viral croup (Viral

laryngotracheitis)

Acute epiglottitis

Congenital Congenital laryngeal stridor (Laryngomalacia), congenital

papilloma or hemangioma

Acute spasmodic laryngitis

(mid-night croup)

Bacterial croup

Diphtheritic laryngitis, Bacterial tracheitis

(pseudomembranous croup)

Laryngeal foreign body

Allergic laryngeal oedema

(angioedema)

Hypocalcaemia stridor

Common cold (acute rhinitis ,

coryza)

sinusitis

Acute otitis media

Sore throat (pharyngitis) & (tonsillitis)

Viral bronchitis (mainly) (common cold, Influenza,

measles)

Bacterial bronchitis (Bordetella pertussis,

Mycoplasma pneumoniae)

Interstitial pneumonia

bronchopneumonia

Lobar pneumonia

1-infection 2-allergy 4-Metabolic 3-Mechanical

Retropharyngeal abscess

Acute Chronic

Acquird Forign body &

tumor

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Upper respiratory tract infection

Laryngeal and tracheal infections

(Stridor)

Bronchitis Bronchiolitis Pneumonia

1- Upper respiratory tract infection (URTI):

* The commonest presentation is a child with a combination of a nasal discharge and blockage, fever, painful throat , earache & sometime Cough. * Approximately 80% of all respiratory infections.

Sinusitis Acute otitis media Sore throat (pharyngitis & tonsillitis) Common cold (acute rhinitis , coryza)

* occur with viral URTIs but not disappear after the nasal inf. Has subsided. * may cause 2ry bacterial Infection.

* is mainly an obstructive disease, when Eustachian tube becomes obstructed by: edema of mucous memb. During URTI & enlarged adenoids (transudate collection in middle ear infected by organism ascending

through Eustachian tube) . * commonest at 6-12 months of age.

* mostly by purely viral & may cause 2ry

bacterial inf.

* virus mostly by RSV and rhinovirus

* bacteria mostly by pneumococcus & H.influenza

* mainly due to viral infection (mostly Adenovirus ) then bacterial infection (mostly group A β-hemolytic Streptococcus (in older children))

* tonsillitis is a form of pharyngitis but with intense inflammation of tonsils with purulent exudates. *EBV (infectious mononucleosis) is also common to cause tonsillitis

* This is the commonest infection of

childhood.

* commonest pathogens are viruses

Rhinoviruses, corona viruses and RSV

* 6-12 attacks per year

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1- fever

2- tenderness & swelling

over involved sinuses

3- mucopurulent nasal

Discharge

4- headache

1- fever . 2- pain in the ear . 3-irritability and head rolling . 4-by otoscope to examine the tympanic membrane: bright red with loss of the normal light reflection and bulging or perforated ear drum with pus. 5- sharp pain , when pressing on mastoid process.

* For recurrent ear infections, can lead to otitis media with effusion (glue ear or serous otitis media). Children are asymptomatic apart from possible decreased hearing. The eardrum is seen to be dull and retracted, often with a fluid level visible

1- fever.

2- sore throat / dysphasia

3- cervical lymph nodes are enlarge & tender.

4- pharynx & soft palate are inflamed.

5- if tonsils are include,red and/or swollen tonsils

white or yellow follicles on the tonsils (pus) or

pseudomembrane.

6-headache.

7- abdominal pain.

1- nasal discharge (clear or mucopurulent)

2- nasal blockage.

3- low grade fever.

4- sore throat.

5- cough

6- sneezing & nasal tone of voice.

7- mouth breathing.

8- headache

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1- x-ray: clouding of the affected sinuses. 2- antibiotic. 3- symptomatic therapy analgesic & antipyretic

1- resolve spontaneously 80% of acute otitis media. 2- Antibiotics (amoxicillin): shorten the duration of pain but doesn't reduce the risk of hearing loss 3- drainage of middle ear 4- symptomatic therapy analgesic & antipyretic 5- myringotomy (grommet) & adenoidectomy: in sever O.M or if no response to medicine

1- symptomatic therapy (antipyretic, fluid) 2- Antibiotics (often penicillin, or erythromycin if there is penicillin allergy) for 10 days to eradicate the organism to prevent Rheumatic fever.

1- symptomatic therapy and have no specific

curative treatment (self-limiting)

2- Fever and pain are best treated with

paracetamol or ibuprofen.

