Download URTI & OM

Runny nose and Throat pain
(URTI, Tonsillitis & OM)
The common cold
• The common cold (viral upper respiratory infection) is the most
common pediatric infectious disease, and the incidence is higher in
early childhood than in any other period of life. Children younger than
5 years typically have 6–12 colds per year. Approximately 30%–40% of
these are caused by rhinoviruses. Other culprits include adenoviruses,
coronaviruses, enteroviruses, influenza and parainfluenza viruses, and
respiratory syncytial virus.
ESSENTIALS OF DIAGNOSIS (common cold)
• Clear or mucoid rhinorrhea, nasal congestion, sore throat. Possible
fever, particularly in younger children (under 5–6 years). Symptoms
resolve by 7–10 days.
Differential diagnosis (common cold)
• Rhinosinusitis (acute or chronic), allergic rhinitis, nonallergic rhinitis,
influenza, pneumonia, gastroesophageal reflux disease, asthma, and
bronchitis.
Clinical findings (common cold)
• The patient usually experiences a sudden onset of clear or mucoid
rhinorrhea, nasal congestion, sneezing, and sore throat. Cough or fever
may develop. The nose, throat, and TMs may appear red and inflamed.
The average duration of symptoms is about 1 week. Nasal secretions
tend to become thicker and more purulent after day 2 of infection due
to shedding of epithelial cells and influx of neutrophils.
• This discoloration should not be assumed to be a sign of bacterial
rhinosinusitis, unless it persists beyond 10–14 days, by which time the
patient should be experiencing significant symptomatic improvement.
A mild cough may persist for 2–3 weeks following resolution of other
symptoms.
Management (common cold)
• Treatment for the common cold is symptomatic. Because colds are viral
infections, antibiotics will not cure or shorten their length. Acetaminophen
or ibuprofen can be helpful for fever and pain. Humidification may provide
relief for congestion and cough. Nasal saline drops and bulb suctioning may
be used for an infant or child unable to blow his or her nose. Studies have
shown that antitussives, antihistamines, antihistamine-decongestant
combinations and antitussive-bronchodilator combinations are no more
effective than placebo. Education and reassurance may be the most
important “therapy” for the common cold. Parents should be informed
about the expected nature and duration of symptoms, efficacy and potential
side effects of medications, and the signs and symptoms of complications of
the common cold, such as bacterial rhinosinusitis, bronchiolitis, or
pneumonia.
Pharyngitis & Tonsillitis - Description
• Pharyngitis specifically refers to inflammation of the pharynx as
indicated by erythema and swelling of the structures in the posterior
portion of the oral cavity including the tonsillar pillars, the tonsils, the
inferior soft palate, the uvula, and the posterior wall.
• Pharyngitis is usually caused by viral or bacterial infections.
ETIOLOGY (pharyngitis)
• Viral; Common causes: adenovirus, Epstein-Barr virus (EBV), influenza
A and B, enteroviruses (specifically, coxsackievirus A), herpes simplex
virus.
• Bacterial; Common: Streptococcus pyogenes (group A β-hemolytic
Streptococcus). Uncommon: Mycoplasma pneumoniae, group C or G
streptococci, N. gonorrhoeae, oral anaerobes.
• Fungal: Candida species (oral thrush).
GENERAL PREVENTION (pharyngitis)
• Most infectious agents that causes pharyngitis are spread through
contact with respiratory droplets or other body fluids. Careful hand
washing and avoiding respiratory secretions are key to minimizing
transmission. Children diagnosed with GAS pharyngitis should be kept
at home for 24 hours after starting antibiotics. Children with
pharyngitis due to presumed viral etiology should be fever-free for 24
hours and have symptoms under control prior to return.
History (pharyngitis)
• Typical: sore throat, fever, headache, nausea, vomiting, abdominal
pain (suggest GAS pharyngitis). Rhinorrhea, cough, hoarseness,
stridor, conjunctivitis (suggest viral etiology). Pharyngitis associated
with rhinorrhea, cough, hoarseness, conjunctivitis, diarrhea, or
nonspecific rash is more likely to have a viral cause. Significant
systemic complaints such as fever and malaise are characteristic of
EBV.
