- Agent: - Group A β hemolytic streptococcus
- Common between 4-14yrs with peak incidence (4-7yr of age) Uncommon before 2-3yr
of age
- Spread: from person to person by droplets.
- Incubation period 2-5 days.
Clinical manifestation;
1) Acute infection: symptoms of GABHS infection include; odynophagia, dry throat,
malaise, fever and chills.- Dysphagia, headache, muscular aches and enlarged cervical
nodes.
2) Chronic infection: children with chronic or cryptic tonsillitis frequently present with
Complications; halitosis, chronic sore throat, foreign body sensation or history of expelling foul tasting
• Poststreptococcal glomerulonephritis. andsmelling cheesy lumps.
• Acute rheumatic fever. 3) Airway obstruction: symptoms of airway obstruction secondary to adenotonsillar
• Peritonsillar infection (abscess or cellulitis) hypertrophy include chronic mouth breathing, nasal obstruction, hyponasal speech,
decreased appetite. - Poor school performance and rarely symptoms of right heart failure - Acute
Nighttime symptoms; snoring, chocking, gasping, frank apnea, restless sleep, abnormal sleep pharyngotonsilitis:
position. - On exam; large tonsils
4) Tonsillar neoplasm: the rapid unilateral enlargement of tonsil with systemic signs of
night sweats, fever, weight loss and lymphadenopathy.
Diagnosis; Pharyngitis refers to inflammation of the pharynx,
Clinically including erythema, edema, exudates or an enanthem
Paraclinical: (ulcer, vesicles)
-leukocytosis with increase PMN cells -rapid detection method for streptococcal antigen
-throat swab culture.
Treatment; Viral pharyngitis;
Medical treatment antibiotics Acute; amoxicillin(50mg/kg/day BD) or penicillin(25- •The onset may be more gradual with rhinorrhea, cough and diarrhea.
50mg/kg/day) for 10 daysChronic; cephalosporin or clindamycin •A viral etiology is suggested by the presence of conjunctivitis, coryza,
Causes; hoarseness and cough.
1)Viruses • Additional manifestations which are specific for each virus include:
Tonsillectomy indications: -EBV the pharyngitis is similar to that caused by streptococcal infection plus
1. 7 or more throat infections treated with antibiotics in the preceding yr. account for 80-85%Viral upper respiratory tract infections are typically spread by
contact with oral or respiratory secretions. generalized lymphadenopathy and hepatospleenomegaly.
2. 5 or more throat infections treated in the preceding 2yr. -adenovirus may be associated with conjunctivitis and fever.
3. 3 or more throat infections treated with antibiotics in each of the preceding 3yr. Important viruses cause pharyngitis include; influenza, parainfluenza, rhinoviruses,
respiratory syncytial virus, Epstein-Barr virus. -coxsackievirus may produce small grayish vesicles and punch-out ulcers
4. 5 or more episodes per year of tonsillitis with disabling symptoms and for longer than a yr. (herpangina).
Symptomatic; rest, antipyretics, throat irrigation, soft diet -primary HSV present with high fever and gingivostomatitis
2)Bacterial causes
Acute pharyngitis: Account for 15-20% Group A streptococcus is the most important bacterial cause
of acute pharyngitis.Other bacteria; Neisseria gonorrhea, mycoplasma pneumonia
and chlamydia. Treatment;
General consideration; Most untreated episodes of streptococcal pharyngitis resolve uneventfully in
Acute inflammation of the upper airway is more frequent and of great 3)Non-infectious causes a fewdays, but early antibiotics therapy hastens clinical recovery by 12-24hr
important in infants and small children than older children because the Tobacco smoke, air pollutants and allergen. •Oral amoxicillin or penicillin-V
airway is smaller, predisposing young children to a great narrowing •Antipyretics (paracetamol or ibuprofen) for fever and sore throat pain.
🔸
during inflammation.
The term croup refers to a heterogeneous group of mainly acute
and infectious conditions that are characterized by: a barking-like,
•Gargling with warm salt water
•Feed the child during illness with soft diet and increase fluid
brassy or croupy cough which may accompanied by
hoarseness, inspiratory stridor and respiratory distress, due to various Clinical manifestation: Complications;
🔸
degree of laryngeal obstruction.
