Transcript Rhinitis - Dr. Dal Corso

Sinusitis – In Brief
Pediatr. Rev. 2006;27;395-397
Allison Taylor and Henry M.
Adam
Pediatric Cough and Cold
Preparations
Pediatr. Rev. 2004;25;115123
Leslee F. Kelly
Update on Allergic Rhinits
Pediatr. Rev. 2005;26;284-289
Todd A. Mahr and Ketan Sheth
Sinusitis
Pediatr. Rev. 2001;22;111117
David Nash and Ellen
Wald
All Slides from PIR
A parent is concerned that her 4-year-old son “always has a
cold.” Given what you know about the
frequency of colds and the duration of their symptoms,
what is the minimum number of “sick days” per
year that would be considered excessive for a typical child?
A. 75.
B. 100.
C. 125.
D. 140.
E. 175.
D - 150
The average number of colds per year generally is
quoted as being 3 to 10. If each cold lasts the
usual 10 to 14 days, this translates to up to 140
days of cold symptoms per year.
Sinusitits:
Rhinosinusitis (RS) is the term currently
used because the inflammation is believed
to begin in the nasal epithelium (rhinitis).
It is estimated that of the average six to eight
upper respiratory tract infections (URIs)
per year experienced by school-age
children, 5% to 10% will be complicated by
RS.
PIR
It also is estimated that 6% to 13% of
children will have had one case of RS by
the age of 3 years. RS also is classified
by the duration of days of persistent
symptoms. Acute rhinosinusitis (ARS)
refers to symptoms that last longer
than 10 days but fewer than 30.
PIR
The maxillary and ethmoid
sinuses are fully formed and clinically
significant from birth. The sphenoid
sinuses begin to develop at age 3
years and are fully formed by age 7 to 8
years. The frontal sinuses are the last to
develop and are not fully formed until
the early teenage years.
ARS is defined as unabated upper respiratory tract
symptoms lasting longer than 10 days or as
worsening of symptoms by 7 to 10 days of illness.
It is important to distinguish a single prolonged
illness from consecutive URIs.
The symptoms of ARS include nasal discharge,
cough (typically day and night), and halitosis.
When fever precedes the URI symptoms, the
illness is more likely to be viral.
Older children and adolescents may present
with symptoms more typical of adult
disease: headaches, facial pain and
pressure, maxillary dental pain, pharyngitis,
and frequent throat clearing.
If purulent nasal discharge is seen draining from
the middle meatus, a diagnosis of ARS can be
fairly certain.
This finding may be recognized by looking
through the otoscope while gently pushing up on
the nares, a technique not easily done, especially
with younger children.
Ethmoid sinusitis may be accompanied by
periorbital edema. In older children and
adolescents, gentle pressure on the maxillary and
frontal sinuses may elicit pain or discomfort
Allergic rhinitis is best characterized by:
A. Cold air-induced rhinorrhea.
B. Fever.
C. Nasal pruritus.
D. Nocturnal cough.
E. Unilateral nasal discharge.
C. Nasal pruritus.
In 1998, the Joint Task Force on Practice
Parameters in Allergy, Asthma, and
Immunology defined rhinitis as
"inflammation of the membrane lining the
nose, characterized by nasal congestion,
rhinorrhea, sneezing, itching of the nose
and/or postnasal drainage."
You are asked to talk to local child care providers about
infection control measures. You advise them that
the single best intervention to reduce the spread of
“common colds” to other children in the center is to:
A. Exclude all ill children from the center.
B. Have all providers wear masks.
C. Isolate sick children within the center.
D. Limit outside playtime during the winter months.
E. Wash hands and toys.
E. Wash hands and toys.
Spread of virus can be prevented through
specific infection control techniques, namely,
those that decrease hand contamination with
virus. This can be accomplished simply by
correct handwashing of both caregiver’s and
children’s hands.
Of the following conditions, the one most
commonly coexisting with allergic rhinitis is:
A. Asthma.
B. Chronic sinusitis.
C. Immunodeficiency.
D. Otitis media with effusion.
E. Sleep apnea.
A. Asthma.
Some studies have found that nearly one third
of children who have AR also have asthma.
As physicians try to limit antibiotic use in children who
have colds, parent education takes on an increasingly
important role. Common colds are caused by viruses. The
most common viral causes are:
A. Adenoviruses.
B. Coronaviruses.
C. Influenza viruses.
D. Reoviruses.
E. Rhinoviruses.
E – Rhinovirus (at least 100 serotypes)
Rhinoviruses
Coronaviruses
Respiratory syncytial virus
Parainfluenza viruses
Adenoviruses
Nonpolio enteroviruses
Influenza viruses
Reoviruses
Your parent information sheet “Colds in Infants”
