Peds ENT

Common Cold

• Etiology:
  • Viral
  • Peak fall –> Spring
    
  • 6-7/year, 10-15% have 12/year
    
  • – decreased with age (2-3/yr in adults)
    
  • Lasts 1wk, 10% last 2wks (coughing persists)
  • rhinoviruses
    
  • MANY others

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   Presentation:
  • Prominent rhinorrhea and nasal obstruction, sore/ scratchy throat, +/- nonproductive cough
    
  • – nasal discharge, generally thin, could be thick/ cloudy intermittently
    
  • +/- fever

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  Complications:
  • OM: 5-10%
    
  • Bacterial sinusitis: no improvement 10-14d, significant sinus infection signs fever, facial pain, swelling
    
  • Asthma

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  Management:
  • symptomatic
    
  • cold meds NOT recommended <4yo
    
  • – APAP/ NSAID for sore throat
    
  • – saline nasal spray, bulb syringe for infants
    
  • – cool mist humidifier
  • Other:
    • Nasal irrigation with saline 6-10yo
      
    • Buckwheat Honey from 2yo (younger = botulism risk)
      
      • – reduce cough and improve sleep
  • no improvement of cold s/s in 10-14d or worsening s/s in a child, consider:
    • bacterial sinusitis

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  Prevention:
  • handwashing

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  Note:
  • Aspirin is associated with Reye syndrome if used w/ flu or chickenpox in children
    
    • – acute encephalopathy and liver failure

Gingivostomatitis

• Path:
  • HSV1 primary infection
    
  • fever, NPO, dehydration, malaise, mouth pain, drooling, fetid breath, oropharyngeal vesicular lesions, lymphadenopathy in 1-5yo (peak 9-36mo)

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  Presentation:
  • MISERABLE
    
  • 1-5yo, peak 9-36mo
    
  • fever, mouth pain, malaise, dehydration, drooling, poor po, lymphadenopathy, vesicular lesions

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  Management:
  • early oral acyclovir may help

Hand-foot-mouth disease

• Presentation:
  • Coxsackievirus
    
  • – oral and pharyngeal mucosal lesions + maculopapular or vesicular lesions on palms, soles, digits, buttocks
    
  • – fussiness and poor PO intake
    
  • Late summer/ early fall onset

Herpangina

• Presentation:
  • vesicular oral lesions in the posterior oropharynx
    
  • +/- fever, V, HA, malaise, sore throat, drooling, dysphagia
    

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  Management:
  • self limited, treat symptoms –> magic mouthwash

Infectious Mononucleosis

• Presentation:
  • fever + pharyngitis + lymphadenopathy (posterior)
    
  • – 50% splenomegaly, 10-20% hepatomegaly
    
  • Fatigue! – may persist –> perform mono testing for persistent fatigue
    
  • >5yo, usually EBV infection

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  Triad:
  • fever
  • + pharyngitis
  • + lymphadenopathy

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  Diagnosis:
  • serologic testing
    
  • 1. monospot test
    
  • – maybe false, ~wait until continued fatigue to test
    
  • 2. IgM antiviral capsid antigen (cases you really want to know)
  • Note:
    • amoxicillin or ampicillin treatment –> 80% get rash!! = MONO dx!!

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  Suspect Mono:
  • 1. rapid strep test AND a mono spot
    
  • 2. negative, consider CBC, >10% atypical lymph supports mono
    
    • – re-eval in 5-7d w/ mono testing (delayed positivity)
      
    • – IgM VCA for contact sport return

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  Management:
  • supportive – hydrated, NSAID, APAP
    
  • Avoid non-contact x3wk and contact x4wk r/t splenomegaly rupture risk

Mastoiditis

• Presentation:
  • -90% have OM too

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  Pathogens:
  • Group A Strep, Pneumococcus, Staph, H. flu

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  Treatment:
  • Cefotaxime +/- Oxacillin (staph coverage)

Obstructive Sleep Apnea Syndrome

• Presentation:
  • 2-3% of children
  • – resp pauses, gasping, restless sleep, daytime, tiredness, FTT, school problems, mouth breathing
    

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  Risk Factor:
  • obesity, tonsil and adenoid hypertrophy
    

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  Diagnosis:
  • sleep study/ polysomnogram
    

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  Treatment:
  • ENT or sleep specialist, adenotonsillectomy, intranasal corticosteroid, wt loss, CPAP

Oral candidiasis

• Presentation:
  • white coating in the mouth that does not wipe off, may see bleeding
    

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  Treatment:
  • Nystatin suspension (fluconazole 2nd line)

Otitis Externa

• Etiology:
  • Pseudomonas, Staph aureus, fungus

• ---

  Presentation:
  • PAIN – inflamed external ear canal w/ erythema and exudate
    
  • pain increases with movement of tragus

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  Risk Factor:
  • ear cleaning, earplugs, hearing aids, water
    

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  Management:
  • optical: Cipro drops ($$), Neomycin and polymixin b + steroid drops, Acetic acid for fungal
    
  • Analgesia (NSAID/APAP)
    
  • Ear wick w/ significant edema
    
  • consider removing debris (gentle!!)

