Upper respiratory tract infection in pediatrics (URTI) RTI ( respiratory tract infection) IMPORTANCE Nearly 50% of all paediatric consultations in industrialized countries are caused by respiratory tract infections (RTIs). Acute RTIs are among the leading causes of childhood mortality, especially in developing countries.
Their annual incidence per child decreases with age: 6.1 in children less than 1 year 5.7 in children aged 1-2 4.7 in children aged 3-4 3.5 in children aged 5-9 2.7 in children aged 10-14 2.4 in children aged 15-19. Upper respiratory tract infection (URTI) represents the most common acute illness . Rates are highest in children younger than 5 years. Children who attend school
or daycare are a large reservoir for URIs, and they transfer infection to those who care for them. Acute pharyngitis accounts for 1% of all ambulatory visits. The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 years. Rhinopharyngitis Nasopharyngitis (rhinopharyngitis or the common cold) = Inflammation of the nares, pharynx, hypopharynx, uvula, and tonsils Occur year round, but mostly during fall and winter. Epidemics is most
common during cold months, with a peak incidence in late winter to early spring. Humidity may also affect the prevalence of colds, because most viral URI agents thrive in the low humidity characteristic of winter months Etiology of rhinopharyngitis Rhinoviruses: These cause approximately 30-50% RSV Coronaviruses: Enteroviruses, including coxsackieviruses, echoviruses, and others: These
are also leading causes of the common cold. Other viruses: Adenoviruses, orthomyxoviruses (including influenza A and B viruses), paramyxoviruses , EBV, account for many URIs. Varicella, rubella, and rubeola Bacteria ( very rare): streptococci , staph, diphteria, B pertussis, Haemophilus, Pneumococcus, Neisseria, Treponema
Risk factors for URIs Contact: Close contact with small children settings, Contact: Close contact with small children settings, such as school or daycare, increases the risk of URI. Travel: , exposure to large numbers of individuals in closed settings. Increased exposure to respiratory pathogens Environmental factors such as passive smoking and exposure to pollutants Immunocompromise that affects cellular or humoral immunity: Splenectomy, HIV infection, corticosteroids, immunosuppressive treatment , familial predisposition with immunological defects or anatomical and/or physiological features Malnutrition Atopic status Lack of breast-feeding Cilia dyskinesia syndrome and cystic fibrosis
Anatomic changes due to facial dysmorphisms Upper airway trauma, and nasal polyposis Anemia, rickets, malnutrition Carrier state Pathophysiology URI Direct invasion of the mucosa lining the upper airway Person-to-person spread of viruses by hand with pathogens to the nose or mouth or inhaling respiratory droplets from an infected
person who is coughing or sneezing. Barriers, including physical, mechanical, humoral, and cellular immune defenses. Hair lining the nose filters Mucus coats Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx, where they are then swallowed into the stomach Adenoids and tonsils contain immune cells that respond to pathogens. local swelling, erythema, edema, secretions,
and fever, result from the inflammatory response of the immune system to invading pathogens and from toxins initial nasopharyngeal infection may spread to adjacent structures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, tracheobronchitis, and pneumonia Humoral immunity (immunoglobulin A) and cellular immunity Normal nasopharyngeal flora, including various staphylococcal and streptococcal species, help defend against potential pathogens Suboptimal humoral and phagocytic immune function have URI increased risk and have severe or prolonged course of disease. SYMPTOMS OF RF
Nasal obstruction Congestion of nasal breathing Sneezing Rhinorrhea : secretions often evolve from clear to opaque white to green to yellow within 2-3 days of symptom onset Cough Anorrhexia Fever 5-10 days Foul breath: This occurs as resident flora process the products of the inflammatory process. Hyposmia: Also termed anosmia, it is secondary to nasal inflammation. Headache
Sinus symptoms: These may include congestion or pressure and are common with viral URIs. Photophobia or conjunctivitis: adenovirus . Influenza : pain behind the eyes, pain with eye movement, or conjunctivitis. Itchy, watery eyes are common in patients with allergic conditions. Fever: This is usually slight or absent, but temperatures can reach 39.5C in infants and young children. If present, fever typically lasts for only a few days. Gastrointestinal symptoms: Symptoms such as nausea, vomiting, and diarrhea may occur in persons with influenza, especially in children. Nausea and abdominal pain may be present in individuals with strep throat and viral syndromes. LABORATORY
CBC, ES, CRP, to find bacterian infection, Leucocytosis with neutrophilia suggest bacterian, low level of WBC, lymphocytes raised in viral infections Because viruses cause most URIs, the diagnostic role of laboratory investigations and radiologic studies is limited. Viral culture, rapid antigen detection, or polymerase chain reaction (PCR) assay of influenza virus on a nasopharyngeal swab could be done if specific antiviral therapy is recommended. Similar tests are also available for adenovirus, respiratory syncytial virus, and parainfluenza virus.
