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Chapters 117-120

Chapters 117-120. Mouth and throat. Mouth and tongue. Geographic tounge Mucocele Aphthous ulcers. Stomatitis. Viral Herpangina Hand foot and mouth HSV. Pharyngitis. Superficial vs. deep Sore throat, fever, HA, cough Bacterial vs. Viral EBV common presentation/ rash with abx.

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Chapters 117-120

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  1. Chapters 117-120

  2. Mouth and throat

  3. Mouth and tongue • Geographic tounge • Mucocele • Aphthous ulcers

  4. Stomatitis • Viral • Herpangina • Hand foot and mouth • HSV

  5. Pharyngitis • Superficial vs. deep • Sore throat, fever, HA, cough • Bacterial vs. Viral • EBV common presentation/ rash with abx

  6. Bacterial Pharyngitis • GABHS usu. 5-15 yo accounts for 15-30% of pharyngits Tx. Amoxicillin 250mg BID or 500mg BID

  7. Dental trauma • Most common in toddlers • Up to 75% of abused children have oral trauma • Subluxation: loosening • Luxation: displacement with ligament damage • Extrusion: displaced form socket

  8. Dental trauma • Do not replace primary teeth • Do replace permanent teeth • 85-97% success rate if replaced in the first 5 min, near 0 if after 1 hour.

  9. Mouth • Close internal lacerations with absorbable suture • “Baby bottle” 24-28% of children ages 2-5yrs • ANUG; teens to early 20’s, usu. Prevotella intermedia. Can lead toLudwigs angina. Tx. Pain control and oral abx. Rinse or oral abx. (pcn)

  10. Neck masses • Cervical lympadenopahty • @ 55% of healthy children will have cervical nodes • <3mm are normal • < 1cm are normal in children >12 yrs The ex utero intrapartum therapy (EXIT)

  11. lympadenitis • Most are reactive and require no tx. • Suppurative cases can be tx. Empirically, cover for staph and strep. • Amoxil or Augmentin 30-40mg/kg div BID • Clinda 30mg/kg div TID/BID for 10-14d

  12. Specifics • Mycobacterium tuberculosis • 1-5 yrsubmandibualr/preauricular. • No empiric tx, need surgical excison • B. Henselae • Fever, HA, malaise, • Dx by history • Empiric tx not recommended, can use rifampin, bactrim, doxy.

  13. Specifics • Toxoplasmosis • T. gondii, protozoan in cat feces • Usu. Asymptomatic in healthy children • Up to 22.5 % U.S. infection rate.

  14. Neck masses • Congenital • Thyroglossal duct cysts • Midline @ 70% of masses • Moves with swalloing • Branchial apparatus cysts • Anterior to SCM • Dermoid cyst/teratomas • Usu. Superhyoid/ can be mistaken for thyroglossal • Lymphatic malformations • Obstructed lymph flow, 75% in neck

  15. Neck masses • Benign • Fibromatosis • Hemangioma • Neurofibroma • Goiter

  16. Neck masses • Malignant • Lymphoma • 50% Hodgkins • Usu. Large firm anterior triangle or supraclavicular • Rhabdosarcoma • 2nd most common, orbit, middle ear or neck • Neuroblastoma • Arise from sympathetic chain • Rarely present as asymptomatic mass

  17. Stridor and drooling • High pitched harsh sound produced by turbulent airflow. • 1mm of edema can reduce the cross-sectional area by 50% in children. • In the presence of stridor, suspect FB until proven otherwise.

  18. <6mo • If long standing than probably congenital. • Laryngomalacia • Tracheomalacia • Vocal cord paralysis • Subglottic stenosis • Airway hemangiomas

  19. >6 month • Croup • Most common cause of stridor outside neonatal period. • Most severe 3rd and 4th days • Clinical diagnosis • Treatment • Mild = steroids • Moderate = steroids +/- nebulized epi • Severe= steroids+epi • Pt’s with persistent stridor at rest or who require 2 epi tx should be admitted

  20. Epiglottitis • Bacterial infxn of epiglottis. • Can result in life threatening swelling • Hib vaccine has greatly reduced incidence • Clinical features • Abrupt onset fever, drooling and sore throat • Treatment • Oxygen, raciemic, intubation as needed, ceftriaxone/vanc.

  21. Foreign body • Most common in 1-3 year olds • Suspect in all young children with respiratory symptoms • Presentation may be delayed • >75% of foreign bodies can be seen on x-ray.

  22. Retropharyngeal abscess • Usu due to fall with object in mouth • Slow onset due to bacterial overgrowth • Dx. When the retro space @ C2 is 2x the diameter of the vertebral body, or greater than ½ the width of C4.

  23. Peritonsiller abscess • Same as adult

  24. Wheezing

  25. Bronchiolitis • Most common lower resp. infxn in <2yr • MCC RSV • Inflammation of LRT with edema • Peaks November-March • Last 7-14 days usu. Worse on day3-5

  26. Dx/Tx • Dx • Clinical • RSV swab • Tx • Oxygen Sa02 >90 • Bi-level/ bi pap • Intubation • Hypertonic saline • Beta agonist/ steroids are controversial

  27. Asthma • Inflammation • Bronchospasm • Airway obstruction

  28. Presentation • More than 95% of children age 2-18 with asthma will present to the ED • Normal PaCO2 should be around 37 • PaCO2 40-42 may be sign of impending failure • Be aware of “silent chest” as an ominous sign

  29. DX • Is there an asthma hx? • What is the severity of the airway obstruction? • Is there a reversible cause of the exacerbation?

  30. CXR? • Rales or dullness that persists after SABA • Temp greater than 102.2 • Respiratory distress out of proportion for physical exam.

  31. Treatment • Oxygen • SABA • Anticholinergics • Corticosteroids • Magnesium • Ketamine • Heliox • Methylxanthines

  32. Near fatal asthma • 33% of fatalities occur in patients that previously had only mild asthma. • BiPap settings should begin at 12/6

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