Upper Upper respiratory respiratory

tract infection tract infection in pediatrics in pediatrics

(URTI)(URTI)

RTI ( respiratory tract RTI ( respiratory tract infection) IMPORTANCEinfection) IMPORTANCE

Nearly 50% of all paediatric consultations in Nearly 50% of all paediatric consultations in industrialized countries are caused by industrialized countries are caused by respiratory tract infections (RTIs). respiratory tract infections (RTIs). Acute RTIs are Acute RTIs are among the leading causes of childhood among the leading causes of childhood mortality, especially in developing countries. mortality, especially in developing countries. Their annual incidence per child decreases with Their annual incidence per child decreases with age: age:

6.1 in children less than 1 year 6.1 in children less than 1 year 5.7 in children aged 1-2 5.7 in children aged 1-2 4.7 in children aged 3-4 4.7 in children aged 3-4 3.5 in children aged 5-9 3.5 in children aged 5-9 2.7 in children aged 10-14 2.7 in children aged 10-14 2.4 in children aged 15-19. 2.4 in children aged 15-19.

Upper respiratory tract infection (URTI) Upper respiratory tract infection (URTI) represents the most common acute represents the most common acute illness . illness .

Rates are highest in children younger Rates are highest in children younger than 5 years. Children who attend than 5 years. Children who attend school or daycare are a large reservoir school or daycare are a large reservoir for URIs, and they transfer infection to for URIs, and they transfer infection to those who care for them. those who care for them.

Acute pharyngitis accounts for 1% of all Acute pharyngitis accounts for 1% of all ambulatory visits.ambulatory visits.

The incidence of viral and bacterial The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 pharyngitis peaks in children aged 4-7 years.years.

RRhinopharyngitishinopharyngitis Nasopharyngitis (rhinopharyngitis or Nasopharyngitis (rhinopharyngitis or

the common cold) the common cold) == Inflammation of Inflammation of the nares, pharynx, hypopharynx, the nares, pharynx, hypopharynx, uvula, and tonsilsuvula, and tonsils

Occur year round, but mostly during Occur year round, but mostly during fall and winter. Epidemics is most fall and winter. Epidemics is most common during cold months, with a common during cold months, with a peak incidence in late winter to early peak incidence in late winter to early spring.spring.

Humidity may also affect the Humidity may also affect the prevalence of colds, because most prevalence of colds, because most viral URI agents thrive in the low viral URI agents thrive in the low humidity characteristic of winter humidity characteristic of winter monthsmonths

Etiology of Etiology of rhinopharyngitisrhinopharyngitis

Rhinoviruses: These cause approximately 30-50%  Rhinoviruses: These cause approximately 30-50%  RSVRSV Coronaviruses: Enteroviruses, including Coronaviruses: Enteroviruses, including

coxsackieviruses, echoviruses, and others: These coxsackieviruses, echoviruses, and others: These are also leading causes of the common cold.are also leading causes of the common cold.

Other viruses: Adenoviruses, orthomyxoviruses Other viruses: Adenoviruses, orthomyxoviruses (including influenza A and B viruses), (including influenza A and B viruses), paramyxoviruses , EBV, account for many URIs. paramyxoviruses , EBV, account for many URIs. Varicella, rubella, and rubeola Varicella, rubella, and rubeola

Bacteria Bacteria ( very rare)( very rare): : streptococci streptococci , staph, , staph, diphteria, B pertussis, Haemophilus, diphteria, B pertussis, Haemophilus, Pneumococcus, Neisseria, TreponemaPneumococcus, Neisseria, Treponema

Risk factors for URIsRisk factors for URIs Contact: Close contact with small children settings, Contact: Close contact with small children settings,

such as school or daycare, increases the risk of URI.such as school or daycare, increases the risk of URI. Travel: , exposure to large numbers of individuals in Travel: , exposure to large numbers of individuals in

closed settings. Increased exposure to respiratory closed settings. Increased exposure to respiratory pathogens pathogens

Environmental factors such as passive smoking and Environmental factors such as passive smoking and exposure to pollutants exposure to pollutants

Immunocompromise that affects cellular or humoral Immunocompromise that affects cellular or humoral immunity: Splenectomy, HIV infection, immunity: Splenectomy, HIV infection, corticosteroids, immunosuppressive treatment , corticosteroids, immunosuppressive treatment , ffamilial predisposition with immunological defects or amilial predisposition with immunological defects or anatomical and/or physiological features anatomical and/or physiological features

MalnutritionMalnutrition Atopic statusAtopic status Lack of breast-feedingLack of breast-feeding Cilia dyskinesia syndrome and cystic fibrosisCilia dyskinesia syndrome and cystic fibrosis Anatomic changes due to facial dysmorphismsAnatomic changes due to facial dysmorphisms Upper airway trauma, and nasal polyposisUpper airway trauma, and nasal polyposis Anemia, rickets, malnutritionAnemia, rickets, malnutrition Carrier stateCarrier state

PathophysiologyPathophysiology URI URI Direct invasion of the mucosa lining the Direct invasion of the mucosa lining the

upper airwayupper airway Person-to-person spread of virusesPerson-to-person spread of viruses by hand by hand

with pathogens to the nose or mouth or with pathogens to the nose or mouth or inhaling respiratory droplets from an infected inhaling respiratory droplets from an infected person who is coughing or sneezing.person who is coughing or sneezing.

Barriers, including physical, mechanical, Barriers, including physical, mechanical, humoral, and cellular immune defenses. humoral, and cellular immune defenses.

Hair lining the nose filters Hair lining the nose filters Mucus coats Mucus coats Ciliated cells lower in the respiratory tract Ciliated cells lower in the respiratory tract

trap and transport pathogens up to the trap and transport pathogens up to the pharynx, where they are then swallowed into pharynx, where they are then swallowed into the stomachthe stomach

Adenoids and tonsils contain immune cells Adenoids and tonsils contain immune cells that respond to pathogens. that respond to pathogens.

local swelling, erythema, edema, secretions, local swelling, erythema, edema, secretions, and fever, result from the inflammatory and fever, result from the inflammatory response of the immune system to invading response of the immune system to invading pathogens and from toxins pathogens and from toxins

initial nasopharyngeal infection may spread initial nasopharyngeal infection may spread to adjacent structures, resulting in sinusitis, to adjacent structures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, otitis media, epiglottitis, laryngitis, tracheobronchitis, and pneumoniatracheobronchitis, and pneumonia

Humoral immunity (immunoglobulin A) and Humoral immunity (immunoglobulin A) and cellular immunity cellular immunity

Normal nasopharyngeal flora, including Normal nasopharyngeal flora, including various staphylococcal and streptococcal various staphylococcal and streptococcal species, help defend against potential species, help defend against potential pathogenspathogens

Suboptimal humoral and phagocytic immune Suboptimal humoral and phagocytic immune function have URI increased risk and have function have URI increased risk and have severe or prolonged course of disease.severe or prolonged course of disease.