Stridor; is a harsh noisy breathing sound, mostly inspiratory, caused
by partial obstruction of the larynx
•The onset of streptococcal pharyngitis is rapid with prominent sore throat, absence of
cough and fever. 1. Acute otitis media. 2. Acute sinusitis. 3. Mastoditis
• Headache and gastrointestinal symptoms (abdominal pain and vomiting) are frequent.
• The pharynx is red and the tonsils are enlarged and classically covered with a yellow, 4. Local supportive complication;
blood-tinged exudate. •parapharyngeal abscess and acute cervical lymphadenitis.
It is a viral infection of the glottis and subglottic regions. - 5. Non-supportive illness; acute rheumatic fever and acute postinfectious
Most patients with croup are between the ages of 3months • They may be petechia or dough nut lesions on the soft palate and posterior pharynx.
• Anterior cervical lymph nodes are enlarged and tender. glomerulonephritis.
and 5years, with the peak in the 2nd year of life. - Higher in 6. Mesenteric adenitis.
male. • Incubation period is 2-5days.
Causes;
- Parainfluenza viruses( type 1, 2 and 3)--- 75% of cases
- Influenza virus A and B, adenovirus, RSV, measles and Acute respiratory
rhinovirus.
infections An acute inflammation of the middle ear caused most frequently by bacterial infection.Common in
the first 6yrs of life, most common under 2yrs with peak incidence is from 6-20mo ofage.
Clinical manifestation;
Most patients have an upper respiratory tract infection with rhinorrhea, pharyngitis, mild
cough and low grade fever for 1-3 days.
🔸
Etiology:
🔸 Bacteria; streptococcus pneumonia, non-typable H.infleunza and Moraxella catarrhalis
Viral; RSV, Rhinovirus and Adenovirus
The child then develops, barking cough, hoarseness and inspiratory stridor.
Risk factors
🔸
The low grade fever may persist, some children are afebrile.
Symptoms are characteristically worse at night and recur with decreasing intensity for
several days and resolve completely within a week.
1. Young age (infants and young children) due to
2. Eustachian tube is short, wide and horizontal
Agitation and crying greatly aggravate the symptoms and signs. 3. Low immunity
The child may prefer to sit up in bed or be held upright. 4. Bottle feeding in supine position
Older children usually are not seriously ill. May there is family history of mild respiratory 5. Male
illness. 6. Low socioeconomic status
Physical examination; Croup (laryngotracheo 7. Children with HIV, cleft palate or trisomy 21
Hoarse voice, coryza, normal to moderately inflamed pharynx and slightly increased
respiratory rate.
bronchitis) 8. Bottle feeding
9. Family history of ear infection
10. Passive exposure to tobacco smoke
11. Increase exposure to infectious agents.
Diagnosis;
Clinically Clinical manifestation; Complications;
Radiography neck x-ray posterioanterior view show the typical subglottic
narrowing or (steeple sign)
Acute otitis media 🔸 Infants
• Nonspecific symptoms include; fever, irritability and poor feeding Diarrhea and vomiting
1. Chronic effusion
2. Hearing loss (mainly conducting hearing loss)
• Rolling head and pulling of ear. 3. Cholesteatoma
Treatment;
Mist has been traditionally used to treat croup
🔸 Older children and adolescents
• Fever and Otalgia (acute ear pain)
4. Acute mastoditis
5. Meningitis
• Otorrhea or ear drainage, after spontaneous rupture of tympanic membrane 6. Intracranial extension(brain abscess, subdural empyema and venous
Mild croup: Oral dexamethasone used at single dose of 0.6mg/kg Oral dosing of dexamethasone is • Headache and irritability thrombosis)
Prevention;
as effective as intramuscular administration
Moderate to severe croup:-
Nebulized racemic epinephrine (dose of 0.25-0.75ml of 2.25% racemic epinephrine in 3 ml normal
🔸
• Anorexia, nausea and vomiting
Otoscopic exam reveals;
• Bulging, immobile and hyperemic tympanic membrane
• Continuous exclusive breastfeeding as long as possible and should
be cautioned about the risk of bottle-propping.
saline can be used every 20mint)- A helium- oxygen mixture (heliox) may be effective in children with • Distortion of the landmarks and light reflex • The home should be smoke-free environment
severe croup who need intubation. • Perforation of the tympanic membrane and otorrhea may be seen • Pneumococcal and influenza vaccine.