The use of reverse-transcriptase PCR for the diagnosis of enterovirus and rhinovirus infections is not currently available for daily clinical care. Serologic tests for mononucleosis Influenza serologies only have epidemiologic value and should not be used for clinical care. A pharyngeal swab for rapid antigen detection of GABHS (Group A BetaHemolytic Streptococci ) is 90% sensitive and 95% specific NOSE AND THROAT cultures COMPLICATIONS
Sinusitis is a complication in only approximately 2% of persons with viral URIs Otitis Epiglottitis occurs at a rate of 6-14 cases per 100,000 children Croup, or laryngotracheobronchitis usually occurs in children aged 6 months to 6 years with peak incidence in the second year of life Pneumonia Digestive complications: anorrhexia, vomiting, diarrhea, dehidration, Seizures may appear when fever is more than 38,5 C Imaging Studies for URTI
A lateral neck radiograph should be taken in a patient with stridor to assess the airways if epiglottitis is clinically suspected Chest radiography should be reserved for patients with acute tracheobronchitis , those with abnormal vital signs or signs of consolidation on chest examination, or those with persistent symptoms for longer than 3 weeks. Plain radiography has been largely replaced by computed tomography (CT) in the evaluation of sinusitis, particularly in preparation for corrective surgery. Complete opacification and air-fluid level are the most specific findings for acute sinusitis.
However, a large proportion of patients with the common cold have radiologic abnormalities on CT. Imaging is recommended for patients who do not respond to treatment with antibiotics and decongestants, but is not advised for the diagnosis of uncomplicated sinusitis. Mastoiditis and other intracranial complications of URIs should be evaluated by CT or magnetic resonance imaging. PREVENTION AND TREATMENT Prevention : VACCINES, IMMUNOSTIMULANTS, VITAMINS Parent education on risk factor modification, in particular avoiding smoking indoors General hygiene methods for children attending day care centres Breast feeding Management
Rest Lot of fluid intake. Nasal wash with hypertonic salt water or 0.9% saline Decongestants to unblock the opening of sinuses and reduce symptoms of nasal congestion in children above 3 years Paracetamol 30-40 mg/kg/day for fever and pain reliever Antibiotics to treat the bacterial infection very rare ( fever, ES high, CRP+leucocytosis, children with immune handicaps) ADENOIDITIS Adenoids begin forming in 3rd month of fetal development Covered by pseudostratified ciliated epithelium Fully formed by 7 month
Palatine tonsils begin development in 3rd month of fetal development Acute adenoiditis ! Symptoms include: Purulent rhinorrhea Nasal obstruction Fever Frequent complication: otitis media Recurrent Acute Adenoiditis
! 4 or more episodes of acute adenoiditis in a 6 month period ! Similar presentation as recurrent acute rhinosinusitis ! In older children nasal endoscopy can help Chronic adenoiditis ! Symptoms include: Persistent rhinorrhea Postnasal drip Malodorous breath Associated otitis media >3 months Think of reflux
Obstructive Adenoid Hyperplasia ! Signs and Symptoms Obligate mouth breathing Hyponasal voice Snoring and other signs of sleep disturbance Obstructive Tonsillar Hyperplasia ! Snoring and other symptoms of sleep disturbance ! Muffled voice
! Dysphagia Surgery to Remove the Adenoids Adenoids are lymph nodes located high in the back of the throat. They can become enlarged from repeated ear infections and can affect the Eustachian tubes that connect the middle ears and the back of the nose. An adenoidectomy (removal of the adenoids) may help children with recurring ear infections have fewer of them. Adenoidectomy is typically done when recurring ear infections continue despite antibiotic treatment. ACUTE PHARYNGITIS (TONSILITIS)
