Upper respiratory tract infection in a child (rhinitis, sinusitis, otitis media/externa, tonsillitis, epiglottitis, pharyngitis, laryngitis) Flashcards
What pathogen is the cause of epiglottitis?
Haemophilus influenzae type B
Other potential pathogens include: Streptococcus pneumonia, Staphylococcus aureus, and MRSA. Rarely Pasteurella multocida has been reported.
Why is epiglottitis more common in adults than children in the UK?
Hib immunisation programme - it used to be more common in children
Describe the onset of epiglottitis.
rapid onset (usually < 24-48 hours)
What are the characteristic signs of epiglottitis?
- rapid onset fevers
- drooling
- stridor/difficulty breathing (NB: chest will be clear)
What proportion of children with epiglottitis require intubation?
Almost all children
About 10% of adults
Should you examine a child with epiglottitis?
No action should be taken that could stimulate a child with suspected epiglottitis, including examination of the oral cavity, starting intravenous lines, blood draws, or even separation from a parent.
Epiglottitis is a clinical diagnosis and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected.
Similar caution is required in fulminant acute epiglottitis in adults.
What investigations should you do for epiglottitis?
Epiglottitis is a clinical diagnosis and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected.
What is the management of epiglottitis?
- Consult senior staff (ENT, anaesthetics, ED)
- Secure the airway - direct rigid laryngoscopy or nasotracheal intubation
- Antibiotics
- +/- Oxygen and steroids
What would a lateral neck radiograph show in epiglottitis?
Markedly enlarged epiglottis, referred to as a ‘thumbprint sign’.
Describe the relative age incidence of these conditions:
- pneumonia
- bronchiolitis
- viral croup
- epiglottitis
- URTI
Is wheeze/stridor/snoring expiratory or inspiratory?
Wheeze - expiratory
Stridor - inspiratory
Snoring (stertor) - inspiratory
How many URTIs do children have per year?
First few years of life - ~5/year but sometimes 10-12/year
What does URTI encompass?
- common cold (coryza)
- sore throat (pharyngitis, tonsillitis)
- acute otitis media
- sinusitis (uncommon)
*cough may be secondary to post-nasal drip
What are the most common causes of coryza?
rhinoviruses (>100 serotypes)
coronaviruses
RSV
What is the management of common cold?
Conservative/symptomatic treatment with ibuprofen or paracetamol
Secondary bacterial infection is uncommon
Cough can persist for 4 weeks
What are the common viral and bacterial causes of pharyngitis?
Tonsillitis/pharyngitis = swelling and inflammation of the pharynx and soft palate; local lymph nodes are enlarged and tender.
Viral: adenoviruses, enteroviruses, rhinoviruses
Bacterial: group A beta-haemolytic strep (in older children)
What are the common viral/bacterial causes of tonsillitis?
Viral: EBV (infectious mononucleosis)
Bacterial: GAS
Only a third are bacterial.
What signs/symptoms of tonsillitis point towards a bacterial rather than viral cause?
- marked constitutional disturbance e.g. headache, apathy, abdominal pain
- white tonsillar exudate
- cervical lymphadenopathy
= more common in bacterial infection but clinically difficult to distinguish
What criteria can be used to assess tonsillitis in a child?
McIsaac score/modified Centor criteria
>3 points = likely to isolate GAS
Breifly describe the FeverPAIN score for tonsillitis.
Another new scoring system for tonsillitis
What is the management of tonsillitis/pharyngitis?
Antibiotics for 10 days
- penicillin or erythromycin (in penicillin allergy)
If severe, admit for IV fluids
What is a complication of tonsillitis?
Quinsy - peritonsillar abscess
Why is amoxicillin best avoided in tonsillitis/pharyngitis?
If caused by EBV/infectious mononucleosis, a wide spread rash can appear with amoxicillin
Why is treatment of pharyngitis/tonsillitis 10 days?
To eradicate GAS and prevent rheumatic fever
What is a typical presentation of scarlet fever?
- Fever precedes headache/tonsillitis by 2-3 days
- Most commonly in 5-12 year olds
- Rash - ‘sandpaper-like’ maculopapular
- Flushed cheeks
- Perioral sparing
- Strawberry tongue with swelling
Treat with penicillin V/erythromycin for 10 days to prevent acute glomerulonephritis or rheumatic fever.
