UNIVERSITATEA DE MEDICIN I FARMACIE V.

BABE TIMIOARA CLINICA I PEDIATRIE

RESPIRATORY TRACT DISEASE

COURSE 01:

Acute nasopharyngitis Adenoiditis

Anatomy of the respiratory tract

Upper respiratory tract anatomy

Acute nasopharyngitis
Definition: Acute nasopharyngitis is an inflammatory process of viral etiology, located at the nasopharyngeal mucosa.

Etiology
Etiology is always viral.
rhinoviruses (30-50%), influenza and parainfluenza adenoviruses, coronaviruses, respiratory syncytial virus, enteroviruses, measles, rubella, Epstein-Barr virus, varicella-zoster virus.

Bacteria and fungi (act only as superinfection):

group A streptococcus, streptococcus pneumoniae, haemophilus influenzae, staphylococcus aureus, mycoplasma pneumoniae, neisseria meningitidis, moraxella catarrhalis.

Etiology
Contributing factors: young age, deficiencies (dystrophy, rickets, anemia), lymphatic and exudative diatheses, cold and wet season (September to April), urban areas, entry to the community (kindergarden, school), homecare deficiencies.

Pathophysiology
A transfer is made through contact with saliva or nasal secretions contaminated with viruses: coughing, sneezing, hand contact of contaminated surfaces and carrying hand to nose or eyes. Gateway: nose or eyes (drain virus in the nasal cavity through the lacrimal ducts). Virus then bind to the ICAM-1 receptors expresed al the surface of nasopharyngeal mucosal cells and adenoid cells. After binding the receptor the virus penetrate into cell and trigger local (vasodilation + edema + infiltration with resident and recruited macrophages, monocytes, neutrophils, and eosinophils) and systemic inflammatory reaction. Release of bradykinin is responsible for local effects and cytokines are responsible for systemic effects.

Pathophysiology
The local defense system opposes the infection and is represented by: hair lining, mucus coats, normal nasopharyngeal flora, cellular immunity (immune cells contained in adenoids and tonsils), humoral immunity (immunoglobulin A). Incubation times before the appearance of symptoms vary: 1-5 days for rhinoviruses, influenza and parainfluenza viruses, up to a week for respiratory syncytial virus (RSV), two weeks for measles and rubella, 4-6 weeks for Epstein-Barr virus (EBV). Then initial nasopharyngeal infection may spread to adjacent structures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, bronchiolitis, tracheobronchitis or pneumonia.

Clinical picture
In infants, clinical manifestations are noisy. Onset with moderate fever (38-39oC), food refusal, ailment, restless sleep or drowsiness. State period last for 3-5 days and is marked by respiratory events like sneezing, nasal obstruction, mouth breathing, runny nose followed by serous or mucopurulent secretions, irritative cough, moderate signs of respiratory distress. Neurological symptoms: irritability, agitation febrile seizures Digestive symptoms: anorexia, difficulties in sucking, vomiting, diarrhea. Physical evidence includes hyperemic throat, Serous or muco-purulent secretions in the cavum.

Clinical picture
In older children clinical symptoms are nonspecific:
mild fever, headache, myalgia, sneezing, dry nasopharyngeal mucosa or runny nose followed by serous or mucopurulent secretions, irritating cough. symptoms lasts for 3 to 5 days.

Laboratory studies and procedures

CBC (complete blood count):
leucopenia with lympho-monocytosis is tipicaly for viral etiology (neutrophilic reaction is a sign of bacterial superinfection). Normal or slightly elevated inflammatory tests: ESR (erythrocyte sedimentation rate), CRP (C reactive protein), fibrinogen. Throat or nasal swab could indicate the etiologic agent in bacterial and fungal infections.

Laboratory studies and procedures

Smear directly from nasal swab:
rich in lymphocytes viral etiology rich in PMN bacterial etiology eosinophils allergic etiology.

Diagnosis
Positive diagnosis si based on:
moderate fever, rhinorrhea, irritating cough, flushing nose and throat. Optional, specific changes in CBC, throat and nasal swab.

