Paeds- Resp, ENT and Ophthalmology Flashcards
what viruses commonly cause respiratory infections in children?
- Respiratory syncytial virus (RSV)
- rhinovirus
- parainfluenza
- metapneumovirus
- adenoviruses
what are some host and environmental factors that can increase the risk fo respiratory infection?
- maternal/ parental smoking
- poor socioeconomic status
- poor nutrition
- underlying disease- CF
- male
what does the term upper respiratory tract infection (URTI) encompass?
- common cold (rhinitis)
- sore throat (pharyngitis, tonsilitis)
- acute ottitis media
- sinusitis
how does the common cold present and what patohgens typically cause this?
- clear/ mucopurulent nasal discharge and nasal blockage
- rhinovirus, coronaviruses, RSV
how is the common cold managed and what advice is given to patients?
- self-limiting- no need for ABx
- paracetamol and ibuprofen
- vapour rob, steam inhalation can help
what viruses (and which bacteria) typically cause pharyngitis?
common cold viruses
adenoviruses
EBV
bacteria- group A B- haemolytic strep
how is pharyngitis managed?
paracetamol and ibuprofen for symptomatic relief
what is tonsilitis?
form of pharyngitis where there is intense inflammation of the tonsils with a purulent exudate
what common pathogens can cause tonsilitis?
- viral- adneoviruses, EBV, rhinovirus
- bacterial- group A- B- haemolytic strep
what symptoms does tonsillitis present with?
- headache
- abdo pain
- tonsillar exudate and cervical lymphadenopathy- if bacterial
what is the CENTOR criteria for tonsillitis?
Cervical lymphadenopathy
Exudate (tonsilar)
No cough
Temperature
3+ of the above= strep infection (so need ABx)
what are some potential complications of tonsililtis?
- peritonsillar abscess
- otitis media
- sinusitis
how is tonsillitis managed?
- symptoms- paracetamol and ibuprofen
- penicillin V or erythromycin if strep infection (if Patient has met CENTOR criteria 3+)
- hospital admission if severe
- tonsillectomy if recurring cases
what is acute otitis media?
infection/ inflammation of the middle ear
what is chloesteatoma?
collection of skin cells in the middle ear- leads to infection and an offensive discharge from the middle ear (and some hearing loss)
when and why does otitis media typically present?
- 6-12 months
- prone to otitis media as the eustachian tubes are short and function poorly
what are some predisposing factors that can lead to otitis media?
- male
- passive smoking
- immune deficiency
- URTI
- asthma
- bottle-feeding
how does a patient with otitis media present clinically?
- rapid onset pain in ear
- pyrexia, fever, irritability
- ottorhoea
what are some potential complications of otitis media?
- mastoiditis
- petrosis
- facial nerve palsy
- meningitis
- labrynthitis
what common pathogens can cause otitis media?
- S. pneumoniae
- H. influenza
- Moraxella catarrhalis
how is otitis media managed?
- paracetamol/ ibruprofen for pain
- most resolve spontaneously within 24h
- immediate ABx if systemicaly unwell/ if patient is immunocompromised- amoxicillin/ erythromycin
what can cause conductive hearing loss?
- glue ear
- ear wax
- ottitis media
- perforated ear drum
what is the name for ottitis media + effusion?
glue ear
what causes glue ear and give some risk factors for this?
infection
- older sibling
- male
- attending nursery
- parental smoking
- allergies
how is conductive hearing loss managed?
- watch and wait
- Grommet insertion
- temporary hearing aid
what is the function of a grommet?
keeps the middle ear aerated and prevents the accumulation of fluid in the middle ear
when might a grommet by indicated clinically?
- reccurent acute ottitis media
- chronic ottitis media + effusion (glue ear)
how does sinusitis occur?
- initially viral infection of paranasal sinuses lasting <10 days
- secondary bacterial infection may occur- pain, swelling and tenderness over cheek from infection of maxillary sinus
how is sinusitis diagnosed?
clinical examination- mucosal inflammation, discharge, oedema
how is sinusitis managed?
98%- viral and self limiting
- if bacterial- amoxicillin/ doxycycline
what is stridor?
rasping sound heard predominantly on inspiration
what is Croup?
