Pediatrics - Upper Respiratory Tract Infections (Sicilio) PDF

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- Pediatrics: URI in Children (Sicilio) Otitis Media: Definition: Acute otitis media: fluid in the middle ear space accompanied by the acute onset of signs and/or symptoms Epidemiology: Otitis media (OM) is the most frequent illnessrelated primary dx for children ≤15 years In the United States, the ...

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Pediatrics: URI in Children (Sicilio) Otitis Media: Definition: Acute otitis media: fluid in the middle ear space accompanied by the acute onset of signs and/or symptoms Epidemiology: Otitis media (OM) is the most frequent illnessrelated primary dx for children ≤15 years In the United States, the majority of episodes of OM occur between 6-24 months of age – this is bc the eustacian tubes are horizontal and do not drain well Significance: most common diagnosis for which antibiotics are prescribed for children in the US Risk Factors Male Bottle fed (don’t get Ab from mom) Day care attendance, History of URIs Smoke exposure (tobacco/fireplace) Chemical rhinitis, Allergic rhinitis All have the nasal and eustachian tube mucosal edema in common Diagnosis: HPI May be completely asymptomatic; May/may not have accompanying fever Irritability  poor sleep  irritable parents Ear pulling and complaints of ear pain (otalgia) Drainage into and/or from external canal (otorrhea) If patient has mastoiditis, it can cause similar ear pain Direct visual observation Color/transparency Contour (bulging, retracted) Landmarks Light reflex Mobility (pneumatic otoscopy/pneumomassage) Anatomy Pars flaccida involved in OM more common than pars tensa bc pars flaccida is loose and becomes more distended with fluid and pus Light reflex points anterior/inferior – use to tell R/L ear Natural History: Otitis media typically decreases in frequency between 2-3 years of age, as with facial growth the Eustachian tube becomes more vertical and thus drains more efficiently Microbiology: Bacterial and/or viral respiratory tract pathogens can be isolated from middle ear space in acute otitis media Bacteria respiratory pathogens are more likely isolated in children with bilateral acute OM (BILATERAL = BACTERIAL) Frequently caused by: Moraxella catarrhalis, strep pneumonia, H. flu (non-typable) Prevention: Encourage completion of routine immunization schedules, including annual influenza vaccination, strep pne Bacterial Etiologies: Overall incidence has not changed significantly over last 20-25 years, but relative proprotions of bacterial etiologies have changed

Above could be caused by PCV immunizations Strep pneumoniae is the most common cause of OM (less common than past from vaccines) Analgesics Pain usually managed with non-aspirin analgesics Acetaminophen 10 mg/Kg every 4 hours and Ibuprofen 15 mg/kg every 6 hours Benzocaine is an allergic sensitizer (irritant) and is no longer routinely recommended Antibiotic Therapy: target towards suspected causative agent Amoxicillin = first line therapy in uncomplicated OM bc majority of bacterial OM still caused by sensitive strep pne Should NOT be considered in those with have received abx therapy within 30 days Should NOT be considered in those with concurrent purulent conjunctivitis bc nontypeable H.flu is common etiology (can be resistant to B-lactam abx) Failure to respond may be secondary to: Penicillinase producing organisms Alteration in PBP – if bacteria can bind penicillin better – give higher dose in amoxicillin Inadequate access of abx into middle ear space Poor compliance with treatment regimen Alternate abx options: Higher dose amoxicillin to exceed PBP capacity Penicillinase-resistant abx (cephalosporin nir, ceftriaxone; amoxicillin + d – augmentin – clavulanic inase binding abx that icillin to kill susceptible -

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abx (macrolides like or azithromycin, clindamycin, erthyromycin-sulfisoxazole, trimethoprim/sulfamethoxazole) If patient has penicillin allergy Non-anaphylactic patients: Cefdinir, ceftriaxone Anaphylactic patients (azithromycin, clindamycin, erythromycin-sulfisoxazole, TMP-SMX) Treatment Controversy: 80% of children would have experienced clinical resolution of OM within 47 days without abx therapy – do NOT overtreat – see them back in a few wks

Otitis Media with Effusion: fluid in middle ear space with no evidence of infection – only treat if infected If bilateral, this will prevent you from being able to hear well – if persistent prolonged effusion, you put in tubes

