UPPER- LOWER
RESPIRATORY
PATHOLOGIES
SINUSITIS
Sinusitis is the inflammation/infection of the mucosa of 1 or more paranasal sinuses.
Definitions: Acute Bacterial Sinusitis: Bacterial infection of the paranasal sinuses lasting less than 30 days in which
symptoms resolve completely.
Subacute Bacterial Sinusitis: Bacterial infection of the paranasal sinuses lasting between
30 and 90 days in which symptoms resolve completely.
Chronic Sinusitis: Episodes of inflammation of the paranasal sinuses lasting more than 90 days.
Patients have persistent residual respiratory symptoms: cough, rhinorrhea, nasal
obstruction.
ANATOMY / DEVELOPMENT
4 Sinuses: Maxillary, Ethmoidal, Frontal, Sphenoidal
MAXILLARY SINUSES DEVELOPS DURING 3rd & 4th GESTATIONAL MONTH WITH PNEUMATIZATION BETWEEN BIRTH AND 12 MONTHS OF AGE
ETHMOID SINUSES DEVELOPS DURING 3rd & 4th GESTATIONAL MONTH.
IS PRESENT AT BIRTH, DEVELOPING UNTIL 12-14 YEARS OF AGE
SPHENOID SINUS DEVELOPED BY AGE 8-10 YEARS
FRONTAL SINUS DEVELOPS DURING 5th AND 6th YEAR.
In the sides of the nasal septum, there is 3 shelf-like structures where discharge is drain and is called
Turbinates
MAXILLARYANT. ETHMOID MIDDLE MEATUSFRONTAL
POST. ETHMOID SUPERIOR MEATUSSPHENOID
LACRIMAL DUCTS INFERIOR MEATUS (Largest and most visible)
ETIOLOGY:
Bacteria: S. pneumoniae (40%) H. influenza (30-40%) Moraxella catarrhalis Virus: Rhinovirus, adenovirus, influenza, parainfluenza
Allergy (chemical and particulate irritants, allergens)
EPIDEMIOLOGY:
Occurs during viral respiratory season
Attendance at Day Care Center
School-age siblings in the household
PHYSIOLOGY:
Usually after URI Mucosal edema ↓ mucus transport obstruction of osteomeatal complex stagnation of secretions ↓ of pH/decrease O2 tension within the sinus promotes Bac/Viral growth.
THREE KEY ELEMENTS:PATENCY OF THE OSTIAFUNCTION OF THE CILIARY APPARATUSQUALITY OF SECRETIONS
-Patency of the Ostia: Mucosa Edema: allergy, viral Mechanical Obstruction: Obstruction of meatus Deviated nasal septum
-The function of the ciliary apparatus: Help nose filter bacteria/pollutant Help regulate temp/humidification
-Quality of secretions: Hypersecretion obstruction less O2 growth of bacteria, impairs defenses, and alters the function of immune cells.
INFLAMED SINUSES
Factors Predisposing To Obstruction Of Sinus Drainage
A. MUCOSAL SWELLING Systemic disorder Viral URI Allergic inflammation Cystic fibrosis Immune disorder Immotile cilia Local insult Facial trauma Swimming Diving Rhinitis medicamentosa
B. MECHANICAL OBSTRUCTION Choanal atresia Deviated septum Nasal polyp Foreign body Tumor Ethmoid bullae
C. MUCUS ABNORMALITIES Viral URI Allergic Rhinitis Cystic fibrosis
.
S/S:
URI symptoms for > than 10 days (acute) or > than 12 weeks (chronic)
*Low grade fever (50%)
*Mucopurulent rhinorrhea in middle meatus or postnasal discharge. (95%)
*Nasal mucosa congested/edematous
*Cough present during daytime but is worse at night (90%)
*Painless periorbital edema occurring in the morning and with bad breath.
*Facial pain/pressure above or below the eyes, and Headache. It may change with position, increasing when leaning forward or during percussion. (70%)
*Frontal, Maxillary, and Ethmoid area are tender to palpation/percussion
*Periorbital swelling is suggestive of ethmoid sinusitis
SIGN/SYMPTOM SINUSITIS ALLERGY COLD
Facial Pressure/ Pain
Yes Sometimes Sometimes
Duration of Illness Over 10-14 days Varies Under 10 days
Nasal Discharge Thick, yellow-green Clear, thin, watery Thick, whitish or thin
Fever Sometimes No Sometimes
Headache Sometimes Sometimes Sometimes
Pain in Upper Teeth Sometimes No No
Bad Breath Sometimes No No
Coughing Sometimes Sometimes Yes
Nasal Congestion Yes Sometimes Yes
Sneezing No Sometimes Yes
Complications of Acute Bacterial Sinusitis
• Preseptal cellulitis
• Orbital cellulitis
• Osteomyelitis
• Subperiosteal orbital abscess
• Subdural or Epidural Empyema
• Meningitis
• Brain abscess
• Cavernous sinus thrombophlebitis
Differential Diagnosis-Purulent Nasal Discharge
• Uncomplicated viral URI
• Group A Strep infection
• Adenoiditis
• Nasal foreign body
Lab: Transillumination of the maxillary and frontal sinuses Sinus X ray: air-fluid level, complete opacity, mucosal thickening Waters-3 views
Coronal CT: demonstrate air fluids levels mucosal thickening, anatomical variations suspected intracranial or orbital complication. G.S. TX: Amoxicillin 40-90 mg/kg/day Amoxicillin/potassium clavulanate 80-90 mg/kg/day Ceftriaxone 50 mg/kg/day Erythromycin 50 mg/kg/day Omnicef (cefdinir) 14 mg/kg/day Azythromycin 10/5 mg/kg/day Humidifier with Normal saline, Mucolytics ( guaifenesin) Topical nasal steroids, Antihistamines (not recommended). Treat for up to 21 days or until free symptoms for 7 days
EAR
The ear is divided in 3 regions:
External ear: (Sound Receptor Complex)
Pinna (auricle), external auditory canal, up to TM
Middle ear: (Transmission Complex)
Middle ear space, inner space of eardrum, ossicles, mastoid
Internal ear: (Perception Complex)
Cochlea-Anterior Labyrinth (hearing),
Semicircular canals-Posterior labyrinth (balance),
Main nerve trunks of the 7th /8th cranial nerves.
