TREAT EAR NOSE THROAT MOUTH CONDITIONS

1. TREAT EAR NOSE THROAT MOUTH CONDITIONS Unit 4: Part 1 Module 2

2. REFERENCES C290- Nelson’s Essentials of Pediatrics C306 - Dipchand, A., The Hospital for Sick Kid’s Handbook of Pediatrics C 18 - Bates “ Guide to Physical Examination” C291- Primary Care for the PA C277 – Toronto Notes

3. OUTLINE Otitis Externa Acute Otitis Media OM with Effusion Chronic OM Ceruminosis URI Nasal Foreign Body Acute Sinusitis Epistaxis

4. OUTLINE Adenoid Hypertrophy Pharyngo-tonsillitis Peritonsillar/Retropharyngeal Abscess Epiglottitis Upper Airway Obstructions Stomatitis Dental Problems Tongue Tie

5. OTITIS EXTERNA In children it is usually a benign painful infection of the outer ear canal Causes: Bacteria – Pseudamonas E coli, Staph aureus Fungi- candida albicans , aspergillus niger More common in summer Associated with swimming, Q-tip usage trauma

6. OTITIS EXTERNA S & S - Pain – worse on moving tragus - Redness - Swelling Discharge – yellow/sticky with bacteria, whitish patchy with candida Conductive hearing loss Posterior auricular adenopathy

7. OTITIS EXTERNA Management - Ear toilet – H2 peroxide ½ strength, irrigate, suction , dry swab - Ear wick 3 % acetic acid - Antibiotic ear drops for bacterial infection 7-10 days - TM intact give garamycin, neosporin, cortisporin - TM perforated give ciprofloxin drops

8. OTITIS EXTERNA Management ( cont’d) - Fungal infection - use alcohol/acetic acid instillation to clean, - locacortin or clotrimazole drops for 4-6 weeks Systemic antibiotics are needed if either cellulitis or cervical lymphadenopathy are present Analgesia i.e. acetaminophen PRN

9. ACUTE OTITIS MEDIA Inflammation of the middle ear 60-70% of children have at least 1 episode before age 3 One third of children have had 3 or more episodes by age 3 18 mos- 6 years most common age group Peak incidence January-April

10. ACUTE OTITIS MEDIA Inflammation of the middle ear 60-70% of children have at least 1 episode before age 3 One third of children ha e had 3 or more episodes by age 3 18 mos- 6 years most common age group Peak incidence January-April

11. ACUTE OTITIS MEDIA Etiology - Viral - RSV, influenza– 25-40 % - precedes bacterial invasion by 3-14 days - Gram negative enteric infection in newborns < 4weeks - S. pneumoniae- 35 % - H. influenza – 25 % - M. cattarhalis - S. aureus and S. pyogenes( beta lactamase producing) - Mycoplasma – less common- bullae on TM - S. pneumoniae- 35 %- - H. influenza – 25 % - M. cattarhalis - S. aureus and S. pyogenens( beta lactamase producing) Children with resistant strains are usually < 18 months, recent antibiotics in the previous 3 months increases the risk of resistance- S. pneumoniae- 35 %- - H. influenza – 25 % - M. cattarhalis - S. aureus and S. pyogenens( beta lactamase producing) Children with resistant strains are usually < 18 months, recent antibiotics in the previous 3 months increases the risk of resistance

12. ACUTE OTITIS MEDIA Predisposing factors include: - Eustachian tube dysfunction /obstruction - URTI, allergic rhinitis, chronic sinusitis, adenoid hypertrophy, barotrauma, cleft palate ( even if repaired) - Down,s ( horizontal position of ET), - Disruption of cilia action in ET, Immunosupression/immunodeficiency states e.g. chemotherapy, steroids, DM, Cystic fibrosis Aboriginal Canadians

13. ACUTE OTITIS MEDIA Risk Factors - Bottle feeding- propping - Second hand smoke - Crowded living conditions - Male > females Family history Daycare Breast feeding reduces the risk – provides IgA antibodies that reduce colonization with otitis pathogens, and decreases the aspiration of contaminated secretions in to the middle EARBreast feeding reduces the risk – provides IgA antibodies that reduce colonization with otitis pathogens, and decreases the aspiration of contaminated secretions in to the middle EAR

