HEAD AND NECK INFECTIONS IN CHILDREN
From Pediatric Otolaryngology Update 2006, presented by Stanford University School of Medicine and Lucile
Packard Children’s Hospital at Stanford
| COMPLICATIONS OF OTITIS MEDIA —Kay W. Chang, MD, Assistant Professor of Otolaryngology–Head and Neck
Surgery, Stanford University School of Medicine, Palo Alto, CA
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| Otitis media (OM): antibiotics reduced mortality; microbiology for complications of—acute OM (AOM; Streptococcus
pneumoniae and Haemophilus influenzae most often; Moraxella catarrhalis less virulent); chronic otitis media
(COM; shift toward Pseudomonas, Staphylococcus aureus, and anaerobes)
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| Minor intratemporal complications: more chronic; long-term sequelae of OM; include—conductive hearing loss
from fluid accumulation or ossicular changes; sensorineural hearing loss (SNHL); speech and developmental delay; vestibular
and balance disturbances from COM; tympanic membrane perforations; external otitis; atelectasis/adhesive OM;
cholesteatoma
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| Major intratemporal complications: acute; require urgent care
|
 | Mastoiditis: most common; develops when AOM spreads from middle ear to mastoid air cell system; if infection
spreads—to veins, thrombophlebitis develops; to bone, osteitis develops; through bone, subperiosteal abscesses form,
involving soft tissue on other side of mastoid; signs and symptoms—otalgia; fever and malaise; tympanic membrane
erythema; postauricular erythema; loss of postauricular sulcus; displacement of pinna, with protruding ear; swelling of
ear canal that can complicate examination of tympanic membrane; postauricular abscess with fluctuance and tenderness;
diagnosis—clinical; supplemented by computed tomography (CT); conservative management—preferred initially;
involves intravenous (IV) antibiotics, myringotomy to drain pus from middle ear, and observation; resolves
problem in ≥50% of cases; surgery—indicated when conservative therapy fails; preferred when patient has large subperiosteal
abscess in soft tissue; corticomastoidectomy exposes infected air cells; after surgical drainage, prolonged
course of antibiotics mandatory
|
| Facial paralysis: partial or complete paralysis occurs when horizontal portion of facial nerve dehiscent and exposed;
caused by mastoiditis or AOM alone; confused with Bell’s palsy if AOM unrecognized; treatment—aggressive to
avoid permanent paralysis; includes IV antibiotics, myringotomy, and/or tympanocentesis
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| Labyrinthitis: occurs when bacteria from middle ear space invade inner ear fluid compartment of cochlea and vestibular
system; presents as sudden SNHL, severe vertigo, nausea and vomiting, nystagmus, and deep ear pain; treatment includes
IV antibiotics and myringotomy; because inner ear fluid compartment communicates with cerebrospinal
fluid (CSF) compartment—meningitis can cause labyrinthitis; labyrinthitis can cause meningitis
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| Intracranial complications: incidence peaks in teenagers; shift to Proteus, pseudomonal, and staphylococcal organisms
|
| Meningitis: most common; caused by AOM or COM; develops from—extension of suppuration from middle ear to dura
and to pia-arachnoid; simultaneous spread of infectious focus from upper respiratory tract to middle ear and CSF
space; primary infecting organisms—S pneumoniae; H influenzae; workup—CT to find mass lesions in central
nervous system; lumbar puncture for diagnosis and culture; management—myringotomy with IV antibiotics; mastoidectomy
if drainage of pus inadequate after myringotomy
|
| Intracranial abscesses: epidural, subdural, or parenchymal; morbidity and mortality high; temporal brain abscesses often
silent with minimal symptoms; dural abscesses more symptomatic; early signs of intracranial abscess mimic meningitis
(focal neurologic signs develop eventually); imaging—key to diagnosis; CT shows disease process in ear better;
magnetic resonance imaging (MRI) demonstrates disease process in brain better
|
| Lateral and sigmoid sinus thrombosis: develops after mastoiditis; thrombi—form after inflammation of sigmoid sinus;
often infected by bacteria in mastoid; embolize throughout body, producing metastatic infections; diagnosis—
contrast CT; magnetic resonance (MR) angiography; treatment—if initial IV antibiotics fail, immediate mastoidectomy
indicated (sometimes with thrombectomy)
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| β -HEMOLYTIC STREPTOCOCCAL PHARYNGITIS —Kathleen M. Gutierrez, MD, Assistant Professor of Pediatric Infectious
