Rhinitis – Dx - Tx

1. Rhinitis – Dx - Tx Pediatric Cough and Cold Preparations Pediatr. Rev. 2004;25;115-123 Leslee F. Kelly Sinusitis Pediatr. Rev. 2001;22;111-117 David Nash and Ellen Wald Sinusitis – In Brief Pediatr. Rev. 2006;27;395-397 Allison Taylor and Henry M. Adam Update on Allergic Rhinits Pediatr. Rev. 2005;26;284-289 Todd A. Mahr and Ketan Sheth All Slides from PIR

2. A parent is concerned that her 4-year-old son “always has a cold.” Given what you know about the frequency of colds and the duration of their symptoms, what is the minimum number of “sick days” per year that would be considered excessive for a typical child? A. 75. B. 100. C. 125. D. 140. E. 175.

3. D - 150 The average number of colds per year generally isquoted as being 3 to 10. If each cold lasts the usual 10 to14 days, this translates to up to 140 days of cold symptomsper year.

4. Sinusitits: Rhinosinusitis (RS) is the term currently used because the inflammation is believed to begin in the nasal epithelium (rhinitis). It is estimated that of the average six to eight upper respiratory tract infections (URIs) per year experienced by school-age children, 5% to 10% will be complicated by RS. PIR

5. It also is estimated that 6% to 13% of children will have had one case of RS by the age of 3 years. RS also is classified by the duration of days of persistent symptoms. Acute rhinosinusitis (ARS) refers to symptoms that last longer than 10 days but fewer than 30. PIR

6. The maxillary and ethmoid sinuses are fully formed and clinically significant from birth. The sphenoid sinuses begin to develop at age 3 years and are fully formed by age 7 to 8 years. The frontal sinuses are the last to develop and are not fully formed until the early teenage years.

9. ARS is defined as unabated upper respiratory tract symptoms lasting longer than 10 days or as worsening of symptoms by 7 to 10 days of illness. It is important to distinguish a single prolonged illness from consecutive URIs. The symptoms of ARS include nasal discharge, cough (typically day and night), and halitosis. When fever precedes the URI symptoms, the illness is more likely to be viral.

10. Older children and adolescents may present with symptoms more typical of adult disease: headaches, facial pain and pressure, maxillary dental pain, pharyngitis, and frequent throat clearing.

11. If purulent nasal discharge is seen draining from the middle meatus, a diagnosis of ARS can be fairly certain. This finding may be recognized by looking through the otoscope while gently pushing up on the nares, a technique not easily done, especially with younger children. Ethmoid sinusitis may be accompanied by periorbital edema. In older children and adolescents, gentle pressure on the maxillary and frontal sinuses may elicit pain or discomfort

12. Allergic rhinitis is best characterized by: A. Cold air-induced rhinorrhea. B. Fever. C. Nasal pruritus. D. Nocturnal cough. E. Unilateral nasal discharge.

13. C. Nasal pruritus. In 1998, the Joint Task Force on Practice Parameters in Allergy,Asthma, and Immunology defined rhinitis as "inflammation ofthe membrane lining the nose, characterized by nasal congestion,rhinorrhea, sneezing, itching of the nose and/or postnasal drainage."

14. You are asked to talk to local child care providers about infection control measures. You advise them that the single best intervention to reduce the spread of “common colds” to other children in the center is to: A. Exclude all ill children from the center. B. Have all providers wear masks. C. Isolate sick children within the center. D. Limit outside playtime during the winter months. E. Wash hands and toys.

15. E. Wash hands and toys. Spread of virus can be prevented through specific infectioncontrol techniques, namely, those that decrease hand contaminationwith virus. This can be accomplished simply by correct handwashingof both caregiver’s and children’s hands.

16. Of the following conditions, the one most commonly coexisting with allergic rhinitis is: A. Asthma. B. Chronic sinusitis. C. Immunodeficiency. D. Otitis media with effusion. E. Sleep apnea.

