Resp 1 - Final 2025 Dr Yasser Farouk PDF

Diseases of upper respiratory tract Dr YASSER FAROUK Pulmonology Unit Pediatric Department Sinusitis Otitis externa Pharyngitis Otitis media Epiglotitis Croup Bronchiolitis Pneumonia ACUTE INFLAMMATORY UPPER AIRWAY OBST...

Diseases of upper respiratory tract Dr YASSER FAROUK Pulmonology Unit Pediatric Department Sinusitis Otitis externa Pharyngitis Otitis media Epiglotitis Croup Bronchiolitis Pneumonia ACUTE INFLAMMATORY UPPER AIRWAY OBSTRUCTION  Objectives (ILOs) At the end of this lecture, students can: 1. Recognize clinical presentation and diagnosis of upper airway obstruction in pediatrics 2. Know lines of treatment of upper airway obstruction in pediatrics A 12-month-old child is brought to your office because of a barky cough. The mother states that over the past 3 days the child has developed a runny nose, fever, and cough. The symptoms are getting worse, and the child seems to have difficulty breathing. He sounds like a seal when he coughs. What is the most probable diagnosis? CROUP  Infective agents: parainfluenza types 1, 2, 3 Age 3 months–5 years most common in winter recurrences decrease with increasing growth of airway Inflammation of subglottis  Signs and symptoms upper respiratory infection 1–3 days, then barking cough, hoarseness, inspiratory stridor; worse at night, gradual resolution over 1 week Complications—hypoxia only when obstruction is complete Drooling, dysphagia, high fever, and toxic appearance are notably absent in viral croup.  Barking cough It sounds unmistakably like a seal or a dog barking. This sound is similarly created by collapse of the upper airway during expiration.  Diagnosis Clinical x-ray not needed (steeple sign if an x-ray is performed) Tapering of the upper trachea in the frontal chest XR due to subglottic narrowing ASSESSMENT OF THE SEVERITY OF CROUP  Mild croup is characterized by an absence of stridor at rest, minimal respiratory distress, and an occasional cough Moderate croup, the child’s behavior and mental status are normal but inspiratory stridor and retractions are present at rest and the amount of respiratory distress is increased. Severe croup is characterized by mental status changes accompanied by significant respiratory distress and decreasing air entry, indicating impending respiratory failure  Treatment Supportive plus: ❖Mild: corticosteroid then observe; if improved, then home but if worsens, treat as moderate croup ❖Moderate: nebulized epinephrine + corticosteroid, then observe; if improved, then home but if worsens, repeat epinephrine and admit to hospital ❖Severe: nebulized epinephrine and corticosteroid then admit to hospital (possibly PICU) EPIGLOTTITIS A 3-year-old male that presents with respiratory distress, drooling, and stridor on inspiration. On exam, the patient is extending his neck with an open mouth and leaning forward. What is the most probable diagnosis? Infection of the cartilaginous structure protecting the airway during swallowing Epiglottis protects airway during swallowing Infective agents ▪Haemophilus influenzae type B (HiB) no longer number one (vaccine success) ▪Now combination of Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma ▪Risk factor—adult or unimmunized child Signs and symptoms Dramatic acute onset with High fever, sore throat, dyspnea, and rapidly progressing obstruction Toxic-appearing, difficulty swallowing, drooling, sniffing-position Stridor is a late finding (near-complete obstruction) Complications Complete airway obstruction and death  Dyspnea Drooling 4D Dysphagia Dysphonia Diagnosis Clinical first (do nothing to upset child) Controlled visualization (laryngoscopy). Feature of a cherry-red, swollen epiglottis X-ray not needed (thumb sign if x-ray is performed) followed by immediate intubation Treatment This disease is a true emergency. Keep the patient (and parents) calm, call anesthesia, and transfer the patient to the OR. Do not examine the throat unless an anesthesiologist or otolaryngologist is present. Treatment lines Establish patent airway (Endotracheal intubation or tracheostomy ) IV antibiotics to cover staphylococci, HiB, and resistant strep (antistaphylococcal plus third-generation cephalosporin) ) Differentiation between croup and epiglottitis Pitfalls to avoid Never forcefully examine the child's throat. Never do anything painful to the child. If they need intravenous access because they are so unwell, this must wait until they are somewhere with an anaesthetist and hopefully also an ENT surgeon. It is better to allow them to have some cardiovascular compromise than complete airway obstruction. Congenital Anomalies of the Larynx Airway Foreign Body  Objectives (ILOs) At the end of this lecture, students can: 1. Recognize clinical presentation and diagnosis of congenital anomalies of larynx in pediatrics 2. Know diagnosis and management of Airway Foreign Body in pediatrics CONGENITAL ANOMALIES OF THE LARYNX  Laryngomalacia Subglottic Stenosis Vocal Cord Paralysis Third most common cause; may occur as Most frequent cause of stridor in infants a result of repair of congenital heart due to collapse of supraglottic structures Second most common cause disease or TE-fistula repair(recurrent in inspiration laryngeal nerve) Clinical: often associated with Chiari Clinical: stridor in supine that decreases Clinical: recurrent or persistent stridor malformation (hydrocephalus); in prone; exacerbated by exertion with no change in positioning inspiratory stridor, airway obstruction, cough, choking, aspiration Diagnosis: laryngoscopy Diagnosis: laryngoscopy Diagnosis: flexible bronchoscopy Treatment: supportive; most