Pediatric Respiratory Tract Illnesses

Front 1

what things lead you to suspect that there is a nasal foreign body and how do you manage it?

Back 1

usually its unilateral and there is a purulent, foul smelling discharge
-- sometimes there is bleeding involved and the foreign body can be a variety of items (erasers, beads, toys etc)

Management
(1) occlude side without foreign body and have child blow their nose
(2) remove with instruments in office
****(3) button batteries must be removed immediately! -- causes rapid tissue damage

Front 2

What causes allergic rhinitis and what are some associated risk factors

Back 2

allergic rhinits can be seasonal or pernnial and the prevalence peaks late in childhood
-- risk factors include:
(1) family history of atopy
(2) serum IgE >100IU/ml before 6 years of age
(3) higher socioeconomic group

Front 3

what clinical symptoms are associated with allergic rhinitis

Back 3

(1) may be mistaken for an upper respiratory infection
(2) sniffling/sneezing
(3) allergic salute -- nasal crease
(4) itchy, watery eyes
morgan denny lines (due to heavy eyes)
(5) allergic shiners

Front 4

what are some physical finding associated with allergic rhinitis?

Back 4

--pale, boggy nasal mucosa
-- cobble stoning of posterior pharynx

Front 5

what labs would you order for allergic rhinitis?

Back 5

diagnosis is usually done based on history and physical so labs are not ordered very often
-- what you can do is take a sample of the nasal secretions and see that the smear would revel eosinophilia

Front 6

how would you treat allergic rhinitis?

Back 6

(1) oral antihistamines
(2) nasal steroids
(3) montelukast (singulair)

Front 7

what is the common cold and when/among which population is it more commonly found

Back 7

the common cold is also known as rhinits, rhinosinusitis or upper respiratory infection
-- it mostly occurs in the early fall through late spring and see a lot more in young children [young children will have 6-7 colds/year -- ***15% will have 12 infections/year ***]
-- children in out-of-home daycare will have 50% more colds than children who stay at home

Front 8

what prevents you from thinking a child that gets 6-7 colds a year is immunocompromised?

Back 8

immunocompromised kids have colds/sinus problems all year around including during the summer time and they get sick more frequently too!

Front 9

what are some clinical manifestations of the common cold?

Back 9

(1) typically occur 1-3 days after infection
(2) sore "scratchy" throat
(3) nasal obstruction / rhinorrhea
(4) cough
(5) may have fever and/or myalgia

Front 10

how do you make a diagnosis of the common cold

Back 10

CLINICALLY! -- labs aren't generally helpful (may obtain nasal smear for eosinophils if you suspect Allergic Rhinitis)

Front 11

how do you treat the common cold?

Back 11

treatment is symptomatic
you can try nasal saline and suction, humidifier and elevate the head of the bed
***DO NOT GIVE CHILDREN ASPIRIN**
- OTC cough/cold meds are not indicated for children under the age of 4

Front 12

What is the natural course of the common cold? complications? how can you prevent it from happening in the first place?

Back 12

natural course: usually lasts 7-10 days (10% will last about 2 weeks)

complications: otitis media and/or sinusitis

prevention: protective equipment in the hospital/clinic
-- vitaminc C and echinacea have no significant effect in studies

Front 13

** WHICH SINUSES ARE PRESENT?**

Back 13

-- ethmoidal and maxillary sinuses are present at birth [maxillary sinuses are not pneumatized until 4 years of age]
-- sphenoid sinuses present at about 5
-- frontal sinuses begin forming at 7-8 years of age and do not completely develop until adolescence (11-12)

Front 14

what can cause sinusitis?

Back 14

sinusitis can be viral or bacterial
-- the most common bacterial pathogens include:
(1) strep pneumo
(2) H. influenza (nontypable)
(3) moraxella catarrhalis

Front 15

when does sinusitis usually occur and what are some predisposing conditions?

Back 15

sinusitis can occur at any age.

predisposing factors include:
(1) viral URI
(2) allergic rhinitis
(3) cigarette smoke exposure -- seen in a lot of kids

Front 16

clinical manifestation of sinusitis includes

Back 16

(1) nasal congestion
(2) nasal discharge
(3) fever
(4) cough
(5) periorbital edema
(6) headache and facial pain -- both of which are rare in children because they dont have maxillary of frontal sinus development yet

Front 17

how do you diagnose sinusitis?

Back 17

diagnosis is based solely on history when it comes to children!
its based on having a persistent URI for 10-14 days without improvement
OR
severe respiratory symptoms including a temperature of at least 102 and purulent nasal discharge for 3-4 days
[sinus aspirate culture is the only accurate method of diagnosis but its not practical]

Front 18

how do you treat sinusitis and what are some complications associated with it?

