Description
● Inflammation of the pharynx most commonly caused by acute infection.
● Group A streptococcus is a focus of diagnosis due to its potential for preventable rheumatic sequelae.
● Chronic low grade symptoms usually related to reflux disease or vocal abuse.
Management
Supportive treatment
● Normal Saline gargle – use 10 to 15mL every 4 - 6hours for all children who can gargle usually above 4years
● Children over 10years can rinse mouth and gargle with a Chlorhexidene or iodine based gargle: Chlorhexidene should be used half an hour before or after brushing teeth. Rinse mouth with 10-15mL held in the mouth for about 30seconds twice daily. Povidone-iodine; 6-18yrs; upto 10mL undiluted or diluted with an equal quantity of warm water held for about 30 seconds upto 4 times daily for upto 14 days
● Oral analgesic in pain: Paracetamol 10-15mg/Kg/dose every 4 - 6 hours as needed
Definitive Treatment
● Oral amoxicillin 90 mg/Kg/day in divided doses every 8 hours for 7 days
● Oral Cefadroxil 30mg/Kg/day in 2 divided doses for 7days Penicillin Hypersensitivity
● Oral erythromycin 20 – 40 mg/Kg/day in divided doses every 6- 8 hours for 7 days
● 3 months, complications or additional diagnoses should be considered
Prevention
● General prevention measures consist of good personal hygiene, hand washing, ingestion of safe drinking water and proper sanitation
● Prevention specific to hepatitis A infection includes the use of HAV immune globulin (IG) and HAV vaccine
● IG is given as an intramuscular injection of 0.02 mL/Kg ● HAV vaccine is currently licensed for use in children aged 12
months or older
Specific measures to prevent HAV can be divided into 2 groups: Pre-exposure prophylaxis and post exposure prophylaxis
● Pre-exposure prophylaxis with HAV vaccine is recommended for persons aged 1 year or older. If the trip is shorter than 2weeks or if the patient is younger than 1 year, IG should be given. If the trip is longer than 3 months, a larger dose of IG (0.06 mL/ Kg) is needed for those who cannot receive the vaccine
● Post exposure prophylaxis consists of the administration of IG to contacts as soon as possible, but not longer than 2 weeks after exposure
Supportive Treatment
● If there is pus draining from the ear, advice the mother to wick the ear repeatedly until the wick is dry and keep doing it severally in a day to keep the ear dry
Definitive treatment
● Pain and fever should be managed with oral Paracetamol 10- 15mg/Kg/dose every 4 – 6 hours or Ibuprofen 4 - 10mg/Kg every 6 to 8 hours
1st line antimicrobial therapy
● Oral Amoxicillin 90 mg/Kg/day in divided doses every 8 – 12 hours for 10 days
Penicillin hypersensitivity
● Oral Azithromycin 10mg/Kg/day once daily for 3 days or ● Oral Erythromycin 30-40mg/Kg/day in divided doses every 6 – 8
hours for 5 – 7 days
2nd line Antimicrobial Therapy
● Oral Coamoxiclav 90mg/Kg/day in divided doses every 12 hours for 10 days or
● Oral Cefprozil 30mg/kg/day in divided doses every 12 hours ● Oral Cefuroxime 30mg/Kg/day in divided doses every 12 hours Alternative antibiotics
● Cefixime 8 mg/Kg/day bid or single daily dose - effective against resistant H. influenzae and M. catarrhalis less effective than amoxicillin for pneumococci
● Cefpodoxime 10 mg/Kg/day bid - less effective in vivo against H. influenzae than other drugs
Follow up
● Follow up after 5 days, if ear pain and discharge persists, treat with same antibiotics for 5 more days and follow up after 5 days 2nd line antibiotics
● Oral Coamoxiclav 90mg/Kg/day in 2 divided doses for 10days ● Oral Azithromycin 10mg/Kg once daily for three days
● Oral Cefuroxime 30mg/Kg/day in 2 divided doses for 10days 3rd line antibiotics
● Intravenous Ceftriaxone 50 - 80mg/Kg/day as a once daily dose
2). OTITIS MEDIA
Description
Infection or inflammation of the middle ear
● Acute Otitis Media (AOM): Usually a bacterial infection
accompanied by viral upper respiratory infection; rapid onset of signs and symptoms
● Recurrent AOM: 3 or more AOM episodes in 6 months or 4 or more AOM episodes in 1 year