Indication of admission
1. Moderate to severe stridor at rest Diagnosis:
2. Progressive stridor clinical
3. Respiratory distress
Treatments;
4. Hypoxia and cyanosis
5. Depressed mental status 🔸 Symptomatic: analgesic and antipyretics (acetaminophen and ibuprofen) and nasal
6. Poor oral intake
7. Need for reliable observation. ACUTE 🔸Specific: antibioticsFirst line therapy; amoxicillin (80-90mg/kg in two divided doses)
decongestants.
Next step treatments;
An acute inflammation of the epiglottis and supraglottic tissues. - INFLAMMATORY High dose amoxicillin-clavulanateCefuroxime axetil(75-100mg/kg/day IV/IM
3DD)CefdinirCeftriaxone (50mg/kg intramuscular in one to the divided doses)
It is dramatic, potentially lethal condition.
Cause; UPPER AIR WAY • Tympanocentesis indication in patients who are difficult to treat or who do not responds to
therapy
Homophiles influenza type b
Other agents; Streptococcus pyogenes, streptococcus
OBSTRUCTION
pneumonia and staphylococcus aureus
Clinical manifestation;
-High fever, sore throat, dyspnea and rapid progressing respiratory obstruction
-The patient appears toxic, swallowing difficulties and breathing is labored
-Drooling is usually present and the neck is hyperextended
-The child may assume the tripod position, sitting upright and leaning forward with the
chin up and mouth open while bracing on the arms
-A brief period of air hunger with restlessness may be followed by rapidly increasing by fatema okoff
cyanosis and coma
-Stridor is a late finding and suggests near-complete airway obstruction
-Complete obstruction of the airway and death can ensure unless adequate treatment is
provided Acute epiglottitis
No other family members are ill with acute respiratory symptoms
Diagnosis;
• Large, cherry and swollen epiglottis by laryngoscope
•Lateral neck radiograph thumb sign
Treatment;
🔸
It is a medical emergency and warrants immediate treatment with an artificial airway
🔸 Admission to ICU
🔸 Nasotracheal intubation for 2-3 days
Antibiotics ceftriaxone(75-100mg/kg once or twice per day) , cefatoxim or
🔸
combination of ampicillin and sulbactam
🔸 Duration of antibiotics 7-10 days
Chemoprophylaxis with rifampicin (20mg/kg orally once a day for 4 days,
🔸
maximum dose 600mg) for all household member
🔸 Any contact <48m of age who is incompletely immunized
🔸 Any contact <12m who has not received the primary vaccination series
An immunocompromised child in the household.
Spasmodic croup;
🔸 occurs in children1-3years of age and is clinically similarto acute laryngeotracheo bronchitis, except the
🔸
Historyof aviral prodromandfeverin the patientand family are frequently absent.
🔸 Cause is allergy and psychological factors
🔸
🔸
Laryngoscopy reveals pale, watery edema
occuring frequently in the evening or nighttime
🔸
🔸
Spasmodic croup begins with sudden onsetthat may be preceded by mild to moderate coryza or hoarseness
The child awakens with barking metallic cough, noisy inspiration and respiratory distress and appears anxious and frightened
🔸 The patient usually afebrile
The severity of the symptoms diminishes within several hours and the following day,the patient appears well
except for slight hoarsene'ss and'cough
🔸
🔸Acute laryngotracheobronchitis (croup)
🔸
🔸
Acute epiglottitis
Bacterial trachitis
Differential diagnosis of upper
🔸
🔸
Foreign body inhalation
Angioneurotic edema airway obstruction
🔸Laryngeal
Tetany
diphtheria
- Common between 4-14yrs with peak incidence (4-7yr of age) Uncommon before 2-3yr
of age
- Spread: from person to person by droplets.
