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Otitis Media Angel Solomon, MS PA‐C June 2011 Infant & Childhood Development y Gross Motor y 3 month –head control y 4 month –roll over y 6 month –sit independently y 9 month –crawl y 12 month –walk y 18 month –climbs stairs, run y 24 month –kick ball Infant & Childhood Development y Language y 2 month –coos y 6 month – babbles y 12 month – mama, dada y 18 month –4‐20 words y 24 month – combining words, 50% comprehensible Infant & Childhood Development y Language cont… y 3 year –75% comprehensible y 4 year – 100% comprehensible y Age 7 or 8 –speech, language, articulations close to adult Infant & Childhood Development y Social/Fine motor y 3 month –laugh y 6 month – reaches, feeds self y 9 month –indicates wants, pincer grasp y 12 month – imitates, follow 1 step commands Infant & Childhood Development y Social/Fine motor cont… y 18 month – scribbles, feeds self w/spoon, potty training, stacks 3‐4 blocks y 24 month –follow 2 step commands, wash/dry hands y 3 yr –dresses with supervision Newborn & Infant Growth y Newborns may lose up to 10% of their birth weight in the first week of life y Most regain birth weight in about 10 days y First 6 months: gain about 1oz/day y At 6 months: weigh 2x birth weight y At 12 months: weigh 3x birth weight, height 1.5x birth length Childhood Growth y After 2 years of age: 2‐3 kg and 5‐7cm/year y Average 30 month child weighs 30 pounds and is 30 inches tall y Average 4 year‐old weighs 40 pounds and is 40 inches tall y Weight LOSS in a child is always suspicious HEENT y URI y Strabismus y Acute Otitis Media y Amblyopia y Chonic Otitis Media y Allergic Rhinitis y Otitis Externa y Oral candidiasis y ENT Foreign Bodies y Epiglottitis y Croup VIRAL URI y Common in any age group; especially infants and toddlers y Lasts 7‐10 days y MCC: Rhinovirus y Symptoms: y Runny nose, nasal congestion, coryza, sneezing, mild conjunctivitis, sore throat, hoarseness, cough. Fever often presents for first 2‐3days y Tx: Cough and cold medications. No antibiotics!!! OTITIS MEDIA y Acute Otitis Media y Suppurative infection of the middle ear cavity y Most prevalent in children between 6 and 24 mo y Bacterial y Streptococcus Pneumoniae (most common) y Haemophilus influenza y Moraxella Catarrhalis y Viral y Respiratory Syncytial Virus y Rhinovirus y Influenza virus Otitis Media y Risk Factors y Day Care Attendance y Formula Fed Infants (feeding position) y Second hand cigarette smoke y Presentation & Diagnosis y Often follows an upper respiratory tract infection(URI) by 1‐7 days y Usually presents with fever, poor feeding, pain and/or irritability, vomiting, ear pulling y TM : bulging, red, landmarks not visualized, immobile (Pneumatic Otoscopy with evaluation of movement of TM) y Antibiotics y DOC: Amoxicillin 40mg/kg/d OR 80‐90mg/kg/d y If antibiotic use or tx failure on Day 3: High dose amox, high dose amoxicillin/clavulanate, cefuroxime axetil or ceftriaxone Chronic Otitis Media y Definintion –recurring or persistent infection or inflammation for several months y Risk Factors ‐ multiple ear infections, allergies, trauma, swelling of the adenoids y Sx – hearing loss, otorrhea, pressure, ear ache y PE: infxn, air‐fluid levels. discharge, perforation y Tx: Abx, Surgery (Myringotomy/Repair/Adenoids) y Complications: Mastoiditis, Deafness OTITIS EXTERNA y Inflammation of the skin in the outer ear canal y Commonly caused by water trapped in the canal from swimming in lakes or pools y Pathogens: y Staphylococcus aureus y Pseudomonas aeruginosa y Symptoms: y Pain, purulent discharge, pain elicited with traction on pinna or tragus y Treatment: y Antibiotic/Corticosteroid drops Epiglottitis / Viral Croup y Epiglottitis: y Most common pathogen is H. influenza y RAPID onset of sore throat, muffled voice, high fever, and drooling y “Thumbprint sign” on lateral neck X‐ray y Assume a critical airway and DO NOT examine the oropharynx unless able to intubate STAT y Viral Croup ‐ Laryngotracheobronchitis y Most common cause of stridor in children y Peak ages : 6 months to 3 years. Fall/Winter y Barking cough, URI symptoms, hoarseness, fever, inspiratory stridor y Pathogen: parainfluenza virus common y Diagnosis: H & P, season helpful (Fall/Winter) y <50% “steeple sign”on ant neck X‐ray y Treatment: Hydration, Humidity! Steroids if severe STRABISMUS y Definition: Misalignment of the visual axes of the eyes; results from imbalance in eye muscle movements y Affects 4‐5% of the US population y Infants may not develop coordinated eye movements until 3‐5 months of age y Eye may deviate inward(esotropia), outward (exotropia), upward (hypertropia) or downward (hypotropia) y Treatment: Glasses, occlusion, surgery Courtesy of Dean John Bonsall, MD, FACS AMBLYOPIA y Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathology y Initiated by any condition that results in abnormal/unequal visual input between the “critical period” of birth to 8‐9 years of age (ie. Congenital cataracts, strabismus) y Treatment is essential within