Back 18

treatment: antibiotics?
complications:
(1) periorbital cellulitis (2) orbital cellulitis <-- emergency (3) meningitis (4) cavernous sinus thrombosis (5) subdural empyema (6) epidural/brain abscess (7) osteomyelitis of frontal bone

Front 19

*** what are the two main components of otitis media?

Back 19

(1) suppurative or acute ottitis media (AOM) --> INFECTION
(2) nonsuppurative or secretory otitis media /otitis media with effusion (OME) --> NONINFECTIVE INFLAMMATION ACCOMPANIED BY EFFUSION

-- both are interrelated: usually infection leads to OME which predisposes to recurrent infection

Front 20

what do you want to talk about if a child keeps getting recurrent ear infections?

Back 20

tube placement (which will fall out in a couple of years and the perforation will fill in over time) -- this will help the ear drum from constantly getting stressed and prevents formation of scars

Front 21

what are some factors that are known or believed to affect occurence of otitis media?

Back 21

(1) age -- peak incidence and prevalence 6-20 months of age [prone to URI and the Eustachian tube is a straight shot]
(2) sex
(3) race - more prevalent and severe among native americans, inuit, and indigenous australian children
(4) genetic background
(5) socioeconomic class
(6) breast milk vs. formula *** breast fed babies have fewere incidences of OM compaired to formula fed babies

Front 22

**what causes otitis media?

Back 22

acute otitis media can be cause by a viral or bacteria pathogen.
bacterial pathogens include***
(1) strep pneumo
(2) h. influenza (nontypable)
(3) moraxella catarrhalis

OME cultures are usually sterile

Front 23

other factors that can cause otitis media include

Back 23

(1) exposure to tobacco smoke
(2) exposure to other children
(3) season
(4) congenital anomalies -- unrepaired cleft palatal clefts, other craniofacial anomalies, and down syndrome

Front 24

what are some clinical manifestations of AOM

Back 24

(1) rupture of TM with purulent otorrhea
(2) ear pain due to holding or pulling on ear -- DOESNT ALWAYS MEAN EAR INFECTION THOUGH -- could be due to teething or strep throat
(3) fever
(4) irritability
(5) no symptoms

-- highly variable in presentation

Front 25

what are some TM findings associated with AOM

Back 25

(1) fullness/bulging/complete retraction
(2) erythema
(3) abnormal whiteness
(4) scarring -- from repeated infections
(5) decreased mobility

Front 26

what are some OME findings that are consistent with middle ear effusion (MEE)

Back 26

(1) air fluid levels
(2) air bubbles

Front 27

how do you diagnose otitis media?

Back 27

diagnosis is based mainly on physical findings.

You can do a tympanometry - gives objective evidence of MEE (middle ear effusion)

Front 28

how do you treate AOM

Back 28

you can do a myringotomy or tympanocentesis (rarely necessary)

-- used when there is unremitting pain or systemic symptoms

Front 29

how do you treat OME

Back 29

Antibiotics can be used if there is evidence of bacterial respirotry infection

efficacy of corticosteroids is debatable --used to relieve swelling and inflammation


myringotomy with tympanostomy tubes are considered after:
(1) 6-12 months of continuous bilateral OME
(2) 9-18 months of continuous unilateral OME
(3) evidence of hearing loss

Front 30

what are some complications associated with otitis media?

Back 30

(1) mastoiditis
(2) facial paralysis
(3) acquired pneumonia
(4) chornic perforation
(5) scarring of TM and hearing loss [with developmental sequelae]
(6) tympanosclerosis

Front 31

what is mastoiditis?

Back 31

Acute mastoiditis traditionally refers to spread of the infection (AOM) to the overlying periosteum, bony trabeculae, or petrous portion of the temporal bone

all cases of AOM are technically accompanied by mastoiditis by virtue of associated inflammation [inflammatory process usually readily reversible]

Front 32

what are some signs/symptoms of acute mastoiditis?

Back 32

(1) redness and/or tenderness over mastoid
(2) swelling behind the ear
(3) may cause the ear to stick out

-- MUST obtain CT scan to clarify nature and extent of disease

Front 33

how do you treat acute mastoiditis?

Back 33

IV antibiotics and/or surgery if there is enough obstruction/destruction --> need to drain

Front 34

what is otitis externa and what causes it?

