Frog in your throat: Supraglottic infections and bacterial tracheitis

Case presentation

A 10-year-old female presents with 2–3 weeks of progressively worsening throat pain and dysphagia. She was diagnosed 2 weeks ago with Streptococcal pharyngitis by her primary care provider. She was treated with a 10-day course of amoxicillin and had mild improvement, but her symptoms returned. She was evaluated by her physician again and told she had a viral infection, since her rapid strep test was negative. Over the past 3–4 days, she has had fever to 103 degrees Fahrenheit; the throat pain and dysphagia have worsened considerably. Her parents note she has had “voice changes”—the child’s voice has taken on a “muffled” quality. She has had no other symptoms, has had no travel, and has been otherwise in her usual state of health.

Physical examination reveals an uncomfortable appearing child; she appears ill. She prefers to sit up, stating that lying down makes it “more difficult for me to breathe.” Her temperature is 101 degrees Fahrenheit, her heart rate is 120 beats per minute, respiratory rate is 25 breaths per minute, blood pressure is 120/80 mm Hg, and oxygen saturation is 95% on room air. She has an erythematous posterior oropharynx without obvious asymmetry, but her examination is limited secondary to difficulty opening her mouth, which she states hurts her throat. Her chest examination is clear, but there is transmitted upper airway noise. There is no obvious stridor.

Imaging considerations

Acutely ill, toxic-appearing children should have immediate treatment, including airway stabilization if clinically indicated. While having an imaging study to assist in diagnosis is advantageous, delaying care to obtain such a study is not advisable, since these children can decompensate quickly. Once a clinician deems it safe, then appropriate imaging studies may be performed.