Differential diagnosis
between viral and bacterial nasopharyngitis allergic rhinitis nasopharyngitis as the onset of other infectious disease (measles, rubella, chickenpox, whooping cough, mononucleosis) with other URIs (upper respiratory tract infections): acute adenoiditis, pharyngitis, croup, bronchiolitis etc.

Evolution - Complications
Evolution in eutrophic infants and older children is benign with healing in 3-5 days. Complications Serous or suppurative otitis media Sinusitis affecting ethmoid or maxillary sinuses and frontal (over 7 years old) Cervical lymphadenitis Retropharyngeal phlegmon Acute laryngitis Bronchiolitis or tracheobronchitis Bronchopneumonia Diarrhea (parenteral)

Prophylactic treatment
Ensuring a good nutrition and hygiene. Prophylaxis and treatment of biological loud: rickets, dystrophy, anemia, exudative diathesis. Avoid congestion and contact with sick people. Epidemiologic triage, rigorously conducted at the entry into the community (nurseries, kindergartens, schools).

Diet
Continue previous diet with supplementation of fluids lost through fever and perspiration. In diarrhea, nutrition will adapt to digestive tolerance.

Etiologic treatment
Not necesary in viral etiology. In overgrowth forms: Amoxicillin, Amoxicillin + Clavulanic Acid, Ampicillin + Sulbactam, Oral first or seccond generation cephalosporins (Cefuroxime, Cefaclor).

Pathogenic treatment
NSAIDs (Ibuprofen).
May be involved in promoting bacterial superinfection or promote evolution to otitis media.

Symptomatic treatment
Fever: acetaminophen (paracetamol), metamizolum (algocalmin, novocalmin). No Aspirin in infants and young children (risk of Reye Syndorme: encefalo-hepato-renal syndrome). Obstructed nose: sea water or normal saline + ephedrine in infant and child under 2 years; Olynth, Pivalone, Picnaz in children over 2 years old. Agitation: Romergan. Control of febrile seizures: rectal diazepam (Desitin).

Adenoiditis
Acute Subacute Chronic Definition Acute, subacute or persistent inflammation of adenoids (pharyngeal tonsil Luschka).

Etiology
Viral: adenoviruses, coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus, Epstein-Barr virus, herpes simplex, etc. Bacterial: gr. A -hemolytic Streptococcus, gr. C -hemolytic Streptococcus, Staphylococcus aureus, Sreptococcus pneumoniae, Gram negative agents Mycoplasmas: Mycoplasma pneumoniae Fungi: Candida albicans.

Etiology
Contributing factors: young age, deficiencies (dystrophy, rickets, anemia), lymphatic and exudative diatheses, cold and wet season (September to April), urban areas, entry to the community (kindergarden, school), homecare deficiencies.

Acute adenoiditis clinical picture

Symptomatic triad: reverse type fever nasal obstruction posterior mucous-purulent secretion. Fever characteristics: abrupt onset, 39-40 C, irregular, reverse type (with morning peak), frequently associated with chills.

Acute adenoiditis clinical picture

Severe nasal obstruction resulting in oral breathing, snoring and sleep apnea, eating difficulty. Posterior mucous-purulent secretion: purulent exudate (whitish or yellowish) which trickles the back of the throat. Rhinorrhea was not previously exhibited due to obstruction by adenoids hypertrophy. Other clinical signs: impaired general condition, agitation, sleeping difficulties, inappetence, irritating cough, vomiting (gastric iritation by the swallowed secretions), parenteral diarrhea, febrile seizures.

Laboratory studies and procedures

CBC: leucopenia with lymphocytosis in viral etiology or neutrophilic reaction in bacterial etiology. Throat or nasal swab indicates the etiologic agent for bacterial infections. Increased inflammatory tests: ESR, CRP, fibrinogen. Posterior rhinoscopy or finger touches reveals enlargement of adenoid mass.

Fiberoptic anterior rhinoscopy

Adenoids

Nasal septum

Eustachian Tube

Adenoids

Posterior rhinoscopy

Diagnosis
Positive diagnosis is based on symptomatic triad (reverse type fever - nasal obstruction posterior mucous-purulent secretion), presence of inflammatory exudate in the posterior pharynx, anterior and posterior rhinoscopy.