- Incubation period 2-5 days.
Clinical manifestation;
1) Acute infection: symptoms of GABHS infection include; odynophagia, dry throat,
malaise, fever and chills.- Dysphagia, headache, muscular aches and enlarged cervical
nodes.
2) Chronic infection: children with chronic or cryptic tonsillitis frequently present with
Complications; halitosis, chronic sore throat, foreign body sensation or history of expelling foul tasting
• Poststreptococcal glomerulonephritis. andsmelling cheesy lumps.
• Acute rheumatic fever. 3) Airway obstruction: symptoms of airway obstruction secondary to adenotonsillar
• Peritonsillar infection (abscess or cellulitis) hypertrophy include chronic mouth breathing, nasal obstruction, hyponasal speech,
decreased appetite. - Poor school performance and rarely symptoms of right heart failure - Acute
Nighttime symptoms; snoring, chocking, gasping, frank apnea, restless sleep, abnormal sleep pharyngotonsilitis:
position. - On exam; large tonsils
4) Tonsillar neoplasm: the rapid unilateral enlargement of tonsil with systemic signs of
night sweats, fever, weight loss and lymphadenopathy.
Diagnosis; Pharyngitis refers to inflammation of the pharynx,
Clinically including erythema, edema, exudates or an enanthem
Paraclinical: (ulcer, vesicles)
-leukocytosis with increase PMN cells -rapid detection method for streptococcal antigen
-throat swab culture.
Treatment; Viral pharyngitis;
Medical treatment antibiotics Acute; amoxicillin(50mg/kg/day BD) or penicillin(25- •The onset may be more gradual with rhinorrhea, cough and diarrhea.
50mg/kg/day) for 10 daysChronic; cephalosporin or clindamycin •A viral etiology is suggested by the presence of conjunctivitis, coryza,
Causes; hoarseness and cough.
1)Viruses • Additional manifestations which are specific for each virus include:
Tonsillectomy indications: -EBV the pharyngitis is similar to that caused by streptococcal infection plus
1. 7 or more throat infections treated with antibiotics in the preceding yr. account for 80-85%Viral upper respiratory tract infections are typically spread by
contact with oral or respiratory secretions. generalized lymphadenopathy and hepatospleenomegaly.
2. 5 or more throat infections treated in the preceding 2yr. -adenovirus may be associated with conjunctivitis and fever.
3. 3 or more throat infections treated with antibiotics in each of the preceding 3yr. Important viruses cause pharyngitis include; influenza, parainfluenza, rhinoviruses,
respiratory syncytial virus, Epstein-Barr virus. -coxsackievirus may produce small grayish vesicles and punch-out ulcers
4. 5 or more episodes per year of tonsillitis with disabling symptoms and for longer than a yr. (herpangina).
Symptomatic; rest, antipyretics, throat irrigation, soft diet -primary HSV present with high fever and gingivostomatitis
2)Bacterial causes
Acute pharyngitis: Account for 15-20% Group A streptococcus is the most important bacterial cause
of acute pharyngitis.Other bacteria; Neisseria gonorrhea, mycoplasma pneumonia
and chlamydia. Treatment;
General consideration; Most untreated episodes of streptococcal pharyngitis resolve uneventfully in
Acute inflammation of the upper airway is more frequent and of great 3)Non-infectious causes a fewdays, but early antibiotics therapy hastens clinical recovery by 12-24hr
important in infants and small children than older children because the Tobacco smoke, air pollutants and allergen. •Oral amoxicillin or penicillin-V
airway is smaller, predisposing young children to a great narrowing •Antipyretics (paracetamol or ibuprofen) for fever and sore throat pain.
🔸
during inflammation.
The term croup refers to a heterogeneous group of mainly acute
and infectious conditions that are characterized by: a barking-like,
•Gargling with warm salt water
•Feed the child during illness with soft diet and increase fluid
brassy or croupy cough which may accompanied by
hoarseness, inspiratory stridor and respiratory distress, due to various Clinical manifestation: Complications;
🔸
degree of laryngeal obstruction.
