Pediatric Otolaryngology: Airway, Infection, and Congenital Lesions
Pediatric otolaryngology emphasizes airway size, congenital anomalies, and age-specific infection patterns. Know that the pediatric airway is narrower and more compliant, so small edema causes disproportionate obstruction. Recognize croup (barking cough, steeple sign) versus epiglottitis (drooling, tripod position, thumb sign) and that epiglottitis is now rare with vaccination but remains an airway emergency-do not examine the throat if epiglottitis is suspected.
Understand congenital neck masses: thyroglossal duct cyst (midline, moves with tongue protrusion), branchial cleft cyst (lateral, anterior to sternocleidomastoid), and cystic hygroma/lymphangioma (posterior triangle, transilluminates). Know laryngomalacia as the most common cause of infant stridor (inspiratory, worse supine, resolves with age) and subglottic stenosis as a cause of biphasic stridor.
Know otitis media management: observation for selected older children, antibiotics for young or severe cases, and tympanostomy tubes for recurrent or persistent effusion with hearing/speech impact. Recognize adenotonsillar hypertrophy as a cause of obstructive sleep apnea in children.
Traps: mistaking laryngomalacia for croup; missing foreign body aspiration (sudden choking, unilateral wheeze); and forgetting that retropharyngeal abscess in children can present with neck stiffness and refusal to feed.
Rule of thumb: "Stridor in an infant is laryngomalacia until proven otherwise; stridor in a toddler with fever is croup until proven otherwise."
Worked example: A 6-month-old with inspiratory stridor that worsens when supine and improves with prone positioning likely has laryngomalacia; flexible laryngoscopy confirms the diagnosis and most cases resolve spontaneously.