Upper respiratory tract

Question 1

Common cold etiology

Answer 1

• most common pathogens: human rhinoviruses
• in youbng children: RSV, human hetapneumovirus, parainfluenza viruses, adenoviruses, influenza viruses, nonpolio enteroviruses, human coronaviruses

Question 2

Clinical manifestations of common cold

Answer 2

• vary by age and virus
• fever is uncommon in older children
• onset 1-3 days after infection
• scratchy throat, nasal obstruction, rhinorrhea
• cough in 2/3
• headache, hoarseness, irritability, difficulty sleeping, decreased appetite
• increased nasal secretion, abnormal middle ear pressure, anterior cervical lymphadenopathy, conjunctival injeciton

Question 3

Laboratory findings in common cold

Answer 3

• PCR, culture, antigen detection, serologic methods –> only when antiviral treatment is available, usually not used
• bacterial cultures when group A streptococcus is suspected

Question 4

Treatment of common cold

Answer 4

• supportive
• oseltamivir and zanamivir when associated with influenza virus –> has effect on duration of symtpoms
• sometimes antihistamines, antitussices and decongestants

Question 5

Treatment of nasal obstruciton

Answer 5

• topical or oral adrenergic agents in older children and adults
• -> xylometazoline, osymetazoline, phylephrine as intranasal sprays
• reduced-strength versions for younger children
• children up to 6 months cannot breath through mouth! –> suck the secrete from nose

Question 6

Treatment of rhinorrhea

Answer 6

• first generation antihistamines

Question 7

Normal physiology of sinuses in children

Answer 7

• ehtmoidal and maxillary sinuses are present at birth (only ethmoidal are pneumatized)
• maxillary sinuses are not pneumatized until 4 years
• Sphenoidal sinuses are present by 5 years of age
• frontal sinuses start developing at 7-8 years and are done by adolescence

Question 8

Pathogenesis of sinusitis

Answer 8

• acute bacterial sinusitis often follows URTI
• viral infection produces viral rhinosinusitis
• nose blowing generates force that porpels nasal secretions into the sinus cavities
• bacteria from the nasopharynx cannot be cleared out because of inflammation and edema

Question 9

Clinical manifestation of sinusitis

Answer 9

• nasal congestion, purulent nasal discharge, fever, cough
• bad breath, decreased sense of smell, periorbital edema (less common)
• headache and facial pain rare in children
• maxillary tooth discomfort, pain exacerbated by bending forward
• erythema and swelling of the nasal mucosa with purulent nasal discharge
• sinus tenderness in adolescents

Question 10

How to identify if sinusitis is bacterial?

Answer 10

• persistence of nasal congestion
• rhinorrhea and daytime cough over 10 days wihtout improvement
• severe symtpoms and T>39° with purulent nasal discharge > 3 days
• worsening symtpoms after initial improvement

Question 11

Diagnosis of sinusitis

Answer 11

• based on history
• sinus aspirate culture is the only accurate mehtod –> not practical for routine use for immunocompetent patients (may be in immunosuppressed pateints with fungal infections)
• radiographic studies: opacification, mucosall thickening, air-fluid level –> cannot tell us what the cause is

Question 12

Differential diagnosis of sinusitis

Answer 12

• viral URTI
• allergic rhinitis
• nonallergic rhinitis
• nasal foreign body

Question 13

Treatment of sinusitis

Answer 13

• Amoxicillin (oral) for children with uncomplicated mild to moderate severity acute bacterial sinusitis
• Ceftriaxone (iv or im) to children who are vomiting or who are at risk for poor compliance; should be followed by course of oral antibiotics

Question 14

Etiology of acute otitis media

Answer 14

1. Streptococcus pneumoniae
2. nontypeable hemophilius influenzae
3. Moraxella catarrhalis

• respiratory viruses can also be present, either alone or together with bacteria –> rhinovirus and RSV

–> go through external ear and aspirate to determine what kind of causative agent

Question 15

Clinical manifestations of acute otitis media

Answer 15

• ear pain
• -> irritability
• -> change in sleeping or eating habits
• -> holding or tugging at ear
• -> fever
• systemic symtpoms and symtpoms with URTI occur

Question 16

Treatment of AOM

Answer 16

• individual episodes: antibiotics
• myringotomy when:
• -> severe, refractory pain
• -> hyperpyrexia
• -> complications of AOM such as facial paralysis, mastoiditis, labyrinthitis, CNS infection
• -> immunologic compromise
• tympanostopmy tube when AOM ir recurrent
• we must keep eustachian tube open by cleaning nose and decongestants

