeal abscess, which is most commonly seen in preschool-age children. Patients typically have a preceding viral upper respiratory infection and subsequently develop neck pain and dysphagia. They may have poor oral intake due to dysphagia, and some might even report chest pain and dyspnea. 

On exam, they are often anxious and ill-appearing, with a stiff neck and limited neck mobility. You may also detect a palpable neck mass, drooling, and respiratory distress. These findings are highly suggestive of a retropharyngeal abscess.

Here’s a clinical pearl! Another diagnosis to consider here is epiglottitis. Usually, children with epiglottitis drool and lean forward in the “tripod position,” while children with retropharyngeal abscesses drool and hyperextend their necks. To diagnose retropharyngeal abscess, you may need to order an x-ray of the neck, which shows a widening of the retropharyngeal space or prevertebral soft tissue swelling.

Now let’s consider patients with peritonsillar abscess, which is most commonly seen in adolescents.

These individuals often present with progressively worsening sore throat, decreased oral intake, and a classic “hot potato” voice. They might also report dysphagia and unilateral otalgia. 

The physical exam typically reveals unilateral tonsillar bulging with or without uvular deviation, drooling, or trismus. At this point, you can diagnose peritonsillar abscess, which is a clinical diagnosis and doesn’t require confirmation with imaging.

Next up is tonsillitis!

These patients may present with sore throat and constitutional symptoms, like fever and fatigue. Physical exam demonstrates an erythematous pharynx and enlarged tonsils, often with exudates. You may detect cervical lymphadenopathy, and in some cases, splenomegaly. These findings are consistent with tonsillitis, which can be caused by bacteria like Group A Streptococcus or Neisseria gonorrhoeae, or by viruses like Epstein-Barr virus.

Finally, let’s go over adenotonsillar hypertrophy!