14. ACUTE OTITIS MEDIA S&S - Triad of otalgia, fever ( infants/toddlers), conductive hearing loss Purulent Discharge – if TM perforated Pain over mastoid Infants/toddlers – ear tugging, irritable, poor sleep, anorexia, vomiting, diarrhea TM red, bulging, normal landmarks disappear Light reflex diffuse/ obscured TM immobile Hallmark of diagnosis is remove cerumen, test TM mobility with pneumatic otoscope Red TM can occur with viral URI, crying Hallmark of diagnosis is remove cerumen, test TM mobility with pneumatic otoscope Red TM can occur with viral URI, crying

15. ACUTE OTITIS MEDIA Rest/ Fluids Acetaminophen 10-15 mg /kg q4-6h prn PO Antibiotics Amoxicillin 90 mg/kg/day divided tid x 10 days for < 2 years, 5 days for > 2 years If penicillin allergy use septra/bactrim Follow up 2-3 days Observation and symptomatic care x 2-3 days over age 2 is an option AOM is considered to be non-resolving if S&S persist after 48-72 hours of antibiotics -Should switch to Cefaclor, Clavulin, Pediazoole or cefixime( suprax) -Biaxin used for recurrent AOM Do not use antihistamine/decongestants in infants/children If child unable to take oral therapy can give single IM dose of ceftriaxone ( Rocephin) Auralgan can relieve pain in those on observation/expectant managementAOM is considered to be non-resolving if S&S persist after 48-72 hours of antibiotics -Should switch to Cefaclor, Clavulin, Pediazoole or cefixime( suprax) -Biaxin used for recurrent AOM Do not use antihistamine/decongestants in infants/children If child unable to take oral therapy can give single IM dose of ceftriaxone ( Rocephin) Auralgan can relieve pain in those on observation/expectant management

16. ACUTE OTITIS MEDIA Other treatments Myringotomy tubes – indicated if: complications such as persistent effusion Recurrent AOM > 5 episodes in 1 year Immunologically compromised child Adenoidectomy Complications of AOM include: Chronic suppurative OM Acute mastoiditis Facial nerve palsies Febrile seizures Nysatagmus- bilateral labrynthitis TM perforation Meningitis Extradural, subdural, cerebral abscess Lateral sinus thrombosisComplications of AOM include: Chronic suppurative OM Acute mastoiditis Facial nerve palsies Febrile seizures Nysatagmus- bilateral labrynthitis TM perforation Meningitis Extradural, subdural, cerebral abscess Lateral sinus thrombosis

17. ACUTE OTITIS MEDIA Prevention - Chemoprophylaxis with Amoxicillin 20 mg/kg/day - Breast feeding - Reduction in second hand smoke exposure - Eliminate pacifier use - Avoid large center daycare - Vaccines – Prevnar, influenza Chemoprophylaxis useful in children with 3 well documented episodes of AOM in 6 months, or 4 in 1 year or infants < 6 monthChemoprophylaxis useful in children with 3 well documented episodes of AOM in 6 months, or 4 in 1 year or infants < 6 month

18. OTITIS MEDIA WITH EFFUSION OME frequently follows AOM in children Feeling of fullness in ear – blocked ear Hearing diminished, +/- tinnutis Pain – minimal Low grade fever possible but usually not Hearing diminished, - confirm with tympanogram (flat), and audiogramHearing diminished, - confirm with tympanogram (flat), and audiogram

19. OTITIS MEDIA WITH EFFUSION TM on otoscopic exam: Amber or dull grey Fluid level Air bubbles Retraction of TM Malleus shortened Prominent short process Immobility of TM – pneumatic otoscope

20. OTITIS MEDIA WITH EFFUSION Management Expectant care- 90% resolve within 3 months Myringotomy/ +/- ventilation tubes/ +/- adenoidectomy Complications of OME Hearing loss, speech delay, learning difficulties Chronic mastoiditis Cholesteatoma No evidence that antibiotics, decongestants, antihistamines clear effusion any faster Ventilation tubes indicated if effusion persists > 3 months, hearing loss > 30 dB, speech/language delay, atelectasis of TM Tubes left in 9-18 monthsNo evidence that antibiotics, decongestants, antihistamines clear effusion any faster Ventilation tubes indicated if effusion persists > 3 months, hearing loss > 30 dB, speech/language delay, atelectasis of TM Tubes left in 9-18 months

21. CHRONIC SUPPURATIVE \OTITIS MEDIA Persistent otorhrrea lasting > 6 weeks Occurs in children with perforated TM or those with ear tubes in place May be a sign of cholesteatoma Culture drainage Meticulous cleansing /ear wick