OTITIS EXTERNA (Swimmer’s ear)Acute otitis externa is defined as diffuse inflammation of the external ear canal, and the ear canal structures, involving the pinna or tympanic membrane.
Characterized by pain caused by infection of macerated skin tissue
Anatomy: The auditory canal is a curved structure Its medial 2/3 comprises a bone lined with a thin layer of skin. The outer 1/3 comprises cartilage with extensive subcutaneous tissue. It contains hair follicles, sebaceous and modified apocrine glands that produce cerumen that keeps the ear canal acidic (pH 6.1), and protects the middle ear from debris and trauma
Etiology:
Bacteria: Pseudomonas aeroginosa (G-) Viral: Herpes zoster/Simplex
Staphyloccocus aureus
Fungal: Aspergillus (90%-black spores)
Candida
OTITIS MEDIA
Inflammation and infection reaction to foreign antigens in the middle ear, that cannot drain via the Eustachian tube. It is the most common infection of early childhood.
Anatomy of the Eustachian tube and immature immune systems of the children, contribute to the frequency of this infection.
Classification: 1-Acute otitis media AOM
2-Otitis media with effusion OME
3-Chronic Otitis media COM
Subcategories: Acute otitis media- Less than 3 weeks
Recurrent otitis media- 3 weeks to 3 months
Chronic otitis media- Greater than 3 months
Etiology
60 - 80% Bacterial Causes:
Streptococcus pneumoniae (~40% ). Haemophilus influenzae (~30%). Moraxella catarrhalis (~20%). Group A beta-hemolytic streptococci (S. pyogenes ~3%).
20 - 40% Viral Infection: RSV, influenza A, adenovirus, parainfluenza type 3, rhinovirus
Pathophysiology:
Nasopharinx is colonized with bacteria’s inflammation of Eustachian tube fluids goes
into middle ear fluids get infected by bacteria's from nasopharinx TM swelling, pain,
pressure inability of TM to vibrate temporary decrease of hearing loss
Pseudomonas aeroginosa
ETIOLOGY OF ACUTE OTITIS MEDIA
Who’s at Risk?
Young age 6-36 months
Attendance at the Day care centers
Male sex
History of enlarged adenoid, tonsillitis, or asthma
Other factors: Recent or recurrent URIs, nasal congestion or obstruction. Multiple previous episodes Has brothers and sisters close in age with Hx of ear infection Bottle feeding while laying in bed
Anatomic position of Eustachian tube
Function of the Eustachian Tube:
• Ventilation of the middle ear to equalize and regulate pressure (ventilatory function),
• Drainage of middle ear secretions
• Protection of the middle ear from nasopharyngeal secretions, and pressures changes.
Eustachian tube dysfunction results in:
• Stagnation of middle ear contents, and bacterial multiplication
• Inflammatory response: fluid accumulation and infection
•Eustachian tube in children is shorter 18mm, acute angle 10 degree, flattened, wider than adult Eustachian tube.
• The shorter tube during infancy, facilitates reflux of bacteria-laden secretions from the nasopharinx.
• The acute angle reduces the protective function of the Eustachian tube.
• At 4/5 years of age, it became more vertical
What are the signs of an Ear infection?
Normal TM
• The tympanic membrane (TM) is intact, thin,
pearly/gray, pink, translucent, and freely mobile on insufflation (respond to pos/neg pressure, pars flacida vibrates)
• Neutral position (not retracted or bulging)
• The malleus as well as a cone- shaped light
reflex are seen.
AOM
Acute middle ear suppuration (suppurative or purulent OM)
Has an acute onset, fever, otalgia, irritability, restless sleep.
Red to yellow opaque and bulging TM with an absence of light reflex and poorly visualized landmarks.
• Decreased mobility on pneumatic otoscopy, light reflex
• Hyperemic TM
• Usually with hearing deficit
Otitis Media With Effusion (OME)
• Is fluid within the middle ear space with visual fullness or high air/fluid level (fluid/bubbles) behind the TM without signs or Sx of infection
• Dull, opaque with minimal erythema in TM with gray/pink colored effusion behind membrane
• Retracted TM (negative middle ear pressure)
• Decrease mobility of TM on pneumatic otoscopy
Hearing loss (clogged ear), speech / language difficulty, fullness in the ears
Erythematous, opaque, bulging TM
Light reflex is reduced, landmarks gone
Air and fluids bubbles TM bulging with a
yellow purulent effusion
LAB: Culture and sensitivity
TX:
Antibiotics:
First Line: Amoxicillin (Amoxil)
If not working: Amoxicillin with Potassium clavulanate (Augmentin)
Cephalosporines 3rd generation: Omnicef, Ceftin
Ceftriaxone: Rocephin IM 3 doses
Tympanocentesis
If allergic to Penicillin: Azythromycin (Zithromax)
Clarithromycin (Biaxin)
Warm compresses on ears to relieve pain
Acetaminophen or Ibuprofen for pain
S. pneumonia produce a more acute course and slower resolution than H. influenza or Moraxella
Complications: Mastoiditis, meningitis.