Stridor; is a harsh noisy breathing sound, mostly inspiratory, caused
by partial obstruction of the larynx
•The onset of streptococcal pharyngitis is rapid with prominent sore throat, absence of
cough and fever. 1. Acute otitis media. 2. Acute sinusitis. 3. Mastoditis
• Headache and gastrointestinal symptoms (abdominal pain and vomiting) are frequent.
• The pharynx is red and the tonsils are enlarged and classically covered with a yellow, 4. Local supportive complication;
blood-tinged exudate. •parapharyngeal abscess and acute cervical lymphadenitis.
It is a viral infection of the glottis and subglottic regions. - 5. Non-supportive illness; acute rheumatic fever and acute postinfectious
Most patients with croup are between the ages of 3months • They may be petechia or dough nut lesions on the soft palate and posterior pharynx.
• Anterior cervical lymph nodes are enlarged and tender. glomerulonephritis.
and 5years, with the peak in the 2nd year of life. - Higher in 6. Mesenteric adenitis.
male. • Incubation period is 2-5days.
Causes;
- Parainfluenza viruses( type 1, 2 and 3)--- 75% of cases
- Influenza virus A and B, adenovirus, RSV, measles and Acute respiratory
rhinovirus.
infections An acute inflammation of the middle ear caused most frequently by bacterial infection.Common in
the first 6yrs of life, most common under 2yrs with peak incidence is from 6-20mo ofage.
Clinical manifestation;
Most patients have an upper respiratory tract infection with rhinorrhea, pharyngitis, mild
cough and low grade fever for 1-3 days.
🔸
Etiology:
🔸 Bacteria; streptococcus pneumonia, non-typable H.infleunza and Moraxella catarrhalis
Viral; RSV, Rhinovirus and Adenovirus
The child then develops, barking cough, hoarseness and inspiratory stridor.
Risk factors
🔸
The low grade fever may persist, some children are afebrile.
Symptoms are characteristically worse at night and recur with decreasing intensity for
several days and resolve completely within a week.
1. Young age (infants and young children) due to
2. Eustachian tube is short, wide and horizontal
Agitation and crying greatly aggravate the symptoms and signs. 3. Low immunity
The child may prefer to sit up in bed or be held upright. 4. Bottle feeding in supine position
Older children usually are not seriously ill. May there is family history of mild respiratory 5. Male
illness. 6. Low socioeconomic status
Physical examination; Croup (laryngotracheo 7. Children with HIV, cleft palate or trisomy 21
Hoarse voice, coryza, normal to moderately inflamed pharynx and slightly increased
respiratory rate.
bronchitis) 8. Bottle feeding
9. Family history of ear infection
10. Passive exposure to tobacco smoke
11. Increase exposure to infectious agents.
Diagnosis;
Clinically Clinical manifestation; Complications;
Radiography neck x-ray posterioanterior view show the typical subglottic
narrowing or (steeple sign)
Acute otitis media 🔸 Infants
• Nonspecific symptoms include; fever, irritability and poor feeding Diarrhea and vomiting
1. Chronic effusion
2. Hearing loss (mainly conducting hearing loss)
• Rolling head and pulling of ear. 3. Cholesteatoma
Treatment;
Mist has been traditionally used to treat croup
🔸 Older children and adolescents
• Fever and Otalgia (acute ear pain)
4. Acute mastoditis
5. Meningitis
• Otorrhea or ear drainage, after spontaneous rupture of tympanic membrane 6. Intracranial extension(brain abscess, subdural empyema and venous
Mild croup: Oral dexamethasone used at single dose of 0.6mg/kg Oral dosing of dexamethasone is • Headache and irritability thrombosis)
Prevention;
as effective as intramuscular administration
Moderate to severe croup:-
Nebulized racemic epinephrine (dose of 0.25-0.75ml of 2.25% racemic epinephrine in 3 ml normal
🔸
• Anorexia, nausea and vomiting
Otoscopic exam reveals;
• Bulging, immobile and hyperemic tympanic membrane
• Continuous exclusive breastfeeding as long as possible and should
be cautioned about the risk of bottle-propping.
saline can be used every 20mint)- A helium- oxygen mixture (heliox) may be effective in children with • Distortion of the landmarks and light reflex • The home should be smoke-free environment
severe croup who need intubation. • Perforation of the tympanic membrane and otorrhea may be seen • Pneumococcal and influenza vaccine.