viral pharyngitis Adenovirus, which may also cause laryngitis and conjunctivitis Influenza viruses Coxsackievirus HSV EBV (infectious mononucleosis) Cytomegalovirus causes of bacterial pharyngitis Group A streptococci (approximately 15% of all cases of pharyngitis) Group C and G streptococci N gonorrhoeae Arcanobacterium (Corynebacterium) hemolyticum Corynebacterium diphtheriae Atypical bacteria (eg, M pneumoniae, C pneumoniae): Anaerobic bacteria
Immunology and Function TONSILS AND ADENOIDS ! Part of secondary immune system ! Exposed to ingested or inspired antigens passed through the epithelial layer ! Immunologic structure is divided into 4 compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle
Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle ! Antigen is presented to T-helper cells ! T-helper cells induce B cells in germinal center to produce antibody ! Secretory IgA is primary antibody produced ! Involved in local immunity Acute Tonsillitis
Signs and symptoms: Fever Sore throat Tender cervical lymphadenopathy Dysphagia Erythematous tonsils with exudates Pharyngeal erythema: Marked erythema :adenoviral infection. In contrast, rhinoviral and coronaviral infections do not have severe erythema. Exudates: half the patients with adenovirus infections. Exudative pharyngitis and tonsillitis may be seen with mononucleosis caused by EBV Yellow or green secretions do not differentiate a bacterial pharyngitis
from a viral one. Foul breath: This may be noted because resident florae process the products of the inflammatory process. Conjunctivitis -adenovirus. Scleral icterus - infectious mononucleosis. Rhinorrhea - viral cause.
Tonsillopharyngeal/palatal petechiae - GAS infections and infectious mononucleosis. A tonsillopharyngeal exudate - streptococcal infectious mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections. exudate does not differentiate viral and bacterial causes. Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus Lymphadenopathy Cardiovascular: Murmurs Pulmonary: Pharyngitis and lower respiratory tract infections with M pneumoniae or C pneumoniae, Abdomen: Hepatosplenomegaly - mononucleosis infection
Tonsillar hypertrophy: Peritonsillar abscess may manifest as unilateral palatal and tonsillar pillar swelling, with downward and medial tonsil displacement; the uvula may tilt to the opposite side. Bulging of the posterior pharyngeal wall may signal a retropharyngeal abscess. Tender anterior cervical adenopathy: This may be present with streptococcal infection or with viral infections. In persons with diphtheria, submandibular and anterior cervical edema may be present along with adenopathy. Erythema: This may be especially prominent in persons with group A streptococcal pharyngitis. Palatal petechiae may be seen. Exudates of the pharynx: These are common
with bacterial pharyngitis, manifesting as white or yellow patches. A whitish coating may appear on the tongue, causing the normal bumps to appear more prominent. Yellow or green coloration does not differentiate bacterial pharyngitis from a viral nasopharyngitis. A whitish adherent membrane forming on the nasal septum, along with a mucopurulent blood-tinged discharge, should prompt a consideration of diphtheria. Pharyngeal and tonsillar diphtheria may manifest as an adherent bluewhite or gray-green membrane over the tonsils or soft palate; if bleeding has occurred, the membrane may appear blackish.