Disease, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
|
| Group A β-hemolytic Streptococcus pyogenes (GABHS) pharyngitis: 15% to 30% of acute pharyngitis in children;
symptoms consistent with infection—fever; pus on tonsils; tender cervical lymph nodes; no cough; differential
diagnosis for severe disease—groups C and G streptococcal pharyngitis; tularemia pharyngitis; diagnosis—throat
culture (aerobic incubation effective; anaerobic incubation unnecessary; hold culture 48 hr); rapid antigen test (primary
diagnostic method; specificity good; if positive, treat; if negative, obtain culture); polymerase chain reaction (PCR;
availability limited); antibiotic resistance—no isolates of S pyogenes resistant to β-lactam antibiotics; macrolide resistance
increasing and varies worldwide; currently, resistance to clindamycin low; when disease untreated—most
children do well (ie, symptoms improve ≤1 wk; sequelae may not develop); some patients carry organism for long time
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| Nonsuppurative complications: acute rheumatic fever (ARF)—develops 2 to 4 wk after onset of pharyngitis; preventable
if antibiotics administered ≤9 days of onset of symptoms; associated with subcutaneous nodules and erythema
marginatum; problem in undeveloped regions; decline in incidence in United States due to improved hygiene, widespread
use of antibiotics, and shift in M types (protein virulence factor)
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| Suppurative complications: necrotizing fasciitis; peritonsillar abscess (risk reduced by antibiotics); invasive streptococcal
disease—incidence stable in United States; infants and elderly at highest risk; rate among school-aged children
low; often associated with M types 1 and 3; mortality high
|
| Management of sore throat: treatment of streptococcal pharyngitis—prevents ARF and invasive disease; decreases
infectivity of children and duration of symptoms by 1 to 2 days; guidelines—empiric antibiotic strategy in
adults may lead to overtreatment and may not be cost effective; pediatric guidelines recommend diagnosis be based on
epidemiology and clinical findings and supported by positive test; drugs evaluated for once-daily administration to
improve compliance—cephalosporins (more expensive than penicillin; broad coverage); azithromycin (concern about
risk for bacterial resistance); amoxicillin (probably useful; not approved by Food and Drug Administration [FDA]); penicillin
(rendered ineffective by short half-life); drugs approved for 5-day therapy, eg, cephalosporins—impact on endogenous
microflora difficult to determine; expensive; cephalosporins—may be better at eliminating carrier state than
penicillin; economic and ecologic impact unknown; recommendations—oral penicillin preferred for children; amoxicillin
reasonable alternative; other options include intramuscular penicillin, first-generation cephalosporins (narrower
spectrum of coverage), and macrolides (for patients allergic to penicillin)
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| Treatment failures in documented GABHS
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| Children: true failure indicated by persistent symptoms or bacterial infection after appropriate antibiotic therapy; recurrent
disease—repeated episodes of acute pharyngitis; positive cultures and consistent clinical findings; initial response
to antibiotic therapy; negative test findings between disease episodes; documented serologic response;
apparent failure—repeated episodes of viral pharyngitis; test results show patient is carrier; noncompliance with prescribed
medication; reinfection with new bacterial strain
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| Management strategies for true failures and recurrences: penicillin with rifampin (rifampin penetrates mucosa to pick up
some persistent organisms; to avoid drug resistance, never administer rifampin alone); clindamycin or amoxicillin and
potassium clavulanate (Augmentin; based on theory that treatment failure may occur when β-lactamase–producing organism
inactivates penicillin); tonsillectomy (last resort)
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| ATYPICAL MYCOBACTERIAL INFECTIONS —Dr. Chang
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| Nontuberculous mycobacterial (NTM) infections: opportunistic in immunocompromised individuals; described
in children with cystic fibrosis (CF); can cause cutaneous infections, osteomyelitis, OM, central catheter infections, and
cervical lymphadenitis; NTM infection of lung—mimics tuberculosis (TB); most common in adults; resistance to standard