OME Hearing decrease Hearing test
Timpanostomy Tubes:
Insertion of ventilation tubes in the TM for ventilation/drainage.(Silicone) most recent development
Incision on Anterior Inferior region.
Not responding to ATB treatment
Recurrent AOM infections in a period of time
*Uni or bilateral chronic OME for more than 3 months.
*Conductive hearing loss in excess of 30 dB in patients with Otitis media with Effusion
*Recurrent AOM infections: Children with > 3 separate episodes within 3 months Children with 4 episodes in a 6 months period or with 6 episodes in a 12 months period
AOM WITH OTORRHEA THROUGH TYMPANOSTOMY
Insertion of ventilation tubes in the TM for ventilation/drainage.Otorrhea is a major complication after their insertion
Bacterial isolated: S.pneumonia, H. influenza, M. catarrhalis,
S.aureus, P. aeruginosa.
S/S: Fever, draining from ear, earache.
Tx: Due to the inflammatory response from these bacterias, it is better to combine an Atb with
dexamethasone 0.1% topical. (Ciprodex Otic for patients above 6 months, Floxin)
If it is necessary, can give oral Atb.
Cholesteatoma.
It is an accumulation of desquamated epithelium or keratin that often appears as a white mass behind or involving the tympanic membrane; it may be congenital or acquired.
The acquired type is commonly caused by recurrent acute or chronic otitis media, but can also be iatrogenic (after tympanostomy tube placement or other procedures).
Cholesteatoma can enlarge and erode the bone, including the ossicles, causing hearing loss.
They can also become infected, leading to a foul-smelling discharge from the ear.
A cholesteatoma needs to be removed surgically.
ALLERGIC RHINITIS
Def. of Rhinitis: Is an inflammation of the nasal mucous membranes.
However, with allergic rhinitis, other organs or tissues are involved,
such as eyes, ears, sinuses, oropharinx.
-Is an Immunologic Hypersensitivity Disorder Type I
-Is often a predisposing factor or exacerbation of asthma, rhinosinusitis, nasal polyps.
-Characterized by one or more nasal Sx- sneezing, itching, congestion, rhinorrhea.
-Diagnosis is based on Hx, physical findings, and Lab.
Impact of Allergic Rhinitis
Most common form of atopic disease
Affects 40 million Americans
Prevalence estimates: 10/30% of adults, 40% of children
Peak incidence in childhood and adolescence
Almost 70% of the patients have nasal congestion
Nearly 17 million office visits a year
Direct costs per year of about 6 billion dollars
Increase absenteeism and reduced productivity
75/80% of patients with asthma have allergic rhinitis.
Genetics:
High incidence in families with atopic disease (eczema, asthma)
Classification:
Seasonal: Yearly intervals, periodic symptoms, often due: to outdoor allergens-pollens, tree pollens (spring), grass (summer), ragweed (mid August). Mold spores
Perennial: Throughout the entire year, due to multiple seasonal allergies or continue exposure to: indoors allergen: Dust mite (Dermatophagoides), animal dander, cigarette smoke, hair spray, paint, mold, cockroaches outdoor allergens: Pollens, tree pollens (spring), grass (summer), ragweed (mid August). Mold spores
PATHOPHYSIOLOGY
Allergens bind to specific IgE on Mast cells in Respiratory mucosa Enzymatic reactions
occurs within the cell Release of mediators (histamine, leukotrienes, prostaglandins)
from mast cells triggering IgE, leads to a complex interaction of inflammatory
mediators, causing inflammation of the mucous membranes of eyes, nose, Eustachian tube,
sinuses and/or pharinx.
There are 2 phases of allergic response:
Early phase response to antigen: < 5- 30 minutes after allergen exposure.
-Allergen comes in contact with IgE-primed mast cells and basophils
-Caused by the immediate release of histamine and other mediators (leukotrienes).
-Causing bronchoconstriction, edema, and stimulation of mucous gland that leads to:
Production of secretions: Increase in vascular permeability leads to plasma exsudation
Vasodilation leads to nasal congestion and sinus pressure
Late phase response to antigen: 2-12 hours after allergen exposure
Characterized by sx beginning 4-8 hours after allergic exposure.
This phase occurs because of inflammation resulting from the recruitment of inflammatory
cells (Cytotoxic proteins released by neutrophils, eosinophils, macrophages, lymphocytes –
damaging the Epithelial cells) to the mucous membranes.
This phase has more congestion, rhinorrhea and less sneeze/itching.
S/S: Seasonal: Clear and watery drainage from nose (rhinorrhea) tearing of the eyes and red eyes frequent sneezing Lesser mouth breather Itching of their nose, eyes, palate / throat (erythema can be seen) eczema, family Hx. of atopy support the Dx. of allergic rhinitis.
Perennial: Year round symptoms, nasal congestion (major complaint) post-nasal drainage (dry cough) mouth breather decreased sense of smell/or taste.
Other SX: ↓ in physical functioning, energy and fatigue, social events, ↑ in pain and limitations of emotions, ↓ quality of life
“allergic shiners” Dark circles under the eyes (Moonshiners). Chronic venous stasis from sinus congestion “Dennie-Morgan”: single or double lines under the eyes due to chronic edema.
