Nose/Upper Resp

Question 1

Risk factors for allergic rhinitis

Answer 1

Family history of atopy (ie, the genetic predisposition to develop allergic diseases)
• Male sex
• Birth during the pollen season
• Firstborn status
• Early use of antibiotics
• Maternal smoking exposure in the first year of life
• Exposure to indoor allergens, such as dust mite
allergen
• Serum IgE >100 int. units/mL before age six
• Presence of allergen-specific immunoglobulin E (IgE)

Question 2

allergic rhinitis pharmacotherapy

Answer 2

• Oral antihistamines
– First line 2nd gen: Loratidine, cetirizine
– Second line 1st gen: Diphenhydramine, hydroxyzine
• Intranasal Corticosteroids
– Fluticasone, Triamcinolone
• Topical Nasal Antihistamines
– Azelastine, Olopatadine
• Ø Decongestants
• Nasal Cromolyn
– LesseffectivethanINCS
• Leukotriene Modifiers
– Montelukast

Question 3

persistent or moderate to severe s/sx allergic rhinitis tx

Answer 3

• INCS as first line therapy. (intranasal corticosteroid)
– Start at the maximal recommended dose
for age, and then taper to the lowest effective dose once symptoms are controlled.
• If INGCs alone are not sufficient to control rhinitis symptoms, suggest adding an oral or topical second generation antihistamine .

Question 4

recurrent sinusitis definition

Answer 4

> 3 episodes of <30 days duration separated by intervals of ≥10 days without symptoms in a 6-month period, or >4 such episodes in a 12-month period; individual episodes respond briskly to antibiotic therapy

acute (symptoms resolve in < 30 days)
subacute ( > 30 days and < 90)
chronic (>90 days)

Question 5

bacteria causing sinusitis

Answer 5

-8% of URIs

S. pneumo (30%)

• HiB (20-30%)
• Moraxella catarrhalis (10-20%)

Question 6

bacterial sinusitis
persistent symptoms (most common)

Answer 6

• Persistent symptoms (most common)
– Nasalsx,cough or both for > 10 days but < 30 that are not improving
– Some with uncomplicated URIs have residual resp sx at the 10 day
point….ABS sign these sx must be persistent without improvement.

Question 7

severe bacterial sinusitis

Answer 7

combination of high fever (39C) and concurrent purulent nasal discharge for at least 3-4 consecutive days in a child who appears ill

Question 8

worsening symptoms

Answer 8

– Uncomplicated URI that around day 6-7 of illness the child becomes acutely ill and worse.

-cough must be present during the daytime (diurnal), although it is often described to be worse at night

Question 9

Complications of ABS

Answer 9

• preseptal (periorbital) cellulitis
• orbital cellulitis
• septic cav sinus thrombosis
• meningitis
• osteomyelitis
• epidural abscess

Question 10

pre septal (periorbital cellulitis)

Answer 10

Mild complication characterized by swelling and erythema of the lids and periorbital area; there is no proptosis or limitation of eye movement.

periorbital swelling is sign of ethmoid sinusitis

Question 11

orbital cellulitis

Answer 11

Pain with eye movement, conjunctival swelling (chemosis), proptosis, globe displacement, limitation of eye movements (ophthalmoplegia), double vision, vision loss.

Question 12

ABS Diagnosis: Major criteria

Answer 12

• Facial pain/pressure*
• Facial congestion
• Nasal congestion
• D/c
• Hyposmia or anosmia
• Fever*
• Purulence

Question 13

ABS minor symptoms (not to be used for diagnosis)

Answer 13

Headache • Fever
• Halitosis
• Fatigue
• Dental pain
• Cough
• Ear pain/pressure/fullness

Question 14

uncomplicated ABS diagnosis

Answer 14

Clinical course suggestive of bacterial rather than viral infection:
– Symptoms present without improvement for >10 and <30 days, or
– Severe symptoms (ill appearance, temperature ≥39oC (102.2°F), and purulent nasal discharge for ≥3 consecutive days), or
– Worsening symptoms (increase in respiratory symptoms, new onset of severe headache or fever, or recurrence of fever after initial improvement)

Question 15

• Uncomplicated ABS (not severe) + no day care + have not been treated with an antimicrobial in the preceding 90 days:

Answer 15

– Amoxicillin (45-90 mg/kg/day) in 2 divided doses

– Amoxicillin-clavulanate (45-90 mg/kg/day) in 2 divided doses

Question 16

Received an antimicrobial agent in the preceding 90 days, or who attend day care-one of the following regimens:

Answer 16

Amoxicillin-clavulanate (80-90 mg/kg/d) in 2 divided doses
– Cefdinir (14 mg/kg/d) in 1-2 doses
– Cefuroxime (30 mg/kg/d)
– Cefpodoxime (10 mg/kg/d)once daily
– A single dose of ceftriaxone (at 50 mg/kg per day), given either
intravenously or intramuscularly, can be used in children with vomiting that precludes administration of oral antibiotics.
• Treatment with an oral antibiotic is necessary after vomiting has resolved.

Question 17

options for patients with PCN allergy & cross reactivity to cephalosporins

Answer 17

– Clarithromycin (15 mg/kg/d in 2 divided doses)
– Azithromycin (10 mg/kg/d on day 1, then 5 mg/kg/d
for 4 days)
– Clindamycin (30 to 40 mg/kg per day)
• Should be reserved for patients with PCN allergy and who are known to be infected with penicillin-resistant pneumococci

Question 18

ABS duration of abx tx

Answer 18

Duration — The optimal duration of therapy for patients with ABS has not received systematic study. Empiric recommendations are typically made for 10, 14, 21, or 28 days of therapy.
• As an alternative, we suggest that antibiotic therapy be continued until the patient becomes free of symptoms and then for an additional seven days

Question 19

adjunctive therapy ABS

Answer 19

Used to reduce or improve sinus drainage
– Saline nasal irrigation
– Decongestants (topical or systemic)
– Antihistamines
– Intranasal corticosteroids
– There are limited data regarding the efficacy of these therapies in children with ABS

Question 20

AAP ABS Tx

Answer 20

Most children with ABS can be treated as outpatients.
• We suggest children with ABS be treated with antimicrobial
therapy
• Respiratory symptoms of children with ABS typically improve
within three days of initiation of appropriate antimicrobial therapy.
– Children whose symptoms fail to improve within this time- frame may require sinus imaging and/or sinus aspiration to confirm the diagnosis and/or tailor antibiotic therapy.
• Suggest antimicrobial therapy be continued for seven days after the child is free of symptoms.
• We suggest saline nose drops and/or saline nasal sprays for children with ABS