SYMPTOMS OF RFSYMPTOMS OF RF NNasal obstructionasal obstruction Congestion of nasal breathingCongestion of nasal breathing SneezingSneezing RRhinorrheahinorrhea : secretions often evolve from : secretions often evolve from

clear to opaque white to green to yellow clear to opaque white to green to yellow within 2-3 days of symptom onsetwithin 2-3 days of symptom onset

CoughCough AnorrhexiaAnorrhexia FeverFever 5-10 days5-10 days

– Foul breath: This occurs as resident flora Foul breath: This occurs as resident flora process the products of the inflammatory process the products of the inflammatory process. process.

– Hyposmia: Also termed anosmia, it is Hyposmia: Also termed anosmia, it is secondary to nasal inflammation. secondary to nasal inflammation.

– HeadacheHeadache

– Sinus symptoms: These may include Sinus symptoms: These may include congestion or pressure and are common with congestion or pressure and are common with viral URIs. viral URIs.

– Photophobia or conjunctivitis: adenovirus .Photophobia or conjunctivitis: adenovirus .– Influenza : pain behind the eyes, pain with Influenza : pain behind the eyes, pain with

eye movement, or conjunctivitis. eye movement, or conjunctivitis. – Itchy, watery eyes are common in patients Itchy, watery eyes are common in patients

with allergic conditions. with allergic conditions. – Fever: This is usually slight or absent, but Fever: This is usually slight or absent, but

temperatures can reach 39.5°C in infants and temperatures can reach 39.5°C in infants and young children. If present, fever typically young children. If present, fever typically lasts for only a few days. lasts for only a few days.

– Gastrointestinal symptoms: Symptoms such Gastrointestinal symptoms: Symptoms such as nausea, vomiting, and diarrhea may occur as nausea, vomiting, and diarrhea may occur in persons with influenza, especially in in persons with influenza, especially in children. Nausea and abdominal pain may be children. Nausea and abdominal pain may be present in individuals with strep throat and present in individuals with strep throat and viral syndromes.viral syndromes.

LABORATORYLABORATORY

CBC, ES, CRP, to find bacterian infection, CBC, ES, CRP, to find bacterian infection, Leucocytosis with neutrophilia suggest bacterian, Leucocytosis with neutrophilia suggest bacterian, low level of WBC, lymphocytes raised – in viral low level of WBC, lymphocytes raised – in viral infectionsinfections

Because viruses cause most URIs, the diagnostic Because viruses cause most URIs, the diagnostic role of laboratory investigations and radiologic role of laboratory investigations and radiologic studies is limited. studies is limited. Viral culture, rapid antigen Viral culture, rapid antigen detection, or polymerase chain reaction (PCR) detection, or polymerase chain reaction (PCR) assay of influenza virus assay of influenza virus on a nasopharyngeal on a nasopharyngeal swab could be done if specific antiviral therapy is swab could be done if specific antiviral therapy is recommended. Similar tests are also available for recommended. Similar tests are also available for adenovirus, respiratory syncytial virus, and adenovirus, respiratory syncytial virus, and parainfluenza virusparainfluenza virus. .

The use of The use of reverse-transcriptase PCR for reverse-transcriptase PCR for the diagnosis of enterovirus and the diagnosis of enterovirus and rhinovirus infections rhinovirus infections is not currently is not currently available for daily clinical care.available for daily clinical care.

Serologic tests for Serologic tests for mononucleosismononucleosis Influenza serologies Influenza serologies only have only have

epidemiologic value and should not be epidemiologic value and should not be used for clinical care. used for clinical care.

A pharyngeal swab for rapid antigen A pharyngeal swab for rapid antigen detection of GABHS (detection of GABHS (Group A Beta-Group A Beta-Hemolytic Streptococci Hemolytic Streptococci ) is 90% ) is 90% sensitive and 95% specificsensitive and 95% specific

NOSE AND THROATNOSE AND THROAT cult culturesures

COMPLICATIONSCOMPLICATIONS

Sinusitis is a complication in only Sinusitis is a complication in only approximately 2% of persons with viral URIsapproximately 2% of persons with viral URIs

OtitisOtitis Epiglottitis occurs at a rate of 6-14 cases per Epiglottitis occurs at a rate of 6-14 cases per

100,000 children100,000 children Croup, or laryngotracheobronchitis usually Croup, or laryngotracheobronchitis usually

occurs in children aged 6 months to 6 years occurs in children aged 6 months to 6 years with peak incidence in the second year of with peak incidence in the second year of lifelife

PneumoniaPneumonia Digestive complications: anorrhexia, Digestive complications: anorrhexia,

vomiting, diarrhea, dehidration, vomiting, diarrhea, dehidration, Seizures may appear when fever is more Seizures may appear when fever is more

than 38,5 F Cthan 38,5 F C

Imaging Studies for URTIImaging Studies for URTI A lateral neck radiograph should be taken in a patient with A lateral neck radiograph should be taken in a patient with

stridor to assess the airways if epiglottitis is clinically stridor to assess the airways if epiglottitis is clinically suspectedsuspected

Chest radiography should be reserved for patients with Chest radiography should be reserved for patients with acute tracheobronchitis , those with abnormal vital signs or acute tracheobronchitis , those with abnormal vital signs or signs of consolidation on chest examination, or those with signs of consolidation on chest examination, or those with persistent symptoms for longer than 3 weeks. persistent symptoms for longer than 3 weeks.

Plain radiography has been largely replaced by computed Plain radiography has been largely replaced by computed tomography (CT) in the evaluation of sinusitis, particularly in tomography (CT) in the evaluation of sinusitis, particularly in preparation for corrective surgery. Complete opacification preparation for corrective surgery. Complete opacification and air-fluid level are the most specific findings for acute and air-fluid level are the most specific findings for acute sinusitis. sinusitis.

However, a large proportion of patients with the common However, a large proportion of patients with the common cold have radiologic abnormalities on CTcold have radiologic abnormalities on CT. Imaging is . Imaging is recommended for patients who do not respond to treatment recommended for patients who do not respond to treatment with antibiotics and decongestants, but is not advised for with antibiotics and decongestants, but is not advised for the diagnosis of uncomplicated sinusitis.the diagnosis of uncomplicated sinusitis. Mastoiditis and Mastoiditis and other intracranial complications of URIs should be evaluated other intracranial complications of URIs should be evaluated by CT or magnetic resonance imaging.by CT or magnetic resonance imaging.