Allergic salute: Rubbing of the tip of the nose upward to ↓ itching
Allergic crease: Transverse line near the tip of the nose, secondary to rubbing
Nasal mucosa: Pale color, edema of turbinates (inferior), clear watery secretion, colored mucus secretion
Nasal polyps: Gray color, peeled-grape appearance, insensitivity to touch
Upper Respiratory Infection-Common Cold
Etiology: Rhinoviruses, Parainfluenza, RSV, Adenovirus
Risk factors: Day care, smoking, crowding, temperature changes
S/S: Nasal/throat irritation
Sneezing, nasal congestion, rhinorrhea
Sore throat, postnasal drip
Low grade fever, HA, malaise, myalgia
Can lead to AOM, Sinusitis, asthma
TX: Fluids, supportive
INFECTIOUS RHINITIS
Most common cause of nasal symptoms in children is viral URI. Specially in day care/kindergarten/winter months
Last between 7-14 days, symptoms resolving around the 7th/8th dayFever may or may not appear
Clear mucus discharge, changing to green/yellow after a few days, Cough post nasal drip
Turbinates can be swollen and erythematous. Secretions are watery or thick, clear or colored.
Complicated by sinusitis or obstruction by adenoidal hypertrophy
TX: ATB (purulent mucus), mucolitics, cough syrup
LAB:
CBC- Eosinophilia
Nasal cytology- Eosinophilia. Greater than 10% is (+)
Skin testing- Prick/puncture in skin 10-20 allergens. Immediate hypersensitivity with immediate results. There is a small chance of triggering a severe allergic reaction in someone highly allergic.
RAST– Radio Allergo Absorbent Test: Measure allergen- specific IgE, measure specific IgE to individual allergen in a sample of blood. Is less sensitive than skin testing.
Total IgE: Elevated in allergic rhinitis
TX:Environmental control: Avoidance of specific allergens.
1-Outdoor allergents: Pollens/outdoor molds: limit outdoor activity during allergy season Keep windows and doors closed Wear a mask while doing yard work.
2-Indoors: Use dust mite anti-allergic pillow and mattress plastic covers Reduce indoor heat and humidity decreasing proliferation of mites Eliminate carpeting, and use linoleum, tiles. Avoid feathers in pillows and covers. Molds: Eliminate areas of dampness and standing water Clean mold area Pets : Avoid as much as possible or don’t have them Use HEPA filters and A/C Eliminate cockroaches
Nasal Steroids: Effective for itching, sneezing, rhinorrhea,
nasal congestion
More effective than oral antihistamine.
Budesonide (Rhinocort), flonase, nasonex
Antihistamine: Block H1 receptors suppressing most of symptoms
First generation: H1 antagonist with anticholinergic effects (sedating, dry mouth, tachycardia)
Effective for most Sx. of allergic rhinitis, but on congestion is limited.
Benadryl (dyphenhydramine)
Second generation:
H1 antagonist with no/less anticholinergic sedating effect.
Effective for most symptoms, improved but not efficient on congestion.
Zyrtec (cetirizine), Clarinex (desloratidine)
Singulair (montelukast-Leukotrienes blockers)
Topical cromolyn sodium (Nasalcrom-Intal): Mast cell stabilizer Used above 6 years of age
Oral decongestants: alpha-1-adrenergic agonists: phenylephrine, phenylpropalamine.- SudafedCause vasoconstriction, ↓ blood supply to nasal mucosa / edema Topical decongestants: Sympathomimetics. Side effects-drying and burning of the mucosa. Using more than 5 days- rebound vasodilation and congestion. Oxymetazoline -Afrin
Combined oral decongestant and antihistamines: Extendryl / Rondec- chlorpheniramine
Mucolytics: Thin mucus, improving mucociliary flow. Steam, NS drops, Guaifenesin, N-acetylcysteine
Immunotherapy: Given to patients that not responded to drug therapy
and good environmental control
POS
ALLERGIC RHINITIS
Pale, edematous mucosa of the inferior nasal turbinate
EPISTAXISIs bleeding from the nose, being evident anteriorly through the nares or posteriorly through the nasopharynx.
Etiology: vide slides
Pathophysiology:
Nasal mucosa blood supply originates from internal/external carotid
Blood vessels of nasal septum and lateral walls have little protection, and the thin mucosa is prone to drying.
Most important vascular plexiform network is the:
Kiesselbach’s plexus in the anterior nasal septum. Woodruff’s plexus in the posterior part of nasal septum
Epidemiology: Children 2-10 years are most commonly affected
Nosebleed are more common in winter.
Local Causes:
[1] Trauma
Nose picking
Fractures.
Caustic/chemical agents
[2] InfectionsViral RhinitisParasites FungalBacterial Rhinitis/sinusitis
[3] Idiopathic:Wegener's granulomatosis Atrophic rhinitisDrying of the nasal mucosaAllergic Rhinitis
[4] Neoplasms:
Of the
– nose
– nasopharynx
– sinuses.
Angiofibroma
Carcinoma of the Nasopharynx
[5] Miscellaneous:
Septal deviation
Foreign bodies
Polyps
Vascular malformations
GENERAL CAUSES:
Hypertension, alcohol,
drugs (aspirin, warfarin)
Coagulopathies, Anemia,
Leukemia, Malignancies
S/S:
Family Hx of hemorrhagic disease
Hx of trauma or nose picking
Hx of medications or drug abuse
Hx of allergies, nasal congestion, discharge, obstruction
Check vital signs with BP determination.
Inspect nose, nasopharinx, oropharinx.
Check liver/spleen enlargement, pallor, lymph nodes.
Lab: CBC, Platelets, PT, PTT, BT, CT
TX:
Keep patient sitting with the head elevated
Direct pressure with gently squeezing of the nostrils.
Ice compresses to the nasal dorsum
Vasoconstricting agents: 0,25% Phenylephrine, 0,05% Oxymetazoline, 1:1,000 Epinephrine.
Cauterization with: Silver nitrate stick or swab with trichloroacetic Acid
Anterior nasal packing with oxycellulose gauze (Surgicel) or absorvable gelatin sponge (Gelfoam)
ENT specialist for: severe bleeding, posterior packing, fracture, reduction/surgery
ANTERIOR NASAL PACKING
ANTERIOR NASAL PACKING
PHARYNGITIS-TONSILITIS
Inflammation/infection of the membrane and underlying structures of pharynx and tonsils.
