Pediatrie IV Curs 01 Eng

7/27/2019 Pediatrie IV Curs 01 Eng

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RESPIRATORY

TRACT

DISEASE

COURSE 01:Acute nasopharyngitis

Adenoiditis

UNIVERSITATEA DE MEDICINI FARMACIE V. BABE TIMIOARACLINICA I PEDIATRIE


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Anatomy of the respiratory tract


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Upper respiratory tract anatomy


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Acute nasopharyngitis

Definition:

Acute nasopharyngitis is an inflammatory

process of viral etiology, located at the naso-pharyngeal mucosa.


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Bacteria and fungi (act only

as superinfection):

group A streptococcus,

streptococcus pneumoniae, haemophilus influenzae,

staphylococcus aureus,

mycoplasma pneumoniae,

neisseria meningitidis,

moraxella catarrhalis.

Etiology

Etiology is always viral.

rhinoviruses (30-50%),

influenza and parainfluenza

adenoviruses,

coronaviruses,

respiratory syncytial virus,

enteroviruses,

measles,

rubella,

Epstein-Barr virus,

varicella-zoster virus.


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Etiology

Contributing factors:

young age,

deficiencies (dystrophy, rickets, anemia),

lymphatic and exudative diatheses,

cold and wet season (September to April),

urban areas,

entry to the community (kindergarden, school),

homecare deficiencies.


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Pathophysiology

A transferis made through contact with saliva or nasal

secretions contaminated with viruses: coughing, sneezing,hand contact of contaminated surfaces and carrying hand

to nose or eyes.

Gateway: nose or eyes (drain virus in the

nasal cavity through the lacrimal ducts).Virus then bind to the ICAM-1 receptors

expresed al the surface of naso-

pharyngeal mucosal cells and adenoid cells.

Afterbinding the receptor the virus penetrate into cell andtrigger local (vasodilation + edema + infiltration with

resident and recruited macrophages, monocytes,

neutrophils, and eosinophils) and systemic inflammatory

reaction. Release of bradykinin is responsible for local

effects and cytokines are responsible for systemic effects.


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Pathophysiology

The local defense system opposes the infection and is

represented by: hair lining, mucus coats, normalnasopharyngeal flora, cellular immunity (immune cells

contained in adenoids and tonsils), humoral immunity

(immunoglobulin A).

Incubation times before the appearance of symptomsvary: 1-5 days for rhinoviruses, influenza and

parainfluenza viruses, up to a week for respiratory

syncytial virus (RSV), two weeks for measles and rubella,

4-6 weeks for Epstein-Barr virus (EBV).

Then initial nasopharyngeal infection may spread to

adjacent structures, resulting in sinusitis, otitis media,

epiglottitis, laryngitis, bronchiolitis, tracheobronchitis or

pneumonia.


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Clinical picture In in fants, clinical manifestations are noisy.

Onset with moderate fever (38-39oC), food refusal,ailment, restless sleep or drowsiness.

State period last for 3-5 days and is marked by respiratory

events like sneezing, nasal obstruction, mouth breathing,

runny nose followed by serous or mucopurulentsecretions, irritative cough, moderate signs of respiratory

distress.

Neurological symptoms: irritability, agitation

febrile seizures Digestive symptoms: anorexia, difficulties

in sucking, vomiting, diarrhea.

Physical evidence includes hyperemic

throat, Serous or muco-purulent secretionsin the cavum.


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Clinical picture

In older chi ldrenclinical symptoms are nonspecific:

mild fever,

headache,

myalgia,

sneezing, dry nasopharyngeal mucosa or runny nose followed by

serous or mucopurulent secretions,

irritating cough.

symptoms lasts for 3 to 5 days.


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Laboratory studies and procedures

CBC (complete bloodcount):

leucopenia with lympho-monocytosis is tipicaly for viral

etiology (neutrophilic reaction is a sign of bacterial

superinfection).

Normal or slightly elevated inflammatory tests: ESR

(erythrocyte sedimentation rate), CRP (C reactive

protein), fibrinogen.

Throat or nasal swab could indicate the etiologic agent in

bacterial and fungal infections.


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Smear directly from nasal swab:

rich in lymphocytes viral etiology

rich in PMN bacterial etiology

eosinophils allergic etiology.


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Diagnosis

Positive diagnosis si based on: moderate fever,

rhinorrhea,

irritating cough,

flushing nose and throat.

Optional, specific changes in

CBC, throat and nasal swab.


