urtipedia_adabbagh

8/7/2019 URTIpedia_ADabbagh

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By

Amal Al dabbagh,MD


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URTI,definition,pathophysiology& etiologyy URTI are those 1rly affecting the structures

above the larynx, but most RI affect bothupper & lower RT simultaneously or

sequentially.

y Inflammatory infiltrates & edema of themucosa, vascular congestion, Kmucussecretion & alteration of ciliary structure &

function.

yMost caused by viruses&Mycoplasma exceptfor epiglottitis.


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Child with Respiratory Diseasey Historical Data:

1. Onset & Duration.2. Severity& Pattern.

3. Associated airway& systemic symptoms.

4. PPtg & predisposing conditions.

5. Immunization & Familyhistory.


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Child with respiratory disease,cont.

y Physical examination:

1. Vitals; RR, pulse, etc

2. General; ENT ,color of lips, clubbing

1. Local; hoarseness,stridor, use of accessorymuscles, air entry, quality, adventitioussounds, cardiac examination.


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Child with respiratory disease,cont

y Investigations:

1. Imaging.

2. Cultures.

3. ABG.


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Acute viral rhinitisy Etiology: rhino, adeno, RSV, Coxsackie's viruses.

y Clinical manifestations: 6-12 attacks/ year inchildren < 5 years.

fever, rhinorrhea, sore throat, cough

similar cases in the family.

y Complications: AOM,pharyngitis,sinusitis,conjunctivitis, pneumonia, adenitis.


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Acute viral rhinitis,conty Treatment: Symptomatic

antipyretics.

saline nasal drops/ solution.

decongestants.

? Antihistamines.


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Otitis Mediay Acute Otitis Media.

y Otitis Media with effusion


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Anatomy ofThe Ear


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Acute Otitis Mediay Defined bythe presence of fluid in the middle ear

accompanied byacute signs of illness.

y

Most prevalent in infancy.

y Fluid maypersist for weeks to months despite Rx withantibiotics.

y Hearing loss with subsequent speech, language andcognitive disabilities are the most common risks.

y In developing countries, suppurative infections asmeningitis and mastoiditis remain importantcomplications.


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Risk Factors for AOMy Age; 6-18 months of age.y Daycare.y

Breast feeding.y Tobacco smoke.y Pacifier use.y Ethnicity.y

Familyhistory.y Genetic factors.y Otherssocioeconomic, sleep, season, altered host

defences, underlying disease.


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Pathogenesis ofAOMy Patient with antecedent event (URTI or allergy).y Congestion of respiratorymucosa of the nose, nasopharynx

and ET.

y Congestion of mucosa of ET obstructs the narrowestportion of the tube, the isthmus.

y Obstruction causes ve pressure followed byaccumulationof secretions produced bythe mucosa of the middle ear.

y Viruses & bacteria that colonize the URT reach the middle

ear via aspiration, reflux.y Microbial growth in the middle ear secretions mayresult in

suppuration with clinical signs of AOM.y The MEE persist for wks to moths after sterilization.


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Microbiologyy Bacteria: S.Pn, H.influenza, M. catarrhalis.

y Viruses: RSV, rhinoviruses, influenza viruses, and

adenoviruses.y Others as Mycoplasma pn, Chlamydia trachomatis,

and C.Pneumoniae.

y Tuberculous OM remains a cause of severe middle ear

disease.


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Clinical Manifestations ofAOMy Non specific S&S: fever, irritability, excessive crying,

headache, apathy, anorexia, vomiting, and diarrhea.

y Specific S&S: Otalgia ,ear rubbing, hearing loss,vertigo and otorrhea.


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Tympanicmembrane

In Acute OtitisMedia


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Diagnosis ofAOM

y Evidence of acute history.

y S&S of middle ear inflammation.y Presence of middle ear effusion.

y Otoscopy.

y Tympanometry.

y Middle ear aspiration.


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Tympanometry


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Complications and Sequelaey Mild conductive hearing loss.

y Intratemporal: perforation, mastoiditis, petrositisand labirynthitis.

y Intracranial: meningitis, epidural abscess, brain

abscess, lateral sinus thrombosis, cavernous sinusthrombosis, subdural empyema, and carotid arterythrombosis.


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Management ofAOMy AAP 2004 guidelines concludes observation without use of

antimicrobial therapyis an option for selected childrenwith uncomplicated AOM based on diagnostic certainty,

age, illness severity, and assurance of follow up.

y Antibacterial therapyshould be administered to anychild


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Management ofAOM, conty For > 2yrs, antibiotics if diagnosis is certain and illness is

severe. Observation is an option when diagnosis is certainand illness not severe and in patients with uncertain

diagnosis.

y Observation is onlyappropriate when follow-up can beensured and antibiotics initiated if symptoms got worse.

y

Amoxicillin remains the drug of choice, because iseffective, safe, inexpensive, and has a narrow spectrum. 40-80 mg/kg/daydivided into 2 doses for 10 days for < 2yearsand 5-7days for > 2years.


