Child Healthcare: Upper respiratory tract condition

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"Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin …

"Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society."

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  • 1. 6 Upper respiratory tract conditions • The trachea and large bronchi Objectives • The small bronchi (bronchioles) • The alveoli. When you have completed this unit you Therefore, the respiratory tract from the larynx should be able to: down is called the lower respiratory tract. • List both the common and dangerous upper respiratory tract conditions. • Recognise these clinical conditions. COMMON COLD • Understand the causes of these conditions. • Provide primary care management for 6-3 What is a common cold? these conditions. • Refer children with these conditions The common cold (coryza or acute viral appropriately. rhinitis) is an acute viral infection of the nasal passages. It is the commonest infection in childhood. The throat, middle ear and sinuses may also be involved. Many children have fiveINTRODUCTION or more common colds a year.6-1 What is the upper respiratory tract? Many young children have five or more commonThe upper respiratory tract (URT) consists of: colds a year.• The nose, sinuses and adenoids• The throat, pharynx and tonsils 6-4 What is the cause of a common cold?• The middle ear and eustachian tubes Usually a rhinovirus. However, many otherTherefore, the respiratory tract above the viruses can also cause the common cold.larynx is called the upper respiratory tract. Children get repeated common colds as immunity to one virus does not give protection against other viruses. The viruses causing6-2 What is the lower respiratory tract? the common cold are infectious and can beThe lower respiratory tract consists of: passed from person to person by sneezing and coughing (droplet spread). The virus is• The larynx then inhaled and infects the lining of the nasal
  • 2. 112 UPPER RESPIRATOR Y TRACT INFECTIONSpassages. The virus can also be spread by hand 6-6 What are the complications of ato hand contact. One person coughs into their common cold?hand, and later hold hands with someone The viral infection may spread to:else who then rubs their nose. In this way thevirus is spread from the nose of one person • The sinusesto another. The common cold is particularly • The middle earfrequent in young children who attend a crèche • The throator play group, nursery school or school for the • The lower respiratory tract, causingfirst time. Here children are exposed to viruses bronchitis, bronchiolitis or pneumoniathey have not met before. The patient is often The viral infection may become complicatedinfectious for a day or two before the signs and by a bacterial infection. Then the clear nasalsymptoms of a common cold appear. discharge will become purulent (green). NOTE As there are more than a hundred subtypes of rhinovirus, one child can repeatedly catch a The viral infection may also trigger an asthma common cold. attack in children who suffer from asthma. Viral complications are most common in6-5 What are the signs and symptoms of infants as they have an immature immunethe common cold? system with little resistance to many viruses.• A blocked or runny nose• Sneezing 6-7 How can the common cold be• Watery eyes prevented?• Mild fever There are no practical methods of avoiding• Mild cough the common cold other than trying to avoidUsually the common cold presents with a contact with other people suffering from arunny nose, nasal discharge and sneezing. common cold. It is best if children with aThe eyes become watery and a mild fever common cold be kept at home for a few daysis common. Initially the nasal discharge is to recover and avoid infecting others.clear and watery but later becomes thickerand white or yellow. After a few days the 6-8 What is the management of a commonnose becomes blocked and nasal breathing cold?may be difficult, especially at night or while Usually no treatment is needed. Make surebreastfeeding. Sleep is commonly interrupted. the child drinks enough fluid. Frequent, smallA mild cough is common and caused by feeds are best. Appetite is often poor for a fewmucous running down the back of the throat days. Older children can blow their nose, but(post-nasal drip). The symptoms and signs of a saline nose drops help to clear the nose incommon cold clear up in a week. Usually there infants and young children. Keeping the roomare no complications of a common cold. warm and raising the head with pillows mayA very sore throat suggests pharyngitis or help at night. Paracetamol syrup will lowertonsillitis while high fever, muscle pains and fever. Aspirin should not be used in children.feeling very unwell suggest influenza rather Decongestant nose drops for a few days orthan a common cold. an oral decongestant (e.g. Actifed) are onlyA blocked nose with a green (purulent) practical to help a blocked nose in olderdischarge on one side in a generally well child children. Antibiotics are not indicated unlesssuggests a foreign body. there is a secondary bacterial infection. Suspect a complication if the child develops a high fever, severe cough or breathes fast.