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Differential diagnosis

between viral and bacterial nasopharyngitis

allergic rhinitis

nasopharyngitis as the onset of other infectious disease

(measles, rubella, chickenpox, whooping cough,mononucleosis)

with other URIs (upper respiratory tract infections): acute

adenoiditis, pharyngitis, croup, bronchiolitis etc.


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Evolution - Complications

Evolution in eutrophic infants and older children is benign

with healing in 3-5 days.

Complications

Serous or suppurative otitis media Sinusitis affecting ethmoid or maxillary sinuses and

frontal (over 7 years old)

Cervical lymphadenitis

Retropharyngeal phlegmon Acute laryngitis

Bronchiolitis or tracheobronchitis

Bronchopneumonia

Diarrhea (parenteral)


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Prophylactic treatment

Ensuring a good nutrition and hygiene.

Prophylaxis and treatment of biological loud: rickets,

dystrophy, anemia, exudative diathesis.

Avoid congestion and contact with sick people.

Epidemiologic triage, rigorously conducted at the entry

into the community (nurseries, kindergartens, schools).


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Diet

Continue previous diet with supplementation of

fluids lost through fever and perspiration.

In diarrhea, nutrition will adapt to digestive

tolerance.


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Etiologic treatment

Not necesary in viral etiology.

In overgrowth forms:

Amoxicillin,

Amoxicillin + Clavulanic Acid,

Ampicillin + Sulbactam,

Oral first or seccond generation cephalosporins

(Cefuroxime, Cefaclor).


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Pathogenic treatment

NSAIDs (Ibuprofen).

May be involved in promoting bacterial superinfection

or promote evolution to otitis media.


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Symptomatic treatment

Fever: acetaminophen (paracetamol), metamizolum

(algocalmin, novocalmin). No Aspirin in infants and young

children (risk of Reye Syndorme: encefalo-hepato-renal

syndrome).Obstructed nose: sea water or normal saline + ephedrine

in infant and child under 2 years; Olynth, Pivalone, Picnaz

in children over 2 years old.

Agitation: Romergan. Control of febrile seizures: rectal diazepam (Desitin).


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Adenoiditis

Acute

Subacute

Chronic

Definition

Acute, subacute or persistent inflammation of

adenoids (pharyngeal tonsil Luschka).


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Etiology

Viral: adenoviruses, coronaviruses,

enteroviruses, rhinoviruses, respiratory syncytial

virus, Epstein-Barr virus, herpes simplex, etc.

Bacterial:gr. A -hemolytic Streptococcus, gr. C-hemolytic Streptococcus, Staphylococcus

aureus, Sreptococcus pneumoniae, Gram

negative agents

Mycoplasmas: Mycoplasma pneumoniae

Fungi: Candida albicans.


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Etiology

Contributing factors:

young age,

deficiencies (dystrophy, rickets, anemia),

lymphatic and exudative diatheses,

cold and wet season (September to April),

urban areas,

entry to the community (kindergarden, school),

homecare deficiencies.


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Acute adenoiditis

clinical picture

Symptomatic triad: reverse type fever

nasal obstruction

posterior mucous-purulent secretion.Fever characteristics:

abrupt onset,

39-40 C,

irregular,

reverse type (with morning peak), frequently

associated with chills.

Acute adenoiditis


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Acute adenoiditis

clinical picture Severe nasal obstruction resulting in oral breathing,

snoring and sleep apnea, eating difficulty. Posterior mucous-purulent secretion: purulent exudate

(whitish or yellowish) which trickles the back of the throat.

Rhinorrhea was not previously exhibited due to

obstruction by adenoids hypertrophy.Other clinical signs: impaired general condition, agitation,

sleeping difficulties, inappetence, irritating cough, vomiting

(gastric iritation by the swallowed secretions), parenteral

diarrhea, febrile seizures.


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CBC: leucopenia with lymphocytosis in viral

etiology or neutrophilic reaction in bacterial

etiology.

Throat or nasal swab indicates the etiologic agentfor bacterial infections.

Increased inflammatory tests: ESR, CRP,

fibrinogen.Posterior rhinoscopy or finger touches reveals

enlargement of adenoid mass.


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Fiberoptic anterior rhinoscopy

Nasal

septum

Adenoids

Eustachian

Tube

Adenoids


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Posterior rhinoscopy


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Diagnosis

Positive diagnosis is based on

symptomatic triad (reverse type fever - nasal

obstruction posterior mucous-purulent

secretion),

presence of inflammatory exudate in the

posterior pharynx,

anterior and posterior rhinoscopy.


