URTI & Stridor

Question 1

Frequency of URTI at each age according to WHO

Answer 1

up to 14 in the first yr of life
4 -10 yr. - 2–5 times per year
10 – 14 - 2.5–5 times per year
Adults – 1.7 times per year

Question 2

How does the paediatric immune system differ to adults

Answer 2

Physiological hypogammaglobulimaenia during 4 –11 mo.

IgG is equal to adults - 7 – 8 yr
IgM  takes -1 yr.
IgA  - 6 – 7 yr.
IgE - 6 – 7 yr
NK - same as adults 

Predominant lymphocytosis - 4 day – 4 yr
Relative neutropenia - 4 day – 4 yr
Complement maturity takes- 1 yr.

thymus largest at 2 yrs/ - shrinks by puberty
tonssillar enlarged for 2 – 4 yr.

Question 3

How does the viral infection rate of children change according to age

Answer 3

Infants younger than 3 months have lower infectious rate – as they’re protected by maternal IgG antibodies

The infection rate increases from 3 to 6 months of age since their own IgG is low until 7/8

The viral infection rate increase during toddler, and preschool years d/2 increased social life of children and increased contact with immature igG

Question 4

Hoe does the paediateic anatomy increase the likelihood of URTI

Answer 4

Smaller diameter of paediatric airways facilites rapid movement of pathogens

Question 5

Which 7 factors contribute the the paediateic resistance from infections

Answer 5

⚫ Deficient immune system 
⚫ Malnutrition
⚫ Anemia
⚫ Fatigue
⚫ Allergies
⚫ Asthma
⚫ Cardiac anomalies

Question 6

How is the respiratory tract divided

Answer 6

Upper resp tract

1) nasal cavity
2) pharynx
3) larynx

Lowr resp tract

1) trachea
2) pulmonary bronchi
3) lungs

Question 7

Types OF URTI

Answer 7

– Rhinitis
– Otitis media – Sinusitis
– Epiglottitis – Pharyngitis – Laryngitis
– Croup
– Tonsillitis
– Retropharengeal abscess Peritonsillar abscess

Question 8

Non specific URTI

Answer 8

Common cold

Influenza

Adenoviruses

Gingivostomatitis

Enteroviruses

Herpangina

Hand, foot, and mouth disease

Pleurodynia

Question 9

What is the common cold and how is it dg

Answer 9

• Etiology: more than 200 viruses
– rhinoviruses 30-50%
– coronaviruses 10-15%
– influenza 5-15%
– parainfluenza 5% – adenoviruses <5% – Enteroviruses <5% 
– unknown 20-30%

• Diagnosis: based on Classical Clinical features 1)clear or mucopurulent nasal discharge w/blockage 2)+/- fever

Question 10

Management of the common cold

Answer 10

• educate parents that colds are self-limiting and have no specific cure

• Symptomatic rx regime:
Nasal blockage: Plenty of fluid intake, rest, humidified air, nasal aspiration
Pain: over-the-counter analgesics and antipyretics.
(paracetamol or ibuprofen)

• Antibiotics are of no benefit as the common cold has viral etio and super bacterial infection is very uncommon.
• assure parents Cough may persist for up to 4 weeks after a common cold.

Question 11

Summarise influenza in 5 points

Answer 11

• Etiology: Influenza A & B
• Symptoms: Fever, myalgias, headache, rhinitis, malaise, nonproductive cough, sore throat
• Diagnosis: Influenza A &B antigen testing
• Treatment: Supportive care, tamiflue, amantidine
• Anti – influenza vaccines indication:
• children w/ chronic lung and heart diseases at school age
• children from 6 mo in USA, in EU from 2yrs

Question 12

Summarise Adenoviral infection in 4 points

Answer 12

• Symptoms: Low grade fever,
Lymphadenomegaly , pharyngitis and NON PURULENT CONJUNCTIVITIS

• Diagnosis: based on clinical sx

• Treatment:
Adequate fluid intake, rest, humidified air, nasal aspiration and over-the-counter analgesics and antipyretics, no aspirin till 14 yr d/2 reyes syndrome

• Possible complication – pneumonia which requires Aggressive treatment

Question 13

Summarise gongivostomatitis

Answer 13

HSV infection from 10mo - 3 years

• charac sx :

1) vesicular lesions on: lips, gums, anterior tongue and hard palate,which often progress to extensive, painful ulceration with/without bleeding
2) high fever and the child is very miserable. The illness may persist for up to 2 weeks.
3) painful eating and drinking (dysphagia), can cause dehydration.

• Management is symptomatic unless severe:
Diet – no salty and spicy food with normal ph
severe disease: intravenous fluids and aciclovir.

Question 14

Summarise heorangina

Answer 14

mouth infection d/2 cocksackie virus

Sx:
General: Fever, ± loose stools
Specific: Vesicular and ulcerated lesions on the soft palate and uvula causing anorexia d/2 pain on swallowing
Rx:
• Severe cases need intravenous fluids, diet is the same as in gingivostomatitis
• No antibiotics, no acyclovir as its caused by cocksackie not HSV

Question 15

Summary of enteroviruses

Enteroviruses are Common in Paeds

Answer 15

coxsackie viruses, echoviruses, and polioviruses

common cause of childhood infection.

