PANCE Blueprint EENT (7%)

Epiglottitis

Patient will present as → a 3-year-old who is brought into the emergency room by her parents. The child has had a high fever, sore throat, and stridor. She has a muffled voice and is sitting up on the stretcher drooling while leaning forward with her neck extended. The patients parents are adamantly against vaccinations, claiming that they are a "government conspiracy." You order a lateral neck x-ray, which shows a swollen epiglottis.

Infection of upper airway with most common cause H. influenzae type B (Hib)

  • Presents with drooling + dysphagia and distress
  • Patients sit with neck hyperextended and chin protruding (sniffing dog position)

X-ray (lateral film) - Thumbprint sign

  • Never use instruments to view as it may cause airway obstruction

Secure airway - call anesthesiology and prepare to establish airway, transfer to OR to perform exam, tracheostomy if necessary to maintain airway

  • Admit for observation, humidified O2, IV antibiotics (ceftriaxone + clindamycin), and IV corticosteroids
Thumbprint Sign

Thumbprint Sign

Question 1
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?
A
Croupy cough and drooling
B
Thick gray, adherent exudate
Hint:
Thick gray adherent exudate is suggestive of diphtheria.
C
Beefy red uvula, palatal petechiae, white exudate
Hint:
Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.
D
Inflammation and medial protrusion of one tonsil
Hint:
Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Question 1 Explanation: 
A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
Question 2
A 35 year-old patient presents with a sudden onset of fever, dysphonia, drooling, and difficulty drinking a few hours ago. Physical examination reveals a temperature of 102 degrees F. The patient appears ill and is sitting forward. Inspiratory retractions are noted and there is a soft stridor. Which of the following is the most likely diagnosis?
A
Angioedema
Hint:
Angioedema would present with swelling of the mouth and upper airway. Patient would not have fever or inspiratory retractions.
B
Foreign body aspiration
Hint:
Patients with foreign body aspiration are unlikely to appear acutely ill or be febrile.
C
Epiglottitis
D
Bacterial pharyngitis
Hint:
Bacterial pharyngitis is not associated with stridor or inspiratory retractions.
Question 2 Explanation: 
Epiglottitis is characterized by fever, dysphonia, drooling, and dysphagia. Patients often appear ill and sit up leaning forward in an attempt to breathe.
Question 3
A 23-month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling and seems to be worsening. The child is not presently crying but has muffled voice sounds. The child has not been immunized due to religious reasons. What is the most appropriate next step?
A
Administer ceftriaxone (Rocephin)
Hint:
See B for explanation.
B
Emergent transfer
C
Administer racemic epinephrine
Hint:
See B for explanation.
D
Obtain intravenous access
Hint:
See B for explanation.
Question 3 Explanation: 
Epiglottitis requires endotracheal intubation to maintain the airway but should be performed only in the operating room or emergency room with a competent physician prepared to place an endotracheal tube or less often to perform a tracheostomy.
There are 3 questions to complete.
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Deep neck infection (Prev Lesson)
(Next Lesson) Oral herpes simplex (ReelDx)
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