THE UPPER RESPIRATORY TRACT IN

CHILDREN

Lore Van Bruwaene

Paediatric pulmonology
Steve Biko Academic hospital
 LITERATURE

• Coovadia Chapter 27 and 36

• EDL Paediatrics 2017 (freely available on internet)
Chapter 17 and chapter 15 (15.5)
• EDL Primary health care 2018 (freely available on internet)
Chapter 19 (19.3 and 19.9)
 COURSE OBJECTIVES

After the lecture, the student should be able to:

• Diagnose and manage upper respiratory tract infections and its complications,
with a focus on antibiotic stewardship
• Identify airway obstruction and localise the obstruction clinically
• Know the different causes of airway obstruction
• Manage obstructive sleep apnea, croup, epiglottitis and Pertussis
 OVERVIEW

• Upper respiratory tract infections (URTI)

• Upper respiratory tract obstruction

• Pertussis (whooping cough)

UPPER RESPIRATORY TRACT INFECTIONS

- Common cold (viral rhinitis)

- Rhinosinusitis and complications
- Otitis media, mastoiditis
- Tonsillitis and complications
UPPER RESPIRATORY TRACT INFECTIONS

- Common cold (viral rhinitis)

- Rhinosinusitis and complications
- Otitis media, mastoiditis
- Tonsillitis and complications
 COMMON COLD (VIRAL RHINITIS)

• Viral infection (mostly Rhinovirus but also other viruses)

• Nasal stuffiness, nasal discharge, troat irritation

• Cough (WITHOUT tachypnea)
• Fever in children is common

• 4-8x/year in normal children

• NO ANTIBIOTICS
(does not imply
bacterial disease)
• Talk to your patient
• Educate them about the disease
• Tell them it s a cold /viral
• Tell them antibiotics wont work
• Tell them that inappropriate antibiotics cause
harm
• Teach them to watch for warning signs
• Welcome them back if they are worried
• Saline nose drops

NOT
Prescribing medication just i ca e because it i afe because the patient wants it
UPPER RESPIRATORY TRACT INFECTIONS

- Common cold (viral rhinitis)

- Rhinosinusitis and its complications
- Otitis media, mastoiditis
- Tonsillitis
 ACUTE BACTERIAL RHINOSINUSITIS

• Viral rhinitis progresses to a bacterial rhino-sinusitis

• Uncommon in children <5 years (sinuses not fully developed)
• Characterised by:
- Deterioration of a common cold after 7 days
- Headache
- Purulent nasal discharge
- Pain and tenderness over one or more sinuses
- Fever
• Treatment: High dose Amoxicillin (45 mg/kg/dose) 12 hourly for
5 days.
SINUS DEVELOPMENT IN CHILDREN

Maxillary and ethmoid sinus present at birth

Sphenoid and frontal sinus from 4 and 6 years onwards
 BACTERIAL RHINOSINUSITIS -
COMPLICATIONS

1. Orbital complications
Pre-septal versus post-septal peri-orbital cellulitis

2. Intracranial complications
Meningitis, intracranial abces, cavernous sinus thrombosis. CT scan and
possible LP indicated.

All cases:
- Urgent surgical advice (ENT, ophthalmology, neurosurgery)
- Admission for IV Rocephine 50-80 mg/kg daily
 ORBITAL COMPLICATIONS OF
RHINOSINUSITIS

Pre-septal cellulitis: peri-orbital swelling

only (eye examination = normal)

Post-septal (orbital) cellulitis: abnormal

eye examination (erythema, chemosis,
proptosis, vision loss and ophthalmoplegia)
UPPER RESPIRATORY TRACT INFECTIONS

- Common cold (viral rhinitis)

- Rhinosinusitis
- Otitis media, mastoiditis
- Tonsillitis
 ACUTE OTITIS MEDIA

• Most commonly precipitated by a viral infection

• When bacterial: Streptococcus Pneumoniae and Haemophilus
Influenzae
• Fever and earache (irritability when lying down, pulling of the
ear)
• Sometimes with acute purulent ottorrhoea
• Must be confirmed by otoscopy
 ACUTE OTITIS MEDIA

Normal ear drum Acute otitis media:

bulging and redness
 ACUTE OTITIS MEDIA

TREATMENT
• Consider watchfull waiting for 72 hours in children >6 months that are not severily ill
and are able to follow-up. Lots of them will settle.

