Upper Respiratory Tract Disorders Lecture PDF

Upper Airway Disorders Department of Pediatrics  Intended Learning Objectives Identify different upper airway disorders in Pediatrics. Describe the clinical picture of each of these disorders. Differentiate between different upper airway disorders in Pediatrics. Under...

Upper Airway Disorders Department of Pediatrics  Intended Learning Objectives Identify different upper airway disorders in Pediatrics. Describe the clinical picture of each of these disorders. Differentiate between different upper airway disorders in Pediatrics. Understand the management options of upper airway disorders in Pediatrics.  Mechanical UPPER AIRWAY OBSTRUCTION 1. Laryngeomalacia: Definition: Treatment: ˜ Self limiting by 12-18 months. ˜ Surgery if persist therafter.  Laryngomalacia Subglottic Stenosis Vocal Cord Paralysis Third most common cause; may occur as a result of repair of congenital heart Most frequent cause of stridor in infants Second most common cause disease or TE-fistula repair(recurrent 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  CASE A toddler presents to the emergency department 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. The most important investigation for this patient is: Chest X-ray Bronchoscopy CT chest CBC with differential count Sputum culture and sensitivity  2. Foreign Body Aspiration: (3-4 years) Complications:  Obstruction Larynx is the most common site in children age 1 year.  Erosion In children age >1 think trachea or  Infection (fever, cough, pneumonia, right mainstem bronchus. hemoptysis, atelectasis) Management: 1. Emergency: 2. Urgency: Laryngoscopic removal of the foreign body. A newborn is noted to be cyanotic in the wellborn nursery. On stimulation, he cries and becomes pink again. The nurse has difficulty passing a catheter through the nose. The provisional diagnosis is ………..  Unilateral or bilateral bony (most) or membranous septum between nose and pharynx. Half have other anomalies. Upper respiratory infection Unilateral—asymptomatic for long time until first URI, then persistent nasal discharge with obstruction. Bilateral: typical pattern of cyanosis while trying to breathe through nose, then becoming pink with crying; if can breathe through mouth, will have problems while feeding Diagnosis Inability to pass catheter 3−4 cm into nasopharynx Fiberoptic rhinoscopy Best way to delineate anatomy is CT scan Treatment Establish oral airway Surgical repair ACUTE INFLAMMATORY UPPER AIRWAY OBSTRUCTION Epiglottitis 1. Rhinitis: Allergic Infectious  2. Sinusitis: Pathophysiology: Fluid in sinuses during URIs from nose blowing. Inflammation and edema may block sinus drainage and impair clearance of bacteria.  S. pneumonia, H. influenzae, M. catarrhalis.  May occur at any age  Predisposing factors: Immune deficiency Ciliary dysfunction Cleft palate Nasal polyps and foreign body URI, allergy cigarette smoke exposure Chronic sinusitis Symptoms and signs: Nonspecific complaints: Nasal congestion Discharge Fever Cough Less commonly: Bad breath Decreased sense of smell Periorbital edema Headache Face pain Sinus tenderness only in adolescents and adults.  Diagnosis Clinical diagnosis Persistent URI symptoms without improvement for at least 10 days. Severe respiratory symptoms with purulent discharge and temperature at least 38.9°C for at least 3 consecutive days. Only accurate method to distinguish viral versus bacterial is sinus aspirate and culture, but this is NOT done routinely. Sinus films/CT scans—show mucosal thickening, opacification, air-fluid levels, but does not distinguish viral versus bacterial. Treatment : Antibiotics for 7-10 days. 3. Pharyngitis:  CASE An 8-year-old girl complains of acute sore throat of 2 days’ duration, accompanied by fever and mild abdominal pain. Physical examination reveals enlarged, erythematous tonsils with exudate and enlarged, slightly tender cervical lymph nodes. The management of this child is …………... Treatment: Treatment: Fluids and rest Antibiotics for 10 days  CASE 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. On examination the child has RR 65 breaths/ minute, HR 140 BPM and temp 38°C. Inspiratory stridor is heard. The provisional diagnosis of this condition is …….………….  4. Acute laryngitis (CROUP): Inflammation of subglottis. Causative organism: parainfluenza virus types 1, 2, 3. Age: 3 months–5 years; more common in winter. Recurrences decrease with increasing growth of airway.  Symptoms and signs Upper respiratory infection 1–3 days, then barking cough, hoarseness, inspiratory stridor; worse at night, gradual resolution over 1 week. Complications: hypoxia when obstruction is complete  Barking cough It sounds like a dog barking. It is caused by collapse of the upper airway during expiration. Drooling, dysphagia, high fever, and toxic appearance are absent in croup  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  Grading Mild characterized by absence of stridor at rest, minimal respiratory distress, and occasional cough Moderate the child’s behavior and mental status are normal but inspiratory stridor and retractions are present at rest and the respiratory distress is increased. Severe 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, discharge but if worsens, treat as moderate croup Moderate: nebulized epinephrine + corticosteroid, then observe; if improved, then discharge but if worsens, repeat epinephrine and admit to hospital Severe: nebulized epinephrine and corticosteroid then admit to hospital (possibly PICU)  CASE A 3-year-old male presents with respiratory distress, drooling, and stridor on inspiration. On exam, the patient has temp 39°C, toxemia and is extending his neck with an open mouth and leaning forward. The most probable diagnosis is ……………...  5. Acute Epiglottitis: Infection of the cartilaginous structure protecting the airway during swallowing Epiglottis protects airway during swallowing Causative organism: Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma. Haemophilus influenzae type B (HiB) no longer number one (vaccine success) Risk factor—adult or unimmunized child Symptoms and signs: 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 Diagnosis: Clinical diagnosis (do nothing to upset child) Controlled visualization (laryngoscopy): Not indicated. Feature of a cherry-red, swollen epiglottis X-ray not needed (thumb sign if x-ray is performed) 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) ) 6. Otitis externa (swimmer’s ear) Causes : Excessive wetness Dryness Skin pathology Trauma Symptoms: significant pain (especially with manipulation of outer ear) conductive hearing loss Signs: edema, erythema, and thick otorrhea, preauricular nodes  Treatment: Topical otic preparations ± corticosteroids Prevention: Earplugs Thorough drying of canal 2% acetic acid after getting wet  CASE 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? 7. Otitis media: Common in the first 2 years of life (shorter and more horizontal orientation of tube). Low socioeconomic standard. 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 Pathogenesis Interruption of eustachian tube function (ventilation) by obstruction → inflammation → middle ear effusion → infection.  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)  Clinical findings highly variable Symptoms: Acute onset of ear pain, fever, purulent otorrhea (ruptured tympanic membrane), irritability, or no symptoms. Pneumatic otoscopy: fullness/bulging or extreme retraction, intense erythema, opacity (underlying effusion) Mobility is the most sensitive and specific factor to determine presence of a middle ear effusion (pneumatic otoscopy) Normal ear drum Purulent effusion behind a Purulent otorrhea bulging tympanic membrane Retraction of the tympanic membrane resulting in a breakdown of the long process of the incus. Bubbles, air-fluid level seen behind tympanic membrane  Treatment Pain relief: acetaminophen, NSAIDs (except acetylsalicylic acid because of risk of Reye syndrome) Advisable to use antimicrobial treatment especially for: Age