Fever: Compared with other URIs, group A streptococcal infections are more likely cause fever, with temperatures around 38.3C fever is not reliable to differentiate viral or bacterial etiologies. Group A beta-hemolytic streptococci: The classic clinical picture includes a fever, tonsillopharyngeal erythema and exudate; swollen, tender anterior cervical adenopathy; headache; emesis in children; palatal petechiae; midwinter to early spring season; and absent cough or rhinorrhea.
Conjunctivitis: This symptom may be seen with adenoviral pharyngoconjunctival fever and is present in one half to one third of all adenoviral URIs. Watery, injected conjunctiva may also be seen with allergic conditions. Cough: This is more suggestive of a viral than a bacterial etiology. Diarrhea: If associated with a URI, it suggests a viral etiology. Fever: EBV infections and influenza cause fever. Bacterial pharyngitis This may be difficult to distinguish from viral pharyngitis. Assessment for group A streptococci warrants special attention. Physical findings that suggest a high risk for group A streptococcal disease are erythema,
swelling, or exudates of the tonsils or pharynx; temperature of 38.3C or higher; tender anterior cervical nodes (>1 cm); and an absence of conjunctivitis, cough, or rhinorrhea, which are suggestive of viral illness. Mucosal ulcers, erosions, vesicles: The presence of palatal vesicles or shallow ulcers is characteristic of primary infection with HSV. Ulcerative stomatitis may also occur in coxsackievirus or other enteroviral infection. Mucosal erosions may also be seen in primary HIV infection. Small vesicles on the soft palate, uvula, and anterior tonsillar pillars suggest infection by coxsackievirus, known as herpangina. Tonsillar hypertrophy Foul breath: Halitosis may be noted because resident florae process the products of the inflammatory process. Anterior cervical lymphadenopathy: This is seen with viral and bacterial infections.
Approximately half of EBV mononucleosis cases involve generalized adenopathy or splenomegaly. An enlarged liver may also be palpable. Primary HIV infection may also include lymphadenopathy. A rash may be seen with group A streptococcal infections, particularly in patients younger than 18 years. This scarlet fever rash appears as tiny papules over the chest and abdomen, creating roughness like sunburned appearance. The rash spreads, causing erythema in the groin and armpits. The face may be flushed, with pallor around the lips. Approximately 2-5 days later, the rash
begins to resolve. Peeling is often noted on the tips of toes and fingers COMPLICATIONS In the neighbourhood: Adenitis Retropharyngeal abscess Peritonsilar abcess Otitis Sinusitis ( epiglotitis) At distance:
acute glomerulonephritis, acute rheumatic fever, and rheumatic heart disease toxic shock syndrome for GAS ( group A Streptococcus ) Recurrent Acute Tonsillitis ! Same signs and symptoms as acute ! Occurring in 4-7 separate episodes per year ! 5 episodes per year for 2 years ! 3 episodes per year for 3 years Medical Management
! Penicillin is first line treatment ! Recurrent or unresponsive infections require treatment with beta-lactamase resistant antibiotics such as Erytromycin, Claritromycin Clindamycin Augmentin: 30-40 mg/kg in 2 doses. Syrup, tablets Cephalosporins ( Ist and II gen)
Tonsillectomy ! Current clinical indicators : 3 or more infections per year despite adequate medical therapy Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by orthodontist Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorder, cardiopulmonary complications
Peritonsillar abscess ! Abscess formation outside tonsillar capsule ! Signs and symptoms: Fever Sore throat Dysphagia/odynophagia Drooling Trismus Unilateral swelling of soft palate/pharynx with uvula
deviation Peritonsillar abscess Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy Chronic or recurrent tonsillitis associated with
streptococcal carrier state and not responding to betalactamase resistant antibiotics Unilateral tonsil hypertrophy presumed neoplastic Chronic Tonsillitis ! Chronic sore throat ! Malodorous breath ! Presence of tonsilliths ! Peritonsillar erythema ! Persistent tender cervical lymphadenopathy ! Lasting at least 3 months
OTITIS MEDIA The eustachian tubes equalize the pressure between the middle ear cavity and the outside atmosphere and allow fluid and mucus to drain out of the middle ear cavity. Inflammation of the middle ear causes the tubes to close causing the fluid to become trapped. Bacteria from the back of the nose travel through the eustachian tube directly into the middle ear cavity and multiply in the fluid. The inflammation can occur as a result of an infection extending up the eustachian tube. This tube may become blocked by a bacterial or viral infection or by enlarged adenoids. Fluid produced by the inflammation cannot drain off through the tube and instead collects in the middle ear. The Eustachian tube is a canal that connects
