Infections of the Mouth, Nose, Pharynx, and Upper Respiratory Tract

Question 1

What are the most frequently occurring illnesses in children?

Answer 1

Viral URIs (AKA the common cold)

Question 2

How many viral URIs will a typical child have each year?

Answer 2

Most children have between 3 and 8 URIs/year. Most often in the fall and winter months.

Question 3

What four factors are associated with increased risk for developing URIs in children?

Answer 3

Attending daycare, exposure to secondhand smoke (or actively smoking), lower socioeconomic status, and overcrowding.

Question 4

Which (4) viruses are most typically responsible for URIs?

Answer 4

Rhinoviruses cause ~1/3 of cases, followed by coronaviruses, adenoviruses, and coxsackieviruses.

Question 5

Which (3) viruses are more likely to cause lower respiratory tract infections?

Answer 5

Parainfluenza, human metapneumovirus, and RSV.

Question 6

Describe the typical pattern of viral shedding in patients with viral URIs.

Answer 6

Viral shedding peaks at 2-7 days after initial symptoms and can last as long as two weeks.

Question 7

What is the role of viral testing in children with routine URIs?

Answer 7

Do not order viral testing unless the diagnosis is unclear or if the history/physical is incompatible with a diagnosis of URI.

Question 8

What is the role of antihistamine use in the management of acute URIs in children?

Answer 8

Avoid antihistamines for most children because they decrease cilia movement and can delay mucus clearance.

Question 9

Why should antitussives and decongestants be avoided in children <2 years of age?

Answer 9

For children < 2 years of age, certain medications (pseudoephedrine, carbinoxamine, and dextromethorphan) have resulted in death and should not be used.

Question 10

What is the most common complication of a typical viral URI?

Answer 10

Acute otitis media

Question 11

Does green nasal discharge in the first few days of a URI indicate that bacterial sinusitis is likely?

Answer 11

No; it usually signifies an increase in the number of inflammatory cells present.

Question 12

Name six risk factors for the development of sinusitis in a child.

Answer 12

Nasal polyposis, anatomic abnormalities, URIs, allergic rhinitis, asthma, and exposure to cigarette smoke.

Question 13

What are the (3) common causes of acute bacterial sinusitis?

Answer 13

S. pneumoniae, M. catarrhalis, and non-typeable H. influenzae.

Question 14

Differentiate the typical presentation of acute bacterial sinusitis in children vs adolescents.

Answer 14

Children typically present with cough, nasal discharge, and halitosis. Adolescents present more like adults, with facial pain, tenderness, and edema.

Question 15

If a child presents at day 9 of a URI with new fever, worsening nighttime cough, and increased sinus drainage, what do you suspect?

Answer 15

Acute bacterial sinusitis

Question 16

A child with severe immunosuppression presents with a suspected sinus infection. What is the best way to diagnose the infection?

Answer 16

Bacterial cultures should be obtained by aspirating the sinus via direct maxillary antral puncture or endoscopic middle meatal aspiration. These procedures should only be performed in those who have life-threatening illness, immunocompromised states, or who are unresponsive to empiric therapy.

Question 17

What is the recommended treatment for acute bacterial sinusitis?

Answer 17

Most centers recommend high-dose amoxicillin, but many use amoxicillin/clavulanic acid, extended-spectrum macrolides, or 2nd and 3rd generation cephalosporins because of the increasing rate of β-lactamase production by H. influenzae and M. catarrhalis. Treatment duration is 10-21 days. Saline nose drops and/or saline nasal sprays are recommended in addition to antibacterial therapy. Decongestants, antihistamines, and nasal corticosteroids are not recommended.

Question 18

Name eight (rare but important) potential complications of bacterial sinusitis.

Answer 18

Preseptal cellulitis, orbital cellulitis, septic cavernous sinus thrombosis, meningitis, Pott’s puffy tumor, epidural abscess, subdural abscess, and brain abscess.

Question 19

Describe the symptoms associated with septic cavernous sinus thrombosis.

Answer 19

Bilateral ptosis, proptosis, ophthalmoplegia, periorbital edema, headache, and change in mental status.

Question 20

A patient presents with bilateral ptosis, proptosis, ophthalmoplegia, periorbital edema, headache, and change in mental status. What condition should you suspect?

Answer 20

Septic cavernous sinus thrombosis.

Question 21

What condition should one suspect in a patient who presents with swelling and erythema of the eyelids and periorbital area without associated proptosis or limitation of eye movement?

Answer 21

Preseptal cellulitis

Question 22

What condition should one suspect in a patient who presents with pain with eye movement, conjunctival swelling, proptosis, limitation of eye movement, diplopia, and vision loss?

Answer 22

Orbital cellulitis

Question 23

What condition should one suspect in a patient who presents with forehead/scalp swelling and tenderness, headache, photophobia, fever, vomiting, and lethargy?

Answer 23

Pott’s puffy tumor (osteomyelitis of the frontal bone with associated subperiosteal abscess)

Question 24

What is Pott’s puffy tumor?

Answer 24

Osteomyelitis of the frontal bone with associated subperiosteal abscess. Patients present with forehead/scalp swelling and tenderness, headache, photophobia, fever, vomiting, and lethargy.

