Sore Throat, Cough, and Stridor PDF

Sorethroat,cough,and stridor Dr. Salah Abdulkareem Ibrahim M.B.Ch.B. F.K.B.M.S. College of medicine/University of Dohuk [email protected] What is a sore throat? It is a pain at the back of your throat. A sore throat is usually a symptom of a...

Sorethroat,cough,and stridor Dr. Salah Abdulkareem Ibrahim M.B.Ch.B. F.K.B.M.S. College of medicine/University of Dohuk [email protected] What is a sore throat? It is a pain at the back of your throat. A sore throat is usually a symptom of an infective process. It refers to a painful problem of the child, usually in the pharynx and often begins as a swallowing complaint. A sore throat can occur in all age groups Sometimes caused by an allergy.  WHAT ARE THE COMMON CAUSES OF SORE THROAT?: Viral pharyngitis: Viruses that cause sore throat include the common cold virus, other upper respiratory tract viruses, adenovirus Streptococcal Pharyngitis: caused by the bacteria group A streptococci. It is most common in children over three years old and begins with a fever, a red, swollen throat and tonsils that can have a white coating of pus, swollen glands, decreased appetite  Less common: Infectious Mononucleosis: a common illness usually caused by the Epstein-Barr virus (EBV). It typically infects teenagers and young adults, but also occurs in younger children, who have a much milder illness that is often not recognized as mono. Symptoms of mono consist of a high fever, sore throat, swollen tonsils with pus on them, fatigue, an enlarged spleen, and swollen glands that may be tender. Herpangina: usually caused by the Coxsackie virus, causing painful blisters in the back of the child’s throat. Gingivostomatitis: caused by a herpes virus, which can also cause blisters in the mouth.  Other less common but severe infections often progressing to pharyngeal swelling, or abscess formation, even approaching surgical emergencies: Epiglotitis Retropharyngeal abscesses Lateral Pharyngeal abscesses Peritonsillar abscesses  These conditions are usually associated with high fever, drooling, severe pain and difficult breathing. Urgent evaluation and treatment is required: Epiglotitis Tracheitis  TAKING THE HISTORY – COMPLAINTS AND DURATION (symptoms): How long has the sore throat been present? Rapid or slower onset? Are there associated colds or coughs? Is there discoloured sputum? Has there been ear ache or runny nose? Has there been a fever? Has anyone else in the family had sore throat recently? Is the immunization schedule up to date? Are there known allergies? Are there other illness factors – fatigue, medications, immunosuppression  EXAMINATION FINDINGS WHAT TO LOOK FOR (signs) examine for fever, fast pulse, difficult painful breathing and swallowing - swollen, tender cervical lymph nodes - oral mucosal ulcers, blisters - swollen purulent tonsils, evidence of foreign body? fishbone? - red, painful pharynx - nasal stuffiness, ear drums - stridor, drooling, wheezing - oral health, dental exam - complete chest examination necessary  CLINICAL FINDINGS: Bacterial Viral Fever > 39.5 ºC absent or present WBC < 5 or > 15 5 – 15 Discharge, Pus (thick, clear or light nasal or throat dark yellow, yellow, runny orange or colour) Seasonal – + Petechiae + – Gram stain / Blood, viral swab culture sputum,  Investigations Throat swab is NOT routinely recommended for sore throat, with the exception of the high-risk group Consider other investigations if: Suspected suppurative complications: relevant imaging Hepatosplenomegaly: FBE, monospot, +/- EBV serology Streptococcal serology has no role in diagnosis of GAS pharyngitis  LABORATORY – GRAM STAIN AND CULTURE: Bacterial (~ 30% of cases) Viral (~ 40% of cases) Common GABHS ,Staphylococcus RhinovirusAdenovirusPar aureus(Moraxella)Branhamella catar ainfluenza rhalisBacteroides fragilis virusCoxsackie virus Bacteroides oralis Coronavirus Bacteroides melaninogenicus Echovirus Fusobacterium species Herpes simplex virus Peptostreptococcus species Epstein-Barr virus Haemophilus influenzae ~~~(mononucleosis) Cytomegalovirus Uncomm Group C streptococciGroup G streptococciNeiseria on gonorrhoeaeChlamydia trachomatis Mycoplasma pneumoniae Rare Corynebacterium diphtheriae Extremel Corynebacterium hemolyticum y rare No pathogen isolated: ~ 30% of cases Principle of Management Symptomatic relief Antibiotic choice dependent on culture, sensitivity and any drug allergies in the child Urgent or emergency care depending on degree of respiratory symptoms  Red flags Unwell/toxic appearance Respiratory distress Stridor Trismus Drooling (muffled voice associated with pharyngeal/peritonsillar pathology) Torticollis Neck stiffness/fullnes cough  Background Cough is a common indication of respiratory illness and is one of the more common symptoms of children seeking medical attention. Not only does it cause discomfort for the child, cough also elicits stress and sleepless nights for their parents.  Physiology/ Mechanics of coughing Three phases: 1. Inspiratory phase: air inhalation lengthens the expiratory muscles (favorable length-tension relationship). 2. Compressive phase: contraction of expiratory muscles against a closed glottis leads to an increase in intrathoracic pressure. 3. Expiratory phase: opening of the glottis results in high expiratory flow and audible coughs. During this phase, the airway undergoes dynamic compression and the expulsion of air facilitates airway debris and secretions clearance.  