22. CHRONIC SUPPURATIVE \OTITIS MEDIA Antibiotic ear drops – coverage for anaerobes/pseudomonas Topical quinolones – e.g cipro gtts 2 weeks of aggressive therapy-if unresponsive think mastoiditis, cholesteatoma, TB, fungal infection Serious CNS complications can occur e.g. meningitis, brain abscess, extradural/subdural abscess Refer to ENT

23. CERUMINOSIS Increased wax in ear canal blocking hearing Pre-soften with warmed oil gtts e.g. mineral oil Syringe canal with warm water until clear

24. URI- COMMON COLD Most frequent pediatric infection of early childhood Children under age 5 have 6-12 colds per year Viral etiologies include Rhinoviruses – 30 % Influenza or parainfluenza – 15 % Coronavirus - 10% Enterovirus – 5 %

25. URI- COMMON COLD S&S – sudden onset Clear /mucoid rhinorrhea Fever – high fever under 5 years – up to 40.6 C, low grade in older child Mild sore throat and cough may develop Nose, throat and TM’s may appear inflamed Symptoms can last for 2 weeks or more RX- supportive- acetaminophen, ibuprofen, fluids , rest, saline nose drops or Otrivin 0.05 % if saline not effective No antihistamines, NO antibiotics! Otrivin use only when needed for a max. of 4 days to prevent rebound rhinitisOtrivin use only when needed for a max. of 4 days to prevent rebound rhinitis

26. FOREIGN BODY OF NOSE Frequent problem in younger children 1-4 Peas, toy parts, beads FB becomes embedded in nasal mucosa Erosion and inflammation occur leading to infection Unilateral foul smelling purulent discharge Unilateral blockage of nostril Attempt removal if able to see FB, with blunt plastic hook DO not try to remove more than once or twice, if child is resisting and unable to cooperate , refer to ENT May need removal under anesthesiaDO not try to remove more than once or twice, if child is resisting and unable to cooperate , refer to ENT May need removal under anesthesia

27. ACUTE SINUSITIS Maxillary/ethmoid sinuses are commonly involved Preceding URI blocks clearing/draining of mucus Pathogens are usually S. pneumoniae, H. influenza(nontypable), M. catarrhalis, Beta-hemolytic Streptococci Onset may be sudden or gradual in children Clinically it is difficult to distinguish this from URI in younger children Persistent high fever > 102 with concurrent purulent nasal discharge for 3-4 days Persistent high fever > 102 with concurrent purulent nasal discharge for 3-4 days

28. ACUTE SINUSITIS Older children may give more typical headaches and sinus tenderness and transillumination more useful here RX; Fluids, acetaminophen/ibuprofen, ice packs Antibiotics – Amoxicillin 90 mg/kg/day divided Tid for mild-moderate uncomplicated Night time cough suppressant – e.g codeine syrup Complications – preseptal then orbital cellulitis; subperiosteal abscess, orbital abscess, then cavernous sinus thrombosis Are most likely to occur with ethmoid sinus involvement Clues to complications include decreased visual acuity, decreased EOM’s, proptois, chemosis, CNS infection – meningitis, peidural/subdural and cerebral abscess occur with frontal sinus involvementComplications – preseptal then orbital cellulitis; subperiosteal abscess, orbital abscess, then cavernous sinus thrombosis Are most likely to occur with ethmoid sinus involvement Clues to complications include decreased visual acuity, decreased EOM’s, proptois, chemosis, CNS infection – meningitis, peidural/subdural and cerebral abscess occur with frontal sinus involvement

29. EPISTAXIS Common in children Related to minor trauma from rubbing, picking or blowing nose to the anterior portion of nasal septum < 5% may be related to bleeding disorder such as Von Willebrand’s Nasal mucosa is a highly vascular structureNasal mucosa is a highly vascular structure

30. EPISTAXIS Patients should have a hematological workup if : a family history of bleeding disorders a history of easy bleeding.bruising, or spontaneous bleeding at any site bleeding that lasts > 30 minutes or blood that won’t clot with direct pressure onset of nosebleeds before age 2 a drop in hematocrit due to epistaxis

31. EPISTAXIS RX: First aid for minor nosebleeds Prevention: - Avoid vigorous nose blowing Avoid nose picking Keep child’ fingernails trimmed Apply water based ointment to nasal mucosa daily until 5 days pass without a bleed , then weekly for a month Humidity in child’s bedroom may be helpful

32. EPISTAXIS Major/persistent nosebleeds - Persistent bleeding despite first aid may signify posterior bleed or an underlying problem such as a bleeding disorder - In a child > six years , try an Otrivin 0.05% solution soaked cotton ball apply pressure x 10 minutes to anterior septum - Nasal packing (anterior and /or posterior) may be needed if bleeding persists and is significant for blood loss Monitor ABC’s carefully !

