Resp - ENT Flashcards
What is tonsillitis?
A form of pharyngitis with intense inflammation of the tonsils
Often with purulent exudate
What are the common pathogens causing tonsillitis?
Group A ß-haemolytic streptococci
Eppstein-Barr virus (infectious mononucleosis)
Which clinical features are more common with bacterial tonsillitis than viral?
Marked constitutional disturbance:
Headache
Apathy
Abdo pain
White tonsillar exudate
Cervical lymphadenopathy
1/3 are bacterial
What advice can you give parents about caring for a child with tonsillitis?
Bacterial vs. viral (which will get better on its own)
Drink a lot of fluids
Plenty of rest
Serve liquids and soft foods if hard to eat (including ice cream lol)
Keep child’s glasses and utensils separate and wash thoroughly in hot, soapy water
Acetaminophen or ibuprofen for pain relief, NOT aspirin!! (Reye syndrome)
Everyone in the family to wash their hands very often, because very contagious
What different courses can tonsilitis go?
Acute
Recurrent
Chronic
What are the symptoms of acute tonsillitis? How long?
Fever Sore throat Foul Breath Dysphagia Odynophagia (painful) Tender cervical LN
Possible airway obstruction
Lethargy
Normally lasts 3-4 days, but up to 2 weeks
When is tonsillitis recurrent?
7 in 1 year
5 in 2 years
3 in 3 years
Needs to be diagnosed with GABHS each time
At which age is otitis media most common?
6-12 months
How many children have at least 1 episode of otitis media (and >3)?
Almost all children get it once.
20% get it >3
Why are children prone to otitis media?
Short Eustachian tube
Horizontal and poorly functional too
What are the pathogens causing otitis media?
Viruses (RSV, rhinovirus)
Bacteria (pneumococcus, non-typeable H.influenza, Moraxella catarrhalis)
What are the complications of otitis media? (and thus its importance)
Mastoiditis
Meningitis
(both uncommon)
Symptoms of otitis media?
Ear pain
Fever
If recurrent, otitis media with effusion (may cause speech and learning difficulties, hearing loss)
What treatment is available for otitis media?
Analgesia (regular paracetamol or ibuprofen)
Most resolve spontaneously
Antibiotics shorten duration of pain but not the risk of hearing loss
(should only use if child remains unwell after 2-3 days)
eg. amoxicillin
What is usually the treatment for otitis media with effusion?
Grommet insertion (ventilation tubes)
If subsequent recurrence, adenoidectomy
What is the peak age of otitis media with effusion?
2.5-5 years (very common at that age)
What are the characteristics of acute upper airway obstruction?
Stridor
Hoarseness of voice due to inflammation of vocal cords
Barking cough
Variable degree of dyspnoea
What is the basic management of upper airway obstruction?
DO NOT examine throat! Reduce anxiety (be calm and confident)
Observe for signs of hypoxia/deterioration.
If severe - nebulised adrenaline
Contact anaesthetist. Resp failure may develop and will need tracheal intubation
Which viruses normally cause croup?
Parainfluenza virus commonest
Human metapneumovirus
RSV
Influenza
What is croup? Aetiology?
laryngotracheobronchitis
Mucosal inflammation and increased secretions affecting the airways
At which ages does croup occur?
6 months to 6 years old
Symptoms of croup? Which time of year
Commonest in autum
Symptom onset/worsen at night
Should resolve in 48 hours
Barking cough
Harsh stridor
Hoarseness
Preceded by fever and coryza
How would parents be advised to care for a child with viral croup?
Observe closely for signs of increasing severity - ambulance
(stridor, restless, agitated, intercostal recession)
Cyanosis
If appears distressed due to fever, can give paracetamol/ibuprofen to lower distress (alternate agents if persists)
Encourage regular fluids
Continue breastfeeding
Which treatment options are available fo croup?
Reduce severity and duration:
Oral dexamethasone (0.15mg/kg)
Oral prednisolone
Nebulised steroids (budesonide)
If severe obstruction:
nebulised adrenaline with oxygen facemask for transient improvement. Close monitoring required (inc anaesthetist) because there may be rebound symptoms after 2 hours
Supplementary oxygen to all children with severe illness
What is the causative organism of epiglottitis?