Differential diagnosis
acute nasopharyngitis subacute and chronic adenoiditis pharyngitis and tonsillitis croup nasal foreign body pharyngeal tumors pre-eruptive period of measles, rubella, whooping cough, etc.

Complications
suppurative otitis media sinusitis (ethmoid, maxillary or frontal sinuses) croup cervical or retropharyngeal phlegmon parenteral diarrhea.

Treatment
Prophylactic treatment
Ensuring a good nutrition and hygiene. Prophylaxis and treatment of biological loud: rickets, dystrophy, anemia, exudative diathesis. Avoid congestion and contact with sick people. Epidemiologic triage, rigorously conducted at the entry into the community (nurseries, kindergartens, schools).

Treatment
Diet
Continue previous diet supplementing fluid and calorie intake. In diarrhea, nutrition will adapt to digestive tolerance.

Etiologic treatment
Antibiotics: Amoxicillin, Amoxicillin + Clavulanic Acid, Ampicillin + Sulbactam, Oral first or seccond generation cephalosporins (Cefuroxime, Cefaclor), Clarithromycin

Treatment
Pathogenic treatment
NSAIDs (Ibuprofen).

Symptomatic treatment
Fever: acetaminophen (paracetamol), metamizolum (algocalmin, novocalmin). No Aspirin in infants and young children (risk of Reye Syndorme: encefalohepato-renal syndrome). Obstructed nose: sea water or normal saline + ephedrine in infant and child under 2 years; Olynth, Pivalone, Picnaz in children over 2 years old.

Subacute adenoiditis
Definition
Persistent or relapsing inflammation of the adenoids.

Clinical picture
Persistent fever for 2-3 weeks with irregular pattern, usualy reverse type (more evident than in the acute form), sometimes tenacious and unresponsive to medication. Persistent nasal obstruction with posterior mucouspurulent secretion. Transient hearing loss and ear pain. Digestive symptoms like anorexia, vomiting, diarrhea, leading to weight loss.

Subacute adenoiditis
Laboratory studies and procedures
CBC: leucocitosis with neutrophilic reaction. Increased inflammatory tests: ESR, CRP, fibrinogen. Throat or nasal swab indicates the etiologic agent for bacterial infections. Posterior rhinoscopy reveals enlargement of adenoid mass that are redness and edematous with purulent secretions in the posterior pharynx.

Subacute adenoiditis
Differential diagnosis
the entities referred to as acute, plus urinary tract infection septicemia tuberculosis mastoiditis.

Complications
similar with acute form.

Treatment
Medical: as in acute form. Surgical: adenoidectomy could be necessary.

Chronic adenoidal hypertrophy

Definition
Chronic irreversible hypertrophy of adenoids, responsible for a persistent respiratory distress.

Clinical picture
Poor general condition with permanently open mouth, peri-oral-nasal cyanosis Oral breathing, Agitation, fatigue, Interrupted sleep with snoring and noisy breathing Recurrent/ frequent infectious events (local and general)

Chronic adenoidal hypertrophy

Consequences of chronic hypoxia:
growth retardation underdeveloped chest, with signs or sequelae of rickets

Adenoid Facies is the long, open-mouthed, dumb-looking face of children with adenoid hypertrophy:
underdeveloped thin nostrils short upper lip prominent upper teeth crowded teeth narrow upper alveolus high-arched palate hypoplastic maxilla

Facies adenoidian

Differential diagnosis
Same as for acute and subacute adenoiditis, plus:
hypertrophic rhinitis choanal atresia deviated nasal septum nasopharyngeal tumors

Complications
Infectious:
pharingitis, tonsilitis, sinusitis, bronchitis, pneumonia, recurrent suppurative otitis, mastoiditis

Functional:
hearing loss

Digestive:
recurrent or chronic diarrhea

General:
growth retardation, low school performance

Treatment
Treatment is surgical - Adenoidectomy Indications for adenoidectomy:
persistent nasal airway obstruction, whith obstructive breathing, obstructive sleep apnea and chronic mouth breathing recurrent or persistent otitis media recurrent and/or chronic sinusitis recurrent pharyngitis

Should be performed at least 2-3 weeks after an acute episode of infection.

Adenoids