● Otitis media with effusion (OME): Persistent inflammation manifested as asymptomatic middle ear fluid that follows AOM or arises without prior AOM
● Chronic Otitis media with or without cholesteatoma a. Acute Otitis Media
Description
Otitis media described by:
● History of ear pain or pus draining from the ear for a period of less than 2 weeks
● Fever
● Systemic signs may or may not be present
● Ear drum is red, inflamed, bulging and opaque or perforated with discharge on otoscopy
3). ALLERGIC RHINITIS
Description
An immediate and/or delayed reaction to airborne allergens, beginning with the generation and presence of specific antigen- responsive IgE antibody receptors on mast cells of the nasal mucosa and associated with
● Stuffy nose, sneezing, itching, runny nose, cough, halitosis and repeated throat clearing,
● Sensation of plugged ears and wheezing may occur ● Red and itchy eyes suggestive of allergic conjunctivitis ● Seasonal, perennial or episodic symptoms and exacerbating
factors may help identify allergen
● Family history of atopic disease supports diagnosis Management
Supportive treatment
● Avoidance therapy – identify and eliminate known/suspected allergens
Definitive treatment
● Normal saline nasal drops; 2-3 drops into both nostrils 3-4 times daily when necessary.
● Steam inhalation
● Menthol with Eucalyptus drops sprinkled onto the pillow, a handkerchief or into steaming water. The child is then allowed to breath in the vapor for some time. Not recommended for infants and not more than 4doses to be used
● Non- sedating Antihistamines – Loratadine, Cetrizine: ● Loratadine; oral; child 2-6yrs, 5mg once daily. Child 6-18 yrs
10mg once daily. Desloratadine can be used at half the dose of Loratadine. Cetrizine; oral; child 1-2yrs; 250mcg/Kg twice daily. Child 2-6yrs; 5mg daily in 1-2 divided doses. Child 6-18 yrs; 10mg once daily in 1-2 divided doses.
b. Chronic Suppurative Otitis Media Description
An Otitis media associated with :
● A history of pus draining from the ear for more than 2 weeks ● Confirmation by otoscopy
Management
Supportive treatment
● Advice the mother to wick the ear repeatedly until the wick is dry
*Consult an E.N.T specialist Definitive Treatment
● Oral Coamoxiclav 90mg/Kg/day in divided doses every 12 hours for 10 days
● Instill topical antibacterial ear drops: Ciprofloxacin ear drops once daily for two weeks
Reference
1. Integrated management of childhood diseases IMCI 2006
2. Rudolf paediatrics 21st edition
3. Currents pediatrics 16th edition
4. McConaghy JR. The evaluation and treatment of children with acute Otitis media. J Fam Pract 2001;50(5):457-9, 463-5 5. Kozyrsky AL, Hildes-Ripstein GE, et al. Treatment of acute
Otitis media with a shortened course of antibiotics. JAMA 1998;279(21):1736-41
6. Stool SE, Berg AO, Bernan S, et al. Otitis media with effusion in young children. Clinical practice guideline. AHCPR Publication no 94-0622, 1994
7. Rosenfield RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute Otitis media: Meta analysis of 5400 children from 33 randomized trials. J Paediatric 1994;124:355-67
● Intravenous therapy with third-generation cephalosporin such as Cefotaxime should be initiated until culture results become available
● Less severe cases of acute sinusitis should be treated with oral antibiotics for 10 days
First line
● Coamoxiclav at 90 mg/Kg/day in 2 divided doses Second line
● 3rd generation cephalosporins Ceftriaxone or Cefpodoxime. ● Patients with underlying allergic rhinitis may benefit from
intranasal corticosteroid nasal spray
● Paracetamol or Ibuprofen if in pain to permit sleep until drainage is achieved
● The application of ice over the sinus may help to relieve pain Chronic or recurrent sinusitis
● Recurrent acute bacterial sinusitis is defined as successive episodes of bacterial infections of the sinuses, each lasting less than 30 days and separated by intervals of at least 10 days, during which the patient is asymptomatic
● Chronic sinusitis is defined as episodes of inflammation of the paranasal sinuses lasting more than 90 days.