includes instructions on correct use of a bulb syringe.
Normal saline, rather than 1/8% phenylephrine drops,
is recommended because:
A. 4-month-old infants are primarily mouth breathers.
B. Phenylephrine causes rebound congestion.
C. Phenylephrine causes vasodilation.
D. Phenylephrine has been associated with
cardiomyopathy.
E. Phenylephrine must be given for 72 hours to be
effective.
B. Phenylephrine causes rebound congestion.
Topical nasal decongestants can cause significant
rebound congestion, which is especially
dangerous in infants 6 months of age and
younger, who are extremely dependent on nasal
airflow for respiration.
Allergen Avoidance
Allergy avoidance is the first recommendation for the
patient who has AR.
Although it may be easy to recommend avoiding pets or pollen, such
avoidance is extremely difficult for many patients.
A more realistic goal is to decrease allergen exposure as much as possible,
keeping in mind that many patients are allergic to multiple allergens.
Strategies include
-staying inside during high pollen times (5 AM to 10 AM),
-keeping air-conditioning on during spring and fall pollen seasons,
-avoiding drying clothes outside during high pollen times.
To avoid molds, strategies include
-Decreasing humidity in the home, using a dehumidifier
-Keeping obvious areas of mold clean with a bleach solution.
Allergic Rhinitis
The ideal solution for pets is to remove them from
the home, although this often is not feasible or
easy to accomplish.
An alternative is to remove pets from the
bedroom at night and during the day.
Reservoirs for pet dander and allergen also
should be avoided, such as pillows and heavy
upholstered furniture.
A 3-year-old boy is coming to see you with what his
mother describes as “probably just a cold.” On the
phone, she said that he has had a runny nose and now
has a worsening cough. Which piece of this patient’s
past medical history would raise the greatest concern?
A. Asthma.
B. Croup.
C. Otitis media.
D. Sinusitis.
E. Tonsillitis.
A. Asthma.
First-generation antihistamines should be used
cautiously in children who have asthma because
they thicken secretions and can make them
harder to clear.
Allergen avoidance, when possible, is the best way to
control allergic rhinitis. Of the following, the most
effective intervention in reducing the symptom
burden of allergic rhinitis is to:
A. Increase home humidity.
B. Keep air-conditioning on during pollen seasons.
C. Prevent all exposure to pets in the first postnatal
year.
D. Restrict outside play to early morning hours.
E. Spray pillows and comforters to eliminate dust
mites.
B. Keep air-conditioning on during pollen
seasons.
Strategies include staying inside during high
pollen times (5 AM to 10 AM), keeping airconditioning on during spring and fall pollen
seasons, and avoiding drying clothes outside
during high pollen times.
Why is it unlikely that a vaccine ever will be developed to
prevent colds?
A. Immunity to one viral serotype does not confer
complete protection against others.
B. More than 100 different viruses cause the common cold.
C. There are numerous antigenic serotypes.
D. A, B, and C.
E. B and C only.
D.
A, B, and C.
It is unlikely that a vaccine ever will be
developed to prevent the common cold
completely because of the numerous different
antigenic serotypes as well as antigenic variation
among many of the respiratory viruses.
Immunity to one serotype offers little protection
against others.
A 6-year-old girl presents in the early spring with a 2week history of paroxysmal sneezing associated
with itching of her nose and eyes. She had similar
symptoms last year that lasted for 2 months before
abating. You diagnose seasonal allergic rhinitis
and review appropriate avoidance measures. Of the
following, the most effective control of her nasal
symptoms would be achieved by proper use of an:
A. Intranasal corticosteroid.
B. Intranasal decongestant.
C. Oral first-generation antihistamine.
D. Oral leukotriene receptor antagonist.
E. Oral second-generation antihistamine.
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
A. Intranasal corticosteroid.
Pharmacologic options for treating AR
include antihistamines (oral and intranasal),
oral leukotriene receptor antagonists (LTRA),
and intranasal corticosteroids (INS).
Treatment guidelines for AR support the use
of INS as first-line therapy. INS are approved
for use in patients as young as 2 years of age.
In considering empiric antibiotic therapy for a
17-year-old boy in whom you suspect acute
sinusitis, you
should prescribe:
A. Amoxicillin 40 to 50 mg/kg per day.
B. Cefotaxime 300 mg/kg per day.
C. Cefuroxime axetil.
D. Erythromycin succinate.
E. Sulfamethoxazole-trimethoprim.