Back 34

otitis externa is also known as 'swimmers ear' and its inflammation and/or infection of the external auditory canal and/or auricle

most common pathogens:
**(1) pseudomonas aeruginosa
(2) staph aureus
(3) enterobacter aerogenes

Front 35

what are some clinical manifestations associated with otitis externa

Back 35

(1) ear pain accentuated by manipulation of pinna or tragus
(2) itching
(3) conductive hearing loss
(4) serous or purulent secretions

IT IS DIAGNOSED CLINICALLY

Front 36

how do you treat otitis externa?

Back 36

(1) topical antibiotics and corticosteroids
(2) wick if there is significant edema of ear canal -- this is painful --> need to push into the ear with a cloth substance to allow the medication to seep into the canal
(3) oral or parenteral antibiotics in severe infections with fever and lymphadenitis

Front 37

what causes pharyngitis

Back 37

90% --> viral
10% --> bacterial

Front 38

what is infectious mononucleosis

Back 38

its known as the 'kissing' disease
and the most common cause of it is the Epstein-Barr virus [other viruses like CMV may cause infectious mono-like illnesses

-- rare in children <4 and adults >40

Front 39

what are some clinical manifestations of infectious mononucleosis

Back 39

(1) exudative tonsillitis
(2) generalized cervical adenitis
(3) fever/fatigue
(4) splenomegaly **** no contact sports allowed

Front 40

what labs do you send for and how do you make the diagnosis of infectious mononucleosis?

Back 40

you send for EBV titers, check for atypical lymphocytes and heterophile antibody

DIAGNOSIS IS BASED ON PRESENTATION AND LABS

Front 41

how do you treat infectious mononucleosis?

Back 41

(1) supportive
(2) limit activity if there is splenomegaly

Front 42

what complications are involved with infectious mononucleosis?

Back 42

sub-capsular splenic rupture from trauma!

Front 43

what is herpangina?

Back 43

enteroviral infection (coxsackie virus) with clinical features such as
(1) sudden onset fever
(2) headache, dysphagia
(3) vomiting and abdominal pain
(4) vesicular and ulcerative lesions with halo on posterior buccal mucosa, pharyngeal wall, soft palate, uvula, and anterior tonsillar pillars

VERY PAINFUL -- there are ulcerations in the oropharynx rather than pus

Front 44

how do you diagnose and treat herpangina?

Back 44

diagnosis is clinical and treatment is supportive

Front 45

what is stomatitis?

Back 45

stomatitis is very similar to herpangina and some causes are caused by HPV

clinical manifestations:
(1) fever
(2) mouth pain (refusal to eat)
(3) ulcerative on any part of oral lining but USUALLY IN THE ANTERIOR PORTION OF THE MOUTH

Front 46

what do you call it when there is gingivitis and stomatitis present?

Back 46

gingivostomatitis

Front 47

how do you treat stomatitis?

Back 47

supportive treatment -- give them lots of fluids (nothing spicy/salty)

acyclovir has little effect on symptoms

Front 48

what is hand, foot, mouth disease?

Back 48

its an enteroviral (coxsackie A) infection wheren the patient can present with fever or no fever, they have vesicles/ulcers anywhere in the mouth, and maculopapular, vesicular, and/or pustular lesions on hands, fingers, feet, buttocks, and groin

THIS IS A CLINICAL DIAGNOSIS and treatment is supportive

Front 49

what is pharyngoconjunctival fever?

Back 49

its caused by adenovirus and concurrent features are (1) conjunctivitis (2) fever (3) exudative phayngitis (4) GI symptoms

Diagnosis --> CLINICAL and the treatment is supportive care

lasts for about 7-10 days

Front 50

what is acute bacterial pharyngitis

Back 50

its cauesd by
(1) group A beta hemolytic strep
(2) group C strep
(3) neisseria gonorrhoeae
(4) arcanobacterium haemolyticum
(5) mycoplasma pneumoniae

Front 51

What happens in GABHS (group A beta hemolytic strep) Pharyngitis

Back 51

its uncommon before 2-3 years of age
clinical manifestation:
rapid onset, sore throat, exudate, peteciae on soft palate, anterior cervical adenopathy, fever, headache, abdominal pain, strawberry tongue and fine, sandpaper rash indicative of scarlet fever

Front 52

how do you diagnose GABHS pharyngitis?

Back 52

you do a rapid antigen test which is very specific and 85-95% sensitive

**a negative test requires confirmation by culture **

Front 53

how do you treat GABHS pharyngitis?

Back 53

antibiotics
or tonsillectomy for recurrent GABHS infections (5 infections or more/year with positive strep screens)

Front 54

What are some complications associated with GABHS pharyngitis?

Back 54

(1) acute rheumatic fever
(2) glomerulonephritis

eradication only indicated if patient or close family member has :
(1) recurrent strep infections
(2) history of rheumatic fecer or glomerulonephritis