Treatment
● Antibiotic therapy is similar to that used for acute sinusitis, but the duration is longer.
● Adjuvant therapies such as saline nasal irrigations,
antihistamines and topical intranasal steroids may be helpful depending on the underlying cause.
● Refer to the ENT surgeons ● Mast cell Stabiliser - Montelukast
Corticosteroid Nasal Sprays
1. Fluticasone, 4 years and above 1 spray (50 mcg) in each nostril once daily. Double the dose to 100mcg in severe symptoms and reduce to 50mcg once symptoms are controlled. A preparation of Fluticasone with a lower dose (25mcg) per spray is available
2. Budesonide 32mcg in children less than 12 years: 4 sprays (2 in each nostril once daily). In children above 12 years, 8 sprays (4 in each nostril once daily) for a max of 3 months Recurrence of allergic rhinitis needs follow up by the ENT sur- geons or an Allergist
References
1. Middleton E. Jr, Reed CE, Ellis EF: Allergy Principles and Practice.
4th Ed. St. Louis, C.V. Mosby Co., 1993
2. Baraniuk JA: Pathogenesis of allergic rhinitis. J of Allergy and Clinical Immunology 1997;99(2):S763-S772
3. JAMA. Primer on Allergic and Immunologic Diseases. 1992 4. Rudolfs pediatrics -21st edition
5. Current paediatric diagnosis and treatment 16th edition
4). SINUSITIS
Acute bacterial Sinusitis Description
Acute bacterial infection of the paranasal sinuses lasting less than 30 days and in which symptoms resolve completely
Management
● Patients with evidence of invasive infection or any CNS complications should be hospitalized immediately
anterior pack using 1/2 x 72 inch ribbon gauze impregnated with petroleum jelly (Vaseline) or nasal tampons may be used ● Use bayonet forceps and nasal speculum to insert in folding
layers as far back as possible. Press each layer firmly down on the last in one continuous strip with the folded ends alternating front and back
Posterior bleed
● Various balloon systems.
● Posterior packing is very effective if balloon systems fail to control bleeding.
Intractable bleed
● Bilateral packing to achieve adequate compression (admission required)
● Bleeding from roof may be controlled by placing double balloon system with small anterior pack placed above anterior balloon. ● Intractable bleed will require surgical cauterization or arterial
ligation (ideally after visual identification of bleeding site to define appropriate arterial supply)
Medication Management
1. Vasoconstrictor: Cocaine 4%, Phenylephrine 0.25%, Xylometazoline 0.1%, epinephrine 1:1000
2. Anesthetic: Tetracaine 2%, lidocaine laryngeal spray, Lidocaine jelly 2%, Lidocaine solution 4%, Lidocaine viscous 2%
3. Systemic antibiotics and decongestants to prevent sinusitis with packs or balloons
4. Consider iron supplementation for patients with considerable blood loss
Prevention/avoidance
● Liberal application of petroleum jelly (Vaseline) to nostril to prevent drying and picking.
● Humidification at night. ● Cut fingernails.
5). EPISTAXIS
Description
Hemorrhage from nostril, nasal cavity or nasopharynx
● Anterior bleed: Originates from anterior nasal cavity, usually little’s area (kiesselbach’s plexus)
● Posterior bleed: Originates from posterior nasal cavity or nasopharynx usually under the posterior half of the inferior turbinate or the roof of the nasal cavity
Management General measures
● Resuscitation as indicated
● Sedation, analgesic, antihypertensive or anticoagulant reversal as needed
● Patient should be gowned and sitting, if stable.
