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Pediatric upper airway conditions: Clinical practice

Pediatric upper airway conditions: Clinical practice


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USMLE® Step 2 style questions USMLE

5 questions

 A 3-year-old boy is brought to the office because of fever, and hoarseness for 2 days. His family says that he developed a sharp “barking” cough last night. Physical examination shows mild erythema of the oral mucosa, moderate chest wall retraction, and inspiratory stridor at rest. There are no other abnormalities present. Which of the following is the most appropriate next step in management? 


Content Reviewers:

Rishi Desai, MD, MPH


Sam Gillespie, BSc

The upper airways include the nasal cavity, paranasal sinuses, pharynx and larynx.

In children, the upper airways can be affected by mechanical obstruction - like in a foreign body aspiration or by a structural defect like in laryngomalacia. There can also be inflammation in these anatomic regions due to an infection.

Let’s start with foreign body aspiration, which most commonly occurs in young toddlers who get something like a small coin or a peanut, lodged in their respiratory tree.

Most of the time, the foreign body goes into the lower respiratory tract, because of gravity and because that main bronchus is a bit larger. But if it’s large and unlucky enough to get stuck in an upper, larger airway, then symptoms are more severe.

Typically, if there’s a partial upper airway obstruction, children begin coughing, gagging, choking, or drooling, and on auscultation, there’s inspiratory stridor.

But, if there’s a complete obstruction, children may be unable to cough or speak and can even pass out. And in this case, we should immediately start Basic Life Saving, or BLS maneuvers to relieve obstruction.

For infants less than one year of age, five back blows are delivered, followed by five chest thrusts. And for children one year of age or older, five abdominal thrusts or Heimlich maneuver should be performed.

Okay, now, if the child is stable, then usually a chest Xray is done - and objects like coins and batteries are radiopaque, and are visible, whereas pieces of food are usually radiolucent, so don’t show up.

If an upper airway foreign body aspiration is suspected, then it’s important to do a neck radiograph.

Sometimes, there are indirect signs of obstruction, like a subglottic density or swelling.

A CT scan can also be done to confirm the suspicion.

Alternatively, the child can be taken for laryngoscopy to visualize and remove the object.

If the object gets lodged in the nose, there may be unilateral, foul- smelling rhinorrhea or epistaxis, which is nasal bleeding.

Visualization of the foreign body is usually done using a headlamp and a nasal speculum.

And then, older children are sometimes able to force the foreign body out by blowing their nose while plugging the unobstructed nostril.

In infants or young children who can’t cooperate or if this fails, positive pressure ventilation can be delivered through the mouth. This is when the parent blows a rapid, soft puff of air in their the child's mouth, while plugging the opposite nostril with their finger.

Next up, is laryngomalacia, which is a congenital abnormality of the laryngeal cartilages, where the shortened aryepiglottic folds pull the soft epiglottis into an omega shape, which obstructs airflow - like a big floppy sail in the wind. This causes inspiratory stridor, which is worse when supine.

In some cases, the obstruction can be so bad that it makes breathing difficult.

These symptoms usually develop a few weeks after birth, and peak around six months.

The diagnosis is made by laryngoscopy or bronchoscopy, and typically, no treatment is necessary because it self-corrects around 12 to 18 months, as the throat muscles strengthen over time. However, if it persists, it can be corrected surgically.

Next, there’s inflammation of the upper airways. It’s called rhinitis in the nasal cavity, sinusitis in the paranasal sinuses, pharyngitis in the pharynx, tonsillitis in the tonsils, and laryngitis in the larynx.

In rhinitis, inflammation can be non-infectious, meaning it’s triggered by allergens, like dust mites, pet dander, pollen, or irritants like tobacco smoke, cold or dry air, and even emotional stress and exercise.

After exposure to an allergen or irritant, there’s nasal congestion, sneezing, and sniffling, along with the so-called allergic salute, which is when a child wipes their nose upwards, creating a line or crease along the nasal bridge. There’s usually conjunctivitis, along wth big, dark circles underneath the eyes, called allergic shiners. This can persist for weeks affecting a child’s ability to sleep and focus.

The diagnosis is based on the symptoms and the treatment is to simply avoid the trigger.

Intranasal antihistamines, like azelastine, corticosteroids sprays, like betamethasone, and nasal irrigation to flush out the sinuses can all help relieve the symptoms.

Now if there’s an infection, it’s usually caused by viruses like rhinovirus, influenza virus, respiratory syncytial virus- or RSV, parainfluenza virus, and adenovirus.

Far less commonly, rhinitis can be caused by bacteria, like Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus.

In children that are immunocompromised, like those with chronic granulomatous disease or acute leukemia, rhinosinusitis can be caused by fungi, like Aspergillus.

Bacteria and fungi often spread to the surrounding sinuses, causing rhinosinusitis - infection in both the nose and sinuses.

But keep in mind that the ethmoid sinuses are the only ones present at birth, maxillary sinuses develop between 1 month to 1 year of age, sphenoid sinuses develop from 1 to 2 years of age, and frontal sinuses develop after age 10.

Symptoms of rhinitis include a low-grade fever, loss of appetite, congestion, sneezing, and nasal discharge for a few days.

Rhinosinusitis, on the other hand, causes a high fever, nasal discharge that lasts for more than 10 days, facial pain or pressure, and a voice change because the tiny echo-chambers get clogged up with mucus or pus.

Diagnosis is based on symptoms, but sometimes a facial X-ray or CT scans is done to visualize “cloudy” sinuses with air- fluid levels.

Rhinitis is treated with rest, fluids, and nasal irrigation.

In bacterial rhinosinusitis, in addition to that, amoxicillin and clavulanic acid, or clindamycin are given for a 10 day course.

In immunocompromised children with fungal rhinosinusitis, surgical debridement, along with IV antifungals, like echinocandins, voriconazole, or amphotericin are given.

Next, pharyngitis can develop if a virus like rhinovirus or coronavirus move beyond the nose and travel down into the pharynx.


Pediatric upper airway conditions refer to the disorders affecting children's nasal cavities, paranasal sinuses, pharynx, or larynx. These conditions include foreign body aspiration, tonsillitis, epiglottitis, and laryngomalacia, which is characterized by congenitally malformed laryngeal cartilages that obstruct the airflow.

Symptoms vary depending on each condition but may include difficulty breathing, noisy breathing, recurrent throat infections, and difficulty swallowing. Treatment options depend on each specific condition. It may require antibiotics, steroids, and in some cases, surgery. Early detection and intervention can help to prevent complications and improve outcomes.