Pediatric Heent Disorders

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allergic rhinitis defined
inflammation of the nasal epithelium caused by a release of chemical mediators from antigen-antibody response
what is the most common atopic disorder
asthma
what is the second most common atopic disorder
allergic rhinitis
what are the causes of allergic rhinitis
1. genetics
2. environmental exposure- repeated exposure to allergens can contribute to sensitizing the immune system to produce an allergic IgE response
3 types of allergic rhinitis
1. episodic
2. perinneal
3. seasonal
causes of seasonal allergic rhinitis
hay fever, pollen, airborne allergens
at what age do you normally see seasonal allergic rhinitis begin
age 3
is allergic rhinitis seen in children under 6 months
rarely
causes of perennial rhinitis
indoor, year round (cold weather=trigger)
at what age do you see perennial rhinitis
onset can be before 2 years old
allergic rhinitis subjective data
1. poor school performance, sleep disturbance
2. rhinorrhea
3. congestion
4. nasal pruritis
5. sneezing
allergic rhinitis objective data
1. mouth breathing, snoring, nasal
2. pale to boggy edema of nasal mucosa
3. nasal crease
4. atopic salute
5. atopic pleats
6. hoarseness
7. red conjuntive, allergic shiners, periorbital edema
considerations for dx of allergic rhinitis
1. overuse of OTC topical nasal decongestions
2. cocaine use
3. idiopathic hypersensitivity
4. hormonal rhinitis
5. food-induced rhinitis
diagnostics for allergic rhinitis
1. family history
2. s/sx
3. nasal smear- eosinophils present but nonspecific findings
4. skin testing for IgE antibody (severe cases)
environmental avoidances for management of allergic rhinitis
-control house dust
-eliminate smoking
-pets outdoors
-reduce mold
-humidifiers, air filter changes
-eliminate egg, milk, wheat products
pharmacologic management for allergic rhinitis
1. oral antihistamines
2. topic nasal antihistamines
3. decongestants
4. nasal cromolyn
5. intranasal corticosteroids
oral antihistamines
1. tx of allergic rhinitis
-relieve symptoms of nasal itching, sneezing, and rhinorrhea, but not nasal congestion
-start at low dose
-may develop tolerance
topical nasal antihistamines
-tx allergic rhinitis
-azelastine
-acts as a h1 receptor site inhibitor
-approved for tx of seasonal AR in children >5
-has a bitter taste
-associated with sedation
decongestants
-AR treatment
-limited long term benefits
-may be used alone or with other antihistamines
-may cause rebound rhinorrhea or congestion
-do not usei n children less than 2 years old
nasal cromolyn
-tx AR
-less effective
-can use in infants
-usually in children with dysphonia
intranasal corticosteriods
-tx AR
-very effective, LT use may lead to growth suppression
-reduce inflammation and obstruction
-may take up to one week to work
side effects of intranasal corticosteriods
-local burning
-irritation
-sneezing
-soreness
-epistaxis
other pharmacologic options for AR
1. leukotriene modifiers (singulair)
2. antibiotics for secondary infections
3. immunotherapy- for severe symptoms
complications from chronic AR
-sinusitis with secondary infection
-ETD
-malocclusion
-allergic facies
-chronic cough and postnasal drip
clinical pearls of AR
-perennial AR- may lessen with growth
-seasonal AR- may worsen from adolescent to early adulthood
- moving to a new environment may give a temporary relief of symptoms (but symptoms will return after sensitization to new environment)
acute purulent rhinitis defined
-superinfection of common cold or purulent sinusitis
-thick yellow discharge
-common occurrence with URI
what color d/c is associated with acute purulent rhinitis
thick yellow discharge
what are the common organisms associated with purulent rhinitis
-pneumococci
-h. influenza
-b hemolytic strep
-staph a
- m cat
when do you normal see acute purulent rhinitis occuring