Question 17

Pathology of acute tonsillitis

Answer 17

• msot episodes are caused by viruses

- group A ß-hemolytic streptococcus most common cause of bacterial infection in pharynx

Question 18

Pathology of chronic tonsillitis

Answer 18

• aerobic species like streptococci and H. infleunzae
• anaerobic species like Peptostreptococcus, Prevotella, Fusobacterium
• tonsillary crypts can accumulate desquamated epithelial cells, lymphocyts, bacteria and other debris –> cryptic tonsillitis
• cryptic plugs can calcify into tonsillar concretions ro tonsillolith

Question 19

Diagnosis of tonsilltis

Answer 19

• testing when GABHS suspected –> thorat cultures
• Rapid antigen detection test (RADT) can detect GABHS
• when spread into deep neck structures is suspected –> radiologic imaging using X-ray or CT
• tender cervial lymph nodes and neck stiffness
• consider infectious mononucleosis, when it accompanied by tender cervical, axillary, or inguinal nodes, splenomegaly, lethargy, malaise, low-grade fever
• grey membrane in EBV infection

Question 20

Symtpoms of acute tonsillitis

Answer 20

• fever
• sore throat
• foul breath
• dysphagia
• odynophagia
• tender cervical lymph nodes
• dry tongue
• erythematous enlarged tonsils
• tonsillar or pharyngeal exudate
• palatine petechiae
• airway obstruction: mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, sleep apnea

Question 21

Symtpoms of acute tonsillitis caused by GABHS

Answer 21

• odynophagia
• dry throat
• malaise
• fever and chills
• dysphagia
• referred otalgia
• headache
• muscular aches
• enalrged cervical nodes

Question 22

Symtpoms of chronic tonsillitis

Answer 22

• halitosis
• chronic sore throats
• foreign-body sensation
• history of expelling foul-tasting cheesy lumps
• tonsils contain copious depris within crypts
• usually not caused by GABHS

Question 23

Treatment of acute tonsillitis

Answer 23

• mostly supprtive
• maintaining hydration and caloric intake
• controlling pain and fever
• Corticosteroids in infectious mononucleosis (for fever and pharyngitis)
• in case of GABHS: antiobiotics –> 10 days of penicillin

Question 24

When is tonsillectomy indicated?

Answer 24

• more than 6 episodes of streptococcal pharyngitis in 1 year
• five episodes of streptococcal pharyngitis in 2 consecutive years
• three or more infections of the tonsils per year for 3 years
• chronic or recurrent tonsillitis associated with streptococcal carrier state that has not responded to ß-lactamase resistant antibiotics

Question 25

Complications of tonsillitis

Answer 25

- GABHS: post-infectious GN, acute rheumatic fever - peritonsillar infection - retropharyngeal space infection

Question 26

Etiology of Laryngitis

Answer 26

- mostly viruses --> parainfluenza, influenza A and B, adenovirus, RSV - diphteria can be bacterial cause, rare in industrialized countries

Question 27

Clinical manifestations of laryngitis (croup)

Answer 27

- URTI with rhinorrhea, pharyngitis, mild cough, low-grade fever 1-3 days before signs of upper airway obstruction - barking cough, hoarseness, inpiratory stridor - edema of the vocal cords and subglottic tissue in laryngoscopy - symtpoms are worse at night - agitation and crying aggrevates it - other family members migth be ill too - airway obstruction: increasing respiratory rate, nasal flaring, costal retractions, stridor

Question 28

Diagnosis of laryngitis/ croup

Answer 28

- does not require radiography (subglotting narrowing)

Question 29

Spasmodic croup

Answer 29

- 1-3 years, history of viral prodrome and fever absent - commonly in evening or night - sudden onset that may be preceded by mild to moderate coryza and hoarseness - barking, metallic cough, noisy inspiration and respiratory distress - anxious and frightened - next day patient is well except hoarseness and cough

Question 30

Differential diagnosis of croup

Answer 30

- bacterial tracheitis - foreign body - retropharyngeal or peritonsillar abscess - angioedema

Question 31

Complicatiosn of laryngitis

Answer 31

- extension of the infection to involve other regions (middle ear, terminal bronchioles, lumonary parenchyma) - bacterial tracheitis

Question 32

Treatment of laryngitis

Answer 32

- airway management and treatment of hypoxia is always most important - Epinephrine (nebulized) - systemic CCS --> decrease edema in laryngeal mucosa (dexamethasone - oxygen therapy --> the aim is 94-95% (give 2-3 liters)