• Antibiotics:
- High dose Amoxycilline (45 mg/kg 12 hourly) to overcome intermediate resistant S.
Pneumoniae
- Augmentin if recent course of antibiotics to overcome beta-lactamase producing
resistant H. Influenzae
- 5 days
 OTITIS MEDIA WITH EFFUSION

• Irritation of the middle ear mucosa overproduction of mucus

obstruction of the Eustachian tube air absorbed from the
middle ear eardrum retracted
• Mild to moderate hearing loss interference with speech and
intellectual development.
• If persistent (> 3 months) ENT referral for grommets
OTITIS MEDIA
 MASTOIDITIS

• Osteitis of the mastoid due to otitis media

• Swelling and redness in post-auricular area, pinna pushed down and
forward
• Can become complicated by intra-cranial infection
• Urgent ENT advice
• Admission for IV Rocephine
MASTOIDITIS
UPPER RESPIRATORY TRACT INFECTIONS

- Common cold (viral rhinitis)

- Rhinosinusitis
- Otitis media, mastoiditis
- Tonsillitis and its complications
 TONSILLITIS/PHARYNGITIS

• Mostly viruses 20% bacteria: group A beta-hemolytic

streptococci (=Streptococcus Pyogenes)
• S. Pyogenes can cause rheumatic heart fever
• Clinically not possible to differentiate viral from bacterial
tonsillitis
 TONSILLITIS/PHARYNGITIS

• Not all sore throat need an antibiotic!!

From: Updated recommendations for the management of upper respiratory tract infections in South Africa. S Afr Med J 2015
 TONSILLITIS

IF antibiotics needed:

• Phenoxymethylpenicillin oral for 10 days

• Benzathine benzylpenicillin, IM, single dose.
• Amoxicillin, oral, 50 mg/kg daily for 10 days.
 COMPLICATIONS OF TONSILLITIS

• Peritonsillar abscess
• Parapharyngeal abscess
• Retropharyngeal abscess

• Urgent ENT referral

• Admission for Augmentin IV
Peritonsillar abscess
 10 COMMANDMENTS OF URTI

1. Call a cold a cold

2. Cough + NO fast breathing = URTI
3. Use an antibiotic only if really needed
4. High dose
5. Short course
6. Treat acute otitis media if severe otalgia/red drum
7. Acute bacterial sinusitis diagnose only if symptoms >10 days
8. Healthy children get frequent URTI
9. Avoid OTC medications
10. Practice hand/sneeze hygiene
TOGETHER WE CAN DO IT!
 OVERVIEW

• Upper respiratory tract infections (URTI)

• Upper respiratory tract obstruction:

NASO(PHARYNGEAL) OBSTRUCTION: stertor or snoring

and obstructed sleep

LARYNX: OBSTRUCTION: stridor

 STERTOR AND SNORING

• Obstruction of air flow through the nasal passages, the post-nasal space and the pharynx

• Causes:
Nose: allergic rhinitis, choanal atresia
Nasopharynx: adenoids
Pharynx: tonsils, hypotonia
 CONSEQUENCES OF
NASO(PHARYNGEAL) OBSTRUCTION

• Naso(pharyngeal) obstruction in infant can lead to difficulty in

feeding, poor growth and apnea (obligate nose breathers)
• Nose obstruction in older children will lead to obstructive sleep
apnea:
- Neurological consequences: lethargy, irritability, ADHD, poor school
performance
- Cardiological consequences: hypoxia pulmonary hypertension cor
pulmonale cardiac failure
- Enuresis nocturna
 HISTORY AND CLINICAL EXAMINATION

• Ask every parent if the child is snoring! Ask about apneas.

• Look for g face -syndrome (facial appearance in child with chronic
open mouth breathing)

Tonsil
enlargement
 DIAGNOSIS AND TREATMENT OF
OBSTRUCTIVE SLEEP APNEA

In every child that snores:

• Look for morbidity due to obstructive sleep apnea (OSA) (cardiac, neurological)
If morbidity present, treatment is a priority!
• Polysomnography (PSG) = golden standard but often not available
Do not delay treatment because PSG not available!
• Alternatives to PSG:
- Standardized questionnaire
- Nocturnal saturation monitoring
- Video by the parents
OBSTRUCTIVE SLEEP APNEA
 TREATMENT OF OSA

• Mostly nasal steroid spray first

• A child that continues to snore despite nasal steroid spray must be
referred to ENT for possible adenectomy
• Multidisciplinary approach in more complex pathology:
- Obese children
- Children with cranio-facial abnormalities
- Hypoplasia of the midface (c i D syndrome)
- Children with muscle/tone weakness
 CHOANAL ATRESIA

• Babies are born unable to breathe through the

nose and if not treated they will die (obligate nose
breathers during first 6 months of life)
• Suction catheter does not pass through the nose
• Strap an anaesthetic airway in the mouth as
emergency measurement
• Surgical treatment
• Unilateral/partial atresia can give less severe
Blockage of choanae by abnormal symptoms
bony or soft tissue
 OVERVIEW

• Upper respiratory tract infections (URTI)

• Upper respiratory tract obstruction:

NASO(PHARYNGEAL) OBSTRUCTION: stertor or snoring and
obstructed sleep
LARYNX OBSTRUCTION: stridor
- Acute stridor
- Chronic stridor
 STRIDOR

Obstruction of the large airways

 ACUTE ONSET STRIDOR

• Infections
- Laryngo-tracheo-bronchitis or croup
- Epiglottitis
- Bacterial tracheitis
- Retropharyngeal abscess
- Paratracheal gland enlargement
• ALWAYS CONSIDER INHALED FOREIGN BODY
• Anaphylaxis
• Trauma
 LARYNGO-TRACHEO-BRONCHITIS
(CROUP)

