URTI & Sinusitis by Udc4XK1S

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									Pediatric URTI
& Sinusitis
Leybie Ang
PEM Fellow
Feb 25 2010

Thanks to Jennifer Puddy
Etiology
 Acute   and subacute pathogens
     S. pneumoniae (20-30%)
     Nontypeable H. influenzae (15-20%)
     Moraxella catarrhalis (15-20%)
     S. pyogenes – beta hemolytic (5%)
 Chronicsinusitis
 Noninfectious conditions
     Allergy
     Cystic fibrosis
     GER
     Cilliary dysfunction
Risk Factors
 Viral   URI

 Allergic      rhinitis

 Anatomic         obstruction

 Mucosal        irritants
AAP Guidelines 2001
 Age  1 to 21 years
 Healthy
 Exclusions:
     Recognized anatomic abnormalities of their
      paranasal sinuses (facial dysmorphisms or
      trauma)
     Immunodeficiencies
     Cystic fibrosis
     Immotile cilia syndrome
Gold Standard
 Recovery  of bacteria of high density from
 cavity of paranasal sinuses

 Notrecommended for the routine
 diagnosis
      aspiration and culture may need to
 Sinus
 be considered in

     Severe illness and toxic looking child


     Immunocompromised child


     Suppurative or IC complications
Recommendation #1
 Diagnosis based on clinical criteria in
 children who present with upper
 respiratory symptoms that either persistent
 or severe
   Persistent: >10 d with no improvement that
       Nasal or postnasal discharge of any quality
       Daytime cough (maybe worse at night)
       Less common complains include low grade
        fever, fatigue, maldodorous breath or periorbital
        edema

   Severe: temp > or = 39 C and purulent nasal
    discharge present for at least 3-4 consecutive
    days in a child who seems ill
 PE does not contribute substantially to the
  diagnosis of ABS

 Facialpain is unusual and facial
  tenderness is rare and unreliable finding

            swelling is suggestive of
 Periorbital
  ethmoid sinusitis

 Value   of transillumintation of sinuses is
  controversial and found to be unreliable
  in children < 10yo
Recommendation #2
 Imagingnot necessary to confirm a
 diagnosis of clinical sinusitis in children < or
 = 6 yo
Radiology
 Plainradiographic or computed
 tomography findings that are consistent
 with sinus inflammation include:

     Complete opacification

     Mucosal thickening of at least 4 mm

     Air-fluid level
Radiologic Assessment
   Abnormalities of the paranasal sinuses are found
    frequently on conventional radiographs and CT
    scans in children without clinical evidence of sinusitis

   The presence of a URI alone (without sinusitis) can
    result in mucosal thickening and abnormal findings in
    the paranasal sinuses on plain radiographs and CT
    scans

   Imaging findings may persist well after symptoms
    improve. CT abnormalities with the common cold
    may last up to two weeks after symptomatic
    improvement
Indications for CT scan
 CT   scan is indicated for patients that

    Fail to respond to medical management

    Severe symptoms suspicious for
     complications related to acute sinusitis

    Surgery is considered
Recommendation #3
   Antibiotics are recommended for the
    management of acute bacterial sinusitis to
    achieve a more rapid clinical cure
   First line :
         Amox or amox-clav
   If PCN allergic (not type 1 hypersensitivity
    reaction)
         Cefdinir, Cefuroxime, Cefpodoxime
   If serious reaction
         Clarithromycin or azithromycin
 Iffailure to improve with amox, NEITHER
  TMP-SMX NOR ERYTHROMYCIN-
  SULFISOXAZOLE are appropriate choices
  for antimicrobial therapy.
Duration of Treatment
   10 days

   14 days

   21days

   28 days

   Until pt is asymptomatic + 7days
Complications
   Preseptal (periorbital) cellulitis
   Orbital cellulitis
   Septic cavernous sinus thrombosis
   Meningitis
   Osteomyelitis of the frontal bone associated
    with a subperiosteal abscess (Pott's puffy
    tumor)
   Epidural abscess
   Subdural empyema
   Brain abscess
Adjuncts
 Saline


 Nasal    irrigation

 Antihistamines


 Mucolytic    agents

 Topical   intranasal steroids
AAP Recommends…
   No well-controlled scientific studies were found that support the efficacy
    and safety of narcotics (including codeine) or dextromethorphan as
    antitussives in children. Indications for their use in children have not been
    established.

   Suppression of cough in many pulmonary airway diseases may be
    hazardous and contraindicated. Cough due to acute viral airway
    infections is short-lived and may be treated with fluids and humidity.

   Dosage guidelines for cough and cold mixtures are extrapolated from
    adult data and clinical experience, and thus are imprecise for children.
    Adverse effects and overdosage associated with administration of
    cough and cold preparations in children are reported. Further research
    on dosage, safety, and efficacy of these preparations needs to be done
    in children.

