STEPTRACKERRESPIRATORY | PATHOLOGY | HIGH-YIELD REVIEW

Upper Airway & Nasopharynx

Nose, nasopharynx and larynx — polyps that point to systemic disease, two pediatric airway emergencies, and head-and-neck tumors.

FOCUS ON
Nasal polyps in a child → cystic fibrosis; with asthma and aspirin sensitivity → AERD. Nasopharyngeal carcinoma = EBV, Chinese or African ancestry, neck node first. Tell epiglottitis (Hib, drooling, thumbprint) from croup (parainfluenza, barking cough, steeple sign).
LESION
CAUSE · MECHANISM
FEATURES
CLUE
Rhinitis
Rhinovirus (common cold); allergic rhinitis = type I hypersensitivity
Sneezing, congestion, rhinorrhea; allergic: eosinophils, seasonal
Allergic rhinitis often with asthma, eczema
Nasal polyps
Inflammatory outgrowths after repeated rhinitis
Nasal obstruction, anosmia
Child → cystic fibrosis · adult with asthma + aspirin reaction → AERD
Juvenile nasopharyngeal angiofibroma
Benign, highly vascular fibrous tumor
Adolescent boys: recurrent profuse epistaxis, nasal obstruction
Biopsy can cause major bleeding
Nasopharyngeal carcinoma
EBV-associated carcinoma; southern Chinese, North African, Inuit adults; African children
Painless cervical node often first; nasal obstruction, epistaxis; unilateral serous otitis media in an adult
Undifferentiated cells with many lymphocytes; radiosensitive
Acute epiglottitis
H influenzae type b (unvaccinated child); now also strep, staph
High fever, drooling, dysphagia, muffled "hot-potato" voice, tripod position, stridor
Thumbprint sign · secure the airway; don't examine the throat first
Croup
laryngotracheobronchitis
Parainfluenza virus; children 6 months–3 years
Barking, seal-like cough, inspiratory stridor, low-grade fever
Steeple sign · dexamethasone; racemic epinephrine if severe
Vocal cord nodules
Overuse of the voice → degenerated myxoid connective tissue
Bilateral nodules on true cords; hoarseness
Singers, teachers · voice rest
Laryngeal papilloma
HPV 6, 11; benign
Hoarseness; single in adults, multiple in children (vertical transmission)
Recurrent respiratory papillomatosis
Laryngeal carcinoma
Squamous cell carcinoma, usually of true cords; smoking + alcohol (synergistic)
Persistent hoarseness, stridor, dysphagia, hemoptysis
Cervical node metastases

Mechanism — where the airway narrows

Nose / nasopharynxPolyps, angiofibroma, NPC
→
SupraglottisEpiglottitis: drooling, muffled voice
→
GlottisNodules, papilloma, SCC: hoarseness
→
SubglottisCroup: barking cough, stridor

Inspiratory stridor = obstruction above the thoracic inlet (extrathoracic). Expiratory wheeze = intrathoracic airways.

Epiglottitis vs croup

FEATURE
EPIGLOTTITIS
CROUP
Organism
H influenzae type b
Parainfluenza virus
Age
2–7 years (unvaccinated); adults too
6 months–3 years
Fever, look
High fever, toxic, drooling
Low-grade, not toxic
Sound
Muffled voice
Barking cough
X-ray
Thumbprint sign
Steeple sign
Treatment
Airway, IV ceftriaxone
Dexamethasone, racemic epinephrine

How it's tested

COMMON CONFUSIONThe nasopharyngeal carcinoma vignette often doesn't mention the nose. It presents with a neck mass or a one-sided middle-ear effusion in an adult.
THE TRAPA drooling, toxic, tripoding child must not have a tongue depressor in the throat. That can trigger complete airway obstruction; secure the airway first.
YOUR APPROACHAge + sound (drooling/muffled, barking, hoarse) + fever → level of obstruction → organism or tumor.

If you see… think…

Child with recurrent nasal polyps → cystic fibrosis — sweat chloride
Adult with asthma, nasal polyps and aspirin reactions → AERD
Adolescent boy with recurrent massive nosebleeds and a nasal mass → juvenile angiofibroma
Southern Chinese adult, neck node, one-sided otitis media → nasopharyngeal carcinoma (EBV)
Unvaccinated child: drooling, tripod, high fever, thumbprint sign → epiglottitis (Hib)
Toddler with barking cough and steeple sign → croup (parainfluenza)
Teacher with hoarseness and bilateral cord nodules → vocal cord nodules
Child with hoarseness and multiple warty laryngeal growths → HPV 6/11 papillomatosis
Smoker and drinker with months of hoarseness → laryngeal SCC