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Causes of persistant sinusitis: 1-hypertrphied adenoids 2-deformiy of nasal septa 3-Allergy 4-recurrent rhinitis

* Otitis media with effusion(OME) is the most common cause of conductive hearing loss in children and can interfere with normal speech development and result in learning difficulties in school. * Infants and young children are prone to OM because their Eustachian tubes are short, horizontal and function poorly * Chronic suppurative O.M: is perforated tympanic membrane With active bacterial inf.for several week * rare complications: mastoiditis and meningitis

* Amoxicillin is best avoided as it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis. * It is not possible to distinguish clinically between viral and bacterial tonsillitis. (next page: differences between viral & bacterial tonsillitis.)

*Complication: 1- recurrent fever 2- pneumonia 3- sinusitis 4- otitis media 5-adenitis

6- conjunctivitis 7-pharyngitis *the common cold viruses are (rhinovirus, influenza, coronavirus, respiratory syncytial virus (RSV)).

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differences between viral & bacterial tonsillitis

viral bacterial

Gradual Sudden Onset

mild sever Course

moderate high Fever

early late Cough

< 10,000 > 10,000 WBCs

+/- membrane both Follicles &/or membrane

+/- + Cervical lymph node

+/- +++ Complication as quinsy (Peritonsillar abscess)

The indications for tonsillectomy are controversial but include:

1. recurrent tonsillitis (as opposed to recurrent URTIs) -

tonsillectomy reduces the number of episodes of

tonsillitis by a third, e.g. from three to two per year

2. a peritonsillar abscess (quinsy)

3. obstructive sleep apnoea

Indications for the removal of both the tonsils and adenoids are controversial but

include:

1. otitis media with effusion with hearing loss, when it gives a small additional

benefit to the insertion of grommets (ventilation tubes).

2. obstructive sleep apnoea (an absolute indication).

3. In young children the adenoids grow proportionately faster than the airway, so

that their effect of narrowing the airway lumen is greatest between 2 and 8 years

of age. They may narrow the posterior nasal space sufficiently to justify

adenoidectomy.

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2( Laryngeal and tracheal infections: * The mucosal inflammation and swelling produced by laryngeal and tracheal infections can rapidly cause life-threatening obstruction of the airway in young children. * characterized by: stridor on inspiration, hoarseness due to inflammation of the vocal cords, a barking cough like a sea lion and dyspnoea.

1-infection

Croup Acute epiglottitis

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* The commonest cause of stridor in childhood & infancy. * 95% of laryngotracheal infections. * Etiology: - mainly viral (mostly Parainfluenza, RSV, Influenza, Adenovirus, Measles, Metapneumovirus.) - Bacterial: 1ry cause → Diphtheria 2ry to viral inf. → most common Staphylococcus aureus, Streptococcus pneumoniae & H. influenza

* Age: 6 months - 6 years of age but the peak incidence is in the second year of life. * Croup is commonest in the autumn and early winter.

*There is mucosal inflammation and ↑ secretions affecting the larynx, trachea and bronchi, but edema in subglottic area is dangerous in young children may cause critical narrowing of the trachea

* Less common but more serious than viral croup. * Is a life-threatening emergency due to respiratory obstruction.

* Etiology: Bacterial infection, mostly H. influenza type B. (Hib immunization in infancy has led to a decrease of over 99% in the incidence of Epiglottitis and other invasive H. influenzae type b infections.)

* Age: 1yrs - 6yrs in children, but can affects all age groups.

* There is intense swelling of the epiglottis and surrounding tissues associated with Septicemia.

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1- onset: over days 2- typical feature: harsh, rasping inspiratory stridor - barking cough - hoarseness 3- usually preceded by low grade fever and coryza. (for 1-2 days) 4- start & worse at night. 5- if sever: marked tachepnea, intercostals chest recession, cyanosis & continuous stridor

1- onset: over hours, sudden. 2- high fever - toxic-looking child - sore throat (prevent speaking or swallowing) - saliva drools down the chin – soft, whispering inspiratory stridor and rapidly dyspnea.

cough is minimal or absent 3- over hours the child sits immobile, upright, with an open mouth to optimise the airway.

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1- mild: can usually be managed at home, by keep him at rest, use of steam of hot shower in close bathroom and use routinely of steroid (Oral dexamethasone ,oral

prednisolone and nebulised steroids, budesonide) can reduce the severity and duration of croup and the need for hospitalization.