Laryngotracheobronchitis- mucosal inflammation and increased secretions affecting the airway.
Oedema of the subglottic area is also present
what viruses typically cause croup?
- parainfluenza 1,2,3
- metapneumovirus
- RSV
- influenza
when does croup typically occur?
6 months- 6 years
peak is at age of 2
how does croup present clinically?
- barking cough- worse at night
- harsh stridor
- hoarseness
- preceding non-specific viral URTI
- severe- restlessness, cyanosis, recession, altered consciousness, rising HR/RR
how is mild croup managed?
oral dexamethasone/ oral prednisolone
ABC+/- oxygen
what can be given and done in severe cases of croup?
nebulised epinephrine and tracheal intubation
what organism causes acute epiglottitis?
haemophilus influenza B
why is acute epiglottitis a life-threatening emergency?
high risk of respiratory obstruction
how does acute epiglottitis present clinically?
- swelling of epiglottis and surrounding tissues (septicaemia)
- acute onset
- high fever, in an ill, toxic looking child
- painful throat- cannot speak or swallow (muffled voice)
- drooling
- soft inspiratory stridor
- child sits upright with open mouth
- MINIMAL COUGH/ ABSENT- DIFFERENTIATES FROM CROUP
what must be avoided when assessing a patient with suspected epiglottitis?
must not examine the throat with a spatula or lie child down
do not cannulate
how is acute epiglottitis managed?
- intubate under general anaesthetic
- IV ABx- cefotaxime
- tracheostomy if complete obstruction
what is bacterial tracheitis and how does it present clinically?
pseudomembranous croup is an uncommon but dangerous disease very similar to croup but with :
- high fever
- toxic appearance
- tracheal tenderness
- rapidly progressive airway obstruction- thick exudate
what organisms cause bacterial tracheitis and how is it managed?
S. aureus, Strep A, haemophilus
IV ABx
what is whooping cough (pertussis)?
- bronchitis in childhoold
acute, highly contagious respiratory infection- 2 weeks of cough associated with paroxysms, whoops or post-cough vomiting
how is whooping cough transmitted?
respiratory droplets
what organism causes whooping cough?
bordetella pertussis- gram negative coccobacillus
what are the 2 stages of the clinical presentation of whooping cough?
- catarrhal phase
- paroxysmal coughing phase
what are the symptoms of the ‘catarrhal phase’ of whooping cough?
- malaise
- conjuctivitis
- nasal discharge
- sore throat
- dry cough
- mild fever
- lasts 1-2 weeks before progressing to paroxysmal coughing stage
how long do symptoms of whooping cough last?
even with treatment commonly lasts 6-8 weeks
what happens during the paroxysmal coughing phase of whooping cough?
- dry hacking cough, brought on by a sudden startle, worse at night/ after feeding
- prolonged coughing episodes followed by a characteristic ‘whoop’
- post-cough vomiting
- apnoea +/- cyanosis
what causes the characteristic ‘whoop’ in whooping cough?
inspiration against closed glottis
how is whooping cough diagnosed?
NOTIFIABLE DISEASE !
- PCR- nasal swab
- culture swabs
- serology testing for anti-pertussis IgG
- marked lymphocytosis
when is hospital admission required in a patient with whooping cough?
- infant <6 months
- respiratory difficulties
how is whooping cough managed?
macrolides- azithromycin, clarithromycin, erythromycin
- erythromycin to close contacts
- patient must remain off school for 48 hours after commencement of Abx
what causes bronchiolitis in infants?
- RSV- majority
- metapneumovirus
- parainfluenza
- rhinovirus
- adenovirus
risk factors for bronchiolitis
- premature infant/ low birth weight
- CF
- congenital heart disease
- Down’s
how does bronchiolitis present clinically?
- Coryza precedes dry cough
- increasing breathlessness
- subcostal and intercostal recession +/- cyanosis and fever
- wheezing + fine end inspiratory crackles
- hyperinflation of chest
- tachycardia
- feeding difficulties
what clinical signs and symptoms, if present, indicate that a patient with bronchiolitis needs to be admitted?