● Clear nasal cavity of blood with suction, forceps withdrawal of clot or patient blowing nose
If bleeding has stopped,
● Rub suspicious areas with wet cotton tipped applicator to identify site. Diffuse ooze or multiple sites suggests systemic cause
● In cases of posterior bleed, identify as either roof or low posterior site since each has different arterial supply (will be important if arterial ligation is necessary).
Anterior bleed
● Place pledget soaked in vasoconstrictor and local anesthetic in cavity and pinch nostril for several minutes to stop bleeding by direct pressure
● Remove pledget and visualize vessel. Cauterize with silver nitrate stick directly on vessel with firm pressure for 30 seconds ● If unsuccessful, apply second dose of anesthetic and place
7). MENIERE’S DISEASE
Description
An inner ear (labyrinthine) disorder in which there is an increase in volume and pressure of the inner-most fluid of the inner ear (endolymph) resulting in recurrent attacks of hearing loss, tinnitus, vertigo, and fullness.
Management General measures
● Reassurance
● Medications are given primarily for symptomatic relief of vertigo and nausea.
● For attacks, bed rest with eyes closed and protection from falling.
Surgical measures: Refer to an ENT Specialist Medication management Acute attack
For severe episode, one of the following may be used. Adult doses are indicated
● Atropine 0.2-0.4 mg IV or ● Diazepam 5 -10 mg IV slowly Maintenance
Meclizine 25-100 mg orally, either at bedtime or in divided doses Monitoring and follow up
● Monitor the status of their hearing, since it is at risk
● Consider the possibility of a more serious underlying problem such as an acoustic tumor.
References
1. Votey R, Dudley JP: Emergency Ear, Nose and Throat procedures. Emerg. Clin. NA 1989;7(1)117-154
2. Perretta LJ, et al: Emergency evaluation and management of epistaxis. Emerg. Clin. NA 1987;5(2)265-277
3. Nelsons textbook of paediatrics
4. Current diagnosis and treatment – 16th edition
5. Rudolfs paediatric 21st edition
6). LUDWIG’S ANGINA
Description
Ludwig angina is a rapidly progressive cellulitis affecting the submandibular, submental and sublingual spaces that can cause airway obstruction and death. It is characterized by:
● Tongue elevation,
● Difficult eating and swallowing, ● Oedema of the glottis,
● Fever, tachypnea and moderate leukocytosis. Management
● Admit for ENT Specialist management ● Broad-spectrum intravenous antibiotics ● Maintain airway
● Tracheostomy if necessary Medical Management
● High doses of intravenous Clindamycin or Nafcillin until the results of cultures and sensitivity tests are available
Monitoring
● The patient must be monitored closely in the intensive care unit and intubation provided for progressive respiratory distress ● An otolaryngologist should be consulted to identify and perform
Management
● Supportive – oxygen, rest ● Antibiotic therapy 1st line
● Crystalline penicillin 50,000 – 100,000IU/Kg/day in divided doses every 6hours or amoxicillin 90mg/Kg/day in 3 divided doses.
● Add IM Gentamicin 5 – 7mg/Kg once a day if age under 3 months, severe malnutrition, immunosuppression and very severe disease
2nd line
● Coamoxiclav 30mg/Kg/dose (oral 90mg/Kg/day in two divided doses) 12 hourly for 7 – 10 days
● Cefuroxime 90mg/Kg/day (Oral 30mg/Kg/day) in three divided doses for 7 – 10 days
● Azithromycin 10mg/Kg/day once daily or Erythromycin 30- 40mg/Kg/day in divided doses every 6 – 8 hours for suspected mycoplasma pneumoniae
Note
● Consider tuberculosis if response is poor, or prolonged history e.g. cough over 2 weeks
● Adjust drugs to specific organism identified by laboratory tests Follow-up/monitoring
● Review one week after discharge for severe pneumonia and very severe disease.
● If there are complications, follow-up should be scheduled. Aspiration Pneumonia
Description
Aspiration syndromes can be divided into two types: The aspiration of oropharyngeal flora or infected secretions and the aspiration of gastric contents