2- sever: need for hospitalization: Nebulised epinephrine (adrenaline) , humidified O2 , (When saturation of <93% →nebulised epinephrine (adrenaline) with oxygen by face

mask and closely monitored) , steroid therapy & few cases require tracheal intubation. If no response: tracheostomy is life saving.

1- Urgent hospitalization & start treatment without delay. 2- transferred the child to ICU and operation room in presence of senior anesthetist ,pediatrician and ENT surgeon in case of obstruction to do tracheostomy if needed 3- Intubated under controlled conditions with a general anesthetic. 4- Urgent tracheostomy is life-saving. 5- Only after the airway is secured , do blood culture and IV antibiotics such as Cefuroxime (zinacef) (2nd generation cephalosporin) for 2-3 days. 6- With appropriate treatment, most children recover completely within 2-3 days.

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Bacterial tracheitis (pseudomembranous croup): caused by infection with Staphylococcus aureus or H. influenzae Rare but dangerous. Similar to severe viral croup except that the child has a high fever, appears toxic, loud stridor and has rapidly progressive airways obstruction with copious thick airway secretions. IV antibiotics and intubation and ventilation if required.

Diphtheritic laryngitis: Gradual onset, mild sore throat, low grade fever, grayish membrane formed On tonsils extending to the larynx, toxemia & enlarge cervical L.N, in addition to typical feature. Death occur from sever obstruction unless tracheostomy performed + Penicillin & antitoxin

* Don't Attempts to lie the child down or examine the throat with a spatula or perform a lateral neck X-ray as they can lead to total airway obstruction and death So, must be performed in the operating room in presence of anesthetist to do urgent tracheostomy if needed * Direct laryngoscope (in the operating room) show red & swollen epiglottis. * As with other serious H. influenzae infection, prophylaxis with Rifampicin is offered to close household contact

Chronic

Congenital laryngeal stridor (Laryngomalacia): * It’s called Laryngomalacia or Tracheomalacia. Stridor occurs immediately at or few days after birth. * Clinical features: - More common in boys. - Noisy respiratory & stridor start immediately at or few days after. * Diagnosis: - Direct laryngoscope. - the condition improve spontaneously by the age of 1 year.

Congenital web or papilloma: need surgical removal.

2-Allergy

Acute spasmodic laryngitis (mid-night croup): * Acute, self limited & usually recurrent laryngeal spasm. The etiology is unknown, but may be due to emotional disturbance. * Clinical feature: sudden onset at midnight of barking cough, hoarseness, stridor and respiratory distress with tachycardia. The attack usually subsides after 1-4 hours. It may occur in the same night or the next 1-2 nights. * Treatment: Humidification (steam from hot shower) is usually sufficient.

Allergic laryngeal oedema (angioedema): * May associated with other evidences of allergy as urticarial skin rash. It improves by epinephrine or hydrocortisone.

3-Mechanical

Laryngeal foreign body: * Very important in pediatric ages. The obstruction is mechanical followed by inflammation.

4-Metabolic

Hypocalcaemia stridor: * the patient is rachitic. Tetany is usually precipitated by infection. The stridor is usually precipitated by crying or any irritation of the child (revise Tetany)

Clinical features of croup (viral laryngotracheitis) and epiglottitis

Croup epiglottitis

Onset Over days Over hours

Preceding coryza Yes No

Cough Severe, barking Absent or slight

Able to drink Yes No

Drooling saliva No Yes

Appearance Unwell Toxic, very ill

Fever <38.5° C >38.5° C

Stridor Harsh, rasping Soft, whispering

Voice, cry Hoarse Muffled, reluctant to speak

3&4( Acute Bronchitis and Acute Bronchiolitis:

Acute Bronchitis Acute Bronchiolitis

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* Inflammation of the bronchial mucosa, usually associated with inflammation of the trachea i.e. traceobronchitis, producing a mixture of wheeze and coarse crackles. The mucosa is red & swollen ± hemorrhagic spot, covered by tenacious mucus, at times it’s purulent.

* Etiology: mainly viral (common cold viruses - influenza - measles) Bacterial (Bordetella pertussis - H.influenza - Mycoplasma pneumoniae)

* the commonest serious respiratory infection of infancy. * 2-3% of all infants are admitted to hospital with the disease each year during annual winter epidemics; 90% are aged 1-9 months (bronchiolitis is rare after 1 year of age).