Epidemiology:
Streptococcal pharyngitis-more common between 5-15 years.
Viral pharyngitis: Most of cases are due to a virus, at young age, winter
Day care/kindergarten is a risk factor
Etiology: Bacterial: G-A beta hemolytic streptococcus (S. pyogenes #1)
Corynebacterium diphteria
Viral: Adenovirus (mcc), EBV virus, Coxsackie (herpangina)
Fungi: Candida (trush)- immunosuppressed infants.
Chlorinated pool: adenovirus pharyngoconjunctival fever
S/S:
Symptoms:Strep: ↑ fever, sudden onset, headache, N/V, often abd. Pain.
Viral: Rhinorrhea, cough, hoarseness, conjunctivitis, ulcerative lesions
Signs:
Pharyngeal erythema, tonsils ↑ yellowish exsudate, cervical tender lymph
Petechia in soft palate and uvula,
White pustules on the palatine tonsils
Dysphagia, bad breath GAS
Scarletiniform rash suggest GAS
Splenomegaly and generalized adenopathy, rash after ampi/amox EBV !!!!!!!
Diagnosis:
Clinically
Rapid Streptococcal test- Specificity 95-98% Sensitivity can be low (70-85%)
Culture (gold standard)
Monospot (Heterophyle Agglutination Antibody test)
Viral Capsid Antigen Immunoglobin-M (vca-IgM) r/o acute EBV (serology)
Risk factors: Acute Rheumatic fever, Glomerulonephritis
Treatment:
Viral: Symptomatic, nasal saline, lozenges, analgesics (Tylenol)
Bacterial: 10 days course of Penicillin, Amoxil, Augmentin
Alternative: one IM injection of benzathine Penicillin G 600.000/1.200.000U
Pen Allergy: Erythromycin, Azythromycin, Cephalosporin
Complications:Peritonsillar Abscess, Retropharyngeal abscess
Risk factors: Acute Rheumatic fever, Glomerulonephritis
Peritonsillar Abscess
Complication of tonsillitis/pharyngitis result in abscess in tonsillar fossa
Cause: Group A B-hemolytic Strept., Staph aureus, Anaerobic bacteria
Complication: Upper Respiratory Obstruction
S/S: Fever, sore throat, dysphagia, trismus (pain when opening the mouth),
Muffled voice (hot potato), Drooling, Cervical adenopathy,
Unilateral peritonsillar bulging, superior soft palate with
deviation of the uvula. Unilateral neck pain.
Pharinx: erythematous/edematous with enlarged and exsudative tonsils.
Lab: CBC- leukocytosis with left shift, Rapid Strep test, gram stain.
Cx of aspirate specimen. CT or U/S
TX: High dose IV penicillin. Surgical drainage if needed. Tonsillectomy.
Clindamycin, nafcillin, oxacillin if Staph is cultured
PERITONSILLAR ABSCESS
Differential Diagnosis of a Sore Throat
VIRAL:
Infectious mononucleosis: EBV Exsudative tonsillitis, cervical adenitis, fever.Pharyngeal inflammation, axillar lymphadenopathy, splenomegaly maculopapular rashes, petecchial enanthema in palate. Common in teenagersDiagnosis: >20% atypical lymphocytes on blood smear, positive Monospot (heterophyle agglutination antibody test) viral capsid antigen IgG / IgM, EBNA
Pharyngoconjunctivitis: Adenovirus (APC)Fever, exsudative pharyngotonsillitis, conjunctivitis
Herpangina:Coxsakie A virusUlcers in anterior pillars and soft palateCommon in summerFever, vesicles in palate
Hand, foot and mouth disease: Coxsakie (vesicles on palms, soles, mouth, buttocks)
Bacterial:Retropharyngeal (tonsillar) abscess: GABHS (S pyogenes) or St. aureus. < 2 years.Fever, stridor, drooling, neck hyperextension w/ resistance to movement, sore throat, hoarseness, trismus, asymmetric tonsillar enlargement, Ant. Cervical nodes enlargedSevere Sx: dyspnea, SOB
Dx: lateral neck films – increase in retropharyngeal space
Tx: Emergency, hospitalization, surgical drainage, IV PCN or Clindamycin
Epiglottitis : Hemophilus type BChildren: high fever, toxic, drooling, absence of cough
Fungal:Candida (oral trush)- on low imunosuppressed patients
RETROPHARANGEAL ABSCESS
FOREIGN BODY ASPIRATIONChildren often ingest or aspirate a foreign body, with variable outcomes.
Missed or late diagnosis may lead to serious morbidity or death.
Children will put almost anything they find into their mouth; like food (peanuts, grapes, candy, hot dog),
batteries, buttons, coins, crayons, jewelry, marbles, paper clips, pen caps, pins, screws, toy parts,
chicken or fish bones.
History: Most ingestions and aspirations of a foreign body occur in a normal child in their home, under their parents care.
Poor safety proofing; unattended child, running with food, or handling a small object It’s a toddler with a sudden onset of cough, choking, persistent wheezing, gags, and vomits at the time of ingestion
Peak age: 6 months-4 years Pathology:Usually foreign object lodge below the carina. In toddlers, lodge in either mainstemIn older children, they lodge in the Right mainstem
S/S: Acute: Coughing, Gagging, Choking, Wheezing (localized) Chronic: asymmetrical/absent breath sounds, recurrent pneumonia
Most common object: Peanut, then Candy, coins, grapes, Hot Dog
CXR: Lower Airway Area: Unilateral hyperinflation, Air trapping on affected side. Atelectasis Mediastinum shift AWAY from affected side/atelectasis
Esophageal area: lodged at one of these locations: Thoracic inlet Level of aortic arch and left mainstem bronchus Gastroesophageal junction,.
