Common Respiratory Tract Infections in Children Pt 1

Question 1

pathophysiology of acute otitis media

Answer 1

Pathophysiology: mucociliary clearance mechanisms in eustachian tube ventilates and drains fluids away from middle ear. Eustachian tube obstruction can impair the drainage, leading to fluid stasis, which can lead to infection colonization. Children get more AOMs than adults because they are exposed to more viral URTIs and have shorter and more horizontal eustachian tubes.

Question 2

Risk factors of acute otitis media

Answer 2

Risk factors: exposure to cigarette smoke, pacifier use, bottle feeding while lying down, shorter duration of breastfeeding, lack of immunization. Household crowding, daycare attendance, siblings, syndromes/craniofacial anomalies, immunodeficiency, atopy, male gender, FN/inuit.

Question 3

Microbiology of acute otitis media

Answer 3

Microbiology of Acute Otitis Media: STREP STREP STREP PNEUMO, Haemophilus influenzae, Moraxella catarrhalis, group A strep.

Clinical Presentation: fever, fussiness, poor feeding, earache, ear discharge (indicates perforation), URTI symptoms are commonly present.

Question 4

3 criteria for diagnosing AOM

Answer 4

Signs of middle ear effusion: decreased mobility of tympanic membrane, acute otorrhea (™ perf), loss of bony landmarks, air-fluid level

• AND sign of middle ear inflammation(bulging tympanic membrane with marked discoloration)
• AND Acute onset of symptoms: rapid onset of ear pain or unexplained irritability in a preverbal child.

Question 5

Management of acute otitis media

Answer 5

Management: if left untreated, spontaneous resolution happens in 2/3ds of cases by 72 hours. Perforation with purulent discharge is very indicative of bacterial>viral, and it’s important to target strep pneumo cases.

First line: high dose amox (75-90) OR low dose amox 10 days if <2yo, or 5 days >2yo.

Second line if allergic to penicillin: 2nd or 3rd gen cephalosporin, azithromycin.

If there is a treatment FAILURE or there is also purulent CONJUNCTIVITS: amox-clav, ceftriaxone.

May need TUBES if >3 months with bilateral hearing loss, or recurrent AOM >3 episodes in 6 months.

Question 6

Complications of acute otitis media

Answer 6

**Distinguish AOM from myringitis: redness of the tympanic membrane seen temporarily in a crying child, OR associated with viral URTI.

Complications of AOM: pus/blood draining from canal (perforation), persistent effusion associated with conductive hearing loss, impacting language development and school performance. Acute mastoiditis (inflammation and potential destruction of the mastoid air spaces leading to abscess formation).

Less common: cranial nerve VII palsy, CN6 palsy, labyrinthitis, Sinus venous thrombosis, meningitis.

Mastoiditis Features: pinnae displaced outward and down. Posterior auricular redness, swelling and tenderness.

Question 7

Definition of otitis externa

Answer 7

ear canal inflammation and infection from broken skin

symptoms: otalgia, fullness, rapid onset

Question 8

risk factors and microbiology of otitis externa

Answer 8

Risk factors: swimming, hearing aides, ear tubes, foreign body, trauma, dermatological conditions, AOM.

Microbiology: pseudomonas aeruginosa, staphylococcus Aureus, group A strep.

Question 9

Diagnostic criteria for otitis externa (3)

Answer 9

Question 10

treatment of otitis externa

Answer 10

Otitis Externa Treatment; analgesics, antibiotic drops (ciprodex, polysporin)

Question 11

T/f usually pharyngitis is group A strep

Answer 11

false. >70% of cases are viral. If its bacterial, it’s usually group A strep.

Viral infection likely if: rhinorrhea, hoarseness, cough, and conjunctivitis → if classic viral symptoms predominante, the etiology is likely viral and no tests or antibiotics are needed

Question 12

clinical presentation of strep pharyngitis,

how do you diagnose?

Answer 12

pharyngeal or tonsillar exudate, fever, tenderness and enlargement of anterior cervical lymph nodes, absence of cough, increased risk if exposure to individual with strep throat in previous 2 weeks

Diagnosis: McIsaac Score– give 1 point for each:

• pharyngeal or tonsillar exudate
• swollen/tender anterior cervical nodes
• a history of a fever greater than 38 C
• absence of cough
• Age < 15 years (-1 point if > 45 years)

Question 13

Treatment for bacterial (GAS) strep pharyngitis

Answer 13

First line: Penicillin V and Amoxicillin

Second line if allergic to Penicillin: clindamycin and erythromycin

Antibiotics Treatment: Antibiotics will reduce: • Severity of symptoms • Duration of symptoms by ONE day • Risk of transmission (after 24h) • Risk of suppurative complications • Risk for rheumatic fever

Antibiotics will NOT reduce • Risk of non-suppurative complications (PSGN or GAS associated movement disorders)

Question 14

___ ____ is a complication of bacterial pharyngitis.

Answer 14

RETROPHARYNGIEAL ABSCESS

Pathophysiology: often a complication of bacterial pharyngitis. Abscess formation often arises from lymph tissue

Microbiology: Group A strep, oral anaerobes

Epi: young kids

Clinical Presentation: pain, drooling, fever, tonsils look normal, loss of extension

Diagnosis: lateral neck X-ray and CT if +

Treatment: antibiotics and surgery

Question 15

differentiating between retropharyngeal abscess and peritonsillar abscess

Answer 15

both can be complications of bacterial pharyngitis.

retropharyngeal: tonsils look normal, loss of extension. drooling
peritonsillar: hot potato voice, fever, unilateral swelling and deviation of the uvual.