TB drugs mandates accurate diagnosis; rapidly growing organisms—pigmented species rarely associated with
clinical disease; nonpigmented (Mycobacterium fortuitum causes cutaneous and catheter-related infections; Mycobacterium
chelonae causes otitis [often cultured from children with CF]; Mycobacterium abscessus causes disseminated-
cutaneous and catheter-related infections); slowly growing organism—Mycobacterium avium-intracellulare responsible
for cervical lymphadenitis
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| Epidemiology: obligate aerobes throughout environment; no definitive evidence for person-to-person transmission; portals
of entry—skin abrasions; surgical incisions; oropharyngeal mucosa (presumed portal for cervical lymphadenitis);
gastrointestinal or respiratory tract (assumed portals for disseminated disease; may enter tract through tympanostomy
tubes)
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| Lymphadenitis: most common NTM problem; M avium-intracellulare main causative organism; necrotizing granulomatous
inflammation of lymph node—key finding; characterized by bright eosinophilic serpiginous necrosis and
Langhans-type giant cells; organisms often do not grow in culture; clinical presentation—chronic cervical lymphadenitis
in immunocompetent children <5 yr of age; slowly enlarging and painless neck mass; absence of fever and other systemic
symptoms; without treatment, infected lymph nodes erupt through surface of skin; diagnosis—often delayed until
after several failed antistreptococcal and antistaphylococcal therapies; head and neck infections characteristically located
at submandibular angle; point—even patients who present with “angry” lesions can remain asymptomatic and nontender
to palpation; typical radiographic finding—ring-enhancing lesion with minimal inflammatory stranding of subcutaneous
fat; options—surgical excision gold standard (≥92% cure rate); curettage (≤86% cure rate); incision and drainage
(contraindicated; produces fistulization with chronic draining sinus tract); needle aspiration (41% cure rate)
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| NTM lymphadenitis: when patient first presents—biopsy helps identify specific organism before initiation of medical
therapy (culture positive 60% of time); needle aspiration less invasive option (positive 60% of time); empiric therapy
with clarithromycin (Biaxin) reasonable option without biopsy (assess response after 2-mo trial); excision—used for
nonresponders or to manage impending complications before end of 2-mo empiric therapy; combination vs monotherapy
with Biaxin—advantage of combination unclear; patients with AIDS and disseminated NTM infections develop resistance
rapidly when treated with Biaxin alone
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| UNUSUAL INFECTIONS OF THE HEAD AND NECK —Anna H. Messner, MD, Associate Professor of Otolaryngology
and Pediatrics, and Vice Chair, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of
Medicine, Stanford, CA
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| Epiglottitis: incidence reduced by vaccine; traditionally, disease—caused only by H influenzae; usually in young children;
currently, disease—caused by many entities, including H influenzae in unvaccinated individuals or after vaccine
failure; common in older children and adults; presentation—abrupt onset; rapid progression; fever; sore throat; dysphagia;
drooling; leukocytosis; muffled or no speech; points—children present in tripod position, not moving neck; lateral
neck x-ray standard; management—intubate; obtain swab culture from epiglottis; keep patient in pediatric intensive
care unit (PICU); administer broad-spectrum antibiotics until culture results obtained
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| Bacterial tracheitis: data show shift away from epiglottitis and toward bacterial tracheitis; viewed as primary infection
of trachea or infection secondary to croup; croup—subglottic edema; seasonal; occurs in 6- to 36-mo age group; typically
caused by parainfluenza virus; treated with steroids or nebulized epinephrine; associated with severe airway compromise
and stridor; tracheitis—child with croup for several days can suddenly develop significant respiratory distress,
high fever, and tracheal obstruction caused by purulent secretions; on rare occasions, healthy child can suddenly develop
upper airway obstruction; steeple sign classic radiographic finding in croup
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| Subglottic hemangioma: frequently misdiagnosed as recurrent croup; be concerned about noninfectious cause in child
