EAR, NOSE, AND THROAT PROBLEMS
| PHARYNGITIS IN CHILDREN —Andrea C.S. McCoy, MD, Associate Professor of Pediatrics, Temple University School of Medicine, Philadelphia |
| Viral pharyngitis: associated with respiratory syncytial virus (RSV), parainfluenza virus, influenza virus, rhinovirus, and coronavirus |
| Infectious mononucleosis: caused by Epstein-Barr virus (EBV); symptoms—fever, malaise, fatigue, and headache, followed by pharyngitis; elevated liver enzymes; fever and pharyngitis can last 1 to 3 wk, but lymphadenopathy and hepatosplenomegaly can last 3 to 6 wk; younger children—no lymphadenopathy; no exudative tonsillitis; vague persistent fever with or without rash or tonsillitis; diagnosis—laboratory evaluation of antibody levels; complete blood count (CBC) shows lymphocytosis (>10% atypical lymphocytes); heterophile antibody or Monospot test (reliable for recent [previous 6 mo] infection; unreliable in children <4 yr of age); treatment—rest; hydration; oral steroids (eg, prednisone 1 mg/kg daily for 7 days [tapering dose recommended]) may be beneficial to children with significant airway compromise, massive hepatosplenomegaly, or symptoms of myocarditis; restrict from contact sports until symptoms resolve |
| Adenovirus: causes sore throat, congestion, conjunctivitis, and significant pneumonia in many children; common cause of croup and bronchiolitis during winter in children <3 yr of age; few strains associated with gastroenteritis; pharyngitis and conjunctivitis self-limited and last ≤7 days; pharyngoconjunctival fever—intensive exudative conjunctivitis and exudative pharyngotonsillitis; supportive treatment; restrict children from school |
| Enterovirus: herpangina—causes discrete posterior pharyngeal ulcers (2-4 mm in size); children present with high fever, sometimes with headache; meningitis not unusual complication during summer; increased risk for dehydration; coxsackievirus B associated with mild pericarditis (concern for pregnant women); hand, foot, and mouth disease— posterior pharyngeal ulcerations in anterior mouth and lips; children have vesicles on hands, feet, trunk, upper and lower extremities, and buttocks; treatment includes adequate hydration, analgesia, mouthwash preparations, and viscous lidocaine solution (for children >2 or 3 yr of age); herpetic gingivostomatitis—anterior oropharyngeal ulceration; sore throat during development of initial outbreak; acyclovir may be beneficial to immunocompromised children; risk for secondary bacterial infection |
| Group A streptococcal infection: clinical Streptococcus infection uncommon in children <3 yr of age, but consider when prevalent in community and child has persistent respiratory symptoms followed by sore throat; sudden onset of fever and sore throat, often with headache, malaise, abdominal pain, nausea, vomiting, joint pain, and no upper respiratory symptoms; children <3 yr of age present with upper respiratory infection (URI) symptoms that persist and develop secondary moderate fever with irritability and poor feeding; children have pharyngeal erythema, exudate, petechiae of palate, and enlarged and erythematous tonsils; some children have strawberry tongue or scarlatiniform rash, most have anterior cervical adenopathy; scarlet fever; diagnosis—know community prevalence; perform culture if rapid Streptococcus test negative; optical immunoassay and chemoluminescent DNA probes may be as sensitive as sheep blood agar cultures; swab both tonsillar pillars; serologic tests not recommended for acute infections; treatment—penicillin V 2 to 3 times daily first-line therapy; better compliance with intramuscular (IM) penicillin G (Bicillin) and amoxicillin bid; erythromycin for patients allergic to penicillin; resistance to erythromycin, clarithromycin, and azithromycin reported; meta-analyses found superior bacteriologic cure rates with cephalosporins, compared to penicillin, amoxicillin, and amoxicillin–clavulanate; treatment of carriers advised if household member has recurrent infections; other bacterial causes—Mycoplasma; Arcanobacterium hemolyticum does not respond to penicillin; gonococcus in sexually active patients (treat penicillin-resistant strains with ceftriaxone [Rocephin]) |
| Signs of more serious infection: fever or sore throat lasting >2 wk; trismus; mouth pain; drooling; cyanosis; airway compromise; asymmetric tonsil swelling; muffled voice |