  • 3. UPPER RESPIRATOR Y TRACT INFECTIONS 113 of hot water. Do not use boiling water or Antibiotics are not indicated for a common cold. steam as the child may be burned. 4. Nasal decongestant drops or sprayACUTE SINUSITIS If the sinusitis does not disappear in 10 days or becomes recurrent, refer the patient to an ENT specialist/clinic. Repeated sinusitis suggests6-9 What is acute sinusitis? an allergy. Chronic sinusitis is not common in children.This is an infection of the lining of one ormore of the air sinuses that develop around thenasal cavity in older children (especially themaxillary sinuses). Sinusitis is usually caused ALLERGIC RHINITISby a bacterial infection, which complicates acommon cold. The common cold virus causes 6-12 What is allergic rhinitis?swelling of the mucus membranes lining thesinuses. As a result, mucous in the sinuses Allergic rhinitis is an allergy of the liningcannot drain normally and secondary bacterial (mucosa) of the nose and may present like ainfection starts a few days after the signs of the common cold. There are two forms of allergiccommon cold. rhinitis:Acute sinusitis is uncommon in preschool 1. Seasonal allergic rhinitis (hay fever). Thischildren as their facial sinuses are not yet is only present during part of the year, e.g.fully formed. Sinusitis is usually acute but can spring and early summer.become chronic. Less commonly sinusitis may 2. Persistent allergic rhinitis. This is occurs allcomplicate allergy. year round. 6-13 What are the symptoms and signs of Acute sinusitis only occurs in older children. allergic rhinitis? Both forms of allergic rhinitis present with:6-10 What are the symptoms and signs ofsinusitis? • Repeated sneezing • A blocked nose with a watery nasal• A green (purulent) nasal discharge discharge• A feeling of fullness or pain over one or • Red, swollen eyes (allergic conjunctivitis) more of the sinuses (to the side and above the nose) Seasonal rhinitis also has itching of the• Headache and tenderness over the infected nose, eyes, ears and soft palate. Itching is sinus uncommon in persistent rhinitis.• Post-nasal drip with a cough. Secretions Children with persistent allergic rhinitis drain from the sinuses when the child lies usually have a pale face with blue colouration down. This irritates the throat and bronchi of the lower eyelids. Due to upward rubbing of causing a cough, especially when the child the nose they often have a crease at the base of lies down to sleep. the nose.6-11 What is the treatment of sinusitis? 6-14 What is the cause of allergic rhinitis?1. Oral antibiotics for 10 days. Amoxycillin is Usually pollens or fungal spores inhaled from usually used the atmosphere in seasonal allergic rhinitis.2. Paracetamol for pain and discomfort Pets or house dust mite which are present all3. Steam inhalation by breathing in warm, year usually cause persistent allergic rhinitis. moist air in a warm shower or over a bowl
  • 4. 114 UPPER RESPIRATOR Y TRACT INFECTIONSCommonly there is a family history of allergies infection can be diagnosed if a throat swab is(rhinitis, asthma and eczema). taken for culture. 6-18 What are the symptoms and signs of There is usually a family history of allergy in pharyngitis? allergic rhinitis. Pharyngitis presents with: NOTE Skin prick testing and IgE blood tests (RAST • A sore throat. This is the main symptom. test) are used to identify the allergen causing the • Pain on swallowing. Young children may rhinitus. refuse to eat. • Fever6-15 What is the management of allergic • Enlarged, tender cervical lymph nodesrhinitis? • Abdominal pain is common in young1. Try to identify and avoid any likely cause children (allergens). • Mild cough2. Use newer non-sedating oral antihistamine The symptoms usually disappear within 5 drugs (e.g. Zyrtec). days.3. Avoid decongestant nose drops.4. Steroid nasal spray is very effective, On examination the throat is very red especially in persistent allergic rhinitis. (inflamed). The mucus membrane of the back of the throat appears swollen and granular. NOTE