A. Amoxicillin 40 to 50 mg/kg per day.
If the patient’s symptoms persist after 3 days of
therapy, you should prescribe a course of:
A. Amoxicillin 40 to 50 mg/kg per day.
B. Cefotaxime 300 mg/kg per day.
C. Cefuroxime axetil.
D. Erythromycin succinate.
E. Sulfamethoxazole-trimethoprim.

C. Cefuroxime axetil.
ALLERGIC RHINITIS SX
Patients who have AR may experience a variety of
signs and symptoms. Parents usually
report mouth breathing, snoring, or a nasal voice
in affected children. Other symptoms typically
include paroxysmal sneezing, nasal itching,
sniffing, snorting, nose blowing, congestion or
postnasal drainage, and occasionally coughing.
Additional symptoms include itchiness of the eyes,
throat, and palate.
Acute bacterial sinusitis is best distinguished
from a viral upper respiratory tract infection
by:
A. Cough.
B. Duration of symptoms for greater than 10
days.
C. Facial pain and headache.
D. Presence of fever for 1 to 2 days.
E. Purulent nasal drainage.

B. Duration of symptoms for greater than 10
days.
A diagnosis of acute bacterial sinusitis should be
based on:
A. A precise clinical history regarding quality and
duration of symptoms.
B. Bacterial culture from the nasopharynx.
C. Computed tomography of the paranasal sinuses.
D. Physical examination of the nose and pharynx.
E. Plain film radiographs of the paranasal sinuses.

A. A precise clinical history regarding quality
and duration of symptoms.
The average number of colds per year
generally is quoted as being 3 to 10. If each cold
lasts the usual 10 to 14 days, this translates to
up to 140 days of cold symptoms per year.
Table 1. Signs and Symptoms of
the Common Cold
● Nasal discharge
● Nasal congestion/obstruction
● Scratchy/sore throat
● Malaise
● Postnasal drip
● Headache
● Cough
● Sneezing
● Decreased appetite
● Low-grade fever (102.2°F [<39°C])
● Myalgias
● Irritability
● Decreased sleep
● Conjunctivitis
● Mild pharyngitis
● Watery eyes
● Fatigue
● Hoarseness