• Transmission:
faecal–oral and respiratory droplet routes.
replication in the pharynx and gut, nthe virus spreads to infect other organs.

• Infections occur most commonly in the summer and autumn.

Sx:
• febrile illness, sometimes with a rash usually over the trunk
that is blanching or consists of fine petechiae.
• Some children have a history of loose stools or vomiting

Question 16

What is pleurodynia

Answer 16

Aka bornholm diease

Acute illness charac by
pleuritic chest pain, fever and muscle tenderness.
• Possible pleural rub,m w/ no other signs on examination
• Recovery occurs within a few days.
• Treatment - ibuprofen

Question 17

Summarise rhinitis posterior

Etio, age, sx, rx,

Answer 17

Pathogens: Staph aureus
• Age up to 6 mo.
• Signs:
– Noisy inspiration
—Difficult feeding
– Cough when laying – can provoke Vomiting!!
• No complications
• No therapy

Question 18

Summarise pharyngitis/ tonsilitis

Pathogenstic types

Age(all)

Sx

Time of resolution w/0 rx

Complications (2)

Answer 18

Acute infalmm of naso/ oropharynx
All ages susceptible
– High risk: 5-15 & Adults in freq contact w/ kids (teachers, parents)

• Signs and symptoms
– Sudden onset of sore throat, fever, dysphagia!!
– Headache, abdominal pain (children)
– Tender, enlarged lymph nodes
– Inflamm and erythema of uvula, pharynx and tonsils, with exudates!!
– Rash, petechiae due to unproductive cough

• Resolution without treatment
– 3-7 days; Few weeks for lymph nodes and tonsils

Complications:
– Acute rheumatic fever or reactive arthritis
– Acute glumerulonephritis

Question 19

Rx of pharyngitis/ tonsillitis

1st line
2nd line
Rx of reccurence

Answer 19

Drug yherwoy for 10 days

Penicillin/ amoxicilline first line

2nd/3rd gen ceph if 1st line fails
-cefuroxime

Amoxiclav or clindamycin in case of reccurence

Question 20

What is infectious mononucleosis and what are it’s cardinal signs and 3 dg criteria

Answer 20

Caused by EBV infection !!
Sx
• General: fever, fatigue in teens
•SEVERE tonsillitis/pharyngitis!!!
• severe petechiae on the soft palate!! limiting fluid and food intake and causing dehydration
• lymphadenopathy – of cervical LN! & diffuse lymphadenopathy elsewhere.
• splenomegaly (50%), hepatomegaly with hepatitis (10%)
• maculopapular rash (5%)
• jaundice - rare.

Dg

1) atypical lymohocytes on blood film
2) Elavated AST/ALT
3) 3 antibodies on seroconversion: IgG and IgM, and EB nuclear antigen (EBNA) antibodies.

Question 21

Rx of infectious mononucleosis

Answer 21

Treatment is symptomatic.

corticosteroids to maintain when airway in sever cases

Ampicillin or amoxicillin can cause a maculopapular rash in children infected with EBV and should be avoided.

Question 22

Dx for inextious mononucleosis

Answer 22

Mononucleosis like syndrome
Causes by CMV
• Pharyngitis and lymphadenopathy are not as prominent as in EBV infections.

• Patients may have atypical lymphocytes on the blood film but are antibody negative.

Question 23

What is ottitis media

Why is it more freq in children

Rf

Answer 23

viral/bac infection of the middle ear! MC-Streptococcus pneumoniae
Other:H. Influenza

common infection in children under five usually follows an upper respiratory tract (URT) infection
D/2 short, horizontal, and poor functioning eustachian tube

MC in infants and children 6mo-3y

RF
Bottle feeding/inadequate breastfeeding 
-increased negative P for bottle
-Reduced passive immunity
Passive cigarette smoke 
-decreased mucocilliary clearance 
Children who attend day care centers 
-increased pathogenic exposure

Question 24

Parhophys of otitis media

Answer 24

The eustachian tube (ET) connects the middle ear with the nasopharynx and is lined with cilia, which drain the middle ear secretions into the nasopharynx.

Obstruction/blockage of the ET → lack of ventilation and drainage of the middle ear →
Resorption of the air in the middle ear

→increaes negative middle ear pressure → retraction of the tympanic membrane → otalgia and conductive hearing loss

Accumulation of middle ear secretions → bacterial superinfection → pus in the middle ear → bulging tympanic membrane → severe otalgia, fever