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Fluid for 3 months – indication for tubes Recurrent OM Treatment: Typanostomy Tubes (bilateral pressure equalizing tympanostomy tubes) Recurrent OM  tympanosclerosis Indications for tubes: Unable to adequately treat persistent AOM Unable to prevent recurrence Persistent middle ear effusions (generally >3 months) Hearing loss Complications: otorrhea (treat with ear drops), scarring of TM, thin TM, fungal overgrowth, tubes fall into middle ear space – do not have to be removed, granulation tissue, cholesteatoma (squamous growth in middle ear space)

Choanal Atresia Non-development or blockage of the posterior nasal aperture ~2/3 are unilateral If bilateral, an infant typically has upper airway obstruction, noisy breathing, ↑ cyanosis during feeding and ↓ cyanosis when the infant cries as they then receive adequate oxygenation when the obstructed airway is bypassed and there is adequate airflow through the open mouth – obligate nasal breather Diagnosis is suspected if small caliber catheter can’t be passed from the nose to oropharynx Primary Ciliary Dyskinesia (Immotile Cilia Syndrome) Defective cilia (defective dynein arm) Absent (ciliary aplasia) Unable to beat (ciliary immotility) Unable to beat normally (ciliary dyskinesia) Defective embryonic cilia could cause defective development, body asymmetry  Situs infersus totalis (~50%) Kartagener syndrome situs inversus with: Chronic sinusitis Bronchiectasis (abnormal bronchial dilation/distortion bc cilia don’t beat and clear airways) The Common Cold viral disease characterized by nasal stuffiness, sneezing, coryza (inflammation of the mucous membranes lining the nasal cavity), throat irritation, and minimal or no fever Epidemiology: The average annual number of “colds” in children is generally 3-8/year with some reports as high as 10-12/year “Colds” are more frequent during winter/rainy season Etiology: There are >100 serologically different viral agents responsible for the “common cold” Clinically, identifying the specific causative viral agent is not as important as understanding the disease process Common viral causes: Rhinoviruses (RV) (September) – MOST COMMON Parainfluenza (October and November) – croup

Respiratory syncytial viruses (RSV) Influenza Coronaviruses Adenovirus Enterovirus (most commonly summer) – GI viruses Pathophysiology: inhalation of small aerosolized particles or by direct inoculation of virus from nasal secretions The local respiratory tract epithelium becomes infected resulting in an increase in nasal secretions  Nasal stuffiness, throat irritation, and sneezing typically Fever, if present, begins in days 1-2 and may last 3-4 days As the viral immune process is activated, neutrophils and macrophages appear at the site of sloughed epithelial cells  the resultant mucopurulent nasal discharge often turns yellow or green with exposure to air (with viruses – if this lasts a long time, consider bacterial infection) The mucopurulent nasal discharge may persist for 2-7 days; as the respiratory epithelium regenerates, the nasal secretions will again become clear and disappear Viremia is not a common occurrence during the “common cold,” as the infection is typically restricted to the epithelial surfaces of the upper respiratory tract Symptoms may return later bc it is a different viral infection Treatment: Appropriate treatment of a “cold” is entirely symptomatic Intranasal decongestants may provide mild temporary relief of the nasal stuffiness but are typically not recommended bc discontinuation  rebound vasodilation  rhinitis medicamentosa, which is treated with nasal steroids, oral steroids and/or ENT referral Antibiotics and anti-histamines should NOT be used Anti-histamines may help w/ coexisting allergic rhinitis Analgesics/antipyretics may relieve some irritability, discomfort and fever associated with the illness Maintaining adequate hydration is critically important in overall management Intranasal Foreign Body: Can be inorganic and organic objects Most can be removed without referral to ENT Button batteries and paired magnets can cause serious damage to nasal structures and merit urgent removal more frequently located on the right side bc of Rhandedness Overwhelming foul smell and unilateral purulent rhinorrhea -

Epistaxis Rare in children m catarrhalis > strep penu Treatment: amoxicillin-clauvinate, 90 mg/kg/day in 2 divided doses for 10-14 days or ceftriaxone, 50 mg/kg/day up to 3 days followed by the preceding If no improvement, consider imaging and/or ENT referral Oral decongestants may reduce tissue edema and facilitate drainage by inc ostial patency; avoid nasal decongestants bc of rebound vasodil and rhinitis medicamentosa Nasal steroids may be effective Nasal saline, drainage, and steam inhalation may provide symptomatic relief