PREVENTION AND PREVENTION AND TREATMENTTREATMENT

Prevention Prevention : VACCINES, IMMUNOSTIMULANTS, : VACCINES, IMMUNOSTIMULANTS, VITAMINSVITAMINS– Parent education on risk factor modification, in particular Parent education on risk factor modification, in particular

avoiding smoking indoors avoiding smoking indoors – General hygiene methods for children attending day care General hygiene methods for children attending day care

centrescentres– Breast feedingBreast feedingManagementManagement– Rest Rest – Lot of fluid intake.Lot of fluid intake.– Nasal wash with hypertonic salt water or 0.9% salineNasal wash with hypertonic salt water or 0.9% saline– Decongestants to unblock the opening of sinuses and Decongestants to unblock the opening of sinuses and

reduce symptoms of nasal congestion in children above 3 reduce symptoms of nasal congestion in children above 3 yearsyears

– Paracetamol 30-40 mg/kg/day for fever and pain relieverParacetamol 30-40 mg/kg/day for fever and pain reliever– Antibiotics to treat the bacterial infection very rare ( fever, Antibiotics to treat the bacterial infection very rare ( fever,

ES high, CRP+leucocytosis, children with immune ES high, CRP+leucocytosis, children with immune handicaps) handicaps)

ADENOIDITISADENOIDITIS

Adenoids begin forming in 3rd month ofAdenoids begin forming in 3rd month of fetal developmentfetal development Covered by pseudostratified ciliatedCovered by pseudostratified ciliated epitheliumepithelium Fully formed by 7 monthFully formed by 7 month Palatine tonsils begin development in 3Palatine tonsils begin development in 3rdrd month month

of fetal developmentof fetal development

Acute adenoiditisAcute adenoiditis

! Symptoms include:! Symptoms include: – – Purulent rhinorrheaPurulent rhinorrhea – – Nasal obstructionNasal obstruction – – FeverFever Frequent complication: otitis mediaFrequent complication: otitis media Recurrent Acute AdenoiditisRecurrent Acute Adenoiditis ! 4 or more episodes of acute adenoiditis in a! 4 or more episodes of acute adenoiditis in a 6 month period6 month period ! Similar presentation as recurrent acute! Similar presentation as recurrent acute rhinosinusitisrhinosinusitis ! In older children nasal endoscopy can help! In older children nasal endoscopy can help

Chronic adenoiditisChronic adenoiditis

! Symptoms include:! Symptoms include: – – Persistent rhinorrheaPersistent rhinorrhea – – Postnasal dripPostnasal drip – – Malodorous breathMalodorous breath – – Associated otitis media >3 Associated otitis media >3

monthsmonths – – Think of refluxThink of reflux

Obstructive AdenoidObstructive Adenoid HyperplasiaHyperplasia ! Signs and Symptoms! Signs and Symptoms – – Obligate mouth breathingObligate mouth breathing – – Hyponasal voiceHyponasal voice – – Snoring and other signs of sleep Snoring and other signs of sleep

disturbancedisturbance Obstructive TonsillarObstructive Tonsillar HyperplasiaHyperplasia ! Snoring and other symptoms of sleep! Snoring and other symptoms of sleep disturbancedisturbance ! Muffled voice! Muffled voice ! Dysphagia! Dysphagia

Surgery to Remove the AdenoidsSurgery to Remove the Adenoids

Adenoids are lymph nodes located high in the back Adenoids are lymph nodes located high in the back

of the throat. They can become enlarged from of the throat. They can become enlarged from

repeated ear infections and can affect the repeated ear infections and can affect the

Eustachian tubes that connect the middle ears and Eustachian tubes that connect the middle ears and

the back of the nose. An adenoidectomy (removal the back of the nose. An adenoidectomy (removal

of the adenoids) may help children with recurring of the adenoids) may help children with recurring

ear infections have fewer of them. Adenoidectomy ear infections have fewer of them. Adenoidectomy

is typically done when recurring ear infections is typically done when recurring ear infections

continue despite antibiotic treatment.continue despite antibiotic treatment.

ACUTE PHARYNGITIS ACUTE PHARYNGITIS (TONSILITIS)(TONSILITIS)

viral pharyngitis  viral pharyngitis  – Adenovirus, which may also cause laryngitis and Adenovirus, which may also cause laryngitis and

conjunctivitisconjunctivitis– Influenza virusesInfluenza viruses– CoxsackievirusCoxsackievirus– HSVHSV– EBV (infectious mononucleosis)EBV (infectious mononucleosis)– CytomegalovirusCytomegalovirus

causes of bacterial pharyngitis causes of bacterial pharyngitis – Group A streptococci (approximately 15% of all cases of Group A streptococci (approximately 15% of all cases of

pharyngitis)pharyngitis)– Group C and G streptococciGroup C and G streptococci– N gonorrhoeaeN gonorrhoeae– Arcanobacterium (Corynebacterium) hemolyticumArcanobacterium (Corynebacterium) hemolyticum– Corynebacterium diphtheriaeCorynebacterium diphtheriae– Atypical bacteria (eg, Atypical bacteria (eg, M pneumoniae,M pneumoniae,  C pneumoniaeC pneumoniae): ):

Anaerobic bacteriaAnaerobic bacteria

Immunology and FunctionImmunology and FunctionTONSILS AND ADENOIDSTONSILS AND ADENOIDS

! ! Part of secondary immune systemPart of secondary immune system ! Exposed to ingested or inspired ! Exposed to ingested or inspired

antigens passed antigens passed through the epithelial through the epithelial layerlayer

! Immunologic structure is divided into 4! Immunologic structure is divided into 4 compartments: compartments: reticular crypt reticular crypt

epithelium, extra follicular area, epithelium, extra follicular area, mantle zone of the lymphoidmantle zone of the lymphoid

follicle, and the germinal center of follicle, and the germinal center of the lymphoid the lymphoid folliclefollicle

Membrane cells and antigen presenting Membrane cells and antigen presenting cellscells

are involved in transport of antigen from are involved in transport of antigen from thethe

surface to the lymphoid folliclesurface to the lymphoid follicle ! Antigen is presented to T-helper cells! Antigen is presented to T-helper cells ! T-helper cells induce B cells in germinal! T-helper cells induce B cells in germinal center to produce antibodycenter to produce antibody ! Secretory IgA is primary antibody ! Secretory IgA is primary antibody

producedproduced ! Involved in local immunity! Involved in local immunity

Acute TonsillitisAcute Tonsillitis

Signs and symptoms:Signs and symptoms: – – FeverFever – – Sore throatSore throat – – Tender cervical lymphadenopathyTender cervical lymphadenopathy – – DysphagiaDysphagia – – Erythematous tonsils with exudatesErythematous tonsils with exudates

Pharyngeal erythema: Marked Pharyngeal erythema: Marked erythema :adenoviral infection. In contrast, erythema :adenoviral infection. In contrast, rhinoviral and coronaviral infections do not rhinoviral and coronaviral infections do not have severe erythema. have severe erythema.

