Sun28November0440PM 18

A 30-year-old male is admitted to the MAU with a 72 hour history of significant lethargy, fever and a sore throat.

The nurse is concerned that his breathing is 'noisy' and describes it to you over the phone as harsh and high pitched. His current observations demonstrate a temperature of 39.4°C and a raised respiratory and heart rate.

What is the most likely diagnosis?

(Please select 1 option)

Croup

Anaphylaxis

Laryngospasm

Bacterial tracheitis Correct

Foreign body aspiration

Explanation

Added airway sounds must always be addressed with the utmost urgency.

Stridor in particular is heard predominantly on inspiration and implies a compromised upper airway. It is important to remember that stridor is a sign and not a diagnosis, and the underlying cause must be sought urgently. All the causes listed above can present with stridor, thus the history is paramount in helping to identify the correct precipitant.

In children croup (viral laryngotracheitis) is the most common reason for a patient to present with stridor, with parainfluenza 1 virus being the most common precipitant. The barking cough of croup and subsequent stridor is predominantly limited to children under the age of 12, and thus stridor in adults should demand that the clinician pursue other more likely diagnoses.

In this case the patient appears toxic with worsening lethargy, pyrexia and overt deterioration of the upper airway. A bacterial cause must be suspected and bacterial tracheitis is the most likely culprit.

Diphtheria can present with stridor, however immunisation programmes have reduced the incidence in the western world. Remember to consider varying levels of immunisation in patients who have grown up abroad.

Laryngospasm is a common cause of stridor in adults but again a relevant precipitant must be sought. Exposure to smoke and toxic fumes in a history should lend a high degree of suspicion, and prompt the clinician urgently to involve the anaesthetic teams in consideration of securing the patient's airway.

The diagnoses of foreign body and anaphylaxis are both life threatening and must always be considered and excluded, however the duration and onset of the stridor will be a key factor. An abrupt onset with a history of eating nuts or even chewing on a pen lid or plastic bead is often present in foreign body aspiration and thus must be sought out.

Anaphylaxis may have a defined food precipitant and the onset is often more rapid than in the other conditions.

Answer Statistics

1

22%

2

1%

3

4%

4

75%

Times answered: 286