Cough pathway Each cough is elicited by the stimulation of the cough reflex arc. Cough receptors, which are afferent endings of the vagus nerve (cranial nerve X), are scattered in the airway mucosa and submucosa. Some of these receptors are mechanosensitive and some are chemosensitive. Mechanoreceptors are sensitive to touch or displacement and are located mainly in the proximal airway such as larynx and trachea. Chemoreceptors are sensitive to acid, heat, and capsaicin derivatives through the activation of type 1 vanilloid receptor (TRPV1) and are located mainly in the distal airways.  Cough pathway/cont. Via the vagus nerve, impulses from the cough receptors are propagated to the cough center in the medulla and nucleus tractus solitaris. Efferent impulses are generated from the cough centre and are propagated via the spinal motor (to expiratory muscles), phrenic (to the diaphragm), and vagus (to the larynx, trachea, and bronchi) nerves to the expiratory organs to produce cough  Classifications of Cough is usually classified based on its duration, quality or etiology. They are helpful indicators to guide your differential diagnosis. Duration: acute (< 2 weeks), subacute (2-4 weeks), chronic (> 4 weeks) Quality: moist/wet/productive vs. dry Etiology: specific (attributable to an underlying problem) or non-specific (absence of identifiable problem)  Questions to Ask Ask about the age/duration of onset (congenital cause). Nature of cough; How long has the child been coughing for? Acute/ subacute? Chronic paroxysmal cough? Chronic productive (wet-moist) cough? Barking/brassy sounding? Staccato sounding? Honking (Goose-like) sounding? Whooping sound? What time of the day is the cough worst? What type of exposure triggers the cough?  Questions to Ask What relieves the cough? Has the child been on medication before (ex. Bronchodilators)? Did this help with the present episode? Is there any shortness of breath ? Is there increased work of breathing? Is there associated vomiting (post-tussive emesis)? Is there hemoptysis? Is there evidence of fevers, failure to thrive or weight loss? Is the child passively or actively exposed to smoke from tobacco, marijuana, cocaine, or wood-burning stove? Ask about a history of choking (suspect foreign objects in airway). What pets or animals did the child have contact with? Ask about prenatal and neonatal history. Is there a family history of atopy (eczema, allergies, asthma), cystic fibrosis, and/or primary ciliary dyskinesia? Differential Diagnosis Duration Common Etiologies Acute cough less than 2 wk Classical recognizable cough: o Laryngotracheobronchitis – barking cough ,Staccato – Chlamydia (infant) , Paroxymal – pertussis and para-pertussis ,Psychogenic – honking cough Acute upper / lower respiratory tract infection (ARI) Foreign body aspiration Asthma Inhalation injury (acute exposure to smoke or volatile substances) Embolism hemorrhage (rare) Subacute cough (2-4 weeks) Post viral cough Acute bronchitis Chronic cough (> 4 weeks) Non specific cough: Post viral. Increased cough receptor sensitivity , Asthma , Gastroesophageal reflux. Upper airway problems ,Functional disorders Subacute bronchitis Bronchiectasis or recurrent pneumonia: Cystic fibrosis Ciliary dyskinesia , Immunodeficiency ,Congenital lung lesions Aspiration Chronic infections:Tuberculosis Non- tuberculous mycobacteria Interstitial lung disease (i.e. Rheumatic diseases)  Physical Examination During the physical examination, you should pay attention to the following signs: ABC! Vital signs, including O2 saturation. Growth parameters – signs of poor growth and/or failure to thrive. Assess work of breathing. If patient able, listen to their cough. Inspect chest wall for signs of hyperinflation and deformities. General inspection for stigmata of chronic disease. Examine for nasal polyps and other nasal passage obstruction. Auscultate: is air entry symmetric? Are there adventitious sounds? Describe its location and quality (crackles, crepitations, wheeze) Auscultate for heart sounds. Examine for edema, cyanosis, clubbing of fingers/toes, and skin lesions  Investigations Chest X-ray Chest radiograph can provide you with additional information, such as infiltrations/ consolidations, hyperinflation, peribronchial thickening, hyperinflation, atelectasis and chronic lung changes. Pulmonary Function Test Can help delineate obstructive vs. restrictive lung disease Required in the diagnosis of asthma (child must be >6y and cooperative) Bronchoscopy Useful if suspicion for foreign body is high. Mantoux Testing (Tuberculin Skin Test) To screen for tuberculosis infection. treatment stridor  In General Stridor is derived from the latin word stridulus, meaning a harsh, shrill sound. Stridor is described as a high-pitched, monophonic sound derived from the upper airways (compared to the polyphonic sound heard in the lower airway in wheezing). Stridor is a common presentation in pediatric patients and requires prompt evaluation. The first priority in the evaluation of a child with stridor is to determine if there is respiratory compromise. The age of onset, patient history, tonal quality, and relation to the timing of the respiratory cycle is critical to the workup of a patient with stridor. Stridor can be inspiratory, expiratory, or biphasic; this may aid in determining the anatomic location of the airway obstruction. Inspiratory stridor is more likely to be caused by extrathorasic obstruction to air flow while expiratory stridor is more likely to occur with intrathorasic pathology.  