The term “common cold” is understood to
mean that the cause is viral.
Cough and cold medicines contain
pharmacologically active ingredients that alone
or in combination are intended to relieve some
or all of a patient’s symptoms.
Management of the common cold is intended to
provide temporary relief of symptoms until the
cold completes its natural history.
If there are complications of the common cold,
treatment is directed at the specific complication.
For infants and young children, relieving nasal
obstruction is one of the most important goals because
this symptom can impair drinking, and dehydration
can result.
Relieving cough often is an important goal of the
family and frequently the reason for seeking care.
Many children and parents lose sleep because the
cough keeps them up at night.
More than 800 cough/cold preparations are available
in the United States.
A Journal of the American
Medical Association review of clinical trials on over-thecounter cold medications from 1950 to 1991:
Concluded that no good evidence has
demonstrated the effectiveness of over-thecounter cold medications in
preschool-age children, but certain medicines and
combinations of medicines have been shown to
reduce cold symptoms in adolescents and adults.
Antihistamines
These drugs block H1 receptors on nasal vasculature and
compete with histamine for receptor sites.
First generation antihistamines:
diphenhydramine, hydroxyzine, chlorpheniramine,
brompheniramine, and clemastine,
cross the blood-brain barrier and affect the central nervous
system (CNS).
Promethazine is a phenothiazine type of antihistamine that
usually is combined with a cough suppressant.
Have anticholinergic properties. Because histamine
is not an inflammatory mediator in the common
cold, the effects of the antihistamines are believed to be
caused by the anticholinergic drying action on mucous
membranes.
Table 4. Adverse Effects of
Antihistamines
● Sedation
● Paradoxic excitability
● Dizziness
● Respiratory depression
● Hallucinations
● Tachycardia
● Heart block
● Arrhythmia
● Dry mouth
● Blurred vision
● Urinary retention
First-generation antihistamines
should be used cautiously in children
who have asthma because they thicken
secretions and can
make them harder to clear.
Cochrane Database of Systematic Reviews
“In general, antihistamines alone in
older children and adults do not offer
clinically significant benefits. In small
children, there is no evidence that
they have any benefit other than
inducing sleepiness.”
The second-generation antihistamines include
terfenadine, astemizole, loratadine, and cetirizine.
Because these do not cross the
blood-brain barrier to any great extent,
they cause fewer CNS effects. They do
not possess anticholinergic properties
and have little drying effect. For this
reason, they are not as effective as the
first-generation antihistamines for the
nasal symptoms of the common cold.
Decongestants
Common decongestants include
pseudoephedrine, phenylephrine, and
oxymetazoline.
Decongestants are sympathomimetic agents
that decrease nasal congestion by causing
vasoconstriction. They improve patency by
reducing blood volume and swelling in the
nasal mucosa and paranasal sinuses.
Topical nasal decongestants can cause significant
rebound congestion, which is especially dangerous
in infants 6 months of age and younger, who are extremely
dependent on nasal airflow for respiration.
If used, they should be administered sparingly for no more
than 72 hours.
Continued use of topical decongestants can cause rhinitis
medicamentosa, a chronic inflammatory rhinitis.
In one study, infants younger than 12 months of age
who had infection with respiratory syncytial virus were
treated with 1/8% phenylephrine or normal saline nasal
drops. There was no change in clinical respiratory scores
Table 5. Adverse Effects of Decongestants
Systemic
● Tachycardia
● Irritability
● Agitation
● Sleeplessness
● Hypertension
● Anorexia
● Headache
● Nausea
● Vomiting
● Palpitations
● Dysrhythmias
● Seizures
● Dystonic reactions
Topical
● Drying of nasal membranes
● Nosebleeds
● Rebound nasal congestion
Antitussives
Cough may be the most frustrating and
concerning cold symptom to parents. It
typically keeps the child up at night, and
parents and siblings lose sleep as well.
It is important
to explain to parents that a cough
is a beneficial protective airway reflex.
Coughing clears excessive secretions
to maintain airway patency.
narcotic and nonnarcotic cough medicines
Narcotic cough medicines typically contain codeine or
hydrocodone, which act on the medullary cough
center in the brainstem.
Narcotic medicines do not suppress cough
completely, even in adults, and have serious
adverse effects, especially in overdose. These
include respiratory depression, which can lead
to apnea, nausea, vomiting, constipation,
dizziness, and palpitations.
Nonnarcotic cough medicines
Dextromethorphan
a narcotic analog
In adults, it suppresses cough as
effectively as codeine, but it still
can cause respiratory depression in
overdose.
Randomized, placebo controlled, blinded trials have
not discovered any difference between the medicine
and placebo in terms of symptom relief for small
children, except that they are more likely to fall
asleep within 2 hours than those receiving placebo or
no medication.
In many cases, this sleepiness is considered a benefit
in a child who is exhausted from lack of sleep due to
the cold.
In older children and adults, there may be some
overall beneficial effect of decreased nasal symptoms.
Nonpharmacologic Therapies
These therapies are primarily supportive and include humidified air,
bulb suctioning, saline nasal drops, positioning with the head
elevated, and increased fluid intake.
Such therapies are safer and less expensive than medications. It
generally is agreed in the literature that such supportive therapies
should form the mainstay of treatment for children who have
common colds.
Saline nasal drops can be used before the nose is suctioned, but
parents need specific instructions to do this correctly. The suction
bulb should be aimed back in the direction of the nasal passage.
Suctioning should be performed sparingly at times most likely to be
helpful, such as prior to feedings and sleep. If suctioned too
frequently, nasal trauma can cause swelling of the nasal mucosa,
leading to greater congestion.
Another “therapy” is education.
Over the Counter but No Longer under
the Radar —
Pediatric Cough and Cold Medications
n engl j med 357;23 www.nejm.org december 6, 2007
Consumers purchase about 95 million
packages of such medication for use in
children each year.
Since 1985, all six randomized, placebo-controlled
studies of the use of cough and cold preparations
in children under 12 years of age have not shown
any meaningful differences between the active
drugs and placebo.
Poison-control centers have reported more than
750,000 calls of concern related to cough and cold
products since January 2000
Centers for Disease Control and Prevention
identified more than 1500 emergency room visits
in 2004 and 2005 for children under 2 years of
age who had been given cough or cold products.
A review by the Food and Drug Administration
(FDA) identified 123 deaths related to the use
of such products in children under six during
the past several decades.
After the meeting, the major manufacturers of these
products announced that they disagreed with the
committee and would continue to market these
preparations for children between 2 and 5 years of
age.
Although the FDA does not need to follow the recommendations of its
advisory committees, we believe that it should immediately ask
companies to remove these products from store shelves and begin
legal proceedings to require them to do so.
Legislation to expedite the FDA’s oversight of the marketing and
advertising of over-the-counter has been proposed.