1w-10 days post URI/cold
subjective data a/w acute purulent rhinitis
history of uri within 7-10 days, profuse continuous, purulent, yellow-green nasal d/c for more than 3 days
differential diagnosis for acute purulent rhinitis
nasal foreign body, sinusitis, acute viral rhinitis
management of acute purulent rhinitis
-conservative treatment, wait and see
-no atb therapy
-remove purulent material- saline flush
-family education- return to clinical in symptoms last more than 10-14 days
when should a parent be considered if their child has acute purulent rhinitis
return to clinic if symptoms persist for more than 10-14 days
atopic or allergic disorders
-allergic reactions
-susceptible individuals
-unknown etiology
-genetics
-environmental factors
____ to offending allergen results in atopic disorder
sensitization
atopic triad
-allergic rhinitis
-asthma
-atopic dermatitis
atopic or allergic disorders, cascade of events
-rapid increase in the number of T helper type cells secrete cytokines
-cytokines synthesize IgE activate eosinophils
-IgE binds to receptors
-chemical mediators release (histamine, prostaglandins, leukotrienes)
-end result-tissue injury of target organ
allergic reactions symptoms and MOA
-inflammation
-hyperresponsiveness
-airway obstruction
-increased mucus production
-prutitis
-wheezing
-sneezing
-hives
-vomiting
pharmacologic therapy for atopic or allergic disorder
-not curative, reduces symptoms, controls allergic process
-corticosteriods-controls inflammation
-antiH- competes with histamine
-montelukast- antagonizes leukotrienes
-cromolyn NA-inhibits mast cells
nonpharmacologic therapy for atopic or allergic disorder
-remove offending substances to prevent IgE development and antigen/antibody interaction
-encourage BF, no cows milk
sinusitis defined
-inflammation and secondary infection of paranasal sinuses
common bacterial organisms involved in sinusitis
-s pneumonia
-h influenza
-m cat
-s. aureus
-streptococci
-anaerobes
acute sinusitis diagnosis
-based one two major or one major and 2 minor criteria
-major criteria (facial congestion, fever, purulent rhinorrhea, facial pain or pressure, nasal obstruction, hypsomnia)
-minor criteria (ha, halitosis, fatigue, dental pain, cough, otalgia)
acute sinusitis
resp sx for more than 10 days but less than 30
recurrent sinusitis
episodes of acute sinusitis separated by periods of 10 days of symptoms-free intervals (commonly due to atopic rhinorrhea that is not treated well)
subacute sinusitis
resp sx more than 30 days less than 12 weeks
chronic sinusitis
resp sx more than 12 weeks
acute on chronic sinusitis
chronic sinusitis with new symptom development, reinfection of overgrowth for new bacteria development
causes of recurrent and chronic sinusitis
a/w recurrent viral URI, day care, smoking, older siblings, nasal polyps, allergies, CF, immunodeficiency
can sinusitis exacerbate asthma
yes
statistics of sinusitis
-60-18% acute cases resolved without atb treatment in 4 weeks
atb management of sinusitis considerations
-atb increase the speed of resolution and reduce mucosal drainage
-normal coarse 10-14 days (7 additional days if not responding) up to 21 day acute or 6 weeks chronic
what could rapid improvement of symptoms in sinusitis with atb therapy indicate
could rebound
sinusitis with atb treatment failing to improve in 48 hours can indicate
resistance, complications (nasal polyps, decreased vascular flow to the area)
management of uncomplicated acute sinusitis
-initial therapy if no atb in 4-6 weeks (amoxicillin, clavulonate, cef, cefuroxime)
-if allergic to amoxicillin- tx with azithromycin, bactrim
children who are at risk for resistant infections in uncomplicated acute sinusitis
-atb therapy in past 3 months
-daycare
-less than 2 years old
if a child fails to respond to meds in 72 hours with acute uncomplicated sinusitis, what would you do?