| Peritonsillar abscesses: asymmetric tonsils and displaced uvula often seen on examination; patients have difficulty swallowing, trismus, and muffled voice; treat with penicillin and clindamycin; may require drainage |
| Retropharyngeal abscess: children have stiff neck, adenopathy, and swelling of posterior pharyngeal space; equally common in adults; treatment—clindamycin, nafcillin, or ceftriaxone; depends on severity; surgical drainage may be necessary if airway compromise present |
| Other parapharyngeal infections: Ludwig’s angina—infection of submandibular space; children present with swollen tongue, sore neck, difficulty swallowing, and muffled voice; treat with penicillin or clindamycin; lateral pharyngeal space infections—caused by local spread of oral anaerobes from dental or tonsillar infections; treat with penicillin, clindamycin, ampicillin-sulbactam, and surgical drainage if indicated; bacterial tracheitis—usually occurs in children <3 yr of age; often presents as croup-like illness followed by acutely toxic deterioration with high fever and respiratory distress; treat with ceftriaxone with or without nafcillin; postanginal sepsis— Lemierre’s disease; internal jugular venous thrombophlebitis; caused by Fusobacterium necrophorum; associated with previous pharyngeal infection and deterioration, with sudden onset of toxic appearance, neck pain, and fever; children often develop septic emboli to lungs and appear ill; patients respond to 6-wk course of clindamycin and penicillin; reflux esophagitis—causes more throat pain than lower chest and upper abdominal pain in many young children |
| OTITIS MEDIA AND SEROUS OTITIS MEDIA —Gil C. Grimes, MD, Assistant Professor, Texas A&M University College of Medicine, and Associate Program Director, Family Medicine Residency, Scott & White Hospital and Clinic, Temple, Texas |
| Diagnosis of otitis media: acute onset; middle ear effusion—indicated by bulging tympanic membrane, absence of motion of tympanic membrane, air-fluid level, and otorrhea; middle ear inflammation—distinct erythema of tympanic membrane or distinct otalgia; most cases mixed picture of bacterial and viral causes |
| Risk factors: formula feeding (fewer cases and shorter duration of otitis media in breast-fed infants); daycare attendance; tobacco smoking (higher incidence of middle ear disease in households with ≥2 tobacco smokers) |
| History and physical findings: low positive likelihood ratio with ear rubbing, ear pain, excessive crying, and fever; “dramatic” (cloudy, red, bulging) tympanic membrane helpful; distinctly impaired mobility likely sign of effusion |
| Prognosis: spontaneous resolution normal, even in children with recurrent otitis media; requirements for more aggressive management—hearing loss independent of otitis media; speech or language delay; autism-spectrum disorder or pervasive developmental disorder; craniofacial problems; sensory impairment (eg, blindness); cleft palate; persistent effusion—watchful waiting recommended for normal child; 25% of cases resolve within 3 mo; warn parents about decreased hearing; follow regularly |
| Treatment: pain—ibuprofen; acetaminophen; initial treatment for children <6 mo of age includes antibiotics to prevent complications; if diagnosis uncertain, illness not severe, and follow-up with parents good, antibiotics can be delayed in healthy children 6 mo to 2 yr of age; waiting and observation recommended for older children; if children do not improve in 48 to 72 hr, examine child and consider changing medication; antibiotic guidelines—amoxicillin (80-90 mg/ kg daily divided tid for 10 days) drug of choice for sensitive communities; if no improvement after 3 days, consider switching to agent with β-lactamase activity, cephalosporin, amoxicillin–clavulanate (Augmentin), or Rocephin; penicillin-sensitive patients—consider cephalosporins for patients with no type 1 reaction (eg, urticaria or anaphylaxis); for children with type 1 reaction, macrolides and sulfas useful; 5 days of therapy may be just as effective as longer therapy; consider side effects |
