What is the appropriate management for a 17-month-old toddler presenting with bumps on the posterior oropharynx?

Posterior Oropharynx Bumps in a 17-Month-Old

Most Likely Diagnosis and Initial Assessment

The most common cause of posterior oropharyngeal bumps in a 17-month-old is lymphoid hyperplasia (cobblestoning) from viral pharyngitis, though you must immediately assess for signs of airway obstruction before proceeding with further evaluation. 1

Critical Red Flags Requiring Immediate Action

Assess immediately for life-threatening signs that indicate severe airway compromise 1:

• Silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort - these require emergent airway management 1
• Stridor at rest - indicates significant upper airway narrowing 1, 2
• Inability to handle secretions or drooling - suggests severe obstruction 3
• Oxygen saturation <94% - requires supplemental oxygen 1
• Severe respiratory distress with suprasternal/intercostal retractions 3, 2

Differential Diagnosis by Clinical Presentation

If Child Has Fever and Acute Onset (Hours to Days)

Infectious causes are most likely 4:

• Viral pharyngitis with lymphoid hyperplasia - most common, presents with fever, sore throat, and posterior pharyngeal cobblestoning 1
• Retropharyngeal abscess - presents with fever, neck stiffness, drooling, muffled voice, and can cause severe airway obstruction requiring emergent tracheotomy 5, 4
• Bacterial tracheitis - increasingly common, presents with high fever, toxic appearance, and stridor 2, 4

If Child Has Stridor or Noisy Breathing

Flexible bronchoscopy should be performed for severe or persistent symptoms not responding to standard treatment, associated hoarseness, oxygen desaturation or apnea, or atypical presentation, as up to 68% of infants with stridor have concomitant lower airway abnormalities requiring complete airway evaluation 1, 3.

Common causes include 3, 1:

• Laryngomalacia - most common congenital laryngeal anomaly causing persistent stridor 3
• Croup - presents with barking cough and inspiratory stridor, typically viral etiology 1, 4
• Foreign body aspiration - must be excluded even with negative history, as event may be unwitnessed 6

If Child Has Chronic/Recurrent Symptoms

Consider 3:

• Adenoidal hypertrophy - most common acquired anatomic cause of nasal obstruction in children, presents with mouth breathing, nasal speech, and snoring 3
• Gastroesophageal/laryngopharyngeal reflux - causes posterior pharyngeal inflammation and can present with choking, apneic spells, and recurrent respiratory symptoms 3, 1
• Congenital malformations - may present over time rather than at birth 4

Management Algorithm

Step 1: Stabilize Airway if Compromised

For any child with respiratory distress 1, 2:

• Administer 100% oxygen via face mask to maintain SpO2 ≥94% 1
• Position appropriately: neutral head position with roll under shoulders for children <2 years 1
• Minimize handling to reduce metabolic oxygen requirements 1
• Never perform blind finger sweeps - may push foreign bodies deeper 6, 1

Step 2: Determine Need for Imaging

Clinical assessment takes precedence over radiographs 1:

• Lateral neck radiographs are often unnecessary and should not delay treatment 1
• Normal chest X-ray does NOT exclude foreign body aspiration 6
• MRI may be needed for suspected mass lesions causing obstruction 7

Step 3: Specific Treatment Based on Etiology

For Suspected Croup

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) immediately for all cases 1, 2. Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for moderate-to-severe cases with stridor at rest, but observe for at least 2 hours after last dose due to risk of rebound symptoms 1.

For Suspected Bacterial Infection

Administer injectable cloxacillin, amikacin, and clindamycin for bacterial tracheitis or retropharyngeal abscess 2. Obtain ENT consultation for surgical drainage if abscess suspected 2.

For Suspected Foreign Body

Flexible bronchoscopy is indicated for diagnostic evaluation, as rigid bronchoscopy is generally contraindicated for removal in most pediatric cases 3, 6.

Critical Pitfalls to Avoid

• Do not be falsely reassured by normal radiographs - clinical history of choking is pathognomonic for foreign body until proven otherwise 6
• Do not discharge within 2 hours of nebulized epinephrine due to rebound risk 1
• Do not delay airway management in children with severe obstruction - all patients with audible stridor may require early endotracheal intubation or tracheostomy 2
• Do not assume viral pharyngitis without excluding serious causes - retropharyngeal abscess can cause fatal airway obstruction 5

Disposition Criteria

Consider hospital admission for 1:

• Age <18 months with severe symptoms
• Oxygen saturation <92-93%
• Need for ≥3 doses of nebulized epinephrine
• Inability of family to provide appropriate observation
• Respiratory rate >70 breaths/min

Discharge criteria include 1:

• Reliable family able to monitor and return if worsening
• No stridor at rest after observation period
• Adequate oral intake maintained