Desensitisation is very effective if the allergic rhinitis is due to a single cause, e.g. grass pollen Often it is difficult to differentiate between or house dust mite. pharyngitis and a common cold as the symptoms overlap. However, a sore throat without a blocked or runny nose suggests aPHARYNGITIS AND pharyngitis.TONSILLITIS NOTE A membrane on the pharyngeal mucosa suggests diphtheria. This is a rare infection as most children are immunised with DPT. Children6-16 What is pharyngitis? with diphtheria are usually severely ill. Children with glandular fever may also have a membrane.Infection and inflammation of the pharynx(throat). This is a common condition. 6-19 What are the complications of pharyngitis?6-17 What are the causes of pharyngitis? • TonsillitisUsually a virus (about 90% of cases). • Spread of the infection to the middle earPharyngitis may also be caused by a bacteria or the lower respiratory tract (bronchitis,such as Group A Streptococcus. It is not bronchiolitis or pneumonia)possible to clinically differentiate between a • Streptococcal pharyngitis may cause acuteviral and streptococcal pharyngitis. glomerulonephritis and acute rheumatic fever. It is not possible clinically to distinguish viral NOTE A Group A beta haemolytic Streptococcal from bacterial pharyngitis. infection of the pharynx is an important cause of acute glomerulonephritis and rheumatic fever, especially in poor communities. The clinical NOTE Infectious mononucleosis due to infection diagnosis of a Streptococcal pharyngitis can be with the Epstein-Barr virus may also cause a difficult without a bacterial culture. pharyngitis, often with a membrane. Diphtheria is a rare cause of membranous pharyngitis. Bacterial
  • 5. UPPER RESPIRATOR Y TRACT INFECTIONS 1156-20 What is the management of 1. Repeated severe tonsillitispharyngitis? 2. Tonsillar abscess 3. Severe airway obstruction1. Make sure that the child has an adequate fluid intake. Unless there is severe airway obstruction,2. Paracetamol syrup for pain and fever. enlarged tonsils alone is usually not an3. Antibiotics are not indicated unless there indication for tonsillectomy. is severe pharyngitis (very sore throat) Tonsillectomy for repeated attacks of without signs of a common cold. Oral tonsillitis remains controversial. While penicillin, amoxycillin or erythromycin for occasional tonsillitis is not an indication 5 days is usually preferred. for tonsillectomy, it has been suggested that more than 5 attacks of tonsillitis per year is a6-21 What is tonsillitis? reasonable indication for tonsillectomy.If a child with enlarged tonsils getspharyngitis, the tonsils also become inflamed. 6-24 What are the signs and managementThis is called tonsillitis. Tonsillitis is usually of enlarged adenoids?seen in children between the age of 2 and 10 Adenoids are situated at the back of the noseyears. It may be caused by either a viral or and cannot be seen without special instruments.bacterial (Streptococcal) infection. They enlarge up to the age of about 7 years and then spontaneously become smaller. Enlarged6-22 What are the signs of tonsillitis? adenoids may obstruct the nasal airway. ThisThe same as pharyngitis. However, both causes snoring, frequent waking at night,tonsils are swollen and red. There may be mouth breathing, nasal speech, and chronicyellow spots (follicles) or an exudate (yellow secretory otitis media. Poor sleep may affectmucoid covering) on the tonsils. With very schooling. Mild enlargement of the adenoidsswollen and inflamed tonsils, the airway may requires no treatment but adenoidectomybecome narrow. (removing the adenoids) is indicated for signs of severe upper airway obstruction, especiallyThe tonsils normally grow and enlarge in snoring and sleep apnoea (stopping breathingyoung infants as part of the development of during sleep).their immune system. Normally the size of thetonsils decreases by 10 years of age. Tonsillitis NOTE Large adenoids can be diagnosed on a lateral X-ray of the neck. Sleep apnoea due tois more common in children with large tonsils. enlarged adenoids is an important condition, as itHowever, many children have enlarged tonsils causes nocturnal hypoxia, and must be urgentlywithout repeated attacks of tonsillitis. treated by adenoidectomy.Usually tonsillitis recovers within a week.However, tonsillitis may become recurrent or Snoring and sleep apnoea are important reasonschronic. for adenoidectomy. Enlarged, swollen tonsils may obstruct the airway. OTITIS MEDIA6-23 What is the management of tonsillitis? 