Exudates: half the patients with Exudates: half the patients with adenovirus infections. Exudative adenovirus infections. Exudative pharyngitis and tonsillitis may be seen pharyngitis and tonsillitis may be seen with mononucleosis caused by EBV Yellow with mononucleosis caused by EBV Yellow or green secretions do not differentiate a or green secretions do not differentiate a bacterial pharyngitis from a viral one. bacterial pharyngitis from a viral one.

Foul breath: This may be noted because Foul breath: This may be noted because resident florae process the products of the resident florae process the products of the inflammatory process. inflammatory process.

Conjunctivitis -adenovirus. Scleral icterus - infectious mononucleosis. Rhinorrhea - viral cause. Tonsillopharyngeal/palatal petechiae - GAS infections

and infectious mononucleosis. A tonsillopharyngeal exudate - streptococcal infectious

mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections.

exudate does not differentiate viral and bacterial causes.

Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus

Lymphadenopathy Cardiovascular: Murmurs Pulmonary: Pharyngitis and lower respiratory tract

infections with M pneumoniae or C pneumoniae, Abdomen: Hepatosplenomegaly - mononucleosis

infection

Tonsillar hypertrophy: Peritonsillar abscess Tonsillar hypertrophy: Peritonsillar abscess may manifest as unilateral palatal and may manifest as unilateral palatal and tonsillar pillar swelling, with downward and tonsillar pillar swelling, with downward and medial tonsil displacement; the uvula may medial tonsil displacement; the uvula may tilt to the opposite side. Bulging of the tilt to the opposite side. Bulging of the posterior pharyngeal wall may signal a posterior pharyngeal wall may signal a retropharyngeal abscess. retropharyngeal abscess.

Tender anterior cervical adenopathy: This Tender anterior cervical adenopathy: This may be present with streptococcal infection may be present with streptococcal infection or with viral infections. In persons with or with viral infections. In persons with diphtheria, submandibular and anterior diphtheria, submandibular and anterior cervical edema may be present along with cervical edema may be present along with adenopathy. adenopathy.

Erythema: This may be especially Erythema: This may be especially prominent in persons with group A prominent in persons with group A streptococcal pharyngitis. Palatal petechiae streptococcal pharyngitis. Palatal petechiae may be seen. may be seen.

Exudates of the pharynx: These are Exudates of the pharynx: These are common with bacterial pharyngitis, common with bacterial pharyngitis, manifesting as white or yellow patches. A manifesting as white or yellow patches. A whitish coating may appear on the tongue, whitish coating may appear on the tongue, causing the normal bumps to appear more causing the normal bumps to appear more prominent. Yellow or green coloration does prominent. Yellow or green coloration does not differentiate bacterial pharyngitis from not differentiate bacterial pharyngitis from a viral nasopharyngitis. a viral nasopharyngitis.

A whitish adherent membrane A whitish adherent membrane forming on the nasal septum, along forming on the nasal septum, along with a mucopurulent blood-tinged with a mucopurulent blood-tinged discharge, should prompt a discharge, should prompt a consideration of diphtheria. consideration of diphtheria. Pharyngeal and tonsillar diphtheria Pharyngeal and tonsillar diphtheria may manifest as an adherent blue-may manifest as an adherent blue-white or gray-green membrane over white or gray-green membrane over the tonsils or soft palate; if bleeding the tonsils or soft palate; if bleeding has occurred, the membrane may has occurred, the membrane may appear blackish. appear blackish.

Fever: Compared with other URIs, group A Fever: Compared with other URIs, group A streptococcal infections are more likely cause streptococcal infections are more likely cause fever, with temperatures around 38.3°C fever fever, with temperatures around 38.3°C fever is not reliable to differentiate viral or is not reliable to differentiate viral or bacterial etiologies.bacterial etiologies.

Group A beta-hemolytic streptococci: The Group A beta-hemolytic streptococci: The classic clinical picture includes a fever, classic clinical picture includes a fever, tonsillopharyngeal erythema and exudate; tonsillopharyngeal erythema and exudate; swollen, tender anterior cervical adenopathy; swollen, tender anterior cervical adenopathy; headache; emesis in children; palatal headache; emesis in children; palatal petechiae; midwinter to early spring season; petechiae; midwinter to early spring season; and absent cough or rhinorrhea.and absent cough or rhinorrhea.

Conjunctivitis: This symptom may be seen Conjunctivitis: This symptom may be seen with adenoviral pharyngoconjunctival with adenoviral pharyngoconjunctival fever and is present in one half to one fever and is present in one half to one third of all adenoviral URIs. Watery, third of all adenoviral URIs. Watery, injected conjunctiva may also be seen injected conjunctiva may also be seen with allergic conditions. with allergic conditions.

Cough: This is more suggestive of a viral Cough: This is more suggestive of a viral than a bacterial etiology. than a bacterial etiology.

Diarrhea: If associated with a URI, it Diarrhea: If associated with a URI, it suggests a viral etiology. suggests a viral etiology.

Fever: EBV infections and influenza cause Fever: EBV infections and influenza cause fever.fever.

Bacterial pharyngitisBacterial pharyngitis

This may be difficult to distinguish from This may be difficult to distinguish from viral pharyngitis. Assessment for group A viral pharyngitis. Assessment for group A streptococci warrants special attention. streptococci warrants special attention. Physical findings that suggest a high risk Physical findings that suggest a high risk for group A streptococcal disease are for group A streptococcal disease are erythema, swelling, or exudates of the erythema, swelling, or exudates of the tonsils or pharynx; temperature of 38.3°C tonsils or pharynx; temperature of 38.3°C or higher; tender anterior cervical nodes or higher; tender anterior cervical nodes ((>>1 cm); and an absence of conjunctivitis, 1 cm); and an absence of conjunctivitis, cough, or rhinorrhea, which are suggestive cough, or rhinorrhea, which are suggestive of viral illness.of viral illness.