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Decongestants
Decongestants can help to relieve symptoms of a runny
nose or stuffy nose. They include ingredients like
phenylephrine and pseudoephedrine.
Phenylpropanolamine (PPA) was a decongestant that
was removed from the market in 2000, and should be
avoided. Although often helpful, decongestants can
make some children hyperactive or irritable.
Sudafed - Children's Nasal Decongestant Chewables
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Cough Suppressants
If your child's cough is interfering with sleep or his daily
activities, then as long as he isn't having any trouble
breathing, he may benefit from a cough suppressant, such as
dextromethorphan (DM). Codeine and hydrocodone are
ingredients in prescription cold medicines and may cause
drowsiness. Since coughs are often caused by post-nasal
drip, you should usually use a decongestant with a cough
syrup (see below).
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Delsym Extended-Release Suspension 12 Hour Cough Relief

Robitussin DM

Triaminic Long Acting Cough (blue)

http://www.pediacare.com/childrens_long_acting_cough

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Effects of Dextromethorphan – Recreational Use
When consumed in small recreational amounts,
DXM is often noted to have a psychedelic effect
related to the combination of alcohol,
marijuana, and opiates. With a greater dose
users may experience intense euphoria, vivid
imagination, and closed-eye hallucinations.
With an even greater dose, intense changes in
consciousness have been noticed, along with
out-of-body experiences or even psychosis.
Many people find such large doses to be
extremely unpleasant and do not want to
repeat them.

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Antihistamines
While effective for a runny nose that is caused by allergies, it is the
side effects of the antihistamines that can make them useful in
treating colds, including drowsiness and a dry mouth and nose.
They include ingredients such as diphenhydramine,
brompheniramine, chlorpheniramine, and carbinoxaimine, and
are usually found in allergy and 'night time' cold medicines.
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Dimetapp - Children's Cold & Allergy Liquid
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Benadryl Allergy Relief
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Triaminic Night Time Cold & Cough Syrup (purple)
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Night Time Triaminic Thin Strips Cold & Cough
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PediaCare NightRest Cough & Cold for Children
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Dimetapp - Children's Nighttime Flu Syrup

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Cough and Cold Medicines
Since most colds are accompanied by a runny nose, post-nasal drip and a cough, 'Cough and
Cold' Medicines are usually the most helpful, since they usually include a decongestant and a
cough suppressant. Unless they are noted to be non-drowsy, they may also contain an
antihistamine.
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Dimetapp - Children's Cold & Cough Elixir
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Dimetapp - Children's Decongestant Plus Cough Infant Drops (non-drowsy)
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Little Colds Decongestant Plus Cough (non-drowsy)
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PediaCare Decongestant & Cough Drops for Infants (non-drowsy)
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Robitussin CF Alcohol-Free Cough Syrup (non-drowsy)
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Triaminic Day Time Cold & Cough (non-drowsy)
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Triaminic Softchews Cough and Runny Nose
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Vicks NyQuil - Children's Cold, Cough Relief
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Vicks Pediatric 44M, Cough & Cold Relief
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http://fdb.rxlist.com/drugs/drug-144973Nariz+Oral.aspx?drugid=144973&drugname=Nariz+Oral&source=0