6-25 What is otitis media?1. Paracetamol syrup for pain and fever2. Penicillin, amoxycillin or erythromycin for It is an infection and inflammation of the 10 days middle ear. Usually otitis media is acute but it can become chronic. Otitis media is moreThe indications for tonsillectomy are: common in bottle-fed infants, especially with
  • 6. 116 UPPER RESPIRATOR Y TRACT INFECTIONS‘bottle-propping’, when milk can run into the 4. Follow up to make sure that the otitiseustachian tube (the narrow tube connecting media has fully recovered.the middle ear to the pharynx). 5. Ear drops and oral decongestants do not help.Acute otitis media is caused by viruses andbacteria that reach the middle ear from With correct treatment, perforation of thethe pharynx via the eustachian tube. The eardrum should heal within 2 weeks. Failureimportant bacteria are Pneumococcus, or incorrect treatment may lead to chronicHaemophilus, Moroxella and Streptococcus. suppurative or secretory otitis media.With a common cold, swelling of the mucosamay block the eustachian tube and causea build up of fluid in the middle ear where The most important treatment in otitis media isbacteria can thrive. pain control and antibiotics in young children. NOTE In older children, acute otitis media will often6-26 What are the symptoms and signs of recover without antibiotics. If severe otitis mediaacute otitis media? does not respond to antibiotics, surgical drainageThis is a common infection in children, of the middle ear may be required. Children underespecially children under 5 years of age. Acute 2 years should always be given antibiotics.otitis media presents with: 6-28 What is chronic suppurative otitis• Sudden onset of severe pain in the ear media? (earache). Infants become irritable, cry and may pull at the affected ear. Chronic suppurative otitis media is diagnosed• Fever, often above 39 °C. if pus has been draining from a perforation in• On examination, the eardrum is red and the eardrum for more than 2 weeks. The hole bulges with loss of the normal light reflex. in the eardrum is now unlikely to heal on its The pain is not made worse if the pinna own. Complications of chronic suppurative (external ear) is pulled. otitis media include destruction of the bones• The eardrum may perforate (rupture) in the middle ear leading to conductive resulting in pus pouring into in the deafness, mastoiditis and bacterial meningitis external ear canal (otorrhoea). The pain is or brain abscess. often relieved when the drum bursts. It is very important to prevent chronic• Otitis media often presents a few days after suppurative otitis media by the correct the onset of a common cold or pharyngitis. management of children with acute otitis media. Always be alert for signs of mastoiditis Acute otitis media presents with sudden, severe (swelling and tenderness over the bone earache and fever. behind the ear), especially in older children. Mastoiditis (infection of the mastoid bone) is a dangerous condition which needs urgent6-27 What is the management of acute referral to hospital for antibiotics and possibleotitus media? surgical drainage.1. Paracetamol for pain and fever.2. Oral antibiotics for 10 days. Usually 6-29 What is the management of chronic amoxycillin is used. suppurative otitis media?3. If there is no decrease in pain and no drop The aim is to treat the infection and keep the in fever after 24 hours of antibiotics, the ear dry so that the perforation in the eardrum child should be referred to an ENT (ear, can heal: nose and throat) clinic.
