Download CM 10- Common ENT Diseases in Children Common Acute ENT Diseases

CM 10- Common ENT Diseases in Children
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Common Acute ENT Diseases in Children
Common Cold (URI)
Otitis Media
Otitis Externa
Sinusitis
Pharyngitis (including Tonsillitis & Adenoid Hypertrophy)
Pharyngitis
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ANY inflammation of the pharynx.
Most common presenting complaint is “sore throat”.
Causes:
o Group A streptococcus (GAS) most common of “treatable” pharyngitis
o Viral
 Epstein Barr virus (EBV)
 Herpes Simplex
 Adenovirus
 Enterovirus
 Influenza
 Parainfluenza
o Other bacterial pathogens
 Corynebacterium diptheriae
 Arcanobacterium haemolyticum
 Neisseria gonorrheae
 Mycoplasma pneumoniae
 Streptococcus-groups C & G
 Tularemia
Group A Strep
• Children 5-15yo
• Atypical symptoms is children under age 3
• Late winter, early spring
• Transmission by inhalation of large droplets or direct contact with respiratory secretions
• Incubation period 2-5 days
• Clinical presentation:
o Acute onset of sore throat
o Headache, fever, malaise
o Abdominal pain
o Anterior cervical lymphadenopathy
o Scarlet fever
The presence of URI symptoms is a negative predictor for strep throat.
• Physical exam
o Tonsils and pharynx appear erythematous
o Exudate in approx. 25%
o Palatal petechia, inflamed uvula
o Tender anterior cervical lymph nodes
• Rapid diagnostic testing “strep test”
o Based on the extraction and identification of the Group A carbohydrate antigen
o High specificity, variable sensitivity
 Send throat culture if negative and GAS suspected
 5-21% of children ages 3-15 years are carriers
CM 10- Common ENT Diseases in Children
Treatment
• Penicillin is the drug of choice
• Amoxicillin – just as effective and better choice for small children
o More palatable
o Easy dosing
• Macrolides for patients allergic to penicillin
• Cephalosporins
• Analgesics
Viral Etiology
• EBV (Epstein Barr Virus)
o Most common clinical syndrome = infectious mononucleosis
o Fever, severe exudative pharyngitis, posterior and anterior cervical adenopathy, fatigue,
anorexia/weight loss
o URI symptoms in younger children
• Adenovirus
o Pharyngitis + Conjunctivitis + Fever (Pharyngoconjunctival fever )
• Coxsackievirus
o Pharyngitis + Herpangina + Stomatitis + Fever
o “Hand foot and mouth disease”
 Small vesicles in the posterior pharynx
 Lesions on the hands and feet
Complications
• Caution!!! Don’t miss possible parapharyngeal infection, retropharyngeal abscess or peritonsillar abscess
• Concerning symptoms include difficulty swallowing, drooling, “hot potato” voice, neck or facial swelling,
asymmetric appearance of tonsils or pharynx
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Peritonsillar Abscess
Seen mostly in older children and adolescents
Fever, drooling, difficulty swallowing, +/- stridor, unilateral sore throat
Uvular deviation and trismus are usually lacking in children
Typically unilateral
CT scan with contrast is useful for diagnosis if unclear
Treatment with antibiotics + surgical drainage
Retropharyngeal Abscess
Ages of 2 to 4 years
Fever, stiff neck, dysphagia
Refusal to move neck
o Especially extension
Voice changes, stridor
Respiratory distress
Neck swelling, neck mass or lymphadenopathy
Chest pain
Treatment: hospitalization with antibiotics, airway support and surgical drainage
CM 10- Common ENT Diseases in Children
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DDx for nasal congestion and cough in child
Viral Upper Respiratory Infection
Pneumonia
Bronchiolitis
Pertussis
Sinusitis
Acute Otitis Media
Allergic Rhinitis
Nasal Foreign Body
Common Cold (Viral URI)
Average six to eight colds per year (up to one per month, September through April)
Typical symptom duration of 14 days
Viral transmission may occur via inhalation of small particle aerosols, deposition of large particle droplets on
nasal or conjunctival mucosa, or direct transfer via hand-to-hand contact
Etiology:
o Rhinoviruses, respiratory syncytial virus (RSV), influenza viruses, parainfluenza viruses, and adenoviruses
are commonly responsible
o Enteroviruses (echoviruses and coxsackieviruses) and coronaviruses
Symptoms
Colored nasal discharge is most
characteristic
Sore throat, cough, irritability, difficulty
sleeping, and decreased appetite also
present in many children
Physical Exam
• Nasal congestion
• Mild erythema and swelling of the nasal mucosa
• Cervical lymphadopathy
• +/- Presence of middle ear effusion or acute otitis media
• Infants may present with mild to moderate increased work of breathing because of nasal obstruction
Treatment
• SUPPORTIVE, SUPPORTIVE, SUPPORTIVE
o Saline irrigation
o Fever control with antipyretics
• Antihistamines: ineffective in relieving the symptoms of children with URI
o Undesirable side effects
• Cough suppressants: none have proven effective in children
o One study showed a tablespoon of honey was just as effective as OTC cough medications (if child over
the age of 1 year)
o Respiratory depression seen with codeine and dextromethorphan - Should be avoided in pediatric
population
CM 10- Common ENT Diseases in Children
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Decongestants: the effectiveness of these medications in children have not been proven.