* Etiology: RSV (80%), Human metapneumovirus & Parainfluenza & adenovirus * pathophysiology: infection→inflamation of bronchioles→↑mucous secretion &edema→

generalized bronchiolar obstruction→air trapping & hyper inflation of lung alveoli (gas exchange is disturbed with the result of hypoxia and in severe case of hypercapnia) * common in the 1st 2 years of life with peak incidence around 6 months

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Whooping cough (pertussis)

1- catarrhal phase: a week of coryza. 2- paroxysmal phase: - paroxysmal or spasmodic cough followed by a characteristic (lasts 3-6 weeks) inspiratory whoop worse at night and may culminate in vomiting. - the child goes red or blue in the face, and mucus flows from the nose and mouth. - Epistaxes and subconjunctival haemorrhages can occur after vigorous coughing. 3- convalescent phase: The symptoms gradually decrease, but may persist for many months.

A- start by mild URTI: 1- sharp, dry cough 2- no fever or low-grade fever. 3- rhinitis B- then gradual development of respiratory distress: 1- hyperinflation of the chest (sternum prominent - liver displaced downwards) 2- subcostal and intercostal recession 3- fine end-inspiratory crackles 4- high-pitched wheezes - expiratory > inspiratory 5- tachycardia 6- cyanosis or pallor. 7- dyspnea & tachypnoea

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1- Culture of a per-nasal swab: can early identify the organism of this disease. 2- Marked lymphocytosis (>15 × 109/L). 3- CXR: may show increase in bronchial marking

1- immuonofluroscent technique: RSV can be identified rapidly on nasopharyngeal secretions demonstrating binding of a fluorescent antibody.

2- A chest X-ray: shows hyperinflation of the lungs due to small airways obstruction, air trapping and opacities area often focal atelectasis.

3- Blood gas analysis: in severe cases, shows lowered arterial oxygen and raised CO2 tension

1- Erythromycin eradicates the organism, it ↓symptoms only if started in catarrhal phase.

2- prophylaxis erythromycin: for close contacts. 3- Immunisation: ↓ the risk of developing pertussis & the severity of disease

1- Hospitalization. 2- Humidified oxygen: to relieve cyanosis, dyspnea & irritability. 3- IV fluid: to prevent dehydration. 4- no response to antibiotic, bronchodilators & corticosteroid 5- Ribavirini ( Virazole ) is antiviral agent, recently they use it in severe cases 6- Mechanical ventilator: in severe cases with respiratory failure

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* The whoop may be absent in infants, but instead apnoea is a feature at this age. * Bronchitis in children is very different from the chronic bronchitis of adult. In children, cough and fever are the main symptoms.

* The cough may persist for about 2 weeks, or longer with pertussis or Mycoplasma inf. * There is no evidence that antibiotics, cough suppressants or expectorants speed recovery because most of this disease caused by virus . * Using antibiotics in patients who do not have bacterial infections promotes the development of antibiotic-resistant bacteria, which ↑morbidity and mortality. You’ve to be sure that is bacterial inf. Before use the antibiotic.

* Complications: pneumonia, convulsions and bronchiectasis, are uncommon. * clinical picture of bronchitis : - cough (most constant symptom) start dry then productive ( In general) - ronchi (most important sign) - fever: milde if present

* Infants born prematurely who develop bronchopulmonary dysplasia and infants with congenital heart disease are most at risk from this disease.

* Feeding difficulty associated with increasing dyspnoea is often the reason for admission to hospital.

* on examination: probably you will find hyper inflated chest with tachepnea, prolonged expiration & uses of accessory muscle, palpable ronchi, diminish tectile vocal fremitus, hyper resonance, diminish air entry, vesicular breathing with prolonged expiration and generalized wheezing and fine crepitating

* total WBC count is normal * respiratory failure is the cause of death in this case.

Differential Diagnosis of Bronchiolitis: 1. Bronchial asthma: in asthma recurrent of the attacks is

the rule, family history, eosinophilia are present in atopic cases and has good response to bronchodilator. However, bronchiolitis doesn't.

2. Congestive heart failure. 3. Foreign body aspiration. 4. Bronchopneumonia with spasm. 5. Pertussis 6. Cystic fibrosis 7- Gastro esophageal reflux