1. Pediatric URTI & Sinusitis Leybie Ang PEM Fellow Feb 25 2010 Thanks to Jennifer Puddy

3. Etiology  Acute 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  Allergy  Cystic fibrosis  GER  Cilliary dysfunction

4. Risk Factors  Viral URI  Allergic rhinitis  Anatomic obstruction  Mucosal irritants

5. AAP Guidelines 2001  Age 1 to 21 years  Healthy  Exclusions:  Recognized anatomic abnormalities of their paranasal sinuses (facial dysmorphisms or trauma)  Immunodeficiencies  Cystic fibrosis  Immotile cilia syndrome

6. Gold Standard  Recovery of bacteria of high density from cavity of paranasal sinuses  Not recommended for the routine diagnosis

7.  Sinus aspiration and culture may need to be considered in  Severe illness and toxic looking child  Immunocompromised child  Suppurative or IC complications

8. Recommendation #1  Diagnosis based on clinical criteria in children who present with upper respiratory symptoms that either persistent or severe

9.  Persistent : >10 d with no improvement that  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

10.  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

11. Recommendation #2  Imaging not necessary to confirm a diagnosis of clinical sinusitis in children < or = 6 yo

12. Radiology  Plain radiographic or computed tomography findings that are consistent with sinus inflammation include:  Complete opacification  Mucosal thickening of at least 4 mm  Air-fluid level

13. Radiologic Assessment  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  Imaging findings may persist well after symptoms improve. CT abnormalities with the common cold may last up to two weeks after symptomatic improvement

16. Indications for CT scan  CT scan is indicated for patients that  Fail to respond to medical management  Severe symptoms suspicious for complications related to acute sinusitis  Surgery is considered

17. Recommendation #3  Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure  First line :  Amox or amox-clav  If PCN allergic (not type 1 hypersensitivity reaction)  Cefdinir, Cefuroxime, Cefpodoxime  If serious reaction  Clarithromycin or azithromycin

18.  If failure to improve with amox, NEITHER TMP-SMX NOR ERYTHROMYCIN- SULFISOXAZOLE are appropriate choices for antimicrobial therapy.

21. Duration of Treatment  10 days  14 days  21days  28 days  Until pt is asymptomatic + 7days

22. Complications  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

23. Adjuncts  Saline  Nasal irrigation  Antihistamines  Mucolytic agents  Topical intranasal steroids

25. 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.

27. Paul et al 2007  Partly double-blinded randomised controlled trial  Paired comparisons of honey and dextromethorphan showed no significant differences  Honey did appear to be superior to no treatment for cough frequency, child sleep and the combined symptoms score  Honey shows early promise as a treatment for the cough and sleep difficulty associated with childhood URTI

28. Chicken Soup

29. 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

30. Questions  What is the dose and drug of choice for uncomplicated sinusitis?  What percentage of viral URI's will progress to acute bacterial sinusitis?  Name some (2) risk factors in the development of sinusitis.  What are some radiographic finding of sinusitis?  What is the most common complication of sinusitis?

31. Case 1  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.

32. Epiglottitis? Croup? EpiglottitisCroup AnatomySupraglotticSubglottic EtiologyBacterialViral Age3-7yr, adult0.5-3yr Onset6-24hr24-72hr ToxicityMarkedMild to moderate DroolingFrequentAbsent CoughUnusualFrequent HoarsenessUnusualFrequent WBC countLeukocytosisNormal

36. Management  SECURE AIRWAY  Postpone further examination  Minimize agitation  Consult anesthesiologists and ENT  IV antibiotics  IV hydration

37. Case 2  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.

39. Retropharyngeal Abcess  Group A streptococcus, anaerobic organisms, and occasionally S. aureus  Most often in children < 4 years of age  High fever and a toxic appearance, less abrupt onset, sore throat, neck pain, cervical lymphadenopathy  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.

42. 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

43. 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.

47. LUDWIGS’S ANGINA  Submandibular space infections  Classical 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

50. Questions

51. References:  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 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