•Mucosal ulcers, erosions, vesicles: The presence of palatal vesicles or shallow ulcers is characteristic of primary infection with HSV.• Ulcerative stomatitis may also occur in coxsackievirus or other enteroviral infection. Mucosal erosions may also be seen in primary HIV infection. Small vesicles on the soft palate, uvula, and anterior tonsillar pillars suggest infection by coxsackievirus, known as herpangina. Tonsillar hypertrophyFoul breath: Halitosis may be noted because resident florae process the products of the inflammatory process. Anterior cervical lymphadenopathy: This is seen with viral and bacterial infections.Approximately half of EBV mononucleosis cases involve generalized adenopathy or splenomegaly. An enlarged liver may also be palpable. Primary HIV infection may also include lymphadenopathy.

A rash may be seen with group A A rash may be seen with group A streptococcal infections, particularly in streptococcal infections, particularly in patients younger than 18 years.patients younger than 18 years.

This scarlet fever rash appears as tiny This scarlet fever rash appears as tiny papules over the chest and abdomen, papules over the chest and abdomen, creating roughness like sunburned creating roughness like sunburned appearance. appearance.

The rash spreads, causing erythema in The rash spreads, causing erythema in the groin and armpits. The face may the groin and armpits. The face may be flushed, with pallor around the lips. be flushed, with pallor around the lips. Approximately 2-5 days later, the rash Approximately 2-5 days later, the rash begins to resolve. Peeling is often begins to resolve. Peeling is often noted on the tips of toes and fingersnoted on the tips of toes and fingers

COMPLICATIONS In the neighbourhood: Adenitis Retropharyngeal abscess Peritonsilar abcess Otitis Sinusitis ( epiglotitis) At distance:  acute glomerulonephritis, acute 

rheumatic fever, and rheumatic heart disease

toxic shock syndrome for GAS ( group A Streptococcus )

Recurrent Acute Recurrent Acute TonsillitisTonsillitis

! Same signs and symptoms as ! Same signs and symptoms as acuteacute

! Occurring in 4-7 separate ! Occurring in 4-7 separate episodes per yearepisodes per year

! 5 episodes per year for 2 years! 5 episodes per year for 2 years ! 3 episodes per year for 3 years! 3 episodes per year for 3 years

Medical ManagementMedical Management

! Penicillin is first line treatment! Penicillin is first line treatment ! Recurrent or unresponsive infections ! Recurrent or unresponsive infections

requirerequire treatment with beta-lactamase resistant treatment with beta-lactamase resistant

antibioticsantibiotics such assuch as Erytromycin, ClaritromycinErytromycin, Claritromycin ClindamycinClindamycin AugmentinAugmentin: 30-40 mg/kg in 2 doses. : 30-40 mg/kg in 2 doses.

Syrup, tabletsSyrup, tablets Cephalosporins ( Ist and II gen)Cephalosporins ( Ist and II gen)

TonsillectomyTonsillectomy ! Current clinical indicators :! Current clinical indicators : – – 3 or more infections per year despite 3 or more infections per year despite

adequateadequate medical therapymedical therapy – – Hypertrophy causing dental malocclusion orHypertrophy causing dental malocclusion or adversely affecting orofacial growthadversely affecting orofacial growth documented by orthodontistdocumented by orthodontist – – Hypertrophy causing upper airway Hypertrophy causing upper airway

obstruction,obstruction, severe dysphagia, sleep disorder,severe dysphagia, sleep disorder, cardiopulmonary complicationscardiopulmonary complications

Peritonsillar abscessPeritonsillar abscess

! Abscess formation outside tonsillar ! Abscess formation outside tonsillar capsulecapsule

! Signs and symptoms:! Signs and symptoms: – – FeverFever – – Sore throatSore throat – – Dysphagia/odynophagiaDysphagia/odynophagia – – DroolingDrooling – – TrismusTrismus – – Unilateral swelling of soft Unilateral swelling of soft

palate/pharynx with uvulapalate/pharynx with uvula deviationdeviation

Peritonsillar abscessPeritonsillar abscess

Peritonsillar abscess unresponsive to medicalPeritonsillar abscess unresponsive to medical management and drainage documented by management and drainage documented by

surgeon,surgeon, unless surgery performed during acute stageunless surgery performed during acute stage – – Persistent foul taste or breath due to Persistent foul taste or breath due to

chronic tonsillitischronic tonsillitis not responsive to medical therapynot responsive to medical therapy – – Chronic or recurrent tonsillitis associated Chronic or recurrent tonsillitis associated

withwith streptococcal carrier state and not streptococcal carrier state and not

responding to betalactamaseresponding to betalactamase resistant antibioticsresistant antibiotics – – Unilateral tonsil hypertrophy presumed Unilateral tonsil hypertrophy presumed

neoplasticneoplastic

Chronic TonsillitisChronic Tonsillitis

! Chronic sore throat! Chronic sore throat ! Malodorous breath! Malodorous breath ! Presence of tonsilliths! Presence of tonsilliths ! Peritonsillar erythema! Peritonsillar erythema ! Persistent tender cervical ! Persistent tender cervical

lymphadenopathylymphadenopathy ! Lasting at least 3 months! Lasting at least 3 months

OTITIS MEDIAOTITIS MEDIA

The eustachian tubes equalize the pressure The eustachian tubes equalize the pressure between the middle ear cavity and the outside between the middle ear cavity and the outside atmosphere and allow fluid and mucus to drain atmosphere and allow fluid and mucus to drain out of the middle ear cavity. Inflammation of the out of the middle ear cavity. Inflammation of the middle ear causes the tubes to close causing the middle ear causes the tubes to close causing the fluid to become trapped. Bacteria from the back fluid to become trapped. Bacteria from the back of the nose travel through the eustachian tube of the nose travel through the eustachian tube directly into the middle ear cavity and multiply in directly into the middle ear cavity and multiply in the fluid. The inflammation can occur as a result the fluid. The inflammation can occur as a result of an infection extending up the eustachian tube. of an infection extending up the eustachian tube. This tube may become blocked by a bacterial or This tube may become blocked by a bacterial or viral infection or by enlarged adenoids. Fluid viral infection or by enlarged adenoids. Fluid produced by the inflammation cannot drain off produced by the inflammation cannot drain off through the tube and instead collects in the through the tube and instead collects in the middle ear.middle ear.

