Question
A 3-year-old girl is brought to the physician by her parents because of a barking cough, a raspy voice, and noisy breathing for the last 3 days. Five days ago, she had a low-grade fever and runny nose. She attends daycare. Her immunizations are up-to-date. Her temperature is 37.8°C (100°F) and respirations are 33/min. Physical examination shows supraclavicular retractions. There is a high-pitched sound present on inspiration. Examination of the throat shows erythema without exudates. Which of the following is the most likely location of the anatomic narrowing causing this patient’s symptoms?
| A. |
Subglottic larynx
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| B. |
Bronchioles
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| C. |
Pharynx
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| D. |
Epiglottis
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Show Answer
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Correct Answer � A
Explanation
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Answer A) Subglottic larynx
A chest x-ray of this patient would most likely reveal a steeple sign.
Subglottic larynx
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Croup, the most likely diagnosis in this patient, is characterized by inflammation and narrowing of the subglottic part of the larynx (below the vocal folds).
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The cricoid cartilage ring of the subglottis cannot expand.
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Given the small size and floppiness of the larynx and trachea in children, mucosal swelling quickly causes hoarseness, barking cough, and inspiratory stridor.
Bronchioles
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Inflammation of the bronchioles (e.g., bronchiolitis) can also present with symptoms of upper respiratory tract infection (e.g., low-grade fever, rhinorrhea, cough).
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Narrowing of the terminal bronchioles due to edema and excessive mucus causes wheezing and crackles.
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Hoarseness and inspiratory stridor do not occur. In addition, bronchiolitis most commonly affects children < 2 years.
Pharynx
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Inflammation of the pharynx (e.g., strep throat) typically presents with erythema and exudates of the pharynx and tonsils.
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Patients primarily develop sore throat and dysphagia.
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Cervical lymphadenopathy is also a typical finding.
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Hoarseness and barking cough do not occur.
Epiglottis
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Inflammation of the epiglottis (e.g., as seen in epiglottitis) can also present with inspiratory stridor.
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Edema of the small and flaccid epiglottic cartilage in children quickly results in drooling, sore throat, dysphagia, and muffled voice, rather than hoarseness and a barking cough.
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Children with epiglottitis typically have a toxic appearance (e.g., respiratory distress, cyanosis, inspiratory retractions, restlessness) and are at high risk of developing respiratory distress.
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