Virtual Pediatric Patients
Donna M. D'Alessandro M.D., Tamra E. Takle M2
Peer Review Status: Internally Peer Reviewed
The Problem / Clinical Presentation
"DeShawn spent the night at his godmother's house 2 days ago, and the next morning when she brought him home, he said his ear was hurting. He had a headache and fever, and wasn't very active. I asked which ear hurt, and he pointed to both of them. I called his pediatrician, and the nurse told me to bring him in. They checked him over, and at first they told me he had a special kind of ear infection, so they had to put a needle into his spine to make sure he didn't have meningitis. They admitted him to the hospital to keep an eye on him yesterday, but he got worse. He was breathing so loud that it sounded like he was snoring, and complained that his neck hurt. So his pediatrician arranged to bring him to Iowa City in the helicopter. It just happened so suddenly; I didn't think DeShawn was that sick."
Clinical Physical Exam
Upon arrival at the University of Iowa, DeShawn was quiet but obviously uncomfortable and stridorous. He was afebrile with stable vital signs. Respiratory rate was 24 per minute. HEENT examination revealed his nose to have greenish discharge. Tonsils were enlarged without exudates with left greater than right and deviation of the uvula to the right. His airway was patent. His neck revealed a painful left anterior cervical and subauricular area with fullness. He had shotty bilateral anterior cervical adenopathy. His lungs were clear and the rest of his physical examination was normal.
Clinical Differential Diagnosis
His CBC showed a hemoglobin of 10.4 g/dl, hematocrit 28%, platelets 329K/mm3. A WBC of 24.1 K/mm3 was high. His peripheral smear showed a normal differential, with a left shift of 75% PMNs and marked toxic granulations. His electrolytes were normal. Blood culture showed no growth. Iron studies were consistent with an iron deficiency anemia.
Laboratory Differential Diagnosis
In addition to this, the clinical differential diagnosis is unchanged.
A lateral radiograph of DeShawn's neck revealed the retropharyngeal space to be dramatically enlarged from the level of the nasopharynx to just above the thoracic inlet. The computed tomography scan of his neck showed prominent retropharyngeal soft tissues and left tonsil causing mass effect on the airway.
Imaging Differential Diagnosis
Left tonsillar and retropharyngeal abscess
No operative intervention was performed
Treatment Course, Prognosis and Follow-up
He was taken to the Pediatric Intensive Care Unit (PICU) for continuous observation of his respiratory status and was given IV antibiotics. He never required intubation or surgical intervention and had resolution of his symptoms by day 2 so that he could be transferred to the floor. Daily bedside laryngoscopies were performed to document the resolving abscess. He also had a repeat computed tomography scan on day 4 which showed almost complete resolution. He will be sent home on oral antibiotics and iron.
"The doctors said DeShawn was really lucky he didn't have to go to the operating room. He's done really well, and he liked all the popsicles they gave him to eat. When he goes home, he'll still have to take some medicine and see his doctors in a few days, but he should be just fine."
Sore throat is a very common illness. Often it is mild and self-limited but may be the initial symptom of a severe illness with spread of infection into adjoining tissues. Inflammation of the tonsils, pharynx and surrounding tissues can be quite painful.
Commonly the differential diagnosis is between group A beta-hemolytic streptococcus and a viral pharyngitis. Depending on the age, history and physical examination, other diagnoses should be considered.
History and Physical Exam
History should include onset of the symptoms, severity, and associated symptoms such as fever, rash, headache, nausea/emesis, and abdominal pain. Fever is often associated with sore throat, as well as behavioral changes or decreased activity. An exposure history including contact with ill persons, especially to group A beta-hemolytic streptococcus, is important.
Physical examination should document the fever and proceed with a careful examination of the pharynx and neck for erythema, exudates, ulcerations and evidence of inability to swallow or difficulty in breathing. Additionally, upper respiratory infection (URI) signs such as rhinorrhea may also be present. Cervical lymphadenopathy may be present with streptococcal disease or with URIs. Streptococcal disease will present with tender lymph nodes, palatal petechiae and tonsillar exudates with fever; typical URI features are enlarged lymph nodes that are non-tender, rhinorrhea, patients generally have no exudates and may have cobblestoning of the pharynx. A complete physical examination including dermatological examination for rashes and genitourinary examination for discharge should also be done.
The laboratory evaluation often includes a throat culture and/or a rapid antigen test for group A beta-hemolytic streptococcus. If other disease entities (especially invasive diseases) are being considered, prompt, appropriate evaluation and treatment are necessary. Below is a list of tests to consider.
Most children usually have a self-limited, localized infectious disease process. Viral pharyngitis and URIs should be treated symptomatically with fluids, humidity and anti-pyretics for comfort. Group A beta-hemolytic streptococcus can be confirmed by a positive rapid antigen test and treated with antibiotics if positive. Alternatively, a throat culture may be used and should always be done if a rapid antigen test is negative. Group A beta-hemolytic streptococcus is sensitive to penicillin, which is the drug of choice. Invasive disease should be treated promptly with attention to airway control. Drainage of abscesses and early initiation of appropriate antibiotic coverage is important.
Clinical features of Retropharyngeal Abscess (RPA) are often nonspecific, consisting of vague symptoms such as fever, fussiness, sore throat, nonspecific neck stiffness and poor feeding. Later, the child appears acutely ill with fever, upper airway compromise, stridor, drooling and respiratory distress. Often the child may have upper respiratory tract infection and be treated with antibiotics before the diagnosis of RPA. Symptoms usually precede the diagnosis by 5-6 days. Cervical lymphadenopathy and neck swelling (retropharyngeal bulge) are important physical findings, but the latter may not always be appreciated.
Retropharyngeal abscess is a potentially life-threatening upper airway infection in children. Over 90% of cases present in children under the age of 6, with a slight male preponderance. The retropharyngeal space contains loose connective tissue and lymph nodes, receiving drainage from adjacent bones and sinuses, teeth, Eustachian tube, middle ear and nasopharynx. Lymphatic spread of infection is common; other causes include direct spread from adjacent areas, trauma or foreign bodies.
Laboratory studies may reveal a leukocytosis, but a normal WBC does not exclude the diagnosis of RPA. Blood cultures are usually negative. Abscess cultures usually contain polymicrobes, such as Staphylococcus aureus, streptococcal species, and anaerobes.
The lateral neck radiograph will show thickening of the retropharyngeal space with anterior displacement of the airway. Occasionally, gas can be seen in the retropharyngeal soft tissues. Computed tomography better delineates the abnormality, and better demonstrates walled off abscess cavities.
Antibiotic therapy alone is successful in 15-25 percent of cases. For patients who do not respond to antibiotics, surgical drainage is warranted. For cases complicated by airway obstruction or severe illness, endotracheal intubation and surgical drainage may be necessary.
Prognosis is good assuming prompt institution of antibiotics, surgical therapy if necessary, and appropriate supportive care.
Berkowitz, Carol D, Pediatrics A Primary Care Approach. W.B. Saunders and Co. Philadelphia, PA, 1996. pp. 186-190.
Fleisher, Gary R, Ludwig, Stephen. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins, Baltimore, MD, 1996. pp. 243-245
Schroeder LL, Knapp JF. Recognition and emergency management of infectious causes of upper airway obstruction in children. Seminars in Respiratory Infections 1995: 10(1), 21-30.
Gagliana MJ, Edwards MS. Clinical indicators of childhood
retropharyngeal abscess. American Journal of Emergency Medicine 1995:
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