The Eustachian tube The Eustachian tube is a canal that is a canal that connects the middle connects the middle ear to the throat. It is ear to the throat. It is lined with mucus, just lined with mucus, just like the nose and like the nose and throat; it helps clear throat; it helps clear fluid out of the middle fluid out of the middle ear and into the nasal ear and into the nasal passages. Cold, flu, passages. Cold, flu, and allergies can and allergies can irritate the Eustachian irritate the Eustachian tube and cause the tube and cause the lining of this lining of this passageway to passageway to become swollen.become swollen.

Ear InfectionEar Infection diagnose an ear diagnose an ear

infection by infection by looking at the looking at the outer ear and outer ear and the eardrum the eardrum with a device with a device called an called an otoscope. A otoscope. A healthy healthy eardrum (shown eardrum (shown here) appears here) appears transparent and transparent and pinkish-gray. An pinkish-gray. An infected infected eardrum looks eardrum looks red and swollen.red and swollen.

If the Eustachian tube If the Eustachian tube becomes blocked, fluid becomes blocked, fluid builds up in the middle builds up in the middle ear. This creates an ear. This creates an environment for bacteria environment for bacteria and viruses, which can and viruses, which can cause infection; fluid is cause infection; fluid is detected in the middle detected in the middle ear with a pneumatic ear with a pneumatic otoscope. This device otoscope. This device blows a small amount of blows a small amount of air at the eardrum, air at the eardrum, making the eardrum making the eardrum vibrate. If fluid is vibrate. If fluid is present, the eardrum present, the eardrum will not move as much will not move as much as it should.as it should.

Ruptured EardrumRuptured EardrumWhen too much fluid When too much fluid builds up in the middle builds up in the middle ear, it can put pressure ear, it can put pressure on the eardrum until it on the eardrum until it ruptures (shown here). ruptures (shown here). Signs of a ruptured Signs of a ruptured eardrum include eardrum include yellow, brown, or white yellow, brown, or white fluid draining from the fluid draining from the ear. Pain may ear. Pain may disappear suddenly disappear suddenly because the pressure because the pressure of the fluid on the of the fluid on the eardrum is gone. eardrum is gone. Although a ruptured Although a ruptured eardrum sounds eardrum sounds frightening, it usually frightening, it usually heals itself in a couple heals itself in a couple of weeks.of weeks.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Ear Infection SymptomEar Infection Symptom Sudden, piercing pain in the ear which may be worse Sudden, piercing pain in the ear which may be worse

when lying down, making it difficult to sleep. when lying down, making it difficult to sleep. Trouble hearing.Trouble hearing. A fever of up to 40 F C .A fever of up to 40 F C . Tugging or pulling at one or both ears.Tugging or pulling at one or both ears. Fluid drainage from ears.Fluid drainage from ears. Loss of balance.Loss of balance. Nausea, vomiting, or diarrhea.Nausea, vomiting, or diarrhea. Congestion.Congestion. Ear Infection Symptoms: BabiesEar Infection Symptoms: Babies It can be difficult to identify an ear infection in It can be difficult to identify an ear infection in

babies or children :crankiness, trouble sleeping, babies or children :crankiness, trouble sleeping, and loss of appetite. Babies may push their and loss of appetite. Babies may push their bottles away because pressure in the middle ear bottles away because pressure in the middle ear makes it painful to swallow.makes it painful to swallow.

LaboratoryLaboratory

WBC, ES, Fg, CRP, high if WBC, ES, Fg, CRP, high if bacterianbacterian

Local exam with otoscopeLocal exam with otoscope Cultures of otic dischargeCultures of otic discharge Imagery when progresses through Imagery when progresses through

otomastoiditisotomastoiditis

COMPLCATIONSCOMPLCATIONS

CRONIC OTITIS CRONIC OTITIS OTOMASTOIDITISOTOMASTOIDITIS DEAFNESSDEAFNESS CEREBRAL VENOUS TROMBOSISCEREBRAL VENOUS TROMBOSIS CEREBRAL ABCESSCEREBRAL ABCESS MENINGITISMENINGITIS DIARRHEEA, DEHIDRATIONDIARRHEEA, DEHIDRATION SEIZURESSEIZURES

PREVENTION OF OTITIS PREVENTION OF OTITIS MEDIAMEDIA • • Encouraging breast-feeding Encouraging breast-feeding • • Feeding child upright if bottle fedFeeding child upright if bottle fed • • Avoiding exposure to passive smokeAvoiding exposure to passive smoke • • Teaching adults and children careful Teaching adults and children careful

hand washing techniquehand washing technique • • Limiting exposure to viral upper Limiting exposure to viral upper

respiratory infectionsrespiratory infections • • Ensure immunizations are up-to-date; Ensure immunizations are up-to-date;

including influenza and 7 valent including influenza and 7 valent conjugated polysaccharide vaccine conjugated polysaccharide vaccine (PCV7) (PCV7)

One solution is for your doctor to One solution is for your doctor to insert small tubes through the insert small tubes through the eardrum. Ear tubes let fluid drain out eardrum. Ear tubes let fluid drain out of the middle ear and prevent fluid of the middle ear and prevent fluid from building back up. This can from building back up. This can decrease pressure and pain, while decrease pressure and pain, while restoring hearing. The tubes are restoring hearing. The tubes are usually left in for 8 to 18 months until usually left in for 8 to 18 months until they fall out on their own.they fall out on their own.

Treatment of otitis Treatment of otitis mediamedia Desinfection of nasopharynxDesinfection of nasopharynx Analgesics (Analgesics (oral and topical oral and topical pain pain

killing therapy)killing therapy) Paracetamol, ibuprophene, NO aspirinParacetamol, ibuprophene, NO aspirin Children with low risk be treated with Children with low risk be treated with

a wait-and-see approach.a wait-and-see approach. Low-dose amoxicillin (40 mg/kg/day) Low-dose amoxicillin (40 mg/kg/day)

may be used if low risk (greater than may be used if low risk (greater than two years, no day care, and no two years, no day care, and no antibiotics for the past three months) antibiotics for the past three months)

Failure to respond to initial treatment drug Failure to respond to initial treatment drug (resistant or persistent acute otitis media)(resistant or persistent acute otitis media)

amoxicillin/clavulanate potassium,amoxicillin/clavulanate potassium, • • cefuroxime axetil,cefuroxime axetil, • • • • cefpodoxime proxetil.cefpodoxime proxetil. • • Trimethoprim sulfaTrimethoprim sulfamethoxasone: Bactrim, biseptol 6-8 methoxasone: Bactrim, biseptol 6-8

mg/kg in 2 daily dosesmg/kg in 2 daily doses • • ClarithromycinClarithromycin 15-20 mg/kg 15-20 mg/kg • • Erythromycin ethylsuccinate and sulfisoxazole acetylErythromycin ethylsuccinate and sulfisoxazole acetyl: 30-: 30-