the middle ear to the throat. It is lined with mucus, just like the nose and throat; it helps clear fluid out of the middle ear and into the nasal passages. Cold, flu, and allergies can irritate the Eustachian tube and cause the lining of this passageway to become swollen. Ear Infection diagnose an ear infection by looking at the outer ear and the eardrum
with a device called an otoscope. A healthy eardrum (shown here) appears transparent and pinkish-gray. An infected eardrum looks red and swollen. If the Eustachian tube becomes blocked, fluid builds up in the middle ear. This creates an environment for bacteria and viruses, which can cause infection; fluid is detected in the middle ear with a pneumatic otoscope. This device
blows a small amount of air at the eardrum, making the eardrum vibrate. If fluid is present, the eardrum will not move as much as it should. Ruptured Eardrum When too much fluid builds up in the middle ear, it can put pressure on the eardrum until it ruptures (shown here). Signs of a ruptured eardrum include yellow, brown, or white fluid draining from the ear. Pain may disappear suddenly because the pressure of the fluid on the
eardrum is gone. Although a ruptured eardrum sounds frightening, it usually heals itself in a couple of weeks. SIGNS AND SYMPTOMS Ear Infection Symptom Sudden, piercing pain in the ear which may be worse
when lying down, making it difficult to sleep. Trouble hearing. A fever of up to 40 C . Tugging or pulling at one or both ears. Fluid drainage from ears. Loss of balance. Nausea, vomiting, or diarrhea. Congestion. Ear Infection Symptoms: Babies It can be difficult to identify an ear infection in babies or children :crankiness, trouble sleeping, and loss of appetite. Babies may push their bottles away because pressure in the middle ear makes it painful to swallow. Laboratory
WBC, ES, Fg, CRP, high if bacterian Local exam with otoscope Cultures of otic discharge Imagery when progresses through otomastoiditis COMPLCATIONS CRONIC OTITIS OTOMASTOIDITIS DEAFNESS CEREBRAL VENOUS TROMBOSIS CEREBRAL ABCESS
MENINGITIS DIARRHEEA, DEHIDRATION SEIZURES PREVENTION OF OTITIS MEDIA Encouraging breast-feeding Feeding child upright if bottle fed Avoiding exposure to passive smoke Teaching adults and children careful hand washing technique Limiting exposure to viral upper respiratory infections Ensure immunizations are up-to-date; including influenza and 7 valent
conjugated polysaccharide vaccine (PCV7) One solution is for your doctor to insert small tubes through the eardrum. Ear tubes let fluid drain out of the middle ear and prevent fluid from building back up. This can decrease pressure and pain, while restoring hearing. The tubes are usually left in for 8 to 18 months until they fall out on their own. Treatment of otitis media
Desinfection of nasopharynx Analgesics (oral and topical pain killing therapy) Paracetamol, ibuprophene, NO aspirin Children with low risk be treated with a wait-and-see approach. Low-dose amoxicillin (40 mg/kg/day) may be used if low risk (greater than two years, no day care, and no antibiotics for the past three months) Failure to respond to initial treatment drug (resistant or persistent acute otitis media)
amoxicillin/clavulanate potassium, cefuroxime axetil, cefpodoxime proxetil. Trimethoprim sulfamethoxasone: Bactrim, biseptol 6-8 mg/kg in 2 daily doses Clarithromycin 15-20 mg/kg Erythromycin ethylsuccinate and sulfisoxazole acetyl: 3040mg/kg Azithromycin a single dose of ceftriaxone 50 mg/kg could be equivalent to a 10-day course of oral antibiotics for new cases of acute otitis media ceftriaxone sodium: prescribe one dose for new onset otitis media and a three-day course for a truly resistant pattern of otitis media or if oral treatment cannot be given, 5 days Acute inflamation of larynx Laryngotracheobronchiti
s (croup) is a viral infection of the upper respiratory tract that causes varying degrees of airway obstruction prodrome of several days of fever and symptoms of mild upper respiratory infection the infection extends to the proximal trachea, diffuse inflammation with exudate and edema of the subglottic area causes narrowing of the airway. 5 cases per 100 children per year during the second year of life
Typically, between 6 pm and 6 am, the child develops stridor (mainly inspiratory), hoarseness, and barking cough. Worsening symptoms on the second night of the illness.