33. ADENOID HYPERTROPHY Common problem Size peaks at age 5, resolves age 12-18 Increase in size related to repeated URI,s allergies Clinically presents as: Nasal obstruction Choanal onbstruction Chronic inflammation nasal obstruction e.g. adenoid facies – open mouth, dull facial expression hypernasal voice history of snoring long term mouth breather minimal air flow through nose Choanal obstruction – e.g chronic sinusitis/rhinitis Chronic inflammation e.g nasal discharge, post nasal drip, cough, cervical lymphadenopathynasal obstruction e.g. adenoid facies – open mouth, dull facial expression hypernasal voice history of snoring long term mouth breather minimal air flow through nose Choanal obstruction – e.g chronic sinusitis/rhinitis Chronic inflammation e.g nasal discharge, post nasal drip, cough, cervical lymphadenopathy

34. ADENOID HYPERTROPHY Enlarged adenoids seen on mirror nasopharyngeal exam or lateral soft tissue x-ray Complications: Mouth breathing Eustachian tube dysfunction leading to SOM Dental malocclusion Sleep apnea/respiratory disturbance

35. ADENOID HYPERTROPHY Indications for adenoidectomy: Chronic upper airway obstruction with sleep disturbance/apnea Chronic nasopharyngitis resistant to medical care Chronic SOM, Chronic suppurative OM Chronic sinusitus Contraindications for adenoidectomy include bleeding disorders, recent pharyngeal infection, short or abnormal palateContraindications for adenoidectomy include bleeding disorders, recent pharyngeal infection, short or abnormal palate

36. PHARYNGO-TONSILLITIS An infection of the mucous membranes of the pharynx and palatine tonsils Peak prevalence is in children <5 years old Caused by a bacteria or virus May be difficult to differentiate between these two forms clinically Viral infections are the most common cause of pharyngotonsillitis in younger children < 3 years Bacterial pharyngo-tonsillitis is very rare in children <3 years old, but its prevalence increases with age

37. VIRAL PHARYNGOTONSILLITIS Acute sore throat combined with symptoms consistent with a viral URTI (rhinorrhea, cough and often hoarseness) S&S are otherwise similar to bacterial type Vesicles and ulcers may be present with coxsackievirus infection (e.g., hand, foot and mouth ulcers occur with coxsackievirus A-16 infection [usually in the area of the soft palate]) or herpes infection (usually in the anterior portion of the mouth)

38. VIRAL PHARYNGOTONSILLITIS Causes – Adenovirus or enterovirus (the latter is more common in children <3 years old) – Influenza virus – Parainfluenza virus – Coxsackievirus – Echovirus – Epstein–Barr virus (mononucleosis) – Herpes simplex virus Strawberry tongue scarletinoform rash ( scarlet fever) palatal petechiae ( monnucleosis)Strawberry tongue scarletinoform rash ( scarlet fever) palatal petechiae ( monnucleosis)

39. VIRAL PHARYNGOTONSILLITIS Supportive care e.g. rest, fluids, acetaminophen for pain/fever Occasionally, children are unable to drink secondary to the pain of pharyngotonsillitis caused by some viral infections, particularly coxsackievirus and herpesvirus In such situations, admission to hospital may be required for IV administration of fluids (to prevent dehydration)

40. BACTERIALPHARYNGO-TONSILLITIS Group A ß-hemolytic streptococci (accounting for 15% to 40% of cases of acute pharyngotonsillitis); Unusual in children <3 years old Mycoplasma pneumoniae (accounting for 10% of cases of pharyngotonsillitis in adolescents) May be secondary to diphtheria or infectious mononucleosis. Predisposing factors: previous episodes of pharyngitis or tonsillitis, overcrowding, poor nutrition

41. BACTERIALPHARYNGO-TONSILLITIS History – Acute onset – Very sore throat – Fever – Headache – Abdominal pain and vomiting – General malaise

42. BACTERIALPHARYNGO-TONSILLITIS Physical Findings – Significant fever – Tachycardia – Pharyngeal and tonsillar erythema – Petechiae of soft palate – Tonsillar exudate (particularly with streptococcal infection, diphtheria or mononucleosis)