Question 16

Clinical Presentation: painful mass in cervical area, URTI symptoms, erythematous phaynx and tonsils, facial swelling, torticolllis

Diagnosis? treatment?

Answer 16

sounds like cervical lymphadnitis.

Ddx: VERY BROAD-

• Diffuse – infectious (reactive), inflammatory/rheumatological, malignant, drug
• Localized – Infectious (Bacterial), inflammatory/rheumatological

Generally, cervical lymphadenitis refers to acute bacterial infection of single, or a group of lymph nodes

Microbiology: staph A, group A strep, cat scratch disease, mycobacterium, HIB

Treament: Cefazolin IV or keflex PO

Question 17

most common cause of cough

Answer 17

viral URTI

Most common cause of cough

Clinical presentation: runny nose, eyes, sore throat, fever, decreased energy and appetite, vomiting with cough is common

Natural history: in kids, might get URTI q3 weeks, especially if in daycare. Usually lasts 5-7 days

Management: conservative, antipyretics, encourage fluids, encourage hand washing, no cough medicine

Question 18

cough red flags

Answer 18

worsening fever

chest pain

immunocompromised

noenate

FTT

prev history of pneumonia

choking episode

tachypnea

hypoxia

resp distress

focal findings on auscultation (pneumonia)

toxic appearance

Question 19

is pneumonia an upper or lower airway disease

Answer 19

Pathophysiology: lower airway infection, causing pus and inflammation in small airways and alveoli

Question 20

How does etiology of pneumonias differ depedning on age of child?

Answer 20

Etiology: Viral if <2, bacterial if older than 2• ***Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Moraxella catarrhalis

• Mycoplasma pneumoniae and Chlamydophila pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)

Question 21

• __ pneumoniae and __ pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)

Answer 21

• Mycoplasma pneumoniae and Chlamydophila pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)

Question 22

Diagnostic crtieria of pneumonia in children

Answer 22

Diagnosis: Fever and Cough, AND ONE OF:

• tachypnea,
• increased work of breathing,
• crackles,
• hypoxia,
• chest/abdo pain.

Question 23

Pneumonia Investigations:

• Can be challenging to distinguish viral from bacterial

• High white count with left shift → more likely ___
• High CRP → more likely ___
• Suspect bacterial if:
• • Airspace __/consolidations
• • Lobar ___/distribution
• • Round opacities
• • Pleural ___
• Normal total WBC with lymphopenia → more likely ___
• Bloodwork: Consider only in patients being admitted for IV treatment or suspected sepsis
• CBC, blood culture (only 10% will be positive with pneumonia but will allow you to identify pathogen)
• CRP
• Consider electrolytes, renal function (at risk of SIADH)
• Nasopharyngeal aspirate if viral suspected

Answer 23

Pneumonia Investigations:

• Can be challenging to distinguish viral from bacterial
• High white count with left shift → more likely bacteria
• High CRP → more likely bacteria
• Suspect bacterial if:
• • Airspace opacities/consolidations
• • Lobar consolidation/distribution
• • Round opacities
• • Pleural effusion
• Normal total WBC with lymphopenia → more likely viral
• Bloodwork: Consider only in patients being admitted for IV treatment or suspected sepsis
• CBC, blood culture (only 10% will be positive with pneumonia but will allow you to identify pathogen)
• CRP
• Consider electrolytes, renal function (at risk of SIADH)
• Nasopharyngeal aspirate if viral suspected

Question 24

first line antibiotic for pneumonia treatment

Answer 24

• First line Antibiotics: Oral: Amoxicillin, IV: Ampicillin
• Will not cover B-lactamase producing strains of H. influenzae and M. catarrhalis. Will not cover S. aureus.–> WOULD NEED A 3rd GENERATION CEPHALOSPORIN +/- MACROLIDE FOR MYCOPLASMA PNEUMONIA (severe pneumonia)
• Pen. allergy:
• 2nd generation Cephalosporin (Cefazolin, Cefuroxime)
• Macrolide (Azithromycin)
• If influenza precedes the pneumonia, consider Staphylococcus aureus
• Amoxicillin-clavulanate (will also cover B. lactamase producing H. influenzae and M. catarrhalis)
• If MRSA is suspected: Septra or Clindamycin

Question 25

• If influenza precedes the pneumonia, consider Staphylococcus aureus and treat with ____.

• if MRSA is suspected cause of pneumonia, treat with:

Answer 25

staph A. treat with amox-clav

if MRSA suspected: septra or clinda

Question 26

treatment for atypical pneumonia (chlam, mycoplasma)

Answer 26

clarithomycin or azithromycin

• CXR generally show bilateral interstitial markings, non- segmental patchy lung opacities

• Subacute onset, prominent cough, minimal leukocytosis, non-lobar opacity, typically school-aged – suspect Mycoplasma pneumoniae