| Serous otitis media: causes—chronic sinus infection with chronic inflammatory state; allergy of nose and nasopharynx; pepsin in middle ear effusion; complications—permanent hearing loss questionable; tympanosclerosis; fibrosis of middle ear space; balance problems; language deficits; no association with attention deficit or behavior problems during first 6 yr of life (questionable effect during teenage years); physical examination— pearly gray color, minimal dullness, and retraction in presence of effusion; pneumatoscopy for compliant tympanic membrane; tympanography; audiometry; prognosis—most cases resolve spontaneously; no significant hearing loss or speech or language delay; sequelae from tympanostomy tubes—retraction pockets (can cause premature hearing loss with age); atrophy of tympanic membrane predisposes to future rupture; myringosclerosis can lead to increased hearing loss; hearing loss; treatment—no benefit from antibiotics, nasal and systemic steroids, and surgery; posttube precautions—swimming may be permitted, depending on depth of water; no diving |
| Management of streptococcal pharyngitis: warm salt water gargles; benzocaine (Cepacol); hard candies; topical sprays; hot and cold foods; antibiotics—penicillin gold standard by which other antibiotics compared; Bicillin; amoxicillin 20 to 50 mg/kg daily divided bid or tid in children, or 750 mg once daily; cephalosporins (know local prevalence); macrolides; sore throat relief—10 mg IM dexamethasone (po dexamethasone not as effective, but more effective than placebo) |
| RHINOSINUSITIS —Ahmed M.S. Soliman, MD, Associate Professor and Deputy Chairperson, Department of Otolaryngology and Head and Neck Surgery, Temple University School of Medicine, Philadelphia |
| Introduction: rhinosinusitis—inflammation of nasal mucosa, sinus mucosa, and neurepithelium; patients complain of decreased sense of smell; fluid in sinuses; bone inflammation; viral or bacterial cause; maxillary sinus puncture gold standard for distinguishing bacterial from viral cause; symptoms include sneezing, rhinorrhea, nasal congestion, hyposmia, facial pressure and pain, discolored nasal discharge; duration of viral URI 6.5 days to >2.0 wk |
| Acute bacterial rhinosinusitis: nose blowing main mechanism; risk factors include decreased local or systemic immunity, virulence, certain bacteria (eg, Streptococcus pneumoniae) in nasopharynx; symptoms—nasal obstruction; congestion; discharge; postnasal drip; facial pressure and pain; alteration in sense of smell |
| Classification of rhinosinusitis: acute—<4 wk duration; subacute—duration 4 to 12 wk; chronic—duration >12 wk; recurrent acute—>4 episodes per year; candidates for endoscopic sinus surgery; acute exacerbation of chronic rhinosinusitis—chronic baseline rhinosinusitis symptoms; treated exacerbations return to baseline |
| Diagnosis: physical examination provides limited information; anterior rhinoscopy—with and without decongestion; examine mucosa of inferior turbinates, orientation of septum, and secretions; nasal endoscopy—use of fiberoptic or rigid telescopes allows visualization of middle meatus; rigid scope allows direct culture of secretions; transillumination—reproducible for maxillary and frontal sinuses; does not differentiate viral from bacterial infection; B-mode ultrasonography—sensitivity ≈73% for maxillary sinus, 23% for frontal sinus, 11% for ethmoid sinus; does not distinguish viral from bacterial infection; plain films—best for maxillary and frontal sinuses; readily available; gives nearly equal amount of radiation as computed tomography (CT); ≤75% discrepancy for definition of anatomy in children, compared to CT; imprecise for determining extent of disease; CT—excellent definition of osteomeatal complex; signs of acute infection include fluid in ≥1 sinus(es), total opacification in ≥1 sinus(es), mucosal thickening of ≥5 mm; findings vary between patients with same signs and symptoms; does not differentiate viral from bacterial infection; magnetic resonance imaging (MRI)—no ionizing radiation; shows difference between mucosal thickening and complete opacification or fluid; not useful for patients with acute infection; fluid may persist for 8 wk; does not distinguish bacterial from viral infection; maxillary sinus puncture—gold standard; causes discomfort; useful in patients with fever of unknown origin, immunocompromised patients, and for researching new drugs; signs and symptoms of bacterial rhinosinusitis —URIs lasting >10 days; worsening after 5 to 7 days; purulent nasal discharge; unilateral dental pain; purulence; sinus tenderness in patient with nonchronic fatigue syndrome; recommendations—amoxicillin or trimethoprim–sulfamethoxazole (Bactrim) for 10 to 14 days; if patient does not improve or worsens after 72 hr, upgrade to stronger antibiotic (eg, amoxicillin–clavulanate or quinolone); if symptoms do not clear in 14 days, perform x-ray or CT of sinuses; consider other causes if sinuses clear but patient still symptomatic; if sinuses partially opacified after 2 wk, continue antibiotic for 2 more wk (consider adding oral steroid); if patient does not improve after 1 mo, obtain culture and refer for endoscopic examination and culture; if patient improves but has >4 episodes per year, obtain CT of sinuses to rule out chronic infection; screen for allergy (treat with topical corticosteroids daily); consider referral to otolaryngologist |