40mg/kg40mg/kg • • AzithromycinAzithromycin

a single dose of ceftriaxone 50 mg/kg a single dose of ceftriaxone 50 mg/kg could be could be equivalent to a 10-day course of oral antibiotics for equivalent to a 10-day course of oral antibiotics for new cases of acute otitis medianew cases of acute otitis media

ceftriaxone sodium: prescribe one dose for new onset otitis ceftriaxone sodium: prescribe one dose for new onset otitis media and a three-day course for a truly resistant pattern media and a three-day course for a truly resistant pattern of otitis media or if oral treatment cannot be given, 5 daysof otitis media or if oral treatment cannot be given, 5 days

Acute inflamation of Acute inflamation of larynx larynx

LaryngotracheobronchitiLaryngotracheobronchitis (croup) s (croup) is a viral infection of the upper respiratory is a viral infection of the upper respiratory

tract that causes varying degrees of airway tract that causes varying degrees of airway obstructionobstruction

prodrome of several days of fever and symptoms of mild upper respiratory infection

the infection extends to the proximal trachea, diffuse inflammation with exudate and edema of the subglottic area causes narrowing of the airway.

5 cases per 100 children per year during the second year of life

Typically, between 6 pm and 6 am, the child develops stridor (mainly inspiratory), hoarseness, and barking cough.

Worsening symptoms on the second night of the illness. The child is fatigued.

Physical The physical examination may range from totally

unremarkable on presentation to severe respiratory distress.

Restless (common); prefers sitting upright in a parent's lap

Appears nontoxic Normal voice or laryngitis Mild fever Tachycardia Tachypnea Varying stridor, predominantly inspiratory Absence of drooling Retractions of the accessory chest muscles No change in stridor with positioning

ETIOLOGY

parainfluenza type 1, although parainfluenza type 2 and type 3 also may cause disease. Paramyxovirus

Influenza virus type A Respiratory syncytial virus (RSV) Adenovirus Rhinoviruses Enterovirus Coxsackievirus Enteric cytopathogenic human orphan virus (ECHO

virus) Reovirus Measles virus

DIFFERENTIAL DG

DiphtheriaForeign Bodies IN TracheaEpiglottitisForeign Body Ingestion

Subglottic stenosisRetropharyngeal abscessSubglottic hemangioma

Laboratory

A pulse oximetry measurement CBC count Leukopenia in early stage of illness,

leukocytosis in later stage of patients with severe disease

Anteroposterior (AP) soft tissue neck radiograph may show subglottic narrowing

Rapid antigen tests Direct laryngoscopy Fiberoptic laryngoscopy Bronchoscopy

Treatment

Make the child as comfortable as possible. Avoid agitating the child Humidified air or mist

therapy may be used, but both have unproven efficacy.

Provide oxygen (humidified) L -epinephrine (1:1000) is as effective as racemic epinephrine.

Dexamethasone has been shown to reduce symptoms in patients with moderate-to-severe croup. (0.6 mg/kg IM, not to exceed 10 mg)

Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled Decadron is also used when budesonide is unavailable.

Racemic epinephrine: 0.25-0.5 mL of 2.25% solution (equivalent to 1% epinephrine) via nebulizer (diluted in 3 mL of isotonic sodium chloride solution or sterile water); may be repeated 3 times

Antiinflamatory: paracetamol, ibuprophen Antibiotherapy: amoxicillin, augmentin,

cephalosporin, macrolides

EpiglottitisEpiglottitis

Epiglottitis, also termed supraglottitis, is an Epiglottitis, also termed supraglottitis, is an inflammation of the epiglottis and/or the inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft including the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula. tissue, and, occasionally, the uvula. 

This condition is more often found in children This condition is more often found in children aged 1-5 years who present with a sudden onset aged 1-5 years who present with a sudden onset of symptoms:of symptoms:

Sore throat Sore throat Drooling, odynophagia or dysphagia, difficulty or Drooling, odynophagia or dysphagia, difficulty or

pain during swallowing, globus sensation of a pain during swallowing, globus sensation of a lump in the throat lump in the throat

Muffled dysphonia or loss of voice Muffled dysphonia or loss of voice Dry cough or no cough, dyspnea Dry cough or no cough, dyspnea Fever, fatigue or malaise Fever, fatigue or malaise

EtiologyEtiology H influenzaH influenza type B (HiB)  type B (HiB)

and and Streptococcus pneumoniaStreptococcus pneumonia, S aureus, Varicella can cause a primary or secondary infection often with group A beta-hemolytic streptococci,C albicans, especially in immunocompromised patients.Several viruses, including herpes species and parainfluenza

The clinical triad of drooling, dysphagia, and distress is the classic presentation. Fever with associated respiratory distress or air hunger occurs in most patients.

the patient appears acutely ill, anxious, and usually assumes a characteristic tripod position 

child may have stridorous respirations, but as the disease progresses, airway sounds may diminish. Additional signs of upper airway obstruction are also evident including suprasternal, subcostal, and intercostal retractions. 

Pathophysiology Bacterial infection of the epiglottis leads to acute

onset of inflammatory edema, beginning on the lingual surface of the epiglottis where the submucosa is loosely attached. Swelling significantly reduces the airway aperture. Edema rapidly progresses to involve the aryepiglottic folds, the arytenoids, and the entire supraglottic larynx. The tightly bound epithelium on the vocal cords halts edema spread at this level. Aspiration of oropharyngeal secretions or mucus plugging can cause respiratory arrest.

Mortality rates as high as 10% can occur in children whose airways are not protected by endotracheal incubation. With endotracheal intubation, mortality is less than 1%.

Differential Diagnoses

Bacterial tracheitisPediatrics, PertussisForeign Bodies, TracheaPharyngitisMononucleosisPneumoniaAnaphylaxisPeritonsillar AbscessCroup or LaryngotracheobronchitisRetropharyngeal AbscessForeign Body IngestionToxicity, Caustic Ingestions

Laboratory

CBC, ESR, Fg, CRP, Oximetry (periferal O2 concentratin in

Blood cultures and culture of the epiglottis ) In cases of HiB epiglottitis, blood cultures

Lateral neck radiographs may show an enlarged epiglottis. Chest radiography may also reveal a pneumonia 

CT scan of the neck

Treatment EMERGENCY:

Immediate transport to the nearest appropriate facility Position of comfort.  Oxygen Orotracheal intubation or needle

cricothyroidotomy may be necessary in emergent situations

Percutaneous transtracheal ventilation Also termed needle cricothyroidotomy or translaryngeal

ventilation, percutaneous transtracheal ventilation is a temporizing method used to treat cases of severe epiglottitis when the patient cannot be intubated proceeding to a formal tracheostomy.