43. BACTERIALPHARYNGO-TONSILLITIS Physical Findings - Anterior cervical lymphadenopathy - Erythematous “sandpaper” rash of scarlet fever (may be present with streptococcal infection) - Erythematous rash (particularly if child is receiving amoxicillin) and lymphadenopathy with splenic enlargement in children with mononucleosis - Usually not associated with coryza

44. BACTERIALPHARYNGO-TONSILLITIS Differential Diagnosis – Viral pharyngotonsillitis – Epiglottitis – Gonococcal pharyngitis in sexually active adolescents Complications – Peritonsillar or retropharyngeal abscess – Acute rheumatic fever (after group A ß-hemolytic streptococcal infection) – Obstruction of the upper airway (with diphtheria); see “Diphtheria,” in chapter 18, “Communicable Diseases” DIAGNOSTIC TESTS – Swab throat for culture and sensitivity in clinically symptomatic childrenDIAGNOSTIC TESTS – Swab throat for culture and sensitivity in clinically symptomatic children

45. BACTERIALPHARYNGO-TONSILLITIS Management - Throat culture as indicated - Increased rest during febrile phase - Increase oral fluids during febrile phase - Avoidance of irritants (e.g., smoke) - Warm saline gargles qid (for older children) -Consult a physician if the child has significant dysphagia or dyspnea signaling obstruction of the upper airway, or if you are concerned about an underlying pathologic state, such as peritonsillar abscess or rheumatic fever Appropriate surveillance of community with respect to complications of rheumatic fever -Consult a physician if the child has significant dysphagia or dyspnea signaling obstruction of the upper airway, or if you are concerned about an underlying pathologic state, such as peritonsillar abscess or rheumatic fever Appropriate surveillance of community with respect to complications of rheumatic fever

46. BACTERIALPHARYNGO-TONSILLITIS Indications for the introduction of antibiotics: - Child appears acutely ill - Child has a history of rheumatic fever - Child has an illness that is clinically compatible with scarlet fever - Evidence of early peritonsillar abscess (urgent consult ) - Triad of fever, tonsillar exudate and lymphadenopathy, absence of cough - See Sore Throat Score In the absence of the above situations, and if the child is relatively asymptomatic, it is appropriate to await culture results before administering antibiotics, if cultures can be obtained quickly. This approach will not increase the risk of acute rheumatic fever but avoids unnecessary use of antibiotics. If the culture results are positive, the child can be recalled for initiation of antibiotic treatment. In the absence of the above situations, and if the child is relatively asymptomatic, it is appropriate to await culture results before administering antibiotics, if cultures can be obtained quickly. This approach will not increase the risk of acute rheumatic fever but avoids unnecessary use of antibiotics. If the culture results are positive, the child can be recalled for initiation of antibiotic treatment.

47. BACTERIALPHARYNGO-TONSILLITIS Antibiotics: - penicillin V (Pen Vee K) (A class drug), 25–50 mg/kg per day, divided tid or qid, PO OR - erythromycin (E-Mycin in tablet form) (A class drug), 30–40 mg/kg per day, divided qid, PO OR (for infants) - erythromycin ethylsuccinate suspension (EES-200) (A class drug), 30–40 mg/kg per day, divided qid, PO Many children are carriers of group A ß-hemolytic Streptococcus. However, assuming compliance with the antibiotic regimen, only routine follow-up is required; culture is not indicated. Antipyretic and analgesic for fever and pain: acetaminophen (Tylenol) (A class drug), 10–15 mg/kg q4–6h prn Monitoring and Follow-Up Many children are carriers of group A ß-hemolytic Streptococcus. However, assuming compliance with the antibiotic regimen, only routine follow-up is required; culture is not indicated. Antipyretic and analgesic for fever and pain: acetaminophen (Tylenol) (A class drug), 10–15 mg/kg q4–6h prn Monitoring and Follow-Up

48. PHARYNGO-TONSILLITIS Follow-up is recommended in 48–72 hours Ascertain culture results at that time Repeat culture on the completion of antibiotic therapy is unnecessary, and cultures need not be obtained from asymptomatic family contacts Children who have had five or more documented group A ß-hemolytic streptococcal infections should be referred for an ENT consultation.They may benefit from tonsillectomy.

49. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS Retropharyngeal Abscess - A collection of pus in the retropharyngeal space Peritonsillar Abscess - A collection of pus between the tonsil capsule and either the anterior or posterior tonsillar pillar

50. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS Causes May be viewed as a complication of bacterial pharyngotonsillitis Retropharyngeal Abscess - Penetrating trauma to the oropharynx Peritonsillar Abscess - Infection spreads from superior pole of the infected tonsil

51. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS History- Retropharyngeal Abscess - More common in young children < 2 years - Fever - Drooling and refusal to swallow - May present with stridor - Stiff neck - Rule out trauma to the oropharynx

52. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS Retropharyngeal Abscess – Child appears acutely ill – Stiffness of the neck and possibly refusal to flex the neck – Obvious redness and swelling on inspection of the posterior pharynx – Exudate may be seen on the tonsils – Cervical lymphadenopathy generally present Before examining the pharynx, consider the diagnosis of epiglottitis. If epiglottitis is suspected, do not examine the throat Before examining the pharynx, consider the diagnosis of epiglottitis. If epiglottitis is suspected, do not examine the throat

53. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS History- Peritonsillar Abscess – Much more common 10-30 years – Previous history of sore throat often present – Fever prominent – Pain, drooling and dysphagia – Trismus (difficulty opening mouth) may be present – Breathing may be difficult

54. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS Peritonsillar Abscess – Child appears acutely ill – Inspection reveals unilateral swelling of the anterior or posterior tonsillar pillar – Tonsils displaced, with uvula shifted to the opposite side from the infection – May be difficult to examine children because of trismus

55. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS Differential Diagnosis – Epiglottitis (if there is stridor, drooling and fever) – Diphtheria – Mononucleosis Complications – Obstruction of the airway – Parapharyngeal abscess – Aspiration (if abscess ruptures)

56. RETROPHARYNGEAL  Throat culture ???? Start IV therapy with normal saline, at a rate adequate to maintain hydration (rate depends on size and hydration status of the child) Bed rest If child is drooling, give nothing by mouth Give sips of cold liquids only if the child is able to swallow saliva

57. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS IV Antibiotics: - Monitor child closely to ensure that an adequate airway is maintained Admission to hospital Consultation with an ENT specialist is usually necessary, and the condition may require surgical intervention Elective tonsillectomy

58. RETROPHARYNGEAL AND PERITONSILLAR ABSCESS General Guidelines For Tonsillectomy – Documented cases of recurrent tonsillitis (child symptomatic or positive culture for group A ß-hemolytic Streptococcus)—five episodes per year for 2 years is generally considered an indication for the procedure – Throat infection complicated by peritonsillar or retropharyngeal abscess requiring drainage – Suspected malignant lesion of tonsil – Cor pulmonale – Obstructive sleep apnea – Severe upper airway obstruction

59. EPIGLOTITIS Inflammation of supraglottic srtuctures Virtually unknown in children since onset of HIB vaccination Causative organism H. influenza B Under immunized or unimmunized children are at risk Peak age 1-4 years, rare > age 8

60. EPIGLOTITIS Sudden onset, toxic looking, fever, restless, agitated, cyanotic/pale Sridor, slow breathing, lungs clear with decreased air entry Sits up, open mouth, drooling, protruding tongue, dysphagia, sore throat DO NOT EXAM THROAT !!!!! O2, IV N/S for hydration, Moist air IV antibiotics – ceftriaxone, cefuroxime Watch for meningitis

61. SUBGLOTTIC STENOSIS Congenital diameter of subglottis is < 4mm in neonate due to thickening of the soft tissue of the subglotttic space or maldevelopment of the cricoid cartilage Acquired - following nasotracheal intubation of long duration, traumatic intubation, tube too large, infection

62. SUBGLOTTIC STENOSIS S&S Biphasic stridor Respiratory distress Recurrent/prolonged croup Laryngoscopy, CT for diagnosis Management - If soft tissue -laser and steroids - If cartilage- laryngotracheoplasty

63. LARYNGOMALACIA Most common laryngeal anomaly Elongated omega shaped epiglottis, short epiglottic fold and pendulous mucosa Presents with high pitched crowing inspiratory stridor at 1-2 weeks of age Stridor constant or intermittent , worse when supine Associated feeding difficulties- gagging, cough Spontaneous resolution 18-24 months as larynx grows