  • 7. UPPER RESPIRATOR Y TRACT INFECTIONS 1171. Oral antibiotics, usually amoxycillin or co- 2. If there is no improvement after 3 months, trimoxazole for 10 days. refer the child to an ENT specialist.2. Clean the external canal at least twice a NOTE An audiogram to assess for hearing loss is day with a cotton bud to keep it dry. Using important, especially if the hearing is abnormal a cotton wick to dry the external canal is in both ears. An ENT specialist may insert a very useful (wicking). grommet (small plastic tube) into the eardrum3. Avoid swimming or showering. to allow the fluid to drain. With correct treatment4. Ear drops are of little help. normal hearing returns.Refer to an ENT specialist/clinic if the ear 6-32 What is otitis externa?continues to drain after 2 weeks of treatment,if the condition recurs or if you suspect a Otitis externa is an infection of the externalcomplication. ear canal (not a true upper respiratory tract infection). It may be caused by a viral, bacterial or fungal infection, a complication Chronic suppurative otitis media may result in of a skin condition (e.g. eczema) or a foreign serious complications. body. Otitis externa may complicate chronic suppurative otitis externa as the draining pus6-30 What is chronic secretory otitis media? irritates the skin of the external canal.Chronic secretory otitis media or ‘glue ear’ is • With mild otitis externa the ear is itchy buta common and important cause of deafness the external canal appears normal.in young children. Chronic infection in the • With moderate otitis externa the ear ismiddle ear and enlarged adenoids can lead painful with a purulent, smelly discharge.to obstruction of the eustachian tube with The pain is worse if the pinna (externalthe collection of a thick, sticky effusion in the ear) is pulled. On examination the externalmiddle ear. This results in the eardrum being canal is red and contains debris. Partialsucked inwards due to the absorption of the obstruction of the external ear canal mayair in the middle ear. The thick fluid prevents cause mild deafness.the bones in the middle ear from vibrating • With severe otitis externa the ear is verynormally. This interferes with normal hearing. painful with deafness due to completeChronic secretory otitis media can delay obstruction of the canal. On examinationspeech development and result in learning the external canal is red and swollen.difficulties at school. On examination, the A boil in the external canal or mumps mayeardrum is dull and retracted. Either one or also present with earache.both ears may be affected. Pain is uncommon.Chronic secretory otitis media is uncommonover the age of 10 years as the eustachian tube 6-33 What is the treatment of otitisbecomes wider with improved drainage of the externa?middle ear with increasing age. 1. Mild and moderate otitis external can be treated locally with ear drops for 10 days. Combined steroid and antibiotic drops give Chronic secretory otitis media is a common cause the best results (e.g. Sofradex). Any debris of deafness in young children. should be removed with a cotton bud or syringing (water at body temperature)6-31 What is the management of chronic before instilling the ear drops. Locacorten-secretory otitis media? Vioform drops can also be used. The infection is usually cured by one week.1. A 10 day course of oral antibiotic to clear Oral antibiotics are usually not needed. any remaining infection. Swimming and showering should be
  • 8. 118 UPPER RESPIRATOR Y TRACT INFECTIONS avoided to keep the canal dry. Recurrence • Drooling. They have a very sore throat is common. and are unable to swallow or even open2. With severe otitis externa the canal should their mouth. This is a very important sign. be packed with a cotton wick soaked in They usually are unable to speak, cry, ichthammol and glycerine to reduce the cough or drink. swelling. Then the infection can be treated • They have progressive airway obstruction. as above. Characteristically, the children sit up,3. A boil in the external canal can be very leaning forward with the neck extended to painful and should be treated with oral keep the airway open. flucloxacillin. • Changing their body position or trying to examine the throat may cause total airway obstruction.EPIGLOTTITIS Acute epiglottitis is the one upper respiratory6-34 What is the epiglottis? tract condition that can present with respiratory distress due to airways narrowing.The epiglottis is positioned at the openingof the larynx to prevent the inhalation offluids and solids when swallowing. It lies at 6-37 How must acute epiglottitis bethe meeting point of the upper and lower managed?respiratory tract. 