high dose amox-clavunate
chronic sinusitis management
decongestants, antiH
-comfort measures tylenol, ibuprofen, codeine, humidifier, increased oral fluid intake, saline irrigation
orbital cellulitis
medical emergency, refer to ER
where do most cases of sinusitis occur in children
ethmoid sinusitis- (frontal sinuses not developed yet) difficult to treat
clinical pearls of sinusitis
seasonal peaks, more common in males, management with surgical drainage and atb
dx of sinusitis
ct scan
intracranial complications of sinusitis
-absence of neurologic s/sx
-early adolescent males
-vomiting
chronic sinusitis and asthmatics
may cause chronic wheezing
acute otitis media defined
acute infection of the middle ear
diagnosis of AOM requires
-requires presence of 3 components (recent, abrupt onset of signs/symptoms of middle ear inflammation, effusion)...ear pain, irritability, otorrhea, and/or fever
-mme confirmed by bulging TM (limited or absent mobility, air-fluid level behind TM, otorrhea)
-distinct erythema of TM (otalgia interfering with normal sleep or activity)
young children and AOM presentation
-fussy, tugging, rubbing ear
AOM is most commonly d/t
-S pneumonia
-also h flu, m cat, rsv
determinants of AOM
-ETD, day care, white, male, family hx, URI, bottle, smoke, asthma, allergies, cleft palate, downs, prior to 2 years old, GERD
eustachian tube in young children
shorter, more horizontal, flaccid, susceptible to viruses
AOM subjective data
-rapid onset
-otalgia
-irritability
-otorrhea
-fever
-premature, congenital
-exposure
-sleep disturbances
-lethargy, vertigo, tinnitus, unsteady gait
-n/v
-sudden hearing loss
-congestion, rhinorrhea, sneezing
AOM objective data
Middle ear effusion, inflammation, increased vascularity, obscured, absent bony landmarks dt fluid, bullae (fluid filled mass), tympanometry reflects effusion
first principle of treatment in AOM
pain management
-topic analgesics (auralgan ear drops)
-distraction
-oil sweet oil
-external application of heat, cold
fever management in AOM
ibuprofen, tylenol, NOT ASA
when to give ATB for AOM
-48-72 hours with no improvement or worsening symptoms
-all chn less than 6 months
-6m-2y with definitie dx
-2 yrs old with severe illness
first line antibiotic treatment for AOM
amoxicillin BID
severe AOM atb treatment
with b lactamase bacteria- tx with amoxicillin clauvonate
atb hypersentivity options for AOM treatment
-not type 1- cefdinir, cefpoxdime, cefuroxime
-type 1- azithromycin, clarithromycin
other treatment possibilities for AOM
-erythromycin
-clindamycin
-ceftriaxone
clinical f/u for AOM
-48-72 hours with no improvement
-3-4 w if clinical improvement
how to treat recurrent AOM
-referral, tubes, broad spectrum ATB
decongestants or antihistamines during AOM
not helpful
when to use antimicrobial ototopical drops for AOM
otorrhea
perforated TM
draining PETs
complications of AOM
-persistant AOM, OME, TM perforation, OE, mastoiditis, cholesteatoma, typanosclerosis, hearing loss, osscile necrosis, cerebral involvement, facial paralysis
prevention and education of AOM
-annual flu vaccine
-sugar free gum
-BF for first 6 months
-avoid daycare
-no pacifiers or bottle propping
-avoid ATB overuse
OME defined
-MEE or fluid without signs and symptoms of acute ear infection
-decreased mobility of TM
-interferes with sound conduction
when does OME occur
spontaneously with ETD after AOM, viral illness, anatomical abnormality, barotrauma, allergies
ETD changes with OME
-middle ear mucosa- secretory, increased mucus production, absorbs water, viscosity, fluid stuck before TM, ETD can cause OME and then become AOM
OME subjective data
-often asymptomatic, afebrile, intermittent or no complaints of ear pain
-fullness in the ear- popping
-hearing loss in older children
-dizziness, impaired balance
-chronic vomiting, failure to thrive
objective data OME (TM findings)
-abnormal appearance (dull, bulging, opaque, landmarks not visible)
-retracted, translucent, visible landmarks
-air fluid level- bullae visible
dx of OME
tympanogram or audigram