PHYSICAL EXAM (pharyngitis)
• Pharynx and oral cavity; Exudative tonsillitis suggestive of GAS but
also present in EBV, N. gonorrhoeae, Arcanobacterium, HSV,
adenovirus. Ulcers on tonsils or tonsillar pillars seen in coxsackievirus,
HSV, echovirus. Lymph nodes; Tender anterior lymphadenopathy
more common in GAS pharyngitis. Diffuse LAD, splenomegaly
suggests EBV. Rash; Scarlatiniform rash (diffuse, erythematous, finepapular, “sandpapery” rash) key feature of scarlet fever from GAS
pharyngitis. Nonspecific, diffuse rash can be associated with viral
infection; may be seen shortly after starting antibiotic if underlying
etiology is EBV. Vesicular lesions on hands, feet, and/or buttocks
characteristic of coxsackievirus.
DIAGNOSIS TESTS & INTERPRETATION (pharyngitis)
• Lab; Rapid antigen detection test (RADT): The diagnosis of GAS
pharyngitis should not be made based on clinical features alone but
should be confirmed by laboratory testing. Therefore, a good test to rule
in GAS, but culture or DNA probe should be used to confirm negative
RADTs. RADT is not recommended when patients present with symptoms
that strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral
ulcers). Monospot (heterophile antibody) test; Detects presence of IgM
for EBV. >10% atypical lymphocytes plus a positive heterophile antibody
test is diagnostic of acute EBV infection.
TREATMENT (pharyngitis)
• General Measures; Treatment is largely supportive for most viral causes of
pharyngitis, including pain control and hydration.
• MEDICATION First Line; Oral penicillin V for 10 days. Amoxicillin for 10 days.
Intramuscular (IM) penicillin G benzathine.
Second Line; A 10-day course of a 1st-generation oral cephalosporin .
Azithromycin for 5 days. Clarithromycin for 10 days or Erythromycin. In
patients with EBV, antibiotics should not be given; in particular, if amoxicillin
or ampicillin is given, a high proportion of patients will develop a
nonallergic rash. Short-course corticosteroids may be beneficial but can also
have significant adverse effects; should only be used in patients with
marked tonsillar inflammation and impending airway obstruction.
Complications (pharyngitis)
• Streptococcal pharyngitis. Suppurative complications include
peritonsillar abscess, and mastoiditis. Most significant
nonsuppurative complication is ARF. This can be prevented if
adequate antibiotic treatment is provided within 10 days. Another
nonsuppurative complication is post streptococcal
glomerulonephritis.
Otitis media-DESCRIPTION
• Otitis media is a general term for middle ear inflammation with or
without symptoms. It can be acute or chronic.
• Two specific diagnoses;
1. Otitis media with effusion, middle ear effusion (MEE)
2. Acute otitis media (AOM)
─ Uncomplicated/non severe
─ Severe
─ Recurrent
RISK FACTORS (OM)
• Age <2 years, Gender: male >female, Family history of AOM,
Anatomic differences; craniofacial abnormalities, environmental
tobacco smoke exposure, Exposure to large numbers of other
children, Day care, Siblings in home.
GENERAL PREVENTION (OM)
• Breastfeeding for at least 3–6 months, decreased pacifier use after 6
months, Vaccines; Pneumococcal conjugate vaccine, Influenza
vaccine. Reduction in secondhand smoke, Reduction of day care
crowding.
PATHOPHYSIOLOGY & ETIOLOGY (OM)
• Eustachian tube dysfunction leads to MEE. If effusion is not cleared by the
mucocilliary system, bacteria and viruses have a good environment for
growth.
Causes:
• Viruses: 40–75%.
