Transcript URTI & Sinusitis

Pediatric URTI
& Sinusitis
Leybie Ang
PEM Fellow
Feb 25 2010
Thanks to Jennifer Puddy
Etiology
 Acute
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
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and subacute pathogens
S. pneumoniae (20-30%)
Nontypeable H. influenzae (15-20%)
Moraxella catarrhalis (15-20%)
S. pyogenes – beta hemolytic (5%)
 Chronic
sinusitis
 Noninfectious conditions
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
Allergy
Cystic fibrosis
GER
Cilliary dysfunction
Risk Factors
 Viral
URI
 Allergic
rhinitis
 Anatomic
 Mucosal
obstruction
irritants
AAP Guidelines 2001
 Age
1 to 21 years
 Healthy
 Exclusions:
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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
 Not
recommended for the routine
diagnosis
 Sinus
aspiration and culture may need to
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
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Persistent: >10 d with no improvement that
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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
 Facial
pain is unusual and facial
tenderness is rare and unreliable finding
 Periorbital
swelling is suggestive of
ethmoid sinusitis
 Value
of transillumintation of sinuses is
controversial and found to be unreliable
in children < 10yo
Recommendation #2
 Imaging
not necessary to confirm a
diagnosis of clinical sinusitis in children < or
= 6 yo
Radiology
 Plain
radiographic or computed
tomography findings that are consistent
with sinus inflammation include:

Complete opacification
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Mucosal thickening of at least 4 mm
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Air-fluid level
Radiologic Assessment
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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
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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
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Fail to respond to medical management
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Severe symptoms suspicious for
complications related to acute sinusitis
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Surgery is considered
Recommendation #3

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Antibiotics are recommended for the
management of acute bacterial sinusitis to
achieve a more rapid clinical cure
First line :
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If PCN allergic (not type 1 hypersensitivity
reaction)
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Amox or amox-clav
Cefdinir, Cefuroxime, Cefpodoxime
If serious reaction

Clarithromycin or azithromycin
 If
failure to improve with amox, NEITHER
TMP-SMX NOR ERYTHROMYCINSULFISOXAZOLE are appropriate choices
for antimicrobial therapy.
Duration of Treatment
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10 days
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14 days
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21days
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28 days
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Until pt is asymptomatic + 7days
Complications
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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
 Topical
agents
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
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Partly double-blinded randomised controlled trial
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Paired comparisons of honey and dextromethorphan
showed no significant differences
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Honey did appear to be superior to no treatment for
cough frequency, child sleep and the combined
symptoms score
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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?
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What percentage of viral URI's will progress to acute
bacterial sinusitis?
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Name some (2) risk factors in the development of
sinusitis.
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What are some radiographic finding of sinusitis?
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What is the most common complication of sinusitis?
Case 1
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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

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
AIRWAY
Postpone further examination
Minimize agitation
Consult anesthesiologists and ENT
 IV
antibiotics
 IV
hydration
Case 2
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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
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High fever and a toxic appearance, less
abrupt onset, sore throat, neck pain, cervical
lymphadenopathy
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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
 Classical
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space infections
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:
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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