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Otitis Media with Effusion (OME)

y Serous OM or glue ear.y OME is the presence of middle ear effusion in the

absence of acute signs of infection.y Encompasses one of the two categories of COM.y Arise after a recognized or unrecognized episode of

AOM.y Accompanied byconductive hearing loss.y Prolonged hearing impairment during 1st years of

life mayaffect development of speech andlanguage.


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Clinical Manifestations ofOMEy Acute illness usuallyabsent, sleep disturbance,

hearing loss, vertigo.y Diagnosis with pneumatic otoscopydemonstrates

immobilityof TM with +ve pressure,tympanometryalso helpful.

y Hearing evaluation at time of diagnosis of OME(learning problems, language delay, hearing loss).

y Speech and language evaluation( OME >3mths)y Natural historyof OME is spontaneous

resolutiondays-months.


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Management ofOMEy Depends on +/- structural damage to TM or ME or speech,

language or learning problems, and severityof hearing loss.

y Prompt surgical referral for structural damage to TM orME( e.g. cholesteatoma).

y Surgical referral for children w OME with hearing lossindependent on OME, speech or language disorder,

developmental delayand uncorrectable visual impairment.

y Surgical referral for hearing loss> 21dB, bilateral OME >3mths, unilateral OME > 6mths.


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Cholesteatoma


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Management ofOME, cont..y Watchful waiting for children without speech,

language or visual problems who have hearing

loss>21dB.

y Not using antihistamines, decongestants, or steroids inthe management of OME in children.


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Pharyngitisy Principal involvement is in the throat.

y Uncommon below 1 year.

y Peak at 4-7 years & continues throughoutchildhood.

y Prominent in cases of Diphtheria, herpangina,adenovirus & Infectious mononucleosis.


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Pharyngitis, etiologyy Viral: Adenovirus, enterovirus, EB virus, Herpes

simplex virus.

y Bacterial: Gp AF hemolytic streptococcus.

y Mycoplasma.


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Pharyngitis, clinical manifestations

y viral vs. streptococcal pharyngitis.

y Fever, variable depending on etiology.y Throat: erythema, exudates, ulceration, enlarged

tonsils & peticheal mottling of the soft palate.

y

Conjunctivitis, rhinitis, hoarseness , coughy Cervical lymphadenopathy.

y Headache, abdominal pain.


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Pharyngitis,Diagnosisy Clinical.

y Throat culture.

y Rapid streptococcal detection kits.


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Pharyngitis,differential diagnosisy Infectious mononucleosis, when a membranous exudate is

present.

y Diphtheria, especiallyin the underimmunized.

y Herpangina, with manyvesiculoulcerative lesions in theanterior pillars & soft palate.

y Agranulocytosis, yellowish dirtywhite exudates coveringthe tonsils & post ph wall.

y Kawasaki disease.


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Pharyngitis, complicationsy Low rate with viral infection.

y Spectrum of illness extend from pharyngitis to tonsillitis,

retropharyngeal abscess or peritonsillar abscess.y In debilitated children, large chronic ulcers in the pharynx

(viral or bacterial).

y Mesenteric adenitis ( viral or bacterial) abdominal pain

with or without vomiting.

y Acute glomerulonephritis & Rheumatic fever, mayfollowstreptococcal infections.


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Pharyngitis, treatmenty Penicillin for 10 days in proven streptococcal

pharyngitis (125-250mg Q 8 hrs) Or erythromycin if

allergic to penicillin.

y Symptomatic Rx, warm saline gargle, steam inhalation,cool bland liquids as ginger ale. Acetaminophen for

throat pain.


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Diseases associated with acute stridor

y Acute laryngothracheitis.

y Acute laryngotracheobronchitis.

yAcute epiglottitis.

y Bacterial tracheitis.

y Foreign body.

Uncommon

y Peritonsillar abscess.

y Retropharyngeal abscess.

y

Diphtheria


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Viral Croupy Common respiratoryillness in young children.

y

Anglo-Saxon word Kropan; cryaloud.

y Hoarse voice; drybarking cough; inspiratorystridor;and variable amount of respiratorydistress thatdevelops over a brief period of time.


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Croup Syndromey Group of diseases that varies in anatomic involvement

and etiologic agents.

y Laryngotracheitis.

y Spasmodic croup.

y Bacterial tracheitis.

y L

aryngotracheobronchitis.y Laryngotracheobronchopneumonitis.


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Croup

Acute laryngotracheitis

y Disease of viral origin causing subglottic &tracheal swelling.

y The narrowed airwayis responsible for thehallmark of clinical picture.

y The cricoid ring in the upper trachea which issubglottic, has a narrow diameter which renderschildren vulnerable to inflammation.