Pathophysiology: 1. Stridor is caused by restriction of airflow through the upper airways. 2. The decrease in the area of the airway leads to a proportional increase in velocity due to the Venturi Effect (this same effect can be seen when a thumb is placed over the end of a garden hose). The increase in velocity creates a low-pressure vacuum, exacerbating airway collapse (Bernoulli Principle). 3. This ultimately leads to increased airway resistance, increase effort of breathing, and the clinical finding of stridor. 4. Due to the smaller diameter of the pediatric airway compared to that of adults, even minor changes can lead to a marked reduction in overall airway calibre. 5. 1mm of edema in the average adult airway leaves 81% of the cross-sectional area patent, while the same 1mm of edema in a pediatric patient results in only 44% patency.  Etiology: a.Congenital anomalies: i.Laryngeal: ii.Tracheal: iii.Bronchial: b.Traumatic c.Infectious Age of Onset: Age of onset is a key factor in developing a differential diagnosis for stridor in pediatric patients. Congenital abnormalities of the upper airway typically present in the first few weeks to months of life and are the most common causes of stridor (87%). a. Common causes of stridor at birth include: vocal cord paralysis, choanal atresia, laryngeal web, or vascular ring. b. Common causes of stridor during the first few weeks of life include: laryngomalacia, tracheomalacia, and subglottic stenosis c. Common causes of stridor from 1-4 years of age: croup, epiglottitis, foreign body aspiration – Stridor occurring in toddlers is most likely due to foreign body aspiration. – Infectious causes can occur in children of all ages.  Acuity of Onset: Acute onset of stridor in toddlers should raise the suspicion for a foreign body aspiration. In some children, stridor will not appear for time due to reactive inflammation of the airway, so a remote history of aspiration should be evaluated in the patient's history. The onset of stridor along with fever, chills, and toxic appearance should allude to an infectious cause of epiglottitis or tracheitis. Chronic stridor may represent an indolent structural process such as laryngomalacia, laryngeal web, or laryngotracheal stenosis.  Past Medical History: Evaluation should include aspects of a patient's prenatal and perinatal history and should include: a. Prematurity, birth weight, mode of delivery, intubation/ventilation, infections, allergies, congenital syndromes. i. A history of intubation should focus on: – Number of intubations, duration of intubation, size of ETT a. This will give an idea about potential trauma to the airway. b. A history of intubation is associated with laryngotracheal stenosis or vocal cord paralysis. b. A history of atopy may indicate angioedema c. A viral prodrome with fevers suggests an infectious etiology. Physical Exam: Vital signs are crucial in identifying patients with impending respiratory collapse. - Continuous pulse oximetry and close observation. Observation of respiratory effort Auscultation helps to determine the possible location of the airway obstruction. Timing of stridor with a respiratory cycle, as well as its tonal quality, is helpful in elucidating the location of the airway narrowing. a.Classically, inspiratory stridor indicates epiglottic pathology while expiratory stridor alludes to intrathorasic obstruction. b.Biphasic stridor is indicative of a "fixed" obstruction, typically located in the larynx or cricoid cartilage. A weak cry or hoarseness can allude to glottic etiologies  Precipitating Factors: Parents are often astute in noticing what factors aggravate or decrease their child's stridor. Worsening with agitation: Laryngomalacia or subglottic hemangioma. Worsening while supine: laryngomalacia, tracheomalacia, macroglossia, or micrognathia. Worsening with feeding: laryngomalacia, TE fistula, vascular malformation.  Diagnostic Testing: Imaging: a. AP and lateral radiographs of the neck may be useful in assessing for size of the epiglottis, retropharyngeal profile, and defining general tracheal anatomy. b. AP and lateral radiographs of the chest may identify radio- opaque foreign bodies. c. Inspiratory and expiratory films may be useful in demonstrating air-trapping due to airway obstruction. i. A positive exam will reveal hyperlucency of the obstructed lobe during expiration compared to inhalation due to air- trapping. ii. May also see a shift of the mediastinum to the side opposite the obstruction. Diagnostic Testing/cont. Flexible Fiberoptic Laryngoscopy: a. Often, direct visualization of the airway is necessary to confirm a suspected diagnosis. b. Flexible laryngoscopy and flexible bronchoscopy is helpful in identifying the exact anatomic location of the obstruction. Direct bronchoscopy under general anesthesia allows for intervention such as removal of foreign bodies or tissue biopsy. Labs: a. A CBC is helpful if a patient presents with an infectious picture. b. Arterial blood gasses may be indicated if a patient present with significant respiratory distress. This allows for an assessment of potential hypoxia and hypercarbia. treatment