64. FOREIGN BODY Ingested Usually stuck at cricopharyngeus Coins, small toy parts Presents with drooling, dysphagia and stridor if very big Aspirated Usually get stuck at right main stem bronchus Peas, carrots, apple core, popcorn, balloons Presents as stridor if in trachea, unilateral “ asthma” if in bronchus If total occlusion of bronchus will have cough, atelectasis, lobar pneumonia, mediastinal shift, pneumothorax

65. FOREIGN BODY Inspiratory-expiratory chest x-ray Bronchoscopy and esophagoscopy with removal

66. STOMATITIS Definition - Ulcers and inflammation of the tissues of the mouth, including the lips, buccal mucosa, gingiva and posterior pharyngeal wall Causes - For most cases in young children: - Herpes simplex virus - Coxsackievirus

67. STOMATITIS History - Fever - Pain - Drooling - Difficulty swallowing - Decreased fluid/nutritional intake - Associated respiratory or GI symptoms - Associated skin rash

68. STOMATITIS Physical Findings - Temperature increased in infectious types (temperature is often very high with herpes infection) - Erythema (herpangina) - Vesicles (early stages of all infectious types) - Painful ulcers: check distribution (confluent ulcers may appear as large, irregular white areas) - Submandibular lymph nodes (most prominent in herpes) Examine outside of lips first. Next, gently retract the lips with a tongue depressor to examine the anterior buccal mucosa and gingiva. Then gently attempt to separate teeth and depress the tongue. Look for the following featuresExamine outside of lips first. Next, gently retract the lips with a tongue depressor to examine the anterior buccal mucosa and gingiva. Then gently attempt to separate teeth and depress the tongue. Look for the following features

69. STOMATITIS See handout of clinical features for various types of stomatitis from– FNIHB Pediatric Guidelines - Attached DIFFERENTIAL DIAGNOSIS Vincent’s infection (Vincent’s angina) Lichen planus Mononucleosis Immunologic: gingival hyperplasia Systemic lupus erythematosus Congenital: epidermolysis bullosa Erythema multiforme DIFFERENTIAL DIAGNOSIS Vincent’s infection (Vincent’s angina) Lichen planus Mononucleosis Immunologic: gingival hyperplasia Systemic lupus erythematosus Congenital: epidermolysis bullosa Erythema multiforme

70. STOMATITIS Complications – Pain – Dehydration – Secondary infection (e.g., gangrenous stomatitis) – Ludwig’s angina Diagnostic Tests - None

71. STOMATITIS Management - Maintenance of hydration is important - Increase oral intake of fluids (i.e., maintenance requirements + fluid deficits caused by fever) - Counsel parents or caregiver about the expected duration of this illness and the signs and symptoms of dehydration - Recommend dietary adjustments: bland, non-acidic fluids (such as milk and water); older children may eat popsicles, ice cream and similar food items; avoid citrus foods, such as orange juice MANAGEMENT There are as yet no specific treatments for any of these conditions. An educated guess must be made as to the cause. Herpes stomatitis usually lasts 10 days and the child can feel miserable for this period. Herpangina lasts for only a few days and has few complications. Aphthous stomatitis requires no treatment. Do not treat this condition with antibiotics, as they are not indicated and are not helpful. MANAGEMENT There are as yet no specific treatments for any of these conditions. An educated guess must be made as to the cause. Herpes stomatitis usually lasts 10 days and the child can feel miserable for this period. Herpangina lasts for only a few days and has few complications. Aphthous stomatitis requires no treatment. Do not treat this condition with antibiotics, as they are not indicated and are not helpful.

72. STOMATITIS Management - Recommend local mouthwashes (1:1 hydrogen peroxide and water), especially after eating - To prevent spread of infection, recommend avoidance of direct contact with infected individuals (e.g., kissing, sharing glasses and utensils, hand contact) - Provide support to parents or caregiver to help them cope with a “cranky” child

73. STOMATITIS Management ( cont’d) - Acetaminophen (Tylenol)for fever and pain 10–15 mg/kg PO or PR q4h prn - Reassess the young child (<2 years of age) in 24–48 hours to ensure maintenance of hydration - The disease is self-limiting, so consultation and referral are usually unnecessary, unless there are complications.

74. COMMON DENTAL PROBLEMS

75. ERUPTION CYSTS Small white, gray or bluish translucent eruptions on crest of maxilla or mandible Remnants of dental lamina, which are usually shed after birth Management - Reassure parents or caregiver that this condition will resolve on its own and needs no treatment.

