ENT Airway Emergencies
A Step 2 CK high-yield lesson on ENT airway emergencies, framed around buzzword recognition and next-best-step decisions across croup, epiglottitis, bacterial tracheitis, deep neck space infections (peritonsillar, retropharyngeal, Ludwig angina), and angioedema. Emphasizes the core rule: secure an unstable airway before imaging or workup.
Overview: recognize the airway before you treat the cause
ENT airway emergencies kill fast, and the boards test whether you can recognize impending obstruction and pick the right next step before imaging or exam. Watch for the triad of stridor (upper-airway obstruction), drooling/dysphagia (the patient can't handle secretions), and a muffled "hot-potato" voice. A patient sitting upright and leaning forward (tripod position), refusing to lie flat, is protecting a marginal airway.
Two unifying principles run through every vignette:
- Do not agitate. In suspected epiglottitis, do not force the child supine, draw blood, or put a tongue depressor/scope into the pharynx until you are ready to secure the airway — agitation can precipitate complete obstruction.
- Airway first, in a controlled setting. Definitive airway control (ideally in the OR with ENT and anesthesia) comes before imaging or definitive workup whenever the airway is unstable. Then treat the underlying cause.
- Stridor localizes the obstruction: inspiratory = supraglottic/laryngeal; expiratory = intrathoracic; biphasic = subglottic or fixed lesion
- Croup (parainfluenza): barking cough, gradual onset, low fever, steeple sign — dexamethasone +/- nebulized racemic epinephrine
- Epiglottitis: rapid high fever, toxic, drooling, no cough, tripod, thumbprint sign — airway in OR, then ceftriaxone
- Peritonsillar abscess: adolescent, trismus, uvula deviated away from the abscess — needle aspiration / I&D
- Retropharyngeal abscess: young child, neck held in extension, widened prevertebral space — CT + drainage
- Ludwig angina: bilateral floor-of-mouth induration from a mandibular molar, tongue elevated — early airway + IV antibiotics
- ACE-inhibitor angioedema: bradykinin-mediated, no urticaria/itch — stop the drug, secure airway; poor response to steroids/antihistamines
Pediatric stridor: the classic four-way comparison
| Feature | Croup | Epiglottitis | Bacterial tracheitis | Retropharyngeal abscess |
|---|---|---|---|---|
| Cause | Parainfluenza | H. influenzae b (unvaccinated); strep/staph | S. aureus (post-viral) | Polymicrobial (strep/anaerobes) |
| Typical age | 6 mo–3 yr | Any; now often adults | 6 mo–8 yr | 2–4 yr |
| Onset | Gradual, URI prodrome | Rapid (hours) | Viral URI then abrupt worsening | Days |
| Cough | Barking/seal-like | Absent | Brassy, thick pus | Variable |
| Appearance | Nontoxic | Toxic, drooling, tripod | Toxic, high fever | Neck stiff/extended, drooling |
| Imaging | Steeple sign (AP film) | Thumbprint sign (lateral film) | Ragged tracheal membrane | Widened prevertebral soft tissue (lateral) |
| Management | Dexamethasone +/- racemic epi | Airway in OR + ceftriaxone | Intubation + IV antibiotics | IV antibiotics + surgical drainage |
Vignette: A 4-year-old recent immigrant with incomplete vaccinations has 6 hours of high fever, a muffled voice, and severe throat pain. He sits leaning forward on his hands, drooling, with soft inspiratory stridor and no cough. He looks anxious and toxic.
Diagnosis: Acute epiglottitis (classically H. influenzae type b).
Next best step: Keep him calm and upright with a parent and give supplemental (blow-by) oxygen without agitating him. Do not examine the pharynx with a tongue depressor, draw blood, or send him to radiology — any agitation can trigger complete obstruction. Take him to the OR for a controlled airway (intubation by anesthesia/ENT with tracheostomy backup) and confirm the cherry-red swollen epiglottis on direct visualization. Then start IV ceftriaxone (add vancomycin if MRSA is suspected). A lateral neck film (only if the airway is stable) shows the thumbprint sign — but imaging must never delay securing the airway.
Vignette: A 19-year-old with several days of worsening sore throat now has trismus, a "hot-potato" voice, and drooling. Exam shows a bulging, fluctuant swelling superior to the left tonsil with the uvula deviated to the right.
Diagnosis: Peritonsillar abscess (quinsy) — usually polymicrobial (Group A strep + anaerobes), a complication of tonsillitis in adolescents and young adults.
Next best step: Needle aspiration or incision and drainage of the abscess, plus antibiotics (amoxicillin-clavulanate or clindamycin). The airway is rarely the immediate threat here, but trismus and a muffled voice signal it could progress. CT with contrast is reserved for diagnostic uncertainty or suspected spread to deep neck spaces. Distinguish from retropharyngeal abscess (younger child, neck held in extension, no uvular shift) and simple pharyngitis (no trismus, no fluctuant mass).
Vignette: A 45-year-old with a neglected lower molar infection has rapidly progressive swelling under the jaw. The floor of the mouth is firm and tender with brawny, board-like induration, the tongue is pushed up and back, and he can barely swallow his secretions.
Diagnosis: Ludwig angina — bilateral cellulitis of the submandibular/sublingual spaces, usually odontogenic (2nd/3rd mandibular molars), polymicrobial.
Next best step: Secure the airway early. Swelling distorts the anatomy, so anticipate a difficult intubation — plan an awake fiberoptic approach with surgical-airway/tracheostomy backup; blind supine attempts can precipitate total obstruction. Give IV broad-spectrum antibiotics (ampicillin-sulbactam or clindamycin) and involve surgery for drainage. The leading cause of death is airway obstruction; also watch for downward spread to the mediastinum.
Epiglottitis presents with the "4 D's":
- Drooling (can't swallow secretions)
- Dysphagia (difficulty and pain on swallowing → refuses to swallow)
- Dysphonia (muffled "hot-potato" voice)
- Distress (respiratory distress, tripod/sniffing position)
Add the classic absence of a barking cough to separate it from croup, plus the thumbprint sign on the lateral neck film.
One-liner: Croup barks; epiglottitis drools.
- ACE-inhibitor angioedema: painless, non-pitting, non-pruritic tongue/lip/face swelling with no urticaria; bradykinin-mediated, so often poor response to epinephrine/steroids/antihistamines. Stop the ACE inhibitor and protect the airway; can begin years after starting the drug.
- Anaphylactic angioedema: urticaria + wheeze + hypotension → IM epinephrine first.
- Hereditary angioedema: C1-esterase-inhibitor deficiency; recurrent, no hives, low C4 with normal C1q → C1-INH concentrate or icatibant.
- Foreign-body aspiration: toddler with sudden choking and unilateral wheeze/decreased breath sounds; expiratory film shows air trapping (right main bronchus most common) → rigid bronchoscopy.
- Bacterial tracheitis: toxic child, thick purulent secretions, no response to racemic epinephrine → intubation + IV antistaphylococcal antibiotics.
- Universal rule: if the airway is unstable, secure it before imaging or definitive workup.
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