HiB
>99% reduction due to vaccine
How does acute epiglottitis present? Age group
Life-threatening emergency (high risk of resp obstruction)
Swelling of epiglottis and surrounding tissues associated with septicaemia
Usually 1-6year olds
VERY ACUTE:
High fever, ill-looking.
Intensely painful throat (prevents from speaking/swallowing).
Saliva drools down the chin
Soft inspiratory stridor and rapidly increasing respiratory difficulty.
Sitting upright, immobile, with open mouth.
How can viral laryngotracheitis (croup) and epiglottitis be distinguished clinically?
CROUP Onset over days. Preceding coryza. Cough - severe, barking. Able to drink. No drooling saliva. Appears unwell and fever <38.5°C. Stridor harsh and rasping. Voice hoarse.
Epiglottitis: Onset over hours. No coryza. Absent cough/slight. Unable to drink. Drooling saliva. Toxic appearance, very ill. >38.5°C. Soft, whispering stridor. Reluctant to speak.
When should a child with fever be taken to the doctor?
< 3 months old with >38°C
3-6 months old with >39°C
Or other signs of being unwell: persistent vomiting, refusal to feed, floppiness, or drowsiness
Sometimes even rash, fits/seizures, SOB
What treatment is available for fever?
Plenty of fluid/milk even if isn’t thirsty.
Appropriately dressed, but eg. thinner sheets
Paracetamol and ibuprofen, but only if DISTRESSED! Never both at the same time. If one does not work, can give the other one later on.
If >41°C, methods such as cooling blankets are indicated
What are febrile seizures?
Can occur in any child <6 years of age
If no previous afebrile seizures or neurological pathology.
Most last <15 min (simple)
What are the physiological consequences of fever?
Can cause febrile seizures in children.
Increases stress in cardiac/pulmonary illness due to raising BMR.
> 41°C can cause damage: protein denaturation, cytokines activate inflammatory cascade leading to cellular and organ failure. DIC due to activation of coagulation cascade.
What is the pathophysiology of fever?
Fever results when something raises the hypothalamic set point, triggering vasoconstriction and shunting of blood from the periphery to decrease heat loss; sometimes shivering, which increases heat production, is induced. These processes continue until the temperature of the blood bathing the hypothalamus reaches the new set point. Resetting the hypothalamic set point downward (eg, with antipyretic drugs) initiates heat loss through sweating and vasodilation.
What are the clinical features of bacterial tracheitis?
Rare but dangerous. Pseudomembranous croup.
The difference to viral croup is that there is:
High fever
Toxic appearance
Rapidly progressing airway obstruction with copious thick airway secretions.
Loud, harsh stridor
What are the differentials for acute upper airway obstruction?
Croup most common (coryza and mild fever)
Foreign body (sudden onset cough)
Epiglottitis (painful throat, high fever, toxic)
Bacterial tracheitis (high fever, toxic)
Laryngomalacia or congenital airway abnormality (recurrent)
Allergic laryngeal angioedema Infectious mononucleosis Measles and diphtheria Trauma Retropharyngeal abscess
What is the immediate danger posed by burns, scalds and smoke inhalation?
Skin thinner, thus burns quicker.
Most deaths caused by house fire are due to smoke inhalation. There is a chance of developing respiratory complications and CO poisoning. There should be a low threshhold to protect the airway.
What can be the consequence of a burn to the mouth or face?
Face - disfiguring
Mouth - compromise to airway from oedema
What is the treatment protocol for burns?
Assess: resusc, smoke inhaled? Depth and surface are of burns
Analgesia (may require iv morphine)
IV fluids (plasma expanders)
Wound care (cling film)
Irrigate only for <10% SA burns. Check tetanus immunisation status.
Advise parents on how to care for a child with acute otitis media
Usually spontaneously resloves within 24h
For pain and fever: paracetamol, change to ibuprofen if persists
Alternate between paracetamol and ibuprofen if still persists
Features of bacterial pharyngitis (tonsillitis)
CENTOR criteria
Tender cervical lymphadenopathy Absence of cough White exudate Temperature >38°C Age 3-14
Which antibiotics are usually prescribed for severe tonsillitis/pharyngitis?
10 day course of penicillin or erythromycin
AVOID amoxicillin, as it may cause widespread maculopapular rash if infection is due to infectious mononucleosis