17. A. Asthma. Some studies have found that nearly one third of children who have AR also have asthma.

19. As physicians try to limit antibiotic use in children who have colds, parent education takes on an increasingly important role. Common colds are caused by viruses. The most common viral causes are: A. Adenoviruses. B. Coronaviruses. C. Influenza viruses. D. Reoviruses. E. Rhinoviruses.

20. E – Rhinovirus (at least 100 serotypes) RhinovirusesCoronavirusesRespiratorysyncytial virusParainfluenza virusesAdenovirusesNonpolioenterovirusesInfluenza virusesReoviruses

21. Your parent information sheet “Colds in Infants” includes instructions on correct use of a bulb syringe. Normal saline, rather than 1/8% phenylephrine drops, is recommended because: A. 4-month-old infants are primarily mouth breathers. B. Phenylephrine causes rebound congestion. C. Phenylephrine causes vasodilation. D. Phenylephrine has been associated with cardiomyopathy. E. Phenylephrine must be given for 72 hours to be effective.

22. B. Phenylephrine causes rebound congestion. Topical nasal decongestantscan cause significant rebound congestion, which is especiallydangerous in infants 6 months of age and younger, who are extremelydependent on nasal airflow for respiration.

24. Allergen Avoidance Allergy avoidance is the first recommendation for the patient who has AR. Although it may be easy to recommend avoiding pets or pollen, such avoidance is extremely difficult for many patients. A more realistic goal is to decrease allergen exposure as much as possible, keeping in mind that many patients are allergic to multiple allergens. Strategies include -staying inside during high pollen times (5 AM to 10 AM), -keeping air-conditioning on during spring and fall pollen seasons, -avoiding drying clothes outside during high pollen times. To avoid molds, strategies include -Decreasing humidity in the home, using a dehumidifier -Keeping obvious areas of mold clean with a bleach solution.

25. Allergic Rhinitis The ideal solution for pets is to remove them from the home, although this often is not feasible or easy to accomplish. An alternative is to remove pets from the bedroom at night and during the day. Reservoirs for pet dander and allergen also should be avoided, such as pillows and heavy upholstered furniture.

26. A 3-year-old boy is coming to see you with what his mother describes as “probably just a cold.” On the phone, she said that he has had a runny nose and now has a worsening cough. Which piece of this patient’s past medical history would raise the greatest concern? A. Asthma. B. Croup. C. Otitis media. D. Sinusitis. E. Tonsillitis.

27. A. Asthma. First-generation antihistamines should be used cautiously inchildren who have asthma because they thicken secretions andcan make them harder to clear.

28. Allergen avoidance, when possible, is the best way to control allergic rhinitis. Of the following, the most effective intervention in reducing the symptom burden of allergic rhinitis is to: A. Increase home humidity. B. Keep air-conditioning on during pollen seasons. C. Prevent all exposure to pets in the first postnatal year. D. Restrict outside play to early morning hours. E. Spray pillows and comforters to eliminate dust mites.

29. B. Keep air-conditioning on during pollen seasons. Strategies include staying inside duringhigh pollen times (5 AM to 10 AM), keeping air-conditioningon during spring and fall pollen seasons, and avoiding dryingclothes outside during high pollen times.

30. Why is it unlikely that a vaccine ever will be developed to prevent colds? A. Immunity to one viral serotype does not confer complete protection against others. B. More than 100 different viruses cause the common cold. C. There are numerous antigenic serotypes. D. A, B, and C. E. B and C only.

31. D. A, B, and C. It isunlikely that a vaccine ever will be developed to prevent thecommon cold completely because of the numerous different antigenicserotypes as well as antigenic variation among many of the respiratoryviruses. Immunity to one serotype offers little protection againstothers.

32. A 6-year-old girl presents in the early spring with a 2-week history of paroxysmal sneezing associated with itching of her nose and eyes. She had similar symptoms last year that lasted for 2 months before abating. You diagnose seasonal allergic rhinitis and review appropriate avoidance measures. Of the following, the most effective control of her nasal symptoms would be achieved by proper use of an: A. Intranasal corticosteroid. B. Intranasal decongestant. C. Oral first-generation antihistamine. D. Oral leukotriene receptor antagonist. E. Oral second-generation antihistamine.