unilateral OME indicates
nasopharangeal CA
management of OME
-watchful waiting
-identify risks for hearing loss, speech, language problems
things to avoid in OME
-antiH, decongestants
-atb, steroids
-tonsillectomy, adenoidectomy
strategies to maximize hearing for OME
-face when speaking
-enunciate
-visual clues
-decrease background noise
-sit close to front of class
OE defined
inflammation of the external auditory canal, swimmers ear
OE is evidenced by
-simple infection with edema, dc, erythema
-furuncles, abscesses of hair follicles
-impetigo, infection of superficial layers of epidermis
-mycotic
-chronic
most common pathogens of OE
-pseudomonas a
-staph a
-polymicrobial causes mainly
causes of OE
-foreign body
-chronic middle ear problems
-trauma (bloody drainage, severe OM, granulation tissue)
-derm d/o (psoriasis, eczema, seborrhea)
OE subjective data
-itching, pressure, fullness, rarely systemic complaints, rarely hearing loss, periauricular edema, lymphadenopathy
OE objective data
-otalgia, swelling, lymphadenopathy, tragel tenderness, red crusty pustular lesion, black spots on TM (fungal), dry ear canal, otorrhea, pain, n/v
medical management of OE
-debridement
-burrows solution
-ear wax
-atb ear drops
-avoid swimming
-analgesic
-lance the furnuncle
clinical pearls of OE
-avoid water in ear canal
-ear plugs
-acidic drops (starotic)
-warm blow dryer
-avoid scratching, excessive clearing of cerumen
-avoid excessive use of ceruminolytic agents
foreign body in the ears
-child reports putting something in the ear
-buzzing, fullness, sense of object in the ear
-persistant cough, hiccups
-unilateral otalgia, otorrhea
-visibility of object
treatment of foreign body in the ears
-if in lateral 1/3, attempt to get it out
when do you not irrigate the ear with a foreign body
battery, vegetable manner or if TM if perforated
considerations of foreign body in the ear
-regional anesthesia not recommended
-conscious sedation
-topic ab with steroids
foreign body in the ear may lead to what?
infection, TM perforation, damage to ossicles
the most common bacterial causes in children and adolescents of strep include
-group a b hemolytic strep (15-30% infections with acute sore throat/fever)
-n gonorrhea/clamydia (STI mimics GABHS or can be subclinical)
-corynebacterium diptheria
GABHS most common at what age
5-15 yr, uncommon less than 2 yrs old
strep subjective data
1. abrupt onset without nasal symptoms
2. fever, malaise, sore throat, dysphagia
3. n, abdominal discomfort, vomiting, ha
4. winter or spring presentation
objective data strep
1. petechiae on soft palate and pharynx, swollen red uvula, red enlarged tonseils
2. yellow and/or blood tinged exudate
3. tender and enlarged cervical lymph nodes
Strep Diagnostics
-positive throat culture
-some rapid strep tests not sensitive for GABHS
-negative strep test should be followed by a culture
drug of choice for strep tx
pcn IM or PO for 10 days, amoxicillin susp for 10 days in children
what causes fungal overgrowth
-host resistance is lowered
-exposure to broad spectrum atb
-immunosuppression
-system disease
when can neonates acquire candidiasis
during vaginal delivery
when can infants acquire candidiasis
sucking fingers, from the breast or bottle, atb treatent
subjective data of oral candidiasis
cotton feeling in mouth, loss of taste, pain on eating/swallowing, mild lymphenodopathy
objective data of oral candidiasis
white patchy raised furry milk like lesions in buccal mucosa
-lesions may bleed if scraped with tongue blade
-may be asymptomatic
-neonates may have more oryphangeal involvement
treatment of oral candidiasis
-in healthy newborns usually self limiting to 3-8 weeks
-nystatin susp
-use for at least 48 hours after disappearance of symptoms
how to treatment persistent oral candidiasis
fluconazole
clinical pearls of oral candidiasis
-thrush in adolescents could indicate HIV
-spit and rinse after oral corticosteriod use
-if dx recurrent, look for underlying causes
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