the critical period; otherwise loss may be permanent ALLERGIC RHINITIS y Inflammation of nasal and sinus packages ‐ associated with sneezing, runny nose, congestion, itchy eyes y Affects 20‐30% of all kids and up to 75% of kids with asthma y Know this triad: asthma/allergy/eczema!!!!! y Physical exam pearls: “Allergic shiners”, “Allergic salute” y Treatment: Removal of offending agents, oral/topical (spray) medications y Note: Check nasal mucosa for polyps! In kids, polyps are suggestive of cystic fibrosis and should be investigated further Oral Candidiasis y Etiology: Candida Albicans y Signs: adherent creamy plaques on buccal, gingival and lingual mucosa y Tx: Nystatin y RF: Inhaled steroids, Abx, immune system disorder ENT FOREIGN BODIES y Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs too y Ear: Ear pain, drainage, hearing loss y Nose: Unilateral purulent rhinitis, persistent sinusitis, blocked nasal passage on exam y Removal: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury Lungs y Bronchiolitis y Hyaline Membrane Disease y Pneumonia y Cystic Fibrosis y Viral y Foreign bodies y Bacterial y Atypical y Pertussis BRONCHIOLITIS y The most common lower respiratory illness in infants and young children less than 2 years old. y Pathogen: Respiratory Syncytial Virus(RSV) in 50‐90% of cases y Symptoms: Cough, mild fever, tachypnea, and wheezing. Thick nasal congestion y Diagnosis: RSV antigen nasal wash. CXR ‐ Hyperinflation WBC ‐ Increases lymphocytes y Treatment: Controversial y Nebulized albuterol commonly used y Oral steroids if sx severe y Ribavirin has been used in hospitalized cases y Synagis now used to prevent RSV in preemies PNEUMONIA ‐ VIRAL y Common in all age groups; follows URI y Etiology: y MCC of pneumonia in children. RSV (MC), parainfluenza, & influenza viruses y Symptoms: y URI precedes onset of cough y Wheezing, grunting, nasal flaring common y Labs: y WBC may be low, normal, or slightly elevated. A high WBC makes viral etiology unlikely y Imaging: y CXR may show perihilar streaking, increased interstitial markings, peribronchial cuffing y Treatment: y It is rarely possible to reliably differentiate viral from bacterial pneumonia based upon history, exam, labs or radiographs y Therefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children PNEUMONIA ‐ BACTERIAL y Inflammation of the lung classified according to the infecting organism and site y Occurs in all age groups, but more commonly in children < 2 years old y Common pathogens: y S. pneumoniae, Group A strep y Group B strep (neonates) y Symptoms: y URI precedes abrupt onset of fever, chills,SOB, anorexia, cough, dyspnea y N/V, abdominal/chest/shoulder pain typical, malaise Pneumonia ‐ Bacterial y Signs: y tachypnea: reliable sign of pneumonia in kids! y Cough, grunting, nasal flaring, y Exam usually shows decreased breath sounds, rales, dullness to percussion, but can be normal y Wheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease y Labs: y WBC >15,000 or greater y Blood cultures positive in 10‐15% of cases y Imaging: y Lobar consolidation, patchy infiltrates common y May see effusions y Atelectasis vs infiltrate ‐ often hard to tell y Treatment: y Neonates: IV ampicillin/gentamycin y Others: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin PNEUMONIA ‐ ATYPICAL y Chlamydia pneumonia y Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeks y Most common cause of pneumonia in children under 6 months of age (25‐45% of cases) y Pathogen: C. trachomatis (maternal STD) y URI prodrome; nearly 100% afebrile y Staccato cough, tachypnea, rales, conjunctivitis y Dx: Nasal wash, eosinophilia common y Tx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress Pneumonia ‐ Atypical y Mycoplasma pneumonia: y Common over the age of 5 years, esp teens y Pathogen: Mycoplasma pneumonia y Long incubation: 2‐3 weeks y Symptoms: Gradual onset, Dry cough, progressing to productive. Fever,HA, malaise, y Signs: Rales, bullous myringitis y CXR: Middle and lower lobe infiltrates y Tx: Macrolides usually shorten course and may lessen severity of symptoms PERTUSSIS “Whooping Cough” y Infants/toddlers; un‐/partially immunized y Pathogen: Bordetella pertussis Spread by teens/adults who are no longer immune y Sx: 3 stages y Cattarhal: URI (1‐2 weeks) y Paroxysmal: Staccato cough and ‘whoop’ on inspiration(1‐2 weeks) y Convalescent: Dry cough (1‐2 weeks) y Dx: Hx, characteristic paroxysmal cough y Tx: Erythromycin Hyaline Membrane Disease y Cause: Deficiency of surfactant y S&S: increased RR, cyanosis, expiratory grunting y Dx: CXR shows hypoexpansion, B/L atelectasis y Tx: Oxygen, early intubation, ventilation Surfactant replacement CYSTIC FIBROSIS y Most common severe inherited disease in the Caucasian population ‐ 1:2500 y Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbing y GI symptoms: meconium ileus (20%), pancreatic insufficiency (85%), failure to thrive y Dx: Sweat chloride is the “gold standard”>60meq/L is abnormal.
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