• Inflammation of the larynx, trachea and occasionally bronchi

• Edema subglottic area stridor
• Almost always viral (Parainfluenza virus)
• Less common: HSV, measles, candidiasis in HIV+
 CROUP

• Clinical triad: barking cough, hoarseness and stridor

• Preceded by URTI
• Common age 6- 24 months
• Usually early winter/ autumn
• Usually at night
LARYNGO-TRACHEO-BRONCHITIS
(CROUP)

Treatment

Steroids
Steroids + adrenaline nebs

Steroids + adrenaline nebs

If no improvement within 1h:
intubate

Steroids + adrenaline nebs

Intubate
 EPIGLOTTITIS

• Caused by Haemophilus Influenza B (now rare because of

immunization)
• Stridor less prominent, drooling
 EPIGLOTTITIS - MANAGEMENT

• Avoid all measures that could agitate the patient

- Let the child sit with the mom
- make no attempt to see the epiglottis,
- do not routinely perform X-rays of neck and chest,
- Secure airway before IV line insertion and blood sampling.
• Intubation by anaesthesist
• Rocephine IV
 FOREIGN BODY ASPIRATION

• Sudden onset of stridor in previously healthy child

• Often gets lodged between the vocal cords and the cricoid
cartilage
• Foreign body in the esophagus can also result in stridor
• Only visible on chest X ray if radio-opaque
• Heimlich manoeuvre
• Removal by ENT specialist
 FOREIGN BODY

5 back-blows

5 chest thrusts
 PERSISTENT (CHRONIC) STRIDOR

• Laryngomalacia
• Anatomical abnormalities of the larynx and large airways
- Web
- Cyst
- Subglottic stenosis
- Vascular compression
• Laryngeal papillomatosis
 LARYNGOMALACIA

• Starts after 14 days of age

• Stridor only on inspiration, typically when crying
• Obstruction improves when nursed in prone position
• Mild laryngomalacia will spontaneously resolve
• Moderate to severe laryngomalacia:
Stridor with feeding difficulty, dyspnea, tachypnea, cyanosis, apnea
Refer to ENT for evaluation
 LARYNGEAL PAPILLOMATOSIS

• Viral infection by human papillomavirus during passage through

the birth canal of an infected mother
• Diagnosis between age 2 and 3 years
• Gradual onset of stridor, hoarseness and aphonia
• Laser treatment
 OVERVIEW

• Upper respiratory tract infections (URTI)

• Upper respiratory tract obstruction

• Pertussis (whooping cough)

 PERTUSSIS

• Infection by Bordetella Pertussis

• Recent increase in incidence due to waning immunity after
vaccination
• - Paroxysmal cough followed by an inspiratory whoop (absent in
young infants) with associated vomiting. Subconjunctival
haemorrhages may be present.
- More severe in young infants, may present with apnoea
- Can be a cause of chronic cough
 PERTUSSIS

• Clinical diagnosis
- May have leucocytosis (lymphocytosis)
- PCR or serology for Bordetella Pertussis
• Treatment: Azithromycine
• Prophylaxis for household contacts
• Vaccination of pregnant women
THANK YOU
 DIFFERENTIAL DIAGNOSIS OF STRIDOR

» acute onset of obstruction without prodromal features:

foreign body or angioneurotic oedema

» incomplete immunisation and a membrane in the upper airway:

diphtheria

» high fever, dysphagia, drooling or sitting position:

epiglottitis, retropharyngeal abscess, bacterial tracheitis

» recurrent upper airways obstruction:

laryngeal papilloma
 WHAT DO WE HEAR WHEN AND WHY

STRIDOR ON INSPIRATION (most common) STRIDOR on EXPIRATION (rare)

Fixed obstruction stridor on in-AND expiration

 CHRONIC OTITIS MEDIA

• A purulent discharge from the middle ear with perforation of the ear drum for
more than two weeks.
• Think also of TB and HIV infection (and other chronic conditions)
• Treatment:
- Dry mopping/cleaning first
- Augmentin oral and topical eardrops
- Fluoroquinolones ear drops if no response (Pseudomonas Aeruginosa)
• Risk for persistence of tympanic membrane perforation with need of
tympanoplasty
 ACUTE BACTERIAL RHINOSINUSITIS

Child with an acute upper respiratory tract infection presenting with:

• persistent illness (nasal discharge or daytime cough or both lasting
more than 10 days without improvement),
• a worsening course (worsening or new onset of nasal discharge,
daytime cough, or fever after initial improvement), OR
• severe onset (c c e fe e [ e e a e 39°C] and purulent
nasal discharge for at least 3 consecutive days).

• Acute (>10d to <3 months) versus chronic (> 3 months)

• Treatment: Amoxicillin, oral, 45 mg/kg/dose 12 hourly for 10 days.

CAUSES OF STRIDOR