CT scanning supplemented with virtual bronchoscopic imaging may further provide such useful information prior to an attempt at bronchoscopy
TX: Removal by Rigid bronchoscopy, under anesthesia Inhalation to relieve bronchospasm following removal
Complications: Aspiration Pneumonia, Lung abscess
FIBEROPTIC LARYNGOSCOPY
Epiglottitis
A rapidly progressive and potentially fatal acute life threatening bacterial infection of the
epiglottis, resulting in narrowing of the glottic opening
Epiglottitis - Pathogenesis
Haemophilus influenzae type B. (Rare due to Hib vaccine)
Streptococcus Pneumonia, Streptococcus Group A
Inflammation and edema of the epiglottis, arytenoids, arytenoepiglottic folds, and subglottic area
Epiglottis pulled down into larynx and occludes the airway
Differential Diagnosis
Viral croup - barking cough, less abrupt, less toxic
Bacterial tracheitis- S. aureus, H. influenzae, Strept., diphtheria
Aspiration of a foreign body
Epiglottitis - Clinical Manifestations
*Abrupt onset of high fever (39- 40 degree celsius)
*Rapid onset of toxicity
*Rapid onset of respiratory distress (12 hours), drooling, chest wall retractions, inspiratory
stridor, ronchi, retraction and late cyanosis, sore throat.
*Muffled voice
*Child prefers sitting in up position and leaning forward with hyperextended chin to
maintain airway open.
*Beefy-red epiglottis, dysphagia
Epiglottitis – Diagnosis: Lab
Visualization of epiglottis - “cherry red”Lateral neck x-rays: Shows “Thumb sign” of edematous epiglottis with narrowing of posterior airwayWBC count > 15,000 left shiftBlood cultures
Treatment:
Airway management: keep child upright, NEVER SUPINE.
Adequate airway - nasotracheal intubation
Take to O.R. to anesthesia and intubate with PPV under visualization. Don’t wait for X-ray
IV fluids
Oxygen by mask and adrenaline nebulizer (0.5 ml/kg of 1:1000 sol.)
Cricothyrotomy if obstruction occur prior to controlled airway mgt.
Prevention: HiB vaccination, Prevnar
ATB: Cover G+ cocci, and G- Cefuroxime, Ceftriaxone, Ampicillin. Use for 10 days. Corticosteroids - reduce post-intubation inflammation
ACUTE EPIGLOTTITIS WITH ERYTHEMA AND SWELLING
On the left, an endoscopic view of the throat shows almost complete blockage of the airway (arrow). This finding is typical of epiglottitis.
On the right, the airway has been opened (arrow) after insertion and removal of an endotracheal tube, although some redness and blood remain
MILD EPIGLOTTITIS SWELLING AND NARROWING
LARYNGITIS-LARYNGOTRACHEOBRONCHITIS-VIRAL CROUP
Viral infection characterized by: Barking cough, Inspiratory stridor, Hoarseness, due to subglottic inflammation
Etiology: Parainfluenza virus type 1(m.c), type 2 and 3, RSV, influenza A/B
Pathophysiology:
-Virus enters body via respiratory droplets through nasopharynx airway
-There is an immune response, resulting in subglottic narrowing
-Edema and erythema of the mucosa of the subglottic tissue and / or tracheal mucosa,
further narrowing the airway, resulting in stridor, hoarseness, cough may lead to those
complications: Ventilation/perfusion mismatch
Hypoxia/hypercarbia: Air hunger, Anxiety/Lethargy
Epidemiology: Occurs mainly between 6-36 months. Self limited Ds. lasting 3-5 days. Prevalent in late fall/winterPerson-to-person transmission via respiratory droplets.
S/S: Prodrome: Coryza, nasal congestion, sore throat, cough, low grade fever
Characteristic: hoarse voice and barking cough (mainly at night), loud inspiratory stridor, mild respiratory distress (sternal / suprasternal retractions, cyanosis) no sign of toxicity.
LAB: X-Ray: The AP x-ray of the neck, shows the “ Steeple” sign. Narrowing of subglottic space The lateral view is useful in ruling out epiglottitis.
Pulse oximetry- determine if hypoxia is present.
Differential Diagnosis: Laryngomalacia, Peritonsillar abscess, Aspiration Epiglotitis, Bacterial Tracheitis
TX:
Rest at home, fluids
Humidified air: by tent, face mask, cool mist vaporizer, steam in bathroom If Resp. distress- Intubate under visualization in the O.R. Don’t wait for X-ray
Epinephrine: Use with NS in a nebulizer (0.5 ml/kg 1:1000 sol.) Dexamethasone: 0,6mg/kg IM. Decrease edema and inflammation
Nebulized Budenoside-decrease laryngeal mucosa edema
If severe: require intubation and ICU. Heliox prevent intubation
Atb: If necessary.
severe
CharacteristicEpiglottitis
3 m-3 y
H. influenza
Croup
3-6 years
Parainfluenza virus
Tracheitis3 y-10 y
Staph aureus
Appearancetoxic and unwell well looking
Well to toxic
Onsetabrupt onset4-12 hours
viral prodrome, slower onset1-7 days
2-3 days SX, with 10 hours decompensation
Feverhigh fever (>38.5oC) Low-moderate Moderate to high
Stridorusually moderate-severe
usually mild-moderate Mild inspiratory
stridor
Coughminimal or absent barking, seal-like
qualityBarking cough
Speechunable to speakMuffled voice
hoarse voice Hoarse voice
Secretions unable to swallow, drooling of saliva
able to swallow Mild secretions
Differences between Croup, Epiglottitis, Tracheitis
BACTERIAL TRACHEITISEtiology:
Patient with prior Croup or influenza infection.