The child is fatigued. Physical The physical examination may range from totally unremarkable on presentation to severe respiratory distress. Restless (common); prefers sitting upright in a parent's lap Appears nontoxic Normal voice or laryngitis Mild fever Tachycardia Tachypnea Varying stridor, predominantly inspiratory Absence of drooling Retractions of the accessory chest muscles No change in stridor with positioning ETIOLOGY
parainfluenza type 1, although parainfluenza type 2 and type 3 also may cause disease. Paramyxovirus Influenza virus type A Respiratory syncytial virus (RSV) Adenovirus Rhinoviruses Enterovirus Coxsackievirus Enteric cytopathogenic human orphan virus (ECHO virus) Reovirus Measles virus DIFFERENTIAL DG
Diphtheria Foreign Bodies IN Trachea Epiglottitis Foreign Body Ingestion Subglottic stenosis Retropharyngeal abscess Subglottic hemangioma Laboratory
A pulse oximetry measurement CBC count Leukopenia in early stage of illness, leukocytosis in later stage of patients with severe disease Anteroposterior (AP) soft tissue neck radiograph may show subglottic narrowing Rapid antigen tests Direct laryngoscopy Fiberoptic laryngoscopy Bronchoscopy Treatment Make the child as comfortable as possible.
Avoid agitating the child Humidified air or mist therapy may be used, but both have unproven efficacy. Provide oxygen (humidified) L -epinephrine (1:1000) is as effective as racemic epinephrine. Dexamethasone has been shown to reduce symptoms in patients with moderate-to-severe croup. (0.6 mg/kg IM, not to exceed 10 mg) Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled Decadron is also used when budesonide is unavailable. Racemic epinephrine: 0.25-0.5 mL of 2.25% solution (equivalent to 1% epinephrine) via nebulizer (diluted in 3 mL
of isotonic sodium chloride solution or sterile water); may be repeated 3 times Antiinflamatory: paracetamol, ibuprophen Antibiotherapy: amoxicillin, augmentin, cephalosporin, macrolides Epiglottitis Epiglottitis, also termed supraglottitis, is an inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft tissue, and,
occasionally, the uvula. This condition is more often found in children aged 1-5 years who present with a sudden onset of symptoms: Sore throat Drooling, odynophagia or dysphagia, difficulty or pain during swallowing, globus sensation of a lump in the throat Muffled dysphonia or loss of voice Dry cough or no cough, dyspnea Fever, fatigue or malaise Etiology H influenza type B (HiB) and Streptococcus pneumonia, pneumonia S aureus, Varicella can cause a primary or secondary infection often with group A betahemolytic streptococci,C
albicans, especially in immunocompromised patients.Several viruses, including herpes species and parainfluenza The clinical triad of drooling, dysphagia, and distress is the classic presentation. Fever with associated respiratory distress or air hunger occurs in most patients. the patient appears acutely ill, anxious, and usually assumes a characteristic tripod position child may have stridorous respirations, but as the disease progresses, airway sounds may diminish. Additional signs of
upper airway obstruction are also evident including suprasternal, subcostal, and intercostal retractions. Pathophysiology Bacterial infection of the epiglottis leads to acute onset of inflammatory edema, beginning on the lingual surface of the epiglottis where the submucosa is loosely attached. Swelling significantly reduces the airway aperture. Edema rapidly progresses to involve the aryepiglottic folds, the arytenoids, and the entire supraglottic larynx. The tightly bound epithelium on the vocal cords halts edema spread at this level. Aspiration of oropharyngeal secretions or mucus plugging can cause respiratory arrest. Mortality rates as high as 10% can occur in children