Question 25

What conditions should one suspect if a patient with bacterial sinusitis presents with focal neurologic signs, headache, lethargy, meningeal irritation, nausea/vomiting, papilledema, seizures, or changes in mental status?

Answer 25

An extension of the infection into the intracranial space, such as with epidural, subdural, or brain abscesses, or meningitis.

Question 26

What would be the recommended next steps in management for a patient with bacterial sinusitis who develops symptoms concerning for one of the complications of sinusitis?

Answer 26

The patient should have a CT scan performed to look for the extent of the infection and be admitted for IV antibiotic therapy.

Question 27

The risk for sinusitis with which (2) uncommon pathogens is increased in patients with prolonged neutropenia due to chemotherapy?

Answer 27

Aspergillus and Candida

Question 28

In a diabetic adolescent with uncontrolled serum glucose and the finding of a black eschar in the nose, what infection do you suspect?

Answer 28

Mucormycosis. This is a life-threatening fungal disease that is so dangerous because it frequently “grows backward” into the bone and brain.

Question 29

What is the definition of chronic sinusitis?

Answer 29

An inflammatory process affecting the paranasal sinuses that lasts at least 12 weeks despite medical therapy.

Question 30

What is the recommended management strategy for treatment of chronic sinusitis?

Answer 30

Treatment requires a combination of nasal or oral steroids, sinus irrigation, and antibiotic therapy. 1st line therapy is Amox/clav, but clindamycin can be used in patients who are PCN-allergic or for whom methicillin resistance is a concern. Antimicribial therapy should be given for a duration of 3-10 weeks, and patients who worsen or fail to improve within the first week of therapy should be referred to ENT for culture and evaluation.

Question 31

What is Ludwig angina?

Answer 31

An aggressive, rapidly spreading, bilateral polymicrobial cellulitis of the submandibular and sublingual spaces. It is most commonly a complication of infection of the 2nd and 3rd mandibular molars.

Question 32

Describe the typical clinical presentation of patients with Ludwig angina.

Answer 32

Patients appear very ill, with fever, severe dysphagia, difficulty opening the mouth, and stiff neck. The cellulitis has a characteristic “brawny” or “woody” texture and is often associated with palpable crepitus within the submandibular and sublingual spaces.

Question 33

If a patient presents with cellulitis of the submandibular/sublingual space with associated crepitus and a “woody” texture, what condition should you suspect?

Answer 33

Ludwig angina

Question 34

What is the recommended treatment for patients with Ludwig angina?

Answer 34

IV Ampicillin/sulbactam or a combination of Penicillin G + metronidazole or clindamycin. Any tooth implicated as the source of the infection should be extracted. If there isn’t improvement with antimicrobial therapy, or if fluctuance is identified, surgical intervention and drainage is required.

Question 35

What is the most common cause of acute pharyngitis in children?

Answer 35

Viruses

Question 36

What are some physical exam features which would suggest viral pharyngitis?

Answer 36

Pharyngitis + concurrent conjunctivitis, coryza, cough, hoarseness, anterior stomatitis, discrete ulcerative lesions, viral exanthems and/or diarrhea.

Question 37

What is the most common bacterial cause of pharyngitis?

Answer 37

S. pyogenes (GAS), but it makes up only 15% of cases of acute pharyngitis.

Question 38

What are four less-common bacterial causes of acute pharyngitis in children?

Answer 38

Mycoplasma, Arcanobacterium haemolyticum, neisseria gonorrhea (in sexually active adolescents), and Corynebacterium diphtheriae.

Question 39

What are the most helpful physical exam clues in making the diagnosis of acute streptococcal pharyngitis?

Answer 39

Diffuse erythema of the tonsils and tonsillar pillars, petechiae of the soft palate, and absence of URI symptoms.

Question 40

Describe the typical presentation of streptococcosis.

Answer 40

Patients <2 years of age who present with coryza with postnasal discharge, fever (can last up to 8 weeks), pharyngitis, poor appetite, and tender cervical lymphadenitis.

Question 41

Is the older child who has a sore throat, conjunctivitis, runny nose, and hoarseness likely to have S. pyogenes?

Answer 41

No, these findings are more typical of a viral pharyngitis.

Question 42

In a 1-year-old with sore throat accompanied by runny nose, hoarseness, cervical lymphadenitis, and poor appetite, is S. pyogenes the likely etiology?

Answer 42

Yes, this presentation is consistent with possible streptococcosis.

Question 43

What are the two worrisome complications of infection with S. pyogenes?

Answer 43

Rheumatic fever and poststreptococcal glomerulonephritis

Question 44

How can rheumatic fever be prevented?

Answer 44

Rrheumatic fever can be prevented in cases of acute streptococcal pharyngitis if antibiotic treatment is started within 9 days of symptom onset.

Question 45

What types of infections can lead to the development of poststreptococcal glomerulonephritis?

Answer 45

Poststreptococcal pharyngitis can occur regardless of therapy or site of infection (i.e. pharynx or skin) with group A strep.

Question 46

What infections can lead to rheumatic fever if left untreated?