76. EPSTEIN PEARLS Small, white, keratinized lesions along the midline of the palate. Remnants of epithelial tissue trapped as the fetus grows, which usually fall off after birth. Management - Reassure parents or caregiver that this condition will resolve on its own and needs no treatment.

77. NEONATAL TEETH Eruption of teeth in neonatal period In 80% of cases, such teeth are lower primary incisors They tend to be hypermobile because of inadequate root formation Management - Reassure parents or caregiver that this condition will resolve without sequelae. - Refer to a dentist - Removal is recommended to prevent aspiration of the teeth

78. DENTAL CARIES There has been a decrease in the prevalence of pediatric dental caries in most southern populations Environmental factors (such as hygiene and diet), particularly as influenced by the parents or caregiver, are the most significant predictors of childhood dental problems With the introduction of fluoride into the drinking water of some urban and rural communities and most toothpaste, and with increased attention to dental healthWith the introduction of fluoride into the drinking water of some urban and rural communities and most toothpaste, and with increased attention to dental health

79. DENTAL CARIES Prevention - Encourage appropriate dental hygiene: tooth-brushing from the time of tooth eruption, flossing from the time the child reaches school age, low sugar consumption. - Where water is not fluoridated, children up to 14 years of age may need fluoride supplements. See the fluoride recommendations of the Canadian Pediatric - Check with the local policy regarding fluoride supplementation in any community

80. MILK BOTTLE CARIES SYNDROME Caries of the deciduous teeth, most commonly the maxillary incisors and mandibular premolars and molars May be severe enough to cause dental abscess Secondary to prolonged nursing (either bottle or breast) at bedtime Liquid pools around the child’s teeth, causing significant caries, particularly in the maxillary incisors Very common in Aboriginal groups in Canada, often resulting in extraction of the affected teeth and problems with permanent teeth.Very common in Aboriginal groups in Canada, often resulting in extraction of the affected teeth and problems with permanent teeth.

81. MILK BOTTLE CARIES SYNDROME Management - Prevention of this problem is a major public health concern, and public health measures to discourage bottle caries are of primary importance: - Discourage bottle propping - Discourage use of sweet fluids in bottle - Encourage drinking from a cup by 1 year and weaning by 18 months

82. MILK BOTTLE CARIES SYNDROME Encourage good oral hygiene: - Cleaning of teeth with gauze as soon as they erupt and cleaning of toddlers’ teeth with a soft toothbrush - Encourage parents or caregiver to take children for their first dental assessment by 3 years of age - Fluoride supplements may be appropriate for infants and children upto14 years of age to ensure effective brushing, an adult must supervise the child until 6 years of age to ensure effective brushing, an adult must supervise the child until 6 years of age

83. MILK BOTTLE CARIES SYNDROME Referral to a dental practitioner for dental fillings/extractions The repair procedure may require a general anesthetic

84. COMMON DENTAL PROBLEMS Congenital Absence Of Teeth (Anodontia) - Very rare. Teeth usually begin to erupt by 6 months, but may be delayed until up to 12 months. Partial Absence Of Teeth (Oligodontia) - This condition is more common with the permanent dentition, particularly the third molars, the mandibular second bicuspids, the maxillary lateral incisors and the maxillary second bicuspids. Management - Appropriate dental referral should be made.

85. DENTAL PROBLEMS Other Common Abnormalities Of The Teeth - Delayed eruption - Rotation of incisors - Large space between maxillary central incisors Children should be assessed by a dentist if any of these common abnormalities have presented

86. DENTAL PROBLEMS Common Malocclusions Anterior open bite (protrusion of maxillary anterior teeth) or crossbite (maxillary teeth positioned behind the mandibular teeth) Children with significant malocclusions should be referred to an orthodontist

87. ANGLYLOGLOSSIA- TONGUE TIE A condition in which a short lingual frenulum attaches the tongue to the floor of the mouth, interfering with protrusion of the tongue No treatment is warranted if the tongue can be protruded beyond the lips In 95% of cases, reassurance is all that is required Very occasionally, a thick fibrous band of tissue interferes with the tongue’s protrusion beyond the lips. In such cases, consultation with an ENT specialist is suggested with a view to possible surgical release

88. THUMB SUCKING Generally benign activity May result in protrusion of the maxillary incisors and anterior over bite. Most children suffer no effects to their dentition Reassure the parents or caregiver Children entering school generally stop sucking the thumb as a result of peer pressure In rare cases, the child with a severe thumb-sucking problem may need referral to a dentist and close follow-up for anterior over bite