• Bacterial: Non-typeable Hemophilus influenzae: 35–50%, Streptococcus
pneumoniae: 25–40%, Moraxella catarrhalis: 5–10% Group A Streptococcus
(3%), Staphylococcus aureus (2%), Gram-negative organisms such as
Pseudomonas aeruginosa: 1–2% (More common in neonatal AOM).
HISTORY & PHYSICAL EXAM (OM)
• Recent abrupt onset of signs and symptoms of middle ear inflammation
and MEE. Ear pain for >48 hours. New onset otorrhea not caused by
acute otitis externa. Fever. Irritability. Recent treatment with antibiotics.
• Look for other causes of fever and irritability in children. Physical exam is
best done with pneumatic otoscopy: The patient should be adequately
restrained if uncooperative. Cerumen should be removed if view of
tympanic membrane (TM) is inadequate. Visualize TM at rest and with
gentle positive and negative pressure via pneumatic otoscopy. The
presence of MEE is determined by the characteristics of the TM. A
diagnosis of AOM is suggested if MEE is present along with ear pain,
fever, erythema, fullness, or bulging of TM. The concomitant presence of
conjunctivitis (otitis media–conjunctivitis syndrome) suggests the
presence of H. influenzae or a virus as a causative organism.
MEDICATION (OM)
• Note: AOM management should include pain evaluation and treatment.
• Initial treatment for suspicion of bacterial OM: Amoxicillin (80–90 mg/kg/24 h PO
divided b.i.d.). Antibiotic treatment after 48–72 hours of no improvement;
Amoxicillin-clavulanate (90 mg/kg/24 h amoxicillin and 12.8 mg/kg/24 h
clavulanate PO divided b.i.d.). (Has received amoxicillin in the last 30 days,
Concurrent purulent conjunctivitis, History of recurrent AOM unresponsive to
amoxicillin.
• Initial oral antibiotic treatment if penicillin allergy; Cefdinir, Cefuroxime,
Cefpodoxime, Or Ceftriaxone (50 mg IM or IV per day for 1 or 3 days). Do not use
prophylactic antibiotics to reduce frequency of episodes of AOM in children with
recurrent AOM.
• Adjunctive therapy; Fever relief with acetaminophen or ibuprofen. Pain may be
treated with acetaminophen, ibuprofen, or topical anesthetic drops.
PROGNOSIS & COMPLICATIONS
• Symptoms of acute infection (fever and otalgia) are relieved within 48–72 hours
in most patients. Treatment failures are more likely with increased severity of
disease and younger age. Development of another infection within 30 days
usually represents a recurrence caused by a different organism rather than a
relapse. Recurrences are frequent and more common in younger children and if
initial episode is severe. Nearly 30–70% of treated children will have an effusion
at 2 weeks. MEE may persist for weeks to months.
• Complications; Hearing loss; Acute conductive hearing loss. Sensorineural
hearing loss may result from spread of infection into the labyrinth.TM
perforation. Chronic suppurative otitis media. Tympanosclerosis. Cholesteatoma.
Acute mastoiditis. Petrositis. Labyrinthitis. Facial nerve paralysis. Bacterial
meningitis. Epidural abscess. Subdural empyema. Brain abscess.
Treatment of common cold including all the following EXCEPT?
a)
b)
c)
d)
e)
Acetaminophen (paracetol)
Bed rest
Antibiotic (amoxicillin)
Normal saline nasal drop
Excessive fluid intake
Answer: c
The following are the initial treatment of bacterial pharyngitis EXCEPT:
a)
b)
c)
d)
e)
IV piperacillin/tazobactam
Oral Erythromycin
Oral Azithromycin
Oral Penicillin V
Oral Amoxicillin
Answer: a
The following are true regarding acute OM EXCEPT;
a)
b)
c)
d)
e)
Pseudomonas AOM may occur in neonates
More common in males
Breast milk is a protective factor against OM
Most common in school aged children
Prolong use of pacifier may increase risk of OM
Answer: d