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ACUTE LARYNGOTRACHEAL INFECTIONS             159

stronger ones are required then one should reconsider the diagnosis and
think of epiglottitis or perichondritis.

ACUTE EPIGLOTTITIS

This is seen in children more commonly than adults and while it may present
as part of a generaTTVe^pperrespi>^or^trartinfr/'t1<r>r>, it may also occur on
its own.

DIAGNOSIS. The usual presentation is witjjjevep-attd severe pain deep in the
throat especialjy_or^sw.allowing. If allowed to progress unchecked the inBan>~
matory oedema will track through the vast lymphatic spaces of the supraglottis—
especially the ary-epiglottic folds—and will causemuffling of the voJce-and
respiratory obstruction. Since these spaces are<~larger in children than in
adults, it is a more dangerous disease in childhood.

Examination with a mirror shows a bright red epiglottis, which will become
very swollen as the disease progresses. The oedema will later be seen in
the ary-epiglottic folds and arytenoids and examination will also become
progressively more difficult since it becomes painful and difficult to protrude
the tongue.

TREATMENT. The commonest infecting organism is H. influenzae but whether
it is an opportunistic invader secondary to a viral cause has not yet been
shown. The antibiotic of choice is therefore ampicillin in larger doses than
would be used in acute laryngitis because it is necessary for the drug to
penetrate cartilage.

All other efforts must be towards preventing supraglottic oedema and
respiratory obstruction. In the early stages, inhalations and adrenaline
hydrochloride (1 : 10 000) sprays may be sufficient, but if the oedema
progresses the patient will have to receive at least lOOmg hydrocortisone
intravenously every 4 hours. If respiratory obstruction continues the
patient should have a tracheostomy oecause intubation may be difficult or
impossible, and if the diagnosis is correct the bronchial tree should be
relatively clear. The tracheostomy is only required for a few days provided that
adequate therapy is maintained.

ACUTE LARYNGOTRACHEOBRONCfflTIS

This is a dangerous and common viral infection of the larynx, trachea and
bronchial tree. It is almost confined to children and is seen more commonly in
Australia and the Western side of the United States than elsewhere.

DIAGNOSIS. The onset is relatively sudden and the child's temperature rises;
he complains of a painful cough; the respiratory rate rises and signs of
respiratory obstruction, such as indrawing of the suprasternal notch and
venous engorgement, soon become obvious. There is increasing evidence of
general toxicity.

TREATMENT. The reason that respiratory obstruction is liable to occur early
is that the subglottic region in the child is very lax and oedema occurs early in
the upper trachea and subglottic space. If this were the only problem, then
tracheostomy, if done in time, would prevent any deaths. This is not the case,
however, because the inflammatory process extends downwards to involve the