Secondary bacterial inf. by S. aureus (M.C.) M. catarrhalis, H. influenza
Epidemiology: Can occur at any age between 3-10 years. Affect trachea
S/S:
Starts with Sx of URI Fever >102F Illness worsening over hours Respiratory distress
(retractions, grunting, dyspnea) Voice normal to hoarse Barking cough, Inspiratory
stridor, Dysphagia/Odinophagia
LAB: X-Ray: irregular tracheal border
TX: O2, Ventilation/Intubation if necessary, ATB, Inhalation, Mist tent
RSV-BRONCHOLITIS
Acute inflammatory Ds. of lower resp. tract, due to obstruction of the small lung airways, following an URI tract.
Etiology: RSV (M.C.), Influenza A, Adenovirus
Epidemiology: Age 2-24 months, peak age 2-10 months
Peak season: November-March
Preemies at higher risk
Incubation period: 4-5 days
Pathophysiology: Transmitted by direct contact with nasal secretions or Resp. dropplets
inducing damage to the bronchial epithelium of the small airways resulting in
inflammation, edema and airway hyperreactivity.
LAB: ABG- Respiratory acidosis Pulse Oxymetry- Hypoxia RSV swab Viral Culture (nasopharinx)
Tx:
Oxygen to correct hypoxia: when O2 is less than 91%. Wean when higher than 94% saturation
Correct Acidosis if necessary
Aerolized B-adrenergic (albuterol): wheezing treatment ?
IV fluids to correct losses secondary to poor intake.
Corticoids: should not be used for routine care
Aerolized Ribavirin. (Virazole- Good if RSV caught before the 3rd day) Only FDA approvedtreatment for RSV-Lower respiratory tract infection in hospitalized infants
Mist tent (nebulization)
RSV vaccine for prematures and high risk infants.- Synagis (Palivizumab)
Admission to hospital: hypoxia, no PO intake, severe Resp. Distress, toxic appearance, < 3 months.
BRONCHITIS: Inflammation of the major conducting airways.
Etiology: Viral (most common), following URI
Bacterial: S. pneumonia, M. catarrhalis, H. influenza
Allergic
S/S: Dry hacking cough, nasal discharge, Low grade fever.
Chest pain worse with coughing
Thin clear sputum becomes purulent over 3-4 days, clears by 10th day
Scattered ronchi, sometimes wheezing
LAB: WBC- normal to elevated
CXR- increase in bronchovascular markings
DD: asthma, foreign body
TX: rest, fluids, mucolitics, cough suppressant (limited use),
Nebulizations, ATB if necessary
ASTHMA
Is a chronic inflammatory disorder affecting large and small airways
Is a Reversible airways Ds, characterized by:
Airway inflammation
Secretion of mucus
Bronchoconstriction
Hyperresponsiveness to various stimuli
Epidemiology: Most common chronic illness in children
12-15% of school age children
80-90% of children will have first symptom by age 3
60-70% will be free of symptoms by adulthood
Etiology:
Extrinsic- caused by several allergens, family history always positive
Intrinsic- caused by: cold, infection, exercise, emotional,
INTRINSIC ASTHMA
Pathophysiology:
Immune system is made up of: B and T cells.
T cells distinguish foreign invaders: bacterias, viruses, allergens
B cells produce antibodies that help fight off infecting organism
Airway is invaded by inflammatory cells- mast cells, baso, eosino, neutrophils, B/T lymphocytes, macrophages
One of the antibodies produced by the immune system is the IgE known as the allergic antibody.
-Allergens/infections antigens triggers inflammatory/immune response in airways.
-IgE binds to Mast cells, found in the lining of nose, lungs, skin making the Mast cells to release chemicals such as histamines
-IgE response initiate inflammation and bronchospasm
-Inflammatory cells respond producing mediators- cytokines, leukotrienes elevating inflammatory response, stimulating constriction of smooth muscle in bronchioles.
-Airway smooth muscle becomes hyperresponsive bronchospasm.
Environmental Allergens and Childhood Asthma
-Dust mites
-Furry pets
-Molds
-Cockroaches
LAB: Blood test: Eosinophilia, Elevated serum IgENasal test for presence of eosinophiliaSkin testing (+) best test for allergen sensitivityProvocational tests: Methacholine challenge- confirm Dx of asthma. Measure airway hyperreactivity.RAST testImmunocap
PFTest Measure degree of airway obstruction and response of broncho dilator
Decreased PEFR
Increased TLC-FRC-RV
ABG: Decreased PO2, initially Respiratory alkalosis (hyperventilation),
later Respiratory acidosis (CO2 retention)
CXR:
Hyperinflation, flat diaphragms, inc. peribronchial thickening, atelectasis
R/O lung malformation, or other pathology.
At home: Peak Flow Meter. Measures PEFR (peak exp. flow rate)
TX-ACUTE:
Epinephrine SC 1:1000 0,01ml/kg/dose
B2-agonists: Inhalation (albuterol- Accuneb) (levalbuterol-Xopenex)
Nebulized Cortisone: Pulmicort
Nebulized B2 agonist HFA: Pro-Air, Xopenex, Ventolin
Theophyline- less safer. Oral/IV. Poor asthma control Monitor serum levels (5-15mg/ml)
Oral steroids: Prednisone 2mg/kg/day 3-5 days. Should be tapered.
Inhaled steroids: Beclomethasone (Beclovent), Fluticasone (Flovent) IV steroids: Dexamethasone (Decadron), Hydrocortisone
Oxygen, Chest physical therapy, Mucolitics, ATB if necessary
Control about known triggers.