o Side effects of decongestants may include tachycardia, elevated diastolic blood pressure, and
palpitations
No role for antibiotics in the treatment of VIRAL URI
Hydration
Compications of Viral URI
• Acute otitis media
• Asthma exacerbation
• Bacterial sinusitis
• Pneumonia
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Otitis Media
Otitis media is a general term for middle ear inflammation
o AOM (Acute Otitis Media)
o OME (Otitis Media with Effusion): middle ear fluid without inflammation, infection
Peak incidence of OM is in the first 2 years of life
Additional risk factors
o Low socioeconomic status
o Daycare attendance
o Smoke exposure
o Bottle propping
o Chronic sinusitis
o Ciliary dysfunction
o Cleft palate and craniofacial anomalies
o Immunocompromised conditions
o Down syndrome or other genetic conditions
o Lack of breastfeeding
AOM Pathophysiology
• Antecedent event is usually viral upper respiratory infection  causes inflammation of the mucosa of the UR
tract including the Eustachian tubes Eustachian tube dysfunction impairs middle ear fluid drainage leads to
an environment conducive to bacterial growth
Predisposition of infants/small children
• Eustachian tube shorter length, horizontal position
• Limited response to antigens and lack of previous exposure to common bacterial and viral pathogens
Microbiology
• Streptococcus pneumoniae
• Non-typable Haemophilus influenzae
• Moraxella catarrhalis (5-10%)
• Group A streptococcus (2%)
• Staphylococcus (1%)
• Viruses-RSV, Rhinovirus, Enterovirus, Coronavirus, Influenza, Adenovirus
Diagnosis
• Ear pain most specific symptom
• Must use a pneumatic otoscope for diagnosis.
CM 10- Common ENT Diseases in Children
Assessment of Tympanic Membrane
• Contour: Normal, retracted, full, bulging
• Color: Gray, yellow, pink, amber, white, red, blue
• Translucency: Translucent, semi-opaque, opaque
• Mobility: Normal, decreased, absent
AOM vs OME
• Otitis media with effusion
o evidence of middle ear effusion without signs of acute inflammation
 TM is discolored
 Air fluid level seen behind TM
 TM is not translucent
 Mobility is decreased
 Position may be normal or retracted
• Acute otitis media
o Evidence of middle ear effusion –plus- signs of acute inflammation
 Pain, fever, erythema or bulging of TM
AOM Treatment
• First line therapy = “High Dose” amoxicillin
o Dose at 80-90mg/kg/day instead of 25-50mg/kg/day
o Effective against intermediate resistant strains of S. pneumoniae and some highly resistant strains
• Second line therapy = amoxicillin/clavulanate potassium
• Alternative second line therapy = IM/IV Ceftriaxone
• Tympanocentesis & Myringotomy
o Aspirating middle ear fluid, relieves pressure
o Permits the identification of pathogen
• Watchful waiting
Remember to treat the pain!
Complications of AOM
• Hearing loss
• Balance problems
• Tympanic Membrane Perforation
• Cholesteatoma
• Mastoiditis
• Labyrinthitis
Otitis Externa: “swimmer’s ear”
Infectious, allergic, dermatologic disease
Seen primarily summer months
The ear has inherent defense mechanisms
Increase risk otitis externa associated with swimming, trauma to canal, devices that occlude the ear canal, and
allergic contact dermatitis
Microbiology
• P. aeruginosa, S. epidermidis, staph aureus
• Anerobes-bacteroides and peptostreptococci
• Fungal-aspergillus and candida
• Infection is often polymicrobial
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CM 10- Common ENT Diseases in Children
Clinical Features
• Ear pain
• Pruritis
• Discharge
• Hearing loss
• Physical exam-tenderness tragus, edema/erythema canal, debris in canal
Treatment
• Clean ear canal
• Treat inflammation and infection
• Control pain
• Avoid promoting factors
• Topical Antibiotics- fluoroquinolones, polymyxin B/neomycin, aminoglycosides
• Antiseptics-alcohol based
• Glucocorticoids
• Acidifying Solutions
• Antifungals
• Oral antibiotics are reserved for patients with evidence of deeper tissue infection outside of external
auditory canal
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Acute Sinusitis
5-10% of upper respiratory tract infections are complicated by acute bacterial sinusitis
Most case of acute bacterial sinusitis are complications of viral URI’s
Microbiology
o Streptococcus pneumoniae (30-40%)
o Nontypable Haemophilus influenzae
o Moraxella catarrhalis
CM 10- Common ENT Diseases in Children
Physical Exam
• +/- mucopurulent discharge in the nose or posterior pharynx
• Erythematous nasal mucosa
• TM’s +/- acute otitis media or effusion
• +/- malodorous breath
• headache
• (ALL SYMPTOMS ABOVE CAN ALSO BE SEEN WITH VIRAL URI)
Diagnosis
• Clinical diagnosis
• Imaging is controversial in children
o Computed Tomography (CT) or MRI can be useful in complicated sinusitis such as extension of the
infection to the orbits or CNS
• Sinus Aspiration
o Performed by ENT
o Done if clinical failure, complicated infection or immunosuppressed patient
Treatment
• Amoxicillin
o High dose (90mg/kg/day) for children at risk for penicillin resistant S. pneumoniae
• Amoxicillin/potassium clavulanate
o Use if failure treatment on amoxicillin, geographical area with high prevalence of beta-lactamase
producing H. influenzae, frontal or sphenoid sinusitis, or protracted coarse
• Duration from 10 days OR resolution of symptoms plus 7 additional days