whose airways are not protected by endotracheal incubation. With endotracheal intubation, mortality is less than 1%. Differential Diagnoses Bacterial tracheitis Pediatrics, Pertussis Foreign Bodies, Trachea Pharyngitis Mononucleosis Pneumonia Anaphylaxis Peritonsillar Abscess Croup or Laryngotracheobronchitis Retropharyngeal Abscess Foreign Body Ingestion Toxicity, Caustic Ingestions Laboratory
CBC, ESR, Fg, CRP, Oximetry (periferal O2 concentratin in Blood cultures and culture of the epiglottis ) In cases of HiB epiglottitis, blood cultures Lateral neck radiographs may show an enlarged epiglottis. Chest radiography may also reveal a pneumonia CT scan of the neck Treatment EMERGENCY:
Immediate transport to the nearest appropriate facility Position of comfort. Oxygen Orotracheal intubation or needle cricothyroidotomy may be necessary in emergent situations Percutaneous transtracheal ventilation Also termed needle cricothyroidotomy or translaryngeal ventilation, percutaneous transtracheal ventilation is a temporizing method used to treat cases of severe epiglottitis when the patient cannot be intubated proceeding to a formal tracheostomy. Percutaneous transtracheal ventilation involves inserting a needle through the cricothyroid membrane, which lies inferior to the thyroid cartilage and superior to the cricoid cartilage.
The cricothyroid artery typically courses through the superior portion of the membrane. Antibiotics Empiric antimicrobial therapy must cover all likely pathogens in the context of the clinical setting for 7-10 days Ceftriaxone (Rocephin) 75-100 mg/kg/d IV q12-24h Ampicillin 100-200 mg/kg/d IV divided q6h Clindamycin 25-40 mg/kg/d IV divided q68h
Ampicillin and sulbactam (Unasyn) 3 months to 12 years: 100-200 mg ampicillin/ kg/d (150-300 mg Unasyn) IV divided q6h SINUSITIS Chronic maxillary sinusitis , frontal sinusitis. Etiology and risk factors: viral upper respiratory tract infections (URTIs) or nasal allergies and the host response to these insults,allergic rhinitis, anatomical abnormalities,gastroesophageal reflux (GER), immune deficiency, and disorders of ciliary function Approximately 5-13% of URTIs are complicated by bacterial sinusitis Children are susceptible to serious sequelae
from a complication of sinusitis such as orbital cellulites (in about 9.3% of the cases) and intracranial complications (in 3.7-11% of patients). ETIOLOGY Streptococcus pneumoniae - 20-30% Haemophilus influenzae - 15-20% Moraxella catarrhalis - 15-20% Streptococcus pyogenes (beta-hemolytic) - 5% Chronic sinusitis more commonly a polymicrobial infection Commonly cultured bacteria Alpha-hemolytic streptococci
Staphylococcus aureus Coagulase-negative staphylococci Nontypeable H influenzae More common than acute sinusitis Moraxella catarrhalis Anaerobic bacteria, including Peptostreptococcus, Prevotella, Bacteroides, andFusobacterium species Pseudomonads - More common after multiple courses of antibiotics; consider immunodeficiency Several anatomical abnormalities of the lateral nasal wall can predispose to sinusitis. Immune deficiencies are more common in the general population than cystic fibrosis or ciliary disorders. In order of decreasing prevalence, the most common
types are common variable, immunoglobulin G (IgG) subclass, and selective antibody. Impaired nasal function increases postnasal drip and irritant burden on the lower airways, which can exacerbate asthma symptoms. Gastroesophageal reflux disease ( GER may lead to inflammation of the eustachian tube orifices or sinus ostia secondary to mucosal irritation. ) SIGNS AND SYMPTOMS Signs and symptoms of severe infection :
Nasal congestion Infrequent fever Otitis media (50-60% of patients) Irritability Headache Purulent rhinorrhea High fever (ie, >39C) Periorbital edema Uncomplicated sinusitis spontaneously resolves in 40% of patients.