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acute nasopharyngitis

subacute and chronic adenoiditis

pharyngitis and tonsillitis

croup

nasal foreign body

pharyngeal tumors

pre-eruptive period of measles, rubella, whooping

cough, etc.


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Complications

suppurative otitis media

sinusitis (ethmoid, maxillary or frontal sinuses)

croup

cervical or retropharyngeal phlegmon

parenteral diarrhea.


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Treatment

Prophylact ic treatment

Ensuring a good nutrition and hygiene.

Prophylaxis and treatment of biological loud: rickets,

dystrophy, anemia, exudative diathesis. Avoid congestion and contact with sick people.

Epidemiologic triage, rigorously conducted at the entry

into the community (nurseries, kindergartens, schools).


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Treatment

Diet Continue previous diet supplementing fluid and calorie

intake.

In diarrhea, nutrition will adapt to digestive tolerance.

Etio logic treatment Antibiotics:

Amoxicillin,

Amoxicillin + Clavulanic Acid,

Ampicillin + Sulbactam,

Oral first or seccond generation cephalosporins

(Cefuroxime, Cefaclor),

Clarithromycin


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Treatment

Pathogenic treatment

NSAIDs (Ibuprofen).

Symp tomat ic treatment

Fever: acetaminophen (paracetamol), metamizolum

(algocalmin, novocalmin). No Aspirin in infants andyoung children (risk of Reye Syndorme: encefalo-

hepato-renal syndrome).

Obstructed nose: sea water or normal saline +

ephedrine in infant and child under 2 years; Olynth,Pivalone, Picnaz in children over 2 years old.


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Subacute adenoiditis

Definition

Persistent or relapsing inflammation of the adenoids.

Clinical picture

Persistent fever for 2-3 weeks with irregular pattern,usualy reverse type (more evident than in the acute

form), sometimes tenacious and unresponsive to

medication.

Persistent nasal obstruction with posterior mucous-purulent secretion.

Transient hearing loss and ear pain.

Digestive symptoms like anorexia, vomiting, diarrhea,

leading to weight loss.


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CBC: leucocitosis with neutrophilic reaction.

Increased inflammatory tests: ESR, CRP, fibrinogen.

Throat or nasal swab indicates the etiologic agent forbacterial infections.

Posterior rhinoscopy reveals enlargement of adenoid

mass that are redness and edematous with purulent

secretions in the posterior pharynx.


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the entities referred to as acute, plus

urinary tract infection

septicemia

tuberculosis

mastoiditis.

Complications

similar with acute form.

Treatment

Medical: as in acute form.

Surgical: adenoidectomy could be necessary.


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Chronic adenoidal hypertrophy

Definition

Chronic irreversible hypertrophy of adenoids,

responsible for a persistent respiratory distress.

Clinical picture Poor general condition with permanently open mouth,

peri-oral-nasal cyanosis

Oral breathing,

Agitation, fatigue,

Interrupted sleep with snoring and noisy breathing

Recurrent/ frequent infectious events (local and

general)


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Chronic adenoidal hypertrophy

Consequences of chronic hypoxia:

growth retardation

underdeveloped chest, with signs or sequelae of rickets

Adenoid Faciesis the long, open-mouthed, dumb-lookingface of children with adenoid hypertrophy:

underdeveloped thin nostrils

short upper lip

prominent upper teeth

crowded teeth

narrow upper alveolus

high-arched palate

hypoplastic maxilla

F i d idi


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Facies adenoidian


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Same as for acute and subacute adenoiditis,

plus:

hypertrophic rhinitis

choanal atresia

deviated nasal septum

nasopharyngeal tumors


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Complications

Infectious:

pharingitis, tonsilitis, sinusitis, bronchitis, pneumonia,

recurrent suppurative otitis, mastoiditis

Functional: hearing loss

Digestive:

recurrent or chronic diarrhea

General:

growth retardation, low school performance


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Treatment

Treatment is surgical -Adenoidectomy

Ind icat ions for adeno idectom y:

persistent nasal airway obstruction, whith obstructive

breathing, obstructive sleep apnea and chronic mouthbreathing

recurrent or persistent otitis media

recurrent and/or chronic sinusitis

recurrent pharyngitis

Should be performed at least 2-3 weeks after an

acute episode of infection.


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Adenoids

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Pediatrie IV Curs 01 Eng