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  Prevention:
  • 2-3 drops vinegar/ alcohol solution after swimming

Otitis Media

• Path:
  • 1. Strep pneumo (30%)
  • 2. Hib (22%)
  • 3. Moraxella cararrhalis (7%)
  • 4. Group A Strep (2%)
  • 5. Staph aureus (1%)
  • 6. Sterile (35%)

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  Presentation:
  • inner ear infection, 62% children <1yo
    
  • Peak Jan/Feb r/t viral URI
  • Otalgia, otorrhea, URI ss, fever, irritable, poor feeding in a young child

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  Physical Exam:
  • apparent findings on ear exam (redness, exudate, bulging TM)
  • erythema/ yellow color, absent light reflex,
  • boney landmarks, bulging TM, limited mobility,
  • air-fluid level, perforation or discharge hole

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  Risk Factors:
  • 6-18mo (eustachian tube)
    Allergies, URIs, Bottles, Pacifier, fam hx, smoke exposure, daycare, craniofacial abnorm

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  Complications:
  • chronic effusion – note on f/u visit
    
  • – Hearing loss
    
  • – mastoiditis (rare w/o abx)
    
  • – meningits, intracranial extension
    
  • – cholesteatoma (foul otorrhea or mass noted)

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  Diagnosis:
  • Hx + clinical exam
    
  • pneumatic otoscopy shows an immobile TM
    
  • ~Tympanogram can confirm effusion
    
  • Middle ear effusion MUST be apparent

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  Management:
  • PAIN tx: NSAID/ APAP
    
  • 1st line: Amox 80-90mg/kg/d in 2 doses x5d + probiotics
    
  • 2nd line: Augmentin (Amox w/in 30d) Cephalosporin, Bactrim, azithro (PCN allergy)
  • or
  • 1. Amox or amp (amp is QID, causes more GI upset, is not absorbed as well as amox)
  • 2. Pediazole (erythromycin EES + sulfisoxazole) /Bactrim (trimethoprim + sulfamethoxazole)
  • 3. Augmentin-useful against beta-lactamase-producing H. flu
  • 4. Ceclor- 2nd gen cephalosporin, can cause serum sickness
  • Wait 48 hours then usually increase from tier 1 to tier 3.
  • PCN resistant – Strep pneumonia, H flu, and Moraxella

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  Prevention of recurrent AOM:
  • NOT prophylactic abx!!
    
  • Refer for tympanostomy tubes in recurrent AOM
    
    • – consider allergies
      
    • – eliminate bottle propping, pacifiers, passive smoke
      
    • – xylitol gum may help (5x/d x5min)

Otitis Media with Effusion 

• Presentation:
  • Effusion w/o acute infection
    dx w/ pneumatic otoscopy (tympanogram possible)
    Risk conductive hearing loss!

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  Diagnosis:
  • ID at risk SLP/ learning problems
    
  • – observe lower risk x3mo
    
  • – hearing testing in high risk and effusion x3mo

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  Management:
  • NOT abx, antihistamine, decongestant
    
  • – ventilating, tympanostomy tubes +/- adenoidectomy if persistent

PFAPA syndrome

Peritonsillar abscess

• Presentation:
  • sore throat, fever, dysphagia, hot potato voice, fever, drooling, asymmetric tonsillar hypertrophy, deviated uvula, trismus
  • uvular deviation toward the contralateral side, ipsilateral tonsillar bulging
  • MC deep space neck infections in children and adolescents

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  Diagnosis
  • intraoral sonography

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  Management:
  • refer ENT, CT, airway management aspiration
    
  • drainage while awake – tx of choice
  • aspiration with an 18g needle vs I&D
  • aspirate sent for C&S
  • oral antibx for 7-10 days
  • IV abx: PCN, cephalosporin or clindamycin, metronidazole, corticosteroid

Retropharyngeal abscess

• Presentation:
  • sore throat, fever, neck stiff/ swollen/ hyperextension, odynophagia, drooling, dyspnea, swollen post wall oropharynx

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  Etiology:
  • lead to significant morbidity and mortality r/t mediastinitis, sepsis, airway obstruction

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  Diagnosis:
  • not recommended for CT
  • plegmon

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  Management:
  • ENT/ emergency consult!
  • Lateral neck XR/ CT
    
  • Airway management
    
  • surgical drainage
    
  • IV abx = PCN or clindamycin
  • ampicillin/sulbactam
  • 3rd gen cephalosporins and metronidazole

Scarlet fever

• Presentation:
  • strep pharyngitis + scarlatina rash, circumoral pallor, strawberry tongue, pastina’s lines (prominent skin folds)
  • fine diffuse erythematous maculopapular rash + sore throat and fever

Sinusitis

• Path:
  • infection of paranasal sinuses complicates cold or allergic rhinitis
    – sinuses should be sterile –> mucosal edema prevents drainage –> bacterial proliferation
  • strep pneumonia, H flu, Moraxella (less staph)

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  Presentation:
  • Persistent (10-14 days) mucopurulent nasal discharge OR
    
  • Worsening course or new nasal d/c, cough or fever after initial improvement OR
    
  • Severe onset (T>102F and purulent nasal d/c for at least 3 days)
    think

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  Risk Factors:
  • cold, allergic rhinitis, nasal polyp, CF, immunodeficiency

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  Management:
  • Bacterial: 
    • >50% improve WITHOUT abx – observe x3d if dx not worsening/ severe
      
    • high dose amoxicillin or augmentin x10d –> continue 7d beyond s/s relief

Strep pharyngitis

• Presentation:
  • red pharynx with enlarged tonsils with exudate and enlarged, tender, anterior cervical nodes

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  Diagnosis:
  • 2 swabs of pharynx
    
  • perform rapid strep test
    
  • send culture if rapid test is negative and strep is likely
  • rapid strep = 85-95% sensitive, very specific
    
  • Culture if rapid is negative + clinical suspicion

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  Treatment:
  • PCN or Amoxicillin 1st line (amox tastes better, PCN has a shot)
  • If PCN/ amox does not get better:
    • Mono testing
      
    • ~Clindamycin x10d
      
    • consider ENT involvement

Tonsillar hypertrophy

• Presentation:
  • children often have large tonsils –> NORMAL finding
    
  • – note recurrent tonsillitis, snoring, etc –> refer
    
  • graded 0-4 r/t how close the tonsils are