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Viral Croup

( Acute laryngotracheitis)y Etiology:

Respiratoryviruses e.g. parainfluenza viruses1,2,and 3, RSV, Influenza viruses A & B.

y Clinical picture:Age 6mths- 3 years, M>F, Fall & winter.Gradual onset of low grade fever,URTI, barkingcough, inspiratorystridor & respiratorydistress.Hoarseness & aphonia mayoccur.


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Croup, diagnosis & treatmenty Clinically

y Lateral neck X-ray( steeple sign).

y

Fluid intakey Cool mist/ hot steamybathroom.

y Aerosolized adrenaline.

y Steroids( controversial)

y Endotracheal intubation.y Helium-Oxygen Mixture.

y Antibiotics


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Acute epiglottitis, etiologyy Bacterial infection of the supraglottic structures(

epiglottis, aryepiglottic folds & arytenoids softtissues) causing rapid airwayobstruction.

y Haemophilus Influenza type B in prevaccinationera.

y Bacteria associated with epiglottitis in the Hibvaccine era include: HiA, Str. Pn, Staph aureus, -hemolytic streptococci Gps A,B,C,and F


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Acute epiglottitis, clinical picturey Age usually2- 7 years.

y Sudden onset.

y High fever.

y Apprehensive, sitting forward, drooling saliva,hyperextended neck & protruded chin.

y Stridor, dysphagia.


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Acute epiglottitis, diagnosis & treatment

y Direct visualization.

y

Blood cultures.y Latex agglutination of serum or urine.

y Treatment is a medical emergency.

y Ventilatorysupport, intubation.

y IV antibiotics, 2nd or 3rd generation cephalosporin'sor chloramphenicol till cultures & sensitivityareknown.


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Common features in DD of Infectious Upper

Airway Obstructn

Feature ALT LTB/Pn Spasmo Epiglotti

prodr URsym URsym No/mini No/mini

Age 3m-3y 3m-8y 3m-3y 1y-8y

Onset gradual variable sudden rapid

Fever variable +/-high No high

Hoarse Yes Yes Yes No

Insstri Y/M-S Yes/S Yes/mo Y/mo-S

Dysph No No No Yes

Toxic No Yes No Yes

Etiology viral V+B V+Aller Bacteria


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Anatomyoftheupper

airway


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Diffusetonsillar&

pharyngealErythemaseen

hereasanon

Specificfinding

thatcanbeproduced

Byavarietyof

pathogens


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Intenseerythema

seenin association

Withacutetonsillarenlargement

& palatalpetichiae

ishighlysuggestive

OfGpAbeta-

streptococcal

Infection,though

otherpathogens

Canproducethese

findings.


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Exudative tonsillitisSeen with either Group ABeta hemolytic streptococcal

Or EB virus infection.


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Peritonsillar abscess

Photograph taken in the OR

Shows an intensely inflamedSoft palatal mass that obscuresThe tonsil & bulges forward &Toward the midline deviatingThe uvula .

Retropharyngeal


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Retropharyngealabscess

This young child presented

With high fever, drooling,Opisthotonous posture.Pharyngeal examination inThe OR reveals an intenselyErythematous unilateral

Swelling of the posteriorPharyngeal wall.


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Retropharyngeal abscess, a lateral neck XR shows prominentPrevertebral swelling displacing the trachea forward.


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Retropharyngeal abscessOn CT scan a thick-walled abscess cavity is evident in theRetropharyngeal space.


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Steeplesignin Croup


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Croup

This radiograph shows a long area of narrowing extending below the

Normally narrowed area at the level of the vocal cords.


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CroupDirect visualization revealed subglottic narrowing that was so severeOnly tracheostomy would enable establishment of an adequate airway.


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EpiglottitisA 3 year old seen a few hours after

Onset of symptoms.She was anxious but with no positionalPreference or drooling.


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Epiglottitis

This 5 year old holds his neckExtended, head forward, is mouthBreathing, drooling, and showsSigns of tiring.


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Epiglottitis

This 2-year old was inSevere distress and wasToo exhausted to holdHis head up.IN the OR the epiglottisAppears intensely red &

Swollen.


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Mild epiglottitis/supraglottitis


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?


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Thumb sign


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Common organismIn AOM & OME


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Questionsy A 12 yr old boywith 4 days of sore throat comes

to your office. Afebrile with rhinorrhea, cough,and one daydiarrhea associated with his sore

throat. Throat is mildlyerythematous a withnormal appearing tonsils. The best course ofaction is:

1. Swab the throat and give 10 days AB.

2. Swab his throat and wait for results.3. Symptomatic Rx.

4. AB without testing for gp A strept.


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Question 2y A 3 yr old fussyboy, febrile with proffuse

rhinorrhea. Shallow ulcers are noted on the softpalate and vesicles are noted on one palm and both

soles of the feet. The etiologyof this infection is1. Gp A strept

2. Acranobacterium hemolyticum

3. Coronavirus.

4. Coxackie virus

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