Adenovirus: ~5-10% of febrile illnesses in infants and young children Epidemic keratoconjunctivitis (EKC) – pink eye Bilateral conjunctivitis Preauricular adenopathy Subsequent painful corneal opacitie; heals w/n weeks Pharyngoconjunctival fever: Benign follicular conjunctivitis, pharyngitis, cervical adenitis Coxsackievirus: Hand, Foot, and Mouth Syndrome Coxsackievirus: a non-polio enterovirus

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Hand, foot, and mouth syndrome (HFM): symptoms of 2-3 days – grayish, oval lesions Fever – most common location Hand Foot Mouth (oral vesicles of buccal mucosa and tongue) Buttocks Genitalia (less commonly)

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Ulcers from Coxsackievirus A: Herpangina Herpangina in children is a generally benign, viral with fever and painful, papulo-vesiculoulcerative oral exanthem Herpangina is caused by >20 enterovirus serotypes, most commonly Coxsackievirus A serotypes

Aphthous Ulcers: Canker Sores Painful, shallow, gray, without associated skin lesions Seen in otherwise healthy patients, but are seen more commonly in those with celiac disease, IBD, and HIV Diphtheria Infection w/ gram-positive bacillus Corynebacterium diphtheria Respiratory diphtheria is caused by toxin-producing strains; dissemination  myocarditis, nervous system and kidney Pseudomembrane: Early symptoms of sore throat and signs of pharyngeal erythema and/or gray and white exudate are noted ~1/3  toxin-induced pseudomembrane (necrotic fibrin, RBCs, WBCs, epithelial cells, and organisms) which adhere tightly to underlying tissue and bleeds with scraping 2/3 are tonsillopharyngeal, but pseudomembrane can extend to any portion of the respiratory tree Malignant Diphtheria: Respiratory Insufficiency swelling of tonsils, uvula, cervical lymph nodes, and submandibular/anterior neck (“bull neck”)  resp insuf, potential aspiration of memb  suffocation and death Gram positive rods in “Chinese character” distribution Group A Strep (Strep pyogenes) Most common cause of bacterial pharyngitis in kids children 1 cm) anterior cervical nodes Absence of usual sx associated w/ viral URI In a patient with a score of 6, the likelihood of a positive throat culture is ~85 percent; in a patient with a score of 5, the likelihood falls to ~50% Confirm with cultures Microbiologic testing – should be performed in those with: Evidence of GAS, symptoms or exposure to someone with sx, or high prevalence in community of GAS Infectious Mononucleosis: Common Symptoms: Lymphadenopathy (100%) Fever (98%) Pharyngitis (85%) Malaise/HA before onset of above sx Etiology: EBV – confirm with monospot – test for Ab Clinical Course: Pharyngeal inflammation and tonsillar exudates, which may appear white, gray-green or even necrotic, are noted Palatal petechiae with streaky hemorrhages and blotchy red macules are occasionally present, as are also seen in some patients with streptococcal pharyngitis Though sore throat and fever have resolved in most patients by 1 month, fatigue may be severe, persisting at 6 months in ~10% Long-term, EBV can cause nasopharyngeal carcinoma -

Mycoplasma Pneumonia: Pharyngitis: Typically affects children >6 Causes ~5-15% of cases of pharyngitis in this age range Responds to macrolide (azithromycin, erythromycin) Neisseria gonorrhea: Pharyngitis: Relatively rare cause of pharyngitis - may occur in sexually active adolescents, particularly those engaging in oral-genital sex no pathognomonic characteristics - throat may appear completely normal, or may have erythema, edema, or exudates

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Pharyngeal cultures for N. gonorrhoeae require special media CDC recommends ceftriaxone (Rocephin), 250 mg IM first line and azithromycin (Zithromax) second line The lower cure rate at pharyngeal mucosa is proposed as Immune defense mechanisms decreased in pharynx Isolates naturally not as susceptible to abx here