Answer 46

Rheumatic fever occurs only after untreated acute streptococcal pharyngitis. Skin infections caused by GAS will not lead to rheumatic fever.

Question 47

Does treatment with penicillin shorten the disease course in acute streptococcal pharyngitis?

Answer 47

Yes; patients defervesce within 24 hours of antibiotic initiation, and penicillin shortens the disease course by an average of 1.5 days.

Question 48

What is the recommended therapy for patients diagnosed with acute streptococcal pharyngitis?

Answer 48

Amoxicillin 750mg once daily x 10 days.

Question 49

What antibiotics may be used to treat acute streptococcal pharyngitis in penicillin-allergic patients?

Answer 49

Erythromycin, clindamycin, or azithromycin.

Question 50

How soon can a child return to school after being treated for acute streptococcal pharyngitis?

Answer 50

A child is considered noninfectious after completing 24 hours of antibiotic therapy and can return to school or daycare at that point.

Question 51

What are the most common pathogens responsible for retropharyngeal abscess formation?

Answer 51

Group A strep, oral anaerobes (most commonly fusobacterium or prevotella), and S. aureus.

Question 52

In what age range is retropharyngeal abscess most likely to occur?

Answer 52

2-4 year olds are most commonly affected

Question 53

In a retropharyngeal abscess, what does the lateral X-ray show?

Answer 53

Lateral x-ray would show widening of the retropharyngeal space with anterior displacement of the airway. The retropharyngeal soft tissue would be >50% of the width of the adjacent vertebral body.

Question 54

What is the typical presentation of children with retropharyngeal abscess?

Answer 54

Abrupt onset of high fever and difficulty swallowing, refusal to eat, severe throat pain, neck stiffness, hyperextension of the head, drooling, and occasionally stridor. Patients often do not want to open their mouths due to pain but, if they do, an erythematous “bulge” is sometimes visible in the posterior pharyngeal wall.

Question 55

What is the recommended treatment for patients with retropharyngeal abscess?

Answer 55

If the abscess is not fluctuant, admit to the hospital for IV therapy with either Nafcillin + clindamycin or Ampicillin-sulbactam monotherapy. Continue IV therapy until the patient is afebrile and clinically improved, then transition to oral Amox/Clav or Clindamycin for a total of 14 days of therapy. Drainage is necessary if the abscess is fluctuant.

Question 56

Why is the presence of a retropharyngeal abscess considered to be a medical emergency?

Answer 56

Without prompt treatment, pus can extend into fascial planes or rupture into the pharynx, which can lead to aspiration. Additionally, if the abscess is large enough, it can cause significant airway obstruction.

Question 57

In what age group is it more common to see peritonsillar abscess formation?

Answer 57

Adolescents

Question 58

What are the predominant bacterial species implicated in peritonsillar abscesses?

Answer 58

Peritonsillar abscesses are often polymicrobial. The predominant bacterial species are GAS, S. aureus, and respiratory anaerobes (including Fusobacterium, Prevotella, and Veillonella species).

Question 59

How is the voice characterized in patients with peritonsillar abscess?

Answer 59

Many describe these patients as having “hot potato” voices.

Question 60

What are the typical physical exam findings in a patient with peritonsillar abscess?

Answer 60

Fever, severe throat pain, trismus, refusal to speak or swallow, “hot potato” voice, and uvula displacement to the side opposite the swelling.

Question 61

How should peritonsillar abscess be diagnosed?

Answer 61

CT scan with IV contrast should be performed to distinguish peritonsillar abscess from peritonsillar cellulitis. If the patient is in moderate-to-severe respiratory distress, skip the CT scan and have these children evaluated in the OR, where an artificial airway can be established if needed.

Question 62

What is the recommended management for peritonsillar abscess?

Answer 62

Operative drainage of the abscess is required. If there is a previous hx of recurrent pharyngitis or prior peritonsillar abscess, they may need tonsillectomy as well. Antiobiotic management includes IV therapy with either Nafcillin + clindamycin or Ampicillin-sulbactam monotherapy. Continue IV therapy until the patient is afebrile and clinically improved, then transition to oral Amox/Clav or Clindamycin for a total of 14 days of therapy.

Question 63

What are the indications for tonsillectomy?

Answer 63

Recurrent pharyngitis, marked/severe adenotonsillar hypertrophy (to exclude a tumor), or severe sleep apnea.

Question 64

What is the definition of recurrent pharyngitis?

Answer 64

7 episodes in the past year, 5 in each of the past 2 years, or 3 in each of the past 3 years.

Question 65

Does tonsillectomy help with chronic otitis media?

Answer 65

No. Tonsillectomy does not help prevent or treat acute or chronic sinusitis or chronic otitis media.

Question 66

Does adenoidectomy help with chronic otitis media?

Answer 66

Yes. This is one of the indications for adenoidectomy.

Question 67

What are the 5 indications for adenoidectomy?

Answer 67

Persistent mouth breathing, repeated or chronic otitis media with effusion, hyponasal speech, adenoid facies, or persistent/recurrent nasopharyngitis when it seems to be temporally related to hypertrophied adenoid tissue.