Percutaneous transtracheal ventilation involves inserting a needle through the cricothyroid membrane, which lies inferior to the thyroid cartilage and superior to the cricoid cartilage. The cricothyroid artery typically courses through the superior portion of the membrane.

Antibiotics

Empiric antimicrobial therapy must cover all likely pathogens in the context of the clinical setting for 7-10 days

Ceftriaxone (Rocephin) 75-100 mg/kg/d IV q12-24h

Ampicillin 100-200 mg/kg/d IV divided q6h Clindamycin 25-40 mg/kg/d IV divided q6-8h Ampicillin and sulbactam (Unasyn) 3 months to 12 years: 100-200 mg

ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h

SINUSITISSINUSITIS CChronic maxillary sinusitishronic maxillary sinusitis ,  , frontal sinusitisfrontal sinusitis.. Etiology and risk factors:  viral upper respiratory tract infections (URTIs) or nasal

allergies and the host response to these insults,allergic rhinitis, anatomical abnormalities,gastroesophageal reflux (GER), immune deficiency, and disorders of ciliary function

Approximately 5-13% of URTIs are complicated by bacterial sinusitis

Children are susceptible to serious sequelae from a complication of sinusitis such as orbital cellulites (in about 9.3% of the cases) and intracranial complications (in 3.7-11% of patients).

ETIOLOGY

– Streptococcus pneumoniae - 20-30%–  Haemophilus influenzae - 15-20%– Moraxella catarrhalis - 15-20% Streptococcus

pyogenes (beta-hemolytic) - 5%– Chronic sinusitis more commonly a

polymicrobial infection– Commonly cultured bacteria

Alpha-hemolytic streptococci Staphylococcus aureus Coagulase-negative staphylococci Nontypeable H influenzae – More common than acute

sinusitis Moraxella catarrhalis Anaerobic bacteria, including Peptostreptococcus,

Prevotella, Bacteroides, andFusobacterium species Pseudomonads - More common after multiple courses

of antibiotics; consider immunodeficiency

 Several anatomical abnormalities of the lateral nasal wall can predispose to sinusitis.

Immune deficiencies are more common in the general population than cystic fibrosis or ciliary disorders. In order of decreasing prevalence, the most common types are common variable, immunoglobulin G (IgG) subclass, and selective antibody.

Impaired nasal function increases postnasal drip and irritant burden on the lower airways, which can exacerbate asthma symptoms.

Gastroesophageal reflux disease ( GER may lead to inflammation of the eustachian tube orifices or sinus ostia secondary to mucosal irritation. )

SIGNS AND SYMPTOMS

– Nasal congestion– Infrequent fever– Otitis media (50-60% of patients)– Irritability– Headache

Signs and symptoms of severe infection :– Purulent rhinorrhea– High fever (ie, >39°C)– Periorbital edema

Uncomplicated sinusitis spontaneously resolves in 40% of patients.

Acute sinusitis :signs and symptoms normally clear within 30 days; URTI symptoms persisting longer than 7-10 days suggest acute sinusitis

Chronic sinusitis is defined as low-grade persistence of signs and/or symptoms lasting longer than 90 days without improvement.

The patient may have 6 or more recurrent episodes per year.

The patient may have a history of acute exacerbations without ever being completely well between episodes.

Night time cough is more prevalent.Anterior rhinoscopy

Difficult in young children. Examine the middle turbinate and middle meatus for

evidence of purulence or sinus discharge with a vasoconstrictive agent, such as oxymetazoline and lidocaine.

Polyps may suggest cystic fibrosis.

Laboratory and Imagery CBC, ES, Fg, IgE, CT scanning is the criterion standard for evaluation of both

mucosal inflammation and anatomical abnormalities in the paranasal sinuses.

Plain radiography/sinus series Rigid or flexible nasal endoscopy

Indications for maxillary sinus puncture in children include the following:

Severe toxic illness Acute illness unresponsive to antibiotics within 72 hours Immunocompromised patients Suppurative complications Workup for fever of unknown origin Nasal and maxillary cultures.

Complications

Preseptal cellulitis - Eyelid edema, erythema, normal globe movement

Orbital cellulitis - Proptosis, chemosis Periorbital abscess - Proptosis with globe displaced

inferolaterally, decreased extraocular muscle movement

Orbital abscess - Severe proptosis, impaired visual acuity, fixed globe, toxic patient

Cavernous sinus thrombosis - High fever, bilateral symptoms

Intracranial involvement usually occurs subsequent to direct spread from sphenoid or frontal sinus disease.

Subdural and frontal lobe abscesses are most common.

Meningitis may occur.

TREATMENT Nasal decongestants and mucolytics orally or nebulization are

effective Antibiotherapy: uncomplicated cases of acute sinusitis are

responsive to amoxicillin; for children allergic to penicillin, a second- or third-generation cephalosporin can be used ; a macrolide or clindamycin can be used. Amoxicillin: 80 mg/kg/d PO divided bid; consider in children in large day care settings

Amoxicillin-clavulanate (Augmentin) <3 months: 125 mg/5mL PO susp based on amoxicillin; 30 mg/kg/d

divided bid for 7-10 d>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO divided q12h; if using 125 mg/5 mL or 250 mg/5 mL suspension, 40 mg/kg/d PO divided q8h for 7-10 d, or high dose 80-90 mg/kg/d PO divided bid

Cefuroxime 20-30 mg/kg/d PO divided bid Azithromycin (Zithromax) 10 mg/kg PO first d, 5 mg/kg/d PO next

4 d Vancomycin:10 mg/kg IV q6 hClindamycin: 8-20 mg/kg/d PO divided tid/qid 20-40 mg IV divided

q6-8h

Allergic rhinitis: Measures include allergen avoidance, optimal environment, nasal steroids, a second-generation antihistamine, and possible immunotherapy.

Gastroesophageal reflux: Conservative measures include elevating the head of the bed, not feeding immediately before bedtime, and thickening feeds. Medical therapy includes H-2 blockers, prokinetic agents, and hydrogen ion pump inhibitors.

Consider surgery as a last resort in the pediatric population