Epiglottitis Hemophilus influenzae type b (Hib) incidence of epiglottitis in US decreased >99% after introduction of the Hemophilus influenza type B conjugated (HibC) vaccine Even so, Hib epiglottitis still occurs, both in the unimmunized and also immunized children secondary to immunocompromise Other H. influenzae types, strep, and Staphylococcus aureus also rarely cause epiglottitis in American children Symptoms: drool, tripoding, muffled voice from swollen neck, thumb sign on lateral cxr Management: In cases of suspected epiglottitis, do not distress the child Walk adjacent the stretcher with bag/mask and resuscitation equipment available, proceeding carefully, yet expeditiously, to the Operating Room where, under general anesthesia, ENT can visualize the epiglottis If epiglottitis is confirmed, endotracheal tube placed Cultures are taken, antibiotics are given and the child is monitored in the Pediatric Intensive Care Unit (PICU) Laryngomalacia (congenital laryngeal stridor) Inspiratory collapse of supraglottic structures – floppy cartilage Most common laryngeal congenital anomaly Proposed etiologies include Delayed maturation or “hypotonia” of laryngeal cartilage Redundant supraglottic soft tissue Underlying neuromuscular disorders Supraglottic edema (possibly secondary to GER)

HPV: Recurrent Respiratory Papillomatosis (RRP) Most common benign laryngeal tumor in children Typically diagnosed between 2-3 years of age Can be seen in those who have been sexually abused/molested RPR is secondary to acquisition of HPV during vaginal birth Infants born to mothers with genital warts are 231 times more likely to develop RRP – only 1% develop RRP HPV 6 and HPV 11 are most commonly involved HPV infected squamous mucosa  metaplasia

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Symptoms: Hoarseness, Breathiness, Respiratory distress, Intermittent respiratory obstruction, aphonia Physical Exam: Multiple verrucous, polypoid growths overlying vocal folds, subglottic region, and trachea Current Routine Treatments: Microlaryngeal surgery, laser, multiple interventions often needed, within mean number of surgical procedures ~4/year with range of 1-19 Investigational Therapies: Interferon, Photodynamic, Carbinol, Acyclovir, Vitamin A, Antivirals, VEGF inhibitor

Croup: identify several different respiratory illnesses characterized by varying degrees of inspiratory stridor, cough, and hoarseness resulting from obstruction in the region of the larynx Croup primarily occurs in infants and children 6 months-6 years of age, with most cases between 6 months-3 years of age Croup is usually viral, the most common of which are the parainfluenza viruses (type 1>2>3); RSV and adenoviruses are also fairly frequent causes Pathophysiology: Initially, similar “cold” in the upper airway passages with eventual spread to the larynx and subglottic structures Significantly, swelling in the subglottic region occurs in an area surrounded by a firm cartilaginous ring Presentation: Initial symptoms = URI symptoms Upper airway obstructive signs occur 12-48 hr after onset of symptoms “Barking” cough with inspiratory stridor is classically heard Untreated, the duration of symptoms is similar to that of a common cold Special care should be taken when examining the posterior pharynx, in the possible event of inducing further airway compromise in cases of epiglottitis Evaluation: AP chest xray of soft tissues of the neck in croup showing the “steeple” sign of the narrowed subglottic region Endoscopy of the swollen subglottic region Management: Humidity, but value of increased humidity is currently being questioned, though adequate hydration is still encouraged Oxygen should be administered if the child is hypoxic, but agitate the child as little as possible Antibiotics are not generally indicated in a viral illness, unless evidence of secondary bacterial infection exists In the most critically ill children, endotracheal intubation may be necessary to establish and control the airway Steroid Therapy: Corticosteroids do reduce airway inflammation

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IM corticosteroids are given to patients too ill (oral refusal, vomiting, etc.) to tolerate oral preparations oral steroids provide similar, benefit with less potential side effects (lipodystrophy at injection site) Nebulized racemic epinephrine may provide temporary relief in airway edema and/or obstruction

Spasmodic Croup: Similar to viral croup, but it always occurs at night The onset and cessation of symptoms are abrupt The duration of illness is short, often resolving by the time they present for medical attn; often recurrent for months No direct viral etiology has been established Management is similar to that of viral croup, except steroids may not be necessary

Stridor: Congenital and Non-infectious Etiologies: Macroglossia (large tongue) Micrognathia (small jaw) Lingual thyroid Thyroglossal duct cyst Vocal cord paralysis Laryngomalacia (supraglottic collapse during inspiration) Subglottic hemangioma Foreign body Trauma (including during or post-intubation) Allergic reaction (acute angioedema) Caustic ingestion(s) Tracheomalacia (abnormally compliant trachea) Vascular rings Tumor Infectious Etiologies: Croup Diphtheria Peritonsillar abscess Retropharyngeal abscess Epiglottitis HPV papillomatosis Bacterial tracheitis...