- inadequate feeding and fluid intake
- respiratory distress
- hypoxia
- apnoea
- persistent O2<92%
how is bronchiolitis diagnosed?
- pulse oximetry
- viral throat swab
- CXR in severe
how is bronchiolitis managed?
- self-limiting- symptoms peak at 3-5 days
- support pt- fluid, nutrition, high flow O2
what is given as a preventative medicine against bronchiolitis in immunocompromised patients?
ribavarin
aetiology of pneumonia in newborns and infants
newborn- group B strep (maternal), gram negative enterococci
infants- strep pneumoniae, heamophilus influenza B
viral causes of pneumonia
RSV
Influenza A and B
Parainfluenza
Adenovirus
clinical presentation of pneumonia
- cough
- fever >38.5
- respiratory distress- tachypnoea, cyanosis, grunting, intercostal recession, use of accessory muscles, nasal flaring
- lethargy
- poor feeding
what features of pneumonia may present in older children?
- end inspiratory crackles
- bronchial breathing
- pleuritic pain
what investigations would be done in severe cases of pneumonia?
- blood cultures
- sputum culture
- FBC, CRP
- CXR- dense, fluffy opacity, blunting of costophrenic angle
how is pneumonia managed?
- O2<92%= ADMIT !
- supportive- oxygen, analgesia, IV fluids, Abx
- 1st line- amoxicillin (or clarithromycin, co-amoxiclav, azithromycin)
- drain empyema
what are the 2 types of wheeze seen in asthma?
transient early wheeze
persistent and recurrent wheezing
what is a transient early wheeze in asthma?
- viral associated- RSV
- small airway obstructed due to inflammation
- more common in males and resolves by the age of 5
what is a persistent and recurrent wheeze in asthma?
- presence of IgE to common inhalant allergens (atopic asthma)
- common in FH and associated with eczema, hayfever and food allergies
in asthma, what does bronchial inflammation lead to?
- airway narrowing and reversible airflow obstruction
- oedema
- excessive mucous production
- infiltration of cells
in asthma, what cells infiltrate the bronchials?
eosinophils
neutrophils
mast cells
lymphocytes
risk factors for the development of asthma?
- ADAM33 gene
- low BW
- FH
- bottle fed
- atopy
- male
- pollution
what tests are done in a patient with suspected asthma?
- CXR- rule out other causes
- spirometry
- peak flow- diurnal variation
- skin prick test for common allergens
how does asthma present clinically?
- polyphonic expiratory wheeze (due to obstruction)
- coughing
- SOB
- symptoms worse at night and morning
what is the main red flag for a severe asthma exacerbation?
silent chest on auscultation
what is the treatment pathway for patients between 5-16 with asthma?
Step 1: SABA (salbutamol)
Step 2: SABA + low dose ICS (beclomethasone)
Step 3: SABA+ ICS + LTRA (Montelukast)
Step 4: SABA+ ICS + LABA (salmeterol)
Step 5:
SABA + low dose MART
(ICS and fast acing LABA- formoterol)
Step 6: SABA + moderate dose MART
what pneumonic can be used to remember what must be given to a patient with a severe asthma attack?
OSHITME
Oxygen Salbutamol (nebulised) Hydrocortisone IV Iproatropium bromide (nebulised) Theophylline IV Magnesium sulphate IV Escalate
how is asthma treated in patients under 5?
- SABA
- 8 week moderate dose ICS trial
- stop trial at 8 weeks and monitor, add back if controlling well
- if ICS not working, and LRTA
what is primary ciliary dyskinesia?
congenital abnormality in the structure or function of cilia, leading to the impairment of mucociliary clearance
how does primary ciliary dyskinesia present clinically?
- recurrent infections of the upper and lower and respiratory tract
- recurrent productive cough
- purulent nasal discharge
- chronic ear infections
- dextrocardia and situs inversus
how is primary ciliary dyskinesia diagnosed?
lab- examination of structure of cilia
how is primary ciliary dyskinesia managed?