1. Allow the child to adopt a position that he prefers to keep the airway open.6-35 What is epiglottitis? 2. Move the child urgently to a facility where intubation or tracheotomy under generalAn acute infection of the epiglottis, is usually anaesthetic is possible. Thereafter, intensivecaused by Haemophilus influenzae. The care is needed to make sure the artificialepiglottis becomes very swollen and may airway remains open.obstruct the airway. This is a rare but very 3. Intravenous chloramphenicol orserious condition which may rapidly cause cefotaxime to treat the epiglottitis anddeath unless correctly diagnosed and rapidly septicaemia.treated. Children with acute epiglottitis alsohave a Haemophilus influenzae septicaemia. With the correct antibiotics, the swelling of theAcute epiglottitis due to Haemophilus epiglottis decreases and the child can usuallyinfluenzae can be prevented by Hib immu- be extubated after 48 hours.nisation of all children. Do not confuseHaemophilus influenzae (a bacteria) with the Acute epiglottitis is a medical emergency.influenza virus. Acute epiglottitis is an exremely serious condition INFLUENZA which can be prevented with Hib immunisation.6-36 How is acute epiglottitis recognised? 6-38 What is influenza?It usually occurs in children between two and Influenza, or ‘flu’, is a common upper5 years of age. The onset is sudden with: respiratory tract infection caused by the influenza virus. However, many other viruses• High fever. These children appear very sick can present with similar symptoms and signs and may be shocked due to the septicaemia. of a ‘flu-like’ illness. Influenza usually occurs in epidemics. These may be very serious and
  • 9. UPPER RESPIRATOR Y TRACT INFECTIONS 119cause many deaths. Like the common cold, the 6-41 How can acute respiratory conditionsinfluenza virus is spread by coughing, sneezing be prevented?and direct hand-to-hand contact. Influenza A number of important steps can be taken tousually presents 1 to 3 days after infection. both prevent and reduce the severity of acute NOTE As is difficult to clinically tell whether a upper and lower respiratory tract infections: patient is infected with the influenza virus or another virus, such as rhinovirus, it is better to • Reduce environmental smoke. The source speak of a flu-like illness unless there is a proven may be active or passive cigarette smoking epidemic of influenza infections at the time. or the smoke of indoor fires in poorly ventilated homes.6-39 What are the symptoms and signs of • Immunise against measles, diphtheria,influenza? whooping cough and Haemophilus influenzae in all children. Also immuniseThe onset is usually sudden, with: selected children with influenza and• Fever pneumococcal vaccines.• A blocked nose and sore throat • Decrease overcrowding in homes and• Tiredness, weakness and a general feeling schools. This will lessen the exposure to of being unwell many acute respiratory tract infections.• Headache • Promote breastfeeding as exclusive• Muscle ache breastfeeding, prevents and reduces the• Cough severity of respiratory infections. • Give vitamin A as a depot injection or asThe symptoms are worse for the first 5 days and an oral supplement.usually recover by 10 days. Complications of • Improve the nutritional status of allinfluenza include otitis media, bronchitis and children.pneumonia. Children may develop convulsions • Educate the public, especially parents, tocaused by the high fever (pyrexial fits). recognise the signs of severe respiratory tract conditions so that these children can6-40 What is the management of influenza? be given early, correct management.Influenza can be prevented by a recentinfluenza immunisation (especially if givenjust before the winter months). CASE STUDY 11. Bed rest.2. Make sure the child has an adequate A 4-year-old child is taken to a family doctor. amount to drink. The mother says he has had a blocked nose, is3. Paracetamol for fever, headache and eating poorly and sleeping badly for the past muscle pains. 2 days. On examination he has a mild fever4. Antibiotics are only indicated if a and is generally unwell. There are no signs of secondary bacterial infection is suspected, pneumonia or otitis media. He attends a crèche e.g. pneumonia. where a number of children have been sick. NOTE As the influenza virus continually changes, 1. What is the most likely diagnosis? one can have repeated attacks of influenza. It is also important to have immunisation which covers A common cold the virus that is current that year. Immunisation is particularly important in children with chronic 2. What is the probable cause? lung disease, e.g. asthma and cystic fibrosis. A rhinovirus