CHRONIC:
-Avoidance of known triggers.
-Beta2 Agonists MDI (Proventil, Ventolin)
-Leukotrienes Modifiers: Montelukast (Singulair). Decrease # of eosinophils. Block effect of inflammatory mediators. -Inhaled steroids (Pulmicort).
-Combination Fluticasone/Salmeterol: Advair
-Exercices (swimming)
-Immunotherapy: XOLAIR anti-IgE immunomodulator, blocking its interaction with mast cell and basophils.
PNEUMONIA
Inflammation and infection of the lung parenchyma due to bacterial or viral pathogens.
Classified by anatomy: Lobar, Interstitial, Bronchopneumonia
Etiology:
Viral:
Adenovirus, Influenza, RSV
Bacterial:
Neonates: GBS, Chlamydia, E. coli, Listeria monocytogenes
1month-6 years: S. pneumonia, H. influenza
Adolescents: S. pneumonia, Mycoplasma pneumonia
Immunocompromised: Pseudomonas, klebsiela, Fungi, PCP
Epidemiology:
Children 2-4 years, are more susceptible than older childrenMay follow epidemics of viral infectionWinter/spring most commonDay care/ kindergarten
S/S: Tachypnea, dyspnea, cough, intercostal retractions, nasal flaring, grunting, fever,
accessory resp. muscles usage, chest pain, lethargy, hypoxia, rales/crackles, decreased
breath sound/dullness to percussion (consolidation). LAB: CBC: WBC with left shift, Blood culture (if severe picture), Pleural fluid studies (effusion), ABG CXR: Lobar consolidation (S. pneumonia and H. influenza), Hilar adenopathy (TB), Pneumatoceles (S. aureus/G-), Bilateral diffuse infiltrate (Mycoplasma),
Abscess (klebsiella)
Mycoplasma: Presence of Cold agglutinin titers
Prevention: Pneumovax vaccine in immunocompromised children, SC Ds.
ATB according to Pathogen:
S. aureus: Nafcillin, Oxacillin
S. Pneumonia: Penicillin G, Ampicillin, Cephalosporin. Resistant: Vancomycin
H. influenza: Cephalosporin 3rd generation
G-: Aminoglycoside with broad activity: Amikacin, Tobramycin, Gentamycin
Anaerobic infection (aspiration pneumonia) Penicillin, Clindamycin
Mycoplasma pneumonia/Chlamydia: Erythro/Azythromycin, Doxycycline
TX: Outpatient: ATB (Amoxil, Ampicillin, Erythro-10 days), inhalation, rest, fluids.
Inpatient: Toxic appearance, Severe Resp. Distress, Hypoxic, Unable to take POAge < 2 Humidified oxygen as needed, IV fluid for hydrationDrainage of pleural effusion if necessary
ATB: Neonates: Ampicillin, Gentamicin, 3rd Gen. Cephalosporin (Cefotaxime), Pen.
Older chidren: Ampicillin, 3rd Gen. Cephalosporin (Cefotaxime, Ceftriaxone)
MYCOPLASMA PNEUMONIA
CYSTIC FIBROSISIt is Autosomal Recessive Ds., and most common lethal inherited metabolic disorder in the white population affecting the exocrine glands of the body
Genetics:
Is a defective gene on long arm of chromossome 7 with a F508 codon mutation resulting in improper sodium chloride transport within the cells Secretions
Incidence: 1: 2000 live births in the Caucasian population
S/S: Characterized by thick, sticky mucus secretions that clogs lungs, pancreas.
Lungs: Thick secretions obstruct airways severe and recurrent infections ( S. aureus, P. aeroginosa)
Pneumonia Bronchiectasy Fibrosis, poor lung function
Pancreas: Obstructed glands ducts prevent enzymes from being released, leading to fat/protein
malabsorption to malnutrition and FTT (steathorrhea).
Intestinal obstruction at birth, known as meconium ileus in 5-10% of CF patients Other S/S: Rectal prolapse, digital clubbing (hypoxemia), recurrent sinus infections, salty sweat ,
persistent cough, bulky foul-smelling stools, hypoxia, cyanosis, male infertility.
LAB:
Sweat chloride above 60mEq/L is positive Pulmonary Function testSputum culture, Lytes, CBC CXR: Hyperinflation, peribronchial thickening, atelectasis, bronchiectasis Stool trypsin levels ( trypsin deficiency)Detection of Delta F-508 genotype by DNA analysis
Treatment:
Genetic CounselingTreat specific pathology with ATB of broad spectrumVitamins, Inhalations (Albuterol), Physical Therapy with chest vibrators Pancreatic enzymes (enteric coated), OxygenDiet: high caloric intake diet with nutritional supplementMucolitic: N-acetyl cysteine (MUCOMYST)DNAse inhaled- thin the mucus plugLung transplantation/ Gene therapy
RECTAL PROLAPSE
NASAL POLYPS
SUDDEN INFANT DEATH SYNDROME- “CRIB DEATH”Sudden and unexpected death of an infant less than 1 year old. Age 2-4 m
Etiology: Poverty (Bed Sharing)
Low birth weight, SGA, Prematurity
Maternal substance abuse
Hypo/Hyperthermia, Exposure to cigarette smoking
Pathophysiology: Unknown.
Theories: central apnea, Upper airway obstruction, Cardiac arrythmias,
prone sleeping position.
Epidemiology: 1.5/ 1000 live births. 6.000/10.000 deaths/year in USA
TX: Resuscitation if possible
Prevention: Avoid prone position and usage of soft or loose bedding.
Place infant on his “ BACK” to sleep on a firm mattress.