- physiotherapy to clear secretions
- proactive treatment of infections with Abx and ENT follow up
what is cystic fibrosis?
alteration of the viscosity and tenacity of mucous produced at epithelial surfaces
what is the classical form of cystic fibrosis?
bronchiopulmonary infection and pancreatic insufficiency with a high sweat sodium and chloride concentration
where are the mutations that cause cystic fibrosis located?
cystic fibrosis transmembrane conductance regulator gene (CFTR) on chromosome 7
how are the features of cystic fibrosis caused?
- mutation in CFTR gene
- decreased excretion of chloride into the airway lumen and an increased reabsorption of sodium into epithelial cells
- with less excretion of salt there is less excretion of water and increased viscosity/ tenacity of airway secretion
aetiology of cystic fibrosis
autosomal recessive inherited disorder
specific deletion at position 508 results in defect in transmembrane regulator protein
how does cystic fibrosis affect the:
Respiratory system?
- structurally normal
- frequent resp infections
- sinusitis
- nasal polyps
- breathlessness
- airflow limitation + bronchiectasis
- spontaneous pneumothorax
- late onset problems- haemoptysis, resp failure and cor pulmonale
how does cystic fibrosis affect the:
- GI system
- symptomatic steatorrhoea (due to pancreatic dysfunction)
- meconium ileus
- cholesterol gallstones
- peptic ulcers
- GI malignancy risk
how does cystic fibrosis affect:
- Nutritional balance
- malnutrition; malabsorption and maldigestion
- risk of pulmonary sepsis
- failure to thrive + slow growth
other than affecting the respiratory and GI systems, what other effects does cystic fibrosis have on the body?
- puberty and skeletal maturity delayed
- males infertile
- females- can conceive but develop secondary amenorrhoea
- arthropathy and DM- rare but can happen
how is cystic fibrosis screened for?
all newborns screened- for abnormally raised immunoreactive trypsinogen and 29 CTFR mutations on Guthrie Card
how is cystic fibrosis diagnosed?
- sweat test- sodium concentration >60mmol/L
- CXR- hyperinflation
- random glucose
- malabsorption screen
- spirometry
what are some pitfalls with the use of the sweat test to diagnose cystic fibrosis?
- false positives- common for newborns to have a high sodium
- sodium concentration naturally falls 2nd day after birth
how is cystic fibrosis managed?
- education- nutrition etc
- general care- stop smoking, keep up-to-date with vaccinations etc
- oxygen therapy if necessary
- physiotherapy
what drug therapy is used in cystic fibrosis?
- B2 agonists
- ICS
symptomatic relief only
how is airway clearance assisted in CF?
- inhalation of recombinant human deoxyribonuclease (rhDNAse)
- hypertonic saline by inhalation
- amiloride
- acetylcysteine
how are pancreatic insufficiency and GI problems managed in CF?
pancreatic insufficiency:
- PERT (pancreatic enzyme replacement therapy)
- older children- Creon
GI:
- omeprazole
what are some complications of CF?
- haemoptysis
- pneumonia
- pneumothorax
- pulmonary osteoarthropathy
- diabetes
- cirrhosis
- cholesterol gallstones
- fibrosing colonopathy
- male infertility
what type of squint may require neuro-imaging?
paralytic squint- may be due a SOL
what can cause a squint?
- idiopathic
- refractive error
- visual loss
- opthlamoplegia
- SOL
what are the 2 types of squint?
- non-paralytic (concomitant)
- paralytic (non-concomitant)
what is a non-paralytic (concomitant) squint?
common and usually due to a refractive error in one or both eyes
what is a paralytic (non-concomitant) squint?
rare and usually due to cranial (motor) nerve palsy. Can also be caused by a SOL
how is a squint managed?
- correct refractive error with glasses
- eye patch- wear over good eye to train weaker eye
- eye muscle exercises
what is periorbital cellulitis?
infection of the eyelid.
what are the complications of periorbital cellulitis?
- intracranial infection (meningitis etc)
- cavernous sinus thrombosis
- vision loss
how does periorbital cellulitis present clinically?
unilateral eyelid swelling and erythema, along with pain and tenderness
what are some red flags in periorbital cellulitis?
- painful/ restricting eye movements
- visual impairment
- severe headache
how is periorbital cellulitis treated?
flucloxacillin/ ceftriaxone