Indication of admission
1. Moderate to severe stridor at rest Diagnosis:
2. Progressive stridor clinical
3. Respiratory distress
Treatments;
4. Hypoxia and cyanosis
5. Depressed mental status 🔸 Symptomatic: analgesic and antipyretics (acetaminophen and ibuprofen) and nasal
6. Poor oral intake
7. Need for reliable observation. ACUTE 🔸Specific: antibioticsFirst line therapy; amoxicillin (80-90mg/kg in two divided doses)
decongestants.
Next step treatments;
An acute inflammation of the epiglottis and supraglottic tissues. - INFLAMMATORY High dose amoxicillin-clavulanateCefuroxime axetil(75-100mg/kg/day IV/IM
3DD)CefdinirCeftriaxone (50mg/kg intramuscular in one to the divided doses)
It is dramatic, potentially lethal condition.
Cause; UPPER AIR WAY • Tympanocentesis indication in patients who are difficult to treat or who do not responds to
therapy
Homophiles influenza type b
Other agents; Streptococcus pyogenes, streptococcus
OBSTRUCTION
pneumonia and staphylococcus aureus
Clinical manifestation;
-High fever, sore throat, dyspnea and rapid progressing respiratory obstruction
-The patient appears toxic, swallowing difficulties and breathing is labored
-Drooling is usually present and the neck is hyperextended
-The child may assume the tripod position, sitting upright and leaning forward with the
chin up and mouth open while bracing on the arms
-A brief period of air hunger with restlessness may be followed by rapidly increasing by fatema okoff
cyanosis and coma
-Stridor is a late finding and suggests near-complete airway obstruction
-Complete obstruction of the airway and death can ensure unless adequate treatment is
provided Acute epiglottitis
No other family members are ill with acute respiratory symptoms
Diagnosis;
• Large, cherry and swollen epiglottis by laryngoscope
•Lateral neck radiograph thumb sign
Treatment;
🔸
It is a medical emergency and warrants immediate treatment with an artificial airway
🔸 Admission to ICU
🔸 Nasotracheal intubation for 2-3 days
Antibiotics ceftriaxone(75-100mg/kg once or twice per day) , cefatoxim or
🔸
combination of ampicillin and sulbactam
🔸 Duration of antibiotics 7-10 days
Chemoprophylaxis with rifampicin (20mg/kg orally once a day for 4 days,
🔸
maximum dose 600mg) for all household member
🔸 Any contact <48m of age who is incompletely immunized
🔸 Any contact <12m who has not received the primary vaccination series
An immunocompromised child in the household.
Spasmodic croup;
🔸 occurs in children1-3years of age and is clinically similarto acute laryngeotracheo bronchitis, except the
🔸
Historyof aviral prodromandfeverin the patientand family are frequently absent.
🔸 Cause is allergy and psychological factors
🔸
🔸
Laryngoscopy reveals pale, watery edema
occuring frequently in the evening or nighttime
🔸
🔸
Spasmodic croup begins with sudden onsetthat may be preceded by mild to moderate coryza or hoarseness
The child awakens with barking metallic cough, noisy inspiration and respiratory distress and appears anxious and frightened
🔸 The patient usually afebrile
The severity of the symptoms diminishes within several hours and the following day,the patient appears well
except for slight hoarsene'ss and'cough
🔸
🔸Acute laryngotracheobronchitis (croup)
🔸
🔸
Acute epiglottitis
Bacterial trachitis
Differential diagnosis of upper
🔸
🔸
Foreign body inhalation
Angioneurotic edema airway obstruction
🔸Laryngeal
Tetany
diphtheria