  • 10. 120 UPPER RESPIRATOR Y TRACT INFECTIONS3. What is the likely source of the infection? pharynx and tonsils. Therefore, many doctors would give an antibiotic.Other children at the crèche. Many childrenhave at least 5 common colds a year. 4. What are the serious complications of a bacterial pharyngitis or tonsillitis?4. Should this child be given an antibiotic? Acute glomerulonephritis and acute rheumaticNo. There is no indication that the child has a fever. Tonsillitis can also result in a tonsillarbacterial infection. abscess.5. What management is needed? 5. Should his tonsils be removed?Paracetamol for fever. Make sure he has Probably not. The indications for tonsillectomyenough to drink. Keeping the room warm and are severe airway obstruction, tonsillar abscessraising to head of the bed may reduce nasal and repeated tonsillitis (more than 5 attacks aobstruction at night. Most colds get better in a year).few days. Nose drops, other than saline drops,and oral decongestants are usually not helpfulin young children. 6. What should you think of if a child with a very sore throat has difficulty swallowing and appears severely ill?6. What is the likely diagnosis if a child ispartially deaf after a common cold? Acute epiglottitis. They have a high fever, often drool and keep their head in a fixed position.Secretory otitis media, with a collection of This is an acute emergency as they may totallyfluid behind the ear drum. obstruct their airway.CASE STUDY 2 7. What treatment is needed? Emergency referral for intubation orA 5-year-old boy presents with fever and a tracheotomy under general anaesthetic. Allowvery sore throat. On examination his tonsils the child to hold his head in any position thatare enlarged and swollen. The mother reports he prefers. Start intravenous antibiotics.that this is the second sore throat he has had in6 months and asks that his tonsils be removed. CASE STUDY 31. What is your diagnosis? Following a runny nose for 3 days, a youngAcute tonsillitis. infant develops a high fever and severe pain in one ear. The next day the child seems better and2. What is the cause? pus is seen in the external canal of that ear.Probably a viral or bacterial infection.However, as there is no history of a common 1. Why did the child have severe earache?cold, the tonsillitis may be due to a bacterial Due to acute otitis media.(Streptococcal) infection. 2. Why did the pain suddenly improve?3. Should the child be given a course ofantibiotics? The ear drum ruptured.It is very difficult clinically to differentiatebetween a viral and bacterial infection of the
  • 11. UPPER RESPIRATOR Y TRACT INFECTIONS 1213. Why did this child develop acute otitis 1. What do you think is the problem?media? Influenza.As a complication of a common cold. Bacteriacan reach the middle ear via the eustachian 2. What is the cause?tube. Blockage of the eustachian tube during acommon cold causes an ideal environment for The influenza virus.bacteria to grow in the middle ear. 3. Why is this not a common cold?4. What treatment should the child have Because the child has a high fever, headachebeen given? and muscle pains.A course of antibiotics. This probably wouldhave avoided the ruptured ear drum. 4. How is the illness spread? By coughing and sneezing (droplet spread). It5. What will happen to the hole in the may also be spread by hand to hand contact.child’s eardrum? One person coughs into their hand, and laterWith antibiotic treatment it should heal hold hands with someone else who then rubswithin 2 weeks. If not, the child must be their nose. In this way the virus is spreadreferred. If the hole in the ear drum does not from the nose of one person to another. Theheal, the child will have chronic suppurative influenza virus almost certainly was spreadotitis media. This may lead to deafness with from the younger brother.destruction of the bones in the middle ear. 5. What is the correct treatment of6. What dangerous complication may influenza?follow chronic suppurative otitis media? Bed rest, plenty of fluids and paracetamol.Mastoiditis. This presents with tenderness over Usually an antibiotic is not needed unless athe mastoid bone behind the ear. Mastoiditis is complication develops such as pneumonia.dangerous as it may result in a brain abscess orbacterial meningitis. 6. Can influenza be prevented? Influenza immunisation in autumn greatly reduces the risk of infection.CASE STUDY 4 7. What complications may young childrenA 10-year-old child has been ill for 4 days with have with a high fever due to an uppera high temperature, headache, blocked nose respiratory tract infection?and muscle pains. His younger brother had asimilar illness the week before. Febrile convulsions (pyrexial fits).