33. A. Intranasal corticosteroid. • Pharmacologic options for treating AR include antihistamines(oral and intranasal), oral leukotriene receptor antagonists(LTRA), and intranasal corticosteroids (INS). Treatment guidelinesfor AR support the use of INS as first-line therapy. INS areapproved for use in patients as young as 2 years of age.

34. In considering empiric antibiotic therapy for a 17-year-old boy in whom you suspect acute sinusitis, you should prescribe: A. Amoxicillin 40 to 50 mg/kg per day. B. Cefotaxime 300 mg/kg per day. C. Cefuroximeaxetil. D. Erythromycin succinate. E. Sulfamethoxazole-trimethoprim.

35. A. Amoxicillin 40 to 50 mg/kg per day.

36. If the patient’s symptoms persist after 3 days of therapy, you should prescribe a course of: A. Amoxicillin 40 to 50 mg/kg per day. B. Cefotaxime 300 mg/kg per day. C. Cefuroxime axetil. D. Erythromycin succinate. E. Sulfamethoxazole-trimethoprim.

37. C. Cefuroxime axetil.

38. ALLERGIC RHINITIS SX Patients who have AR may experience a variety of signs and symptoms. Parents usually report mouth breathing, snoring, or a nasal voice in affected children. Other symptoms typically include paroxysmal sneezing, nasal itching, sniffing, snorting, nose blowing, congestion or postnasal drainage, and occasionally coughing. Additional symptoms include itchiness of the eyes, throat, and palate.

39. Acute bacterial sinusitis is best distinguished from a viral upper respiratory tract infection by: A. Cough. B. Duration of symptoms for greater than 10 days. C. Facial pain and headache. D. Presence of fever for 1 to 2 days. E. Purulent nasal drainage.

40. B. Duration of symptoms for greater than 10 days.

41. A diagnosis of acute bacterial sinusitis should be based on: A. A precise clinical history regarding quality and duration of symptoms. B. Bacterial culture from the nasopharynx. C. Computed tomography of the paranasal sinuses. D. Physical examination of the nose and pharynx. E. Plain film radiographs of the paranasal sinuses.

42. A. A precise clinical history regarding quality and duration of symptoms.

43. The average number of colds per year generally is quoted as being 3 to 10. If each cold lasts the usual 10 to 14 days, this translates to up to 140 days of cold symptoms per year.

44. Table 1. Signs and Symptoms of the Common Cold ● Nasal discharge ● Nasal congestion/obstruction ● Scratchy/sore throat ● Malaise ● Postnasal drip ● Headache ● Cough ● Sneezing ● Decreased appetite ● Low-grade fever (102.2°F [<39°C]) ● Myalgias ● Irritability ● Decreased sleep ● Conjunctivitis ● Mild pharyngitis ● Watery eyes ● Fatigue ● Hoarseness

45. The term “common cold” is understood to mean that the cause is viral. • Cough and cold medicines contain pharmacologically active ingredients that alone or in combination are intended to relieve some or all of a patient’s symptoms.

46. Management of the common cold is intended to provide temporary relief of symptoms until the cold completes its natural history. If there are complications of the common cold, treatment is directed at the specific complication.

47. For infants and young children, relieving nasal obstruction is one of the most important goals because this symptom can impair drinking, and dehydration can result. Relieving cough often is an important goal of the family and frequently the reason for seeking care. Many children and parents lose sleep because the cough keeps them up at night. More than 800 cough/cold preparations are available in the United States.

50. A Journal of the American Medical Association review of clinical trials on over-the-counter cold medications from 1950 to 1991: Concluded that no good evidence has demonstrated the effectiveness of over-the-counter cold medications in preschool-age children, but certain medicines and combinations of medicines have been shown to reduce cold symptoms in adolescents and adults.