NB this is the ONLY childhood exanthem caused by a bacterium
When is acute otitis media most common? What are the most common viral/bactrial causes?
6-12 months of age
Viral: RSV, rhinovirus
Bacteria: penumococcus, haemophilus influenzae, moraxella catarrhalis
Why is otitis media common in young children?
Prone because their Eustachian tubes are short, horizontal and function poorly.
What is seen on examination in acute otitis media?
Tympanic membrane - bright red, bulging, loss of light reflec, may have acute perforation of the eardrum with visible pus in the external canal
Pain and fever
How is acute otitis media managed? Is there a role for antibiotics?
Analgesics - paracetamol and ibuprofen regularly (not intermittently) and may be needed for a week until acute inflammation has resolved
Antibiotics do not reduce risk of hearing loss; can give parents perscription but only ask them to use it if the child remains unwell after 2-3 days
What are the complications of acute otitis media?
Mastoiditis (uncommon)
Meningitis (uncommon)
Glue ear - from recurrent ear infections causing otitis media with an effusion; asymptomatic apart from some decreased hearing
When is glue ear most common?
2-7 years
What is seen on examination in glue ear?
Conductive hearing loss on pure tone audiometry (>4 years) or a flat trace on tympanometry in younger children
Tympanic membrane is dull and retracted with a fluid level visible
What is the most common cause of conductive hearing loss in children?
Glue ear/otitis media with effusion
What are the complications of otitis media with effusion?
Conductive hearing loss which can interfere with normal speech and cause learning difficulties in school
What is the management for recurrent otitis media with effusion?
Insertion of ventilation tubes/grommets - benefits last <12 months
If problems persist then reinsertion of grommets with adjuvant adenoidectomu is advised (adenoidectomy shown to offer longer term benefits)
What do these images show?
Normal
Acute otitis media
With effusion
Grommet
What is sinusitis and when is it most common in children?
Infection of the paranasal sinuses which may occur with viral URTI and get a secondary bacterial infection
Uncommon in <10years because frontal sinuses form later
How does sinusitis present and what is the management?
Presentation: pain, swelling, tenderness over cheek with infection from maxillary sinuses
Management: antibiotics and analgesia
What are the indications and contraindications for tonsillectomy and adenoidectomy?
Large tonsils/adenoids are NOT an indication for removal as these usually reach maximum size at 8 years then shrink.
Tonsillectomy indications:
- recurrent severe tonsillitis
- peritonsillar abscess
- obstructive sleep apnoea
Tonsillectomy and adenoidectomy:
- recurrent otitis media with effusion with hearing loss (+indication of significant long term benefit)
- obstructive sleep apnoea (absolute indication)
Define laryngitis.
Laryngitis is inflammation of the larynx, which can lead to oedema of the true vocal folds leading to hoarseness.
What are the causes of laryngitis?
Virus infection (most common):
- Rhinovirus
- Parainfluenza virus, RSV, influenza, and adenoviruses
Bacterial infection:
- Moraxella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae
- Epiglottitis (Hib)
- Diphtheria
- TB
- Syphilis
Fungal infections:e.g. Candida albicans
Non-infectious laryngitis
- Irritant laryngitis (e.g., due to toxic exposure)
- Allergic
- Traumatic, especially due to heavy vocal use
- Reflux laryngitis
- Autoimmune
What is a typical presentation of laryngitis?
- Hoarseness - generally <7 days, some aphonia, normal pitch is lowered*
- Dysphagia, odynophagia, sore throat, cough(from postnasal drip)
- History of excessive vocal usage
- Gastro-oesophageal reflux
- Enlarged tonsils, fever, enlarged anterior lymph nodes
In TB this can last <3 weeks.
What is the management of laryngitis?
Usually self limiting (but exclude laryngitis secondary to croup or epiglottitis) - voice rest and hydration
No evidence for antibiotics; little evidence for corticosteroids
What is a common cause of bactrial tracheitis? What is a typical presentation and management?
Staphyloccocus aureus
Presentation: similar to epiglottitis, high fever, airway obstruction with thick secretions
Management: IV antibiotics, intubation and ventilation if required