improve in Treatment: supportive; most improve in 6 months but surgery may be needed in Treatment: cricoid split reconstruction 6-12 months but tracheostomy may be severe cases needed AIRWAY FOREIGN BODY A toddler presents to the emergency center after choking on some coins. On physical examination, the patient is noted to be drooling and in moderate respiratory distress. There are decreased breath sounds on the right with intercostal retractions  Larynx is the most common site of foreign body aspiration in children age 1 year. In children age >1 think trachea or right mainstem bronchus ▪Most seen in children age 3–4 years ▪Items that are most commonly implicated in accidental foreign body ingestion include food as peanuts, coins, toys, and other small objects. ▪Highly suggested if symptoms are acute choking, coughing, wheezing; often a witnessed event ❖ Clinical—depends on location: Sudden onset of respiratory distress Cough, hoarseness, shortness of breath Wheezing (asymmetric) and decreased breath sounds (asymmetric) ❖Complications Obstruction Erosion Infection (fever, cough, pneumonia, hemoptysis, atelectasis) Foreign body aspiration can be a life-threatening emergency. An aspirated solid or semisolid object may lodge in the larynx or trachea. If the object is large enough to cause nearly complete obstruction of the airway, asphyxia may rapidly cause death ❖Diagnosis Chest x-ray reveals air trapping (ball-valve mechanism). Most of FB are radiolucent. Bronchoscopy for definite diagnosis. ❖ Therapy: removal by rigid bronchoscopy A) Hyperlucency of left lung due to a check-valve effect of a foreign body. B) Total atelectasis of the left lung Examples of radio opaque foreign bodies A toddler presents to the emergency center after choking on some small objects. On physical examination, the patient is noted to be drooling and in moderate respiratory distress. There are decreased breath sounds on the right with intercostal retractions. Which of the following is considered for definitive diagnosis of this patient? a) Chest X-ray b) Bronchoscopy c) CT chest d) CBC with differential count e) Sputum culture and sensitivity DISORDERS OF THE EAR, NOSE, AND THROAT  Objectives (ILOs) At the end of this lecture, students can: 1. Recognize clinical presentation and diagnosis of common diseases of ear, nose and throat in pediatrics 2. Know lines of treatment of disorders of the ears, nose, and throat in childhood EAR  EXTERNAL EAR Otitis externa (swimmer’s ear) Normal flora of external canal includes: ❖ Pseudomonas aeruginosa (most common cause) ❖ S. aureus (second most common cause) ❖ coagulase-negative Staphylococcus, diphtheroids, Micrococcus spp., and viridans streptococci Causes of otitis externa: ❖ excessive wetness ❖ dryness ❖ skin pathology ❖ trauma  Symptoms: significant pain (especially with manipulation of outer ear), conductive hearing loss Findings: edema, erythema, and thick otorrhea, preauricular nodes Malignant external otitis is invasive to temporal bone and skull base, with facial paralysis, vertigo, other cranial nerve abnormalities; requires immediate culture, IV antibiotics, and imaging (CT scan) → may need surgery  Treatment: topical otic preparations ± corticosteroids Prevention: earplugs thorough drying of canal 2% acetic acid after getting wet MIDDLE EAR A 4-year-old child is seen in the office with a 3-day history of fever and cold symptoms and now complains of right ear pain. Physical examination is remarkable for a bulging tympanic membrane with loss of light reflex and landmarks. What is the most probable diagnosis? Otitis media (OM)  Otitis Media Correlated Factors Commonly first 2 years of life boys > girls low socioeconomic Heritable genetic component Protective effect of breast milk vs formula Positive correlation to both tobacco smoke and exposure to other children Season: cold weather Congenital anomalies: more with palatal clefts, other craniofacial anomalies, and Down syndrome  Acute, suppurative otitis media; accompanied by a variable degree of hearing loss (20–30 dB) Etiology: Bacterial (up to 75%): S. pneumoniae (40%); nontypeable H. influenzae (25– 30%); Moraxella catarrhalis (10–15%). Other 5%: Group A strep, S. aureus, gram negatives (neonates and hospitalized very young infants), respiratory viruses (rhinovirus, RSV most often)  Pathogenesis Interruption of normal eustachian tube function (ventilation) by obstruction → inflammatory response → middle ear effusion → infection; most with URI Shorter and more horizontal orientation of tube in infants and young children allows for reflux from pharynx (and in certain ethnic groups and syndromes)  Clinical findings highly variable Symptoms: ear pain, fever, purulent otorrhea (ruptured tympanic membrane), irritability, or no symptoms Pneumatic otoscopy: fullness/bulging or extreme retraction, intense erythema (otherwise erythema may be from crying, fever, sneezing; erythema alone is insufficient unless intense), some degree of opacity (underlying effusion) Mobility is the most sensitive and specific factor to determine presence of a middle ear effusion (pneumatic otoscopy) Diagnosis It must have acute onset, tympanic membrane inflammation, middle ear effusion tympanic membrane inflammation middle ear acute onset effusion Acute otitis media  Treatment Advisable to use routine antimicrobial treatment especially for: ❖age 2 years with no high fever or severe pain, observation and reevaluation in 2-3 days is acceptable; if no improvement, start antibiotics. ❖Duration:10 days; shorter if mild, older child ❖Follow up: within days for young infants, continued pain or severe; ❖otherwise, 8-12 weeks if age