   Education of patients and parents about the lack of proven antitussive
    effects and the potential risks of these products is needed.
Paul et al 2007
   Partly double-blinded randomised controlled trial

   Paired comparisons of honey and dextromethorphan
    showed no significant differences

   Honey did appear to be superior to no treatment for
    cough frequency, child sleep and the combined
    symptoms score

   Honey shows early promise as a treatment for the
    cough and sleep difficulty associated with childhood
    URTI
Chicken Soup
Rennard et al 2000
 One recent study at the University of
 Nebraska found that nonparticulate
 component of chicken soup in vitro
 inhibited neutrophil mechanism by which
 chicken soup mitigates the symptoms of
 URI
Questions
   What is the dose and drug of choice for
    uncomplicated sinusitis?

   What percentage of viral URI's will progress to acute
    bacterial sinusitis?

   Name some (2) risk factors in the development of
    sinusitis.

   What are some radiographic finding of sinusitis?

   What is the most common complication of sinusitis?
Case 1
   A previously healthy 4-year-old girl is
    transported via ambulance of a rapid
    onset of severe respiratory distress.
   In the ED, she appears toxic and very
    anxious. She is drooling and prefers to sit
    forward.
   The girl recently immigrated to this
    country.
Epiglottitis? Croup?
             Epiglottitis   Croup
Anatomy      Supraglottic   Subglottic
Etiology     Bacterial      Viral
Age          3-7yr, adult   0.5-3yr
Onset        6-24hr         24-72hr
Toxicity     Marked         Mild to moderate
Drooling     Frequent       Absent
Cough        Unusual        Frequent
Hoarseness   Unusual        Frequent
WBC count    Leukocytosis   Normal
Management
 SECURE     AIRWAY
      Postpone further examination
      Minimize agitation
      Consult anesthesiologists and ENT


 IV   antibiotics

 IV   hydration
Case 2
   A 4 year-old female patient presents to
    you with sore throat, poor PO intake, and
    recent fever. She doesn’t want to turn her
    head.
   FHx is remarkable for a sibling with strep
    throat 2 weeks ago.
   Examination is difficult due to patient’s
    inability to open mouth. You note she is
    drooling and has bilateral SM and ant
    cervical lymphadenopathy.
Retropharyngeal Abcess
   Group A streptococcus, anaerobic
    organisms, and occasionally S. aureus

   Most often in children < 4 years of age

   High fever and a toxic appearance, less
    abrupt onset, sore throat, neck pain, cervical
    lymphadenopathy

   Inflammation surrounding the abscess may
    lead to meningismus; thus, this diagnosis
    should be considered in the child with nuchal
    rigidity but no pleocytosis in the CSF.
Management
   Careful monitoring in the ED and be
    hospitalized in consultation with ENT.

   Unless the airway is in immediate jeopardy, IV
    access should be secured and treatment
    given with IV antibiotics

   Most patients require drainage, either
    transcutaneously with ultrasound guidance or
    at surgery
Case 3
   In ED you see a 6 y/o girl with 2 days of
    fever, sore throat, mild rhinorhea. Over
    the past 6 hours her throat has been
    increasingly painful. Currently, she is
    drooling and unable to swallow
    secretions.
   On exam she is febrile to 104.2, her
    tongue is quite large, and she is very
    agitated.
LUDWIGS’S ANGINA
 Submandibular      space infections

 Classical   description:
     Bilateral infection
     Involve both submandibular and sublingual
      spaces
     Rapidly spreading cellulitis without abscess
      formation or lymphatic involvement
     Infection begins in the floor of the mouth
Questions
References:
   AAP Committee on Quality Improvement; clinical practice guideline: management of sinusitis.
    Pediatrics, 108(3): 798-808, 2001
   AAP Committee on Drugs. Use of codeine- and dextromethorphan-containing cough remedies in
    children. Pediatrics, 99(6): 918-20, 1997
   AMA Diagnosis and Management of Acute Bacterial Sinusitis: Children Update 2008
   Anzai et al Diagnostic imaging in 2009: update on evidence-based practice of pediatric imaging.
    What is the role of imaging in sinusitis? Pediatric Radiology. 2009;39:S239-S241
   Dart et al. Pediatric fatalities associated with over the counter (nonprescription) cough and cold
    medications. Ann Emerg Med. 2008;53:411-417
   Doern GV, Pfaller MA, Kugler K, Freeman J, Jones RN. Prevalence of antimicrobial resistance among
    respiratory tract isolates of Streptococcus pneumoniae in North American: 1997 results from the
    SENTRY antimicrobial surveillance program. Clin Infect Dis. 1998;27:764–770
   Glasier et al Incidental paranasal sinus abnormalities on CT of children: clinical correlation. AJNR Am J
    Neuroradiol, 7(5): 861-4, 1986
   Jacobs etal. Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral
    antimicrobial agents based on pharmacodynamic parameters: 1997 US Surveillance study.
    Antimicrob Agents Chemother. 1999;43:1901–1908
   Paul et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep
    quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140–6.
   Radiology cases in Pediatric Emergency Medicine
   http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
   Uptodate
   Evidence-Based Care Guideline for Management of Acute Bacterial Sinusitis in children 1 to 18 years
    of age. Cincinnati Children’s Hospital Medical Center 2008

								
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