with biphasic stridor and hemangioma on lip; avoid—tracheotomy; interferon (≈30% rate of neurotoxicity); realistic
options—laser ablation; systemic steroids; surgical excision
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| Cytomegalovirus (CMV) infection: in utero exposure not uncommon; infants with—symptomatic CMV develop
hepatomegaly, splenomegaly, seizures, and microcephaly; asymptomatic CMV (≈90% of patients; rate of hearing loss
7% to 15%); hearing loss from CMV can be—delayed in onset; rapidly progressive; IV ganciclovir—can arrest some
hearing loss in newborn with symptomatic CMV; causes severe neutropenia in two thirds of children
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| Kawasaki disease: multisystem vasculitis of unknown etiology; usually occurs in children <5 yr of age; clues—high
fever lasting 5 days combined with 4 of 5 additional key symptoms, ie, nonexudative conjunctivitis, oral cavity changes,
rash, changes in extremities, and acute cervical lymphadenopathy of >1.5 cm that can precede other symptoms by ≤5
days; key points—suspect Kawasaki disease in child with large lymph nodes, spiking fever unresponsive to several days
of therapy, and rash; 20% of untreated children develop coronary artery abnormalities; treatment options include IV
gamma globulin and aspirin, plus monitoring with echocardiography
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Educational Objectives
| The goal of this program is to educate the listener about infections in pediatric patients. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Diagnose and manage complications of otitis media.
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| 2. Effectively treat β-hemolytic streptococcal pharyngitis.
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| 3. Identify and manage atypical mycobacterial infections in children.
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| 4. Describe clinical characteristics and treatment options for bacterial tracheitis
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| 5. Discuss factors complicating the management of cytomegalovirus (CMV) infection and Kawasaki disease.
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Discussed on This Program
Amoxicillin [several trade names and preparations]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]
Aspirin [several trade names and preparations]
Azithromycin [Zithromax, Zmax]
Budesonide [Pulmicort; several others]
Clarithromycin [Biaxin, Biaxin XL]
Clindamycin [several trade names and preparations)]
Epinephrine (nebulized) [Several trade names and preparations]
Ethambutol HCl [Myambutol]
Filgrastim (granulocyte colony stimulating factor; G-CSF) [Neupogen]
Ganciclovir sodium (DHPG) [Cytovene]
Immune globulin intravenous (IGIV) [several trade names]
Interferon [several formulations and trade names]
Levalbuterol HCl [Xopenex, Xopenex HFA]
Penicillin [several trade names and preparations]
Rifampin (rifampicin) [Rifadin, Rimactane]
Suggested Reading
Agrawal S et al: Complications of otitis media: an evolving state. J Otolaryngol 34 Suppl 1:S33, 2005; Brook I: A
pooled comparison of cefdinir and penicillin in the treatment of group a β-hemolytic streptococcal pharyngotonsillitis. Clin
Ther 27:1266, 2005; Gerber MA: Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am 52:729,
2005; Hogan M et al: Atypical mycobacterial cervical lymphadenitis with extensive local spread: a surgical disease. Pediatr
Surg Int 21:758, 2005; Hopkins A et al: Changing epidemiology of life-threatening upper airway infections: the
reemergence of bacterial tracheitis. Pediatrics 118:1418, 2006; Hyden D et al: Inner ear and facial nerve complications
of acute otitis media with focus on bacteriology and virology. Acta Otolaryngol 126:460, 2006; Leung AK et al: Rapid
antigen detection testing in diagnosing group A β-hemolytic streptococcal pharyngitis. Expert Rev Mol Diagn 6:761,
2006; Rosenfeld RM et al: Clinical practice guidelines: Otitis media with effusion. Otolaryngol Head Neck Surg
130:S59, 2004; Smets K et al: Selecting neonates with congenital cytomegalovirus infection of ganciclovir therapy. Eur
J Pediatr 165:885, 2006; Thavagnanam S et al: Atypical mycobacterial infections in children: the case for early diagnosis.
Ulster Med J 75:192, 2006.
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.
Drs. Chang, Gutierrez, and Messner gave their scientific presentations at Pediatric Otolaryngology Update 2006, presented
October 27-28, 2006, in Palo Alto, CA, by Stanford University School of Medicine and Lucile Packard Children’s
Hospital at Stanford. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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