Educational Objectives
| The goal of this program is to educate the listener about ear, nose, and throat problems in children and adults. After hearing and assimilating this program, the participant will be better able to: |
 | 1. Select appropriate antibiotics for streptococcal pharyngeal infections. |
| 2. Recognize signs and symptoms of otitis media. |
| 3. List complications of serous otitis media. |
| 4. Classify rhinosinusitis, based on duration and clinical findings. |
| 5. Use appropriate tools to diagnose rhinosinusitis. |
Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several trade names] Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric Drops, Wymox] Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR] Ampicillin [Principen] Ampicillin sodium and sulbactam sodium [Unasyn] Azithromycin [Zithromax] Benzocaine (ethyl aminobenzoate) (several trade names) Ceftriaxone sodium [Rocephin] Clarithromycin [Biaxin, Biaxin XL] Clindamycin (several trade names) Dexamethasone (several trade names) Erythromycin (several trade names) Ibuprofen (several trade names) Lidocaine HCl (several trade names) Nafcillin sodium [Nallpen, Unipen] Penicillin G [Bicillin, others] Penicillin V (phenoxymethyl penicillin) [Beepen-VK, Pen•Vee K, Veetids, Veetids 𣝢’] Pneumococcal 7-valent conjugate vaccine (diphtheria CRM197 protein) [Prevnar] Prednisone (several trade names) Trimethoprim-sulfamethoxazole (co-trimoxazole; TMP-SMZ) (several trade names)
Suggested Reading
American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media With Effusion: Otitis media with effusion. Pediatrics 113:1412, 2004; Casey JR et al: Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J 23:824, 2004; Casey JR et al: Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 113:866, 2004; Celedon JC et al: Day care attendance in the first year of life and illnesses of the upper and lower respiratory tract in children with a familial history of atopy. Pediatrics 104:495, 1999; Feder HM Jr et al: Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics 103:47, 1999; Gasper K et al: Clinical inquiries. Are antibiotics effective for otitis media with effusion? J Fam Pract 52:321, 2003; Gieseker KE et al: Comparison of two rapid Streptococcus pyogenes diagnostic tests with a rigorous culture standard. Pediatr Infect Dis J 21:922, 2002; Johnson DR et al: False-positive rapid antigen detection test results: reduced specificity in the absence of group A streptococci in the upper respiratory tract. J Infect Dis 183:1135, 2001; Kozyrskyj AL et al: Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA 279:1736, 1998; Pace WD et al: Seasonal variation in diagnoses and visits to family physicians. Ann Fam Med 2:411, 2004; Peyramond D et al: 6-day amoxicillin versus 10-day penicillin V for group A beta-haemolytic streptococcal acute tonsillitis in adults: a French multicentre, open-label, randomized study. The French Study Group Clamorange. Scand J Infect Dis 28:497, 1996; Wilson KS et al: The family pet as an unlikely source of group A beta-hemolytic streptococcal infection in humans. Pediatr Infect Dis J 14:372, 1995.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported nothing to disclose.
Dr. McCoy spoke in Lancaster, Pennsylvania at the 29th Annual Spring Family Practice Review, presented March 14-18, 2005, by Temple University School of Medicine and Lancaster General Hospital. Dr. Grimes was recorded in Austin on April 6, 2005, at Scott & White’s 21st Annual Family Medicine Review. Dr. Soliman spoke in Lancaster, Pennsylvania at the 28th Annual Fall Family Practice Review, presented September 27 to October 1, 2004, by Temple University School of Medicine and Lancaster General Hospital. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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