Question 25

Main sx of otitis media and compilations

Answer 25

``` Sx 1)infants Irritability,Incessant crying, Refusal to feed (anorexia) Repeatedly touching the affected ear Fever and febrile seizures Tender mastoid in late stages 2)older children Otalgia/earache, commonly with throbbing Hearing loss in the affected ear Tender mastoid in late stages d/2 spread ``` Complications: mastoiditis and meningitis, but these are now uncommon.

Question 26

Dg of otitis media Early and late findings on otoscopy Lab

Answer 26

Otoscopy of tympanic membrane Early: retracted and reduced mobility Late: Red bulging & w/o landmarks, discharge if ruptures Tuning fork test: conductive hearing loss( stronger on mastoid) Lab: gram stain and culture of aspiration

Question 27

Rx of otitis media

Answer 27

- lSymptomatic pain management (paracetamol, ibuprofen) ``` -Antibiotics: not always indicated Indications 1)Bilateral otitis media 2)Symptoms do not improve after 48 hours 3)Severe illness in children (very high fever, vomiting, malaise, and immunosuppression) ``` First line: oral amoxicillin Add clavulanic acid if no improvement after 48 hours

Question 28

Indications for tonsillectomy & adenectomy

Answer 28

Tonsilectomy - Recurrent severe tonsillitis( decreases recurrence by a 1/3) - peritonsilar abscess - obstructive sleep apnea Adenectomy - recurrent otitis media w/ effusion or hearing loss - recurrent sleep apnea adenectomy is mandatory!

Question 29

What is sinusitis? Causative agents Types & prevalence according to age

Answer 29

Def: inflammation of paranasal sinuses mucous membrane usually occurs with inflammation of the nasal mucosa (rhinitis) and is therefore commonly referred to as rhinosinusitis. More common in childhood Acute -usually viral -possible Bac superinfection w/ S.pneum// Influenza ``` Chronic -anerobe: Prevotella, fusobac -aerobe: P. Aeriginosa, haemophillus RF’s (obstruc, shit cillia, increased mucus, stasis and pathogenic proliferation) ``` ``` Cold and dry air Recurrent virus infections Allergic rhinitis Swimming GERD Immune deficiency Cillia diskynesia Pollyps Tonssillar Hypertrophy Cystic fibrosis ```

Question 30

Signs and sx of acute vs chronic sinusitis

Answer 30

``` Acute: sinus inflamm under 4 wks – Teens • Mucopurulent nasal discharge • Maxillary tooth, sinus, or facial pain (unilateral) • swelling, and tenderness on cheek d/2 maxillary sinus infection • Morning preorbital swelling • Halitosis – Children • Cough, nasal discharge (> 10-14 days) • Fever (> 39C), facial swelling ``` Chronic: sinus inflamm over 3 months - same as acute except - history of long lasting sx - anosmia

Question 31

Rx & dg of sinusitis

Answer 31

Usually clinical dg Lab for underlying etio CT of sinuses (imaging modality of choice) Soft tissue swelling, mucoperiosteal thickening, and air-fluid levels Rx Viral: Rest, adequate fluids, and antipyretics Oral analgesics Bac Acute: amoxicillin, with or without clavulanate for 5–10 days or macrolides (clarithromycin or azithromycin) if allergic to penicillin Chronic: Surgical debridement of necrotic tissue and removal of anatomical obstructions

Question 32

What is Croup Cause Typical sx and rx

Answer 32

Aka spasmodic laryngotracheitisis (inflammation of larynx & trachea ) 3 etio Viral, bac (S.auraus/ group b strep), spasmodic ``` charac features Barking cough from tracheal collapse hoarseness from vocal cord inflamm Worse at night Fever & dyspnea ``` Dg: clinical sx laryngoscopy neck xray shows subglottic narrowing= steeple sign ``` Rx: 1st line Corticosteroids Oral dexamethasone oral prednisolone, nebulized steroids budesonide ``` severe upper airways obstruction: nebulized epinephrine + with oxygen by face mask —rapid but transient improvement. Close observation for 2–3 hours after administration as the effects wear off.

Question 33

Difference betw retro and peritonsillar abscess

Answer 33

Retropharyngeal Affects kids under 6 Caused by S. aureus, anaerobes •Insidious to sudden onset • located Posterior to the pharynx • No stridor but with disphagia and retractions Rx: Antibiotics; surgical drainage of abscess ``` Peritonsillar abscess >10 yrs and above Cause by Group A streptococci, anaerobes • Biphasic with sudden worsening • Drooling, trismus Rx: Antibiotics; and aspiration of abscess ```

Question 34

What is stridor Obs at SGST

Answer 34

``` abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, trachea. ``` It is an indication of respiratory distress

Question 35

Indications of respiratory distress

Answer 35

``` Moderate (HI TURN for the worst) • Tachycardia • Use of accessory muscles • Respiratory rate over 50 bpm • Nasal flaring • Intercostal and subcostal recession • Head retraction • Cant feed to feed ``` Severe: low O2 high CO2 • Cyanosis • Fatigue • Reduced consciousness • Saturation below 92% despite oxygen therapy • Rising partial pressure of carbon dioxide

Question 36

Management of acute upper airway obstruction

Answer 36

reduce anxiety by being calm Look for signs of respiratory failure oxygen if required and tolerated do not examine the throat with a spatula! It may precipitate upper airway obstruction oral, nebulized or intravenous steroids are beneficial in case of croup and have similar speed of onset (90–120 min) if respiratory failure develops from increasing airways obstruction urgent tracheal intubation is required If obstruction is from severe croup An Anesthesiologist is required d/2 sublottal narrowing