Acute sinusitis :signs and symptoms normally clear within 30 days; URTI symptoms persisting longer than 7-10 days suggest acute sinusitis Chronic sinusitis is defined as low-grade persistence of signs and/or symptoms lasting longer than 90 days without improvement. The patient may have 6 or more recurrent episodes per year. The patient may have a history of acute exacerbations without ever being completely well between episodes. Night time cough is more prevalent. Anterior rhinoscopy Difficult in young children. Examine the middle turbinate and middle meatus for
evidence of purulence or sinus discharge with a vasoconstrictive agent, such as oxymetazoline and lidocaine. Polyps may suggest cystic fibrosis. Laboratory and Imagery CBC, ES, Fg, IgE, CT scanning is the criterion standard for evaluation of both mucosal inflammation and anatomical abnormalities in the paranasal sinuses. Plain radiography/sinus series Rigid or flexible nasal endoscopy Indications for maxillary sinus puncture in children include the following:
Severe toxic illness Acute illness unresponsive to antibiotics within 72 hours Immunocompromised patients Suppurative complications Workup for fever of unknown origin Nasal and maxillary cultures. Complications Preseptal cellulitis - Eyelid edema, erythema, normal globe movement Orbital cellulitis - Proptosis, chemosis
Periorbital abscess - Proptosis with globe displaced inferolaterally, decreased extraocular muscle movement Orbital abscess - Severe proptosis, impaired visual acuity, fixed globe, toxic patient Cavernous sinus thrombosis - High fever, bilateral symptoms Intracranial involvement usually occurs subsequent to direct spread from sphenoid or frontal sinus disease. Subdural and frontal lobe abscesses are most common. Meningitis may occur. TREATMENT Nasal decongestants and mucolytics orally or nebulization are effective Antibiotherapy: uncomplicated cases of acute sinusitis are responsive to amoxicillin; for children allergic to penicillin, a second- or third-generation cephalosporin can be used ; a macrolide or clindamycin can be used. Amoxicillin: 80 mg/kg/d PO divided bid; consider in children in large day care settings
Amoxicillin-clavulanate (Augmentin) <3 months: 125 mg/5mL PO susp based on amoxicillin; 30 mg/kg/d divided bid for 7-10 d >3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/ d PO divided q12h; if using 125 mg/5 mL or 250 mg/5 mL suspension, 40 mg/kg/d PO divided q8h for 7-10 d, or high dose 80-90 mg/kg/d PO divided bid Cefuroxime 20-30 mg/kg/d PO divided bid Azithromycin (Zithromax) 10 mg/kg PO first d, 5 mg/kg/d PO next 4d Vancomycin:10 mg/kg IV q6 h Clindamycin: 8-20 mg/kg/d PO divided tid/qid 20-40 mg IV divided q6-8h Allergic rhinitis: Measures include allergen
avoidance, optimal environment, nasal steroids, a second-generation antihistamine, and possible immunotherapy. Gastroesophageal reflux: Conservative measures include elevating the head of the bed, not feeding immediately before bedtime, and thickening feeds. Medical therapy includes H-2 blockers, prokinetic agents, and hydrogen ion pump inhibitors. Consider surgery as a last resort in the pediatric population