PEDIATRICS 2

Upper Respiratory Tract Disorders

Maria Cristina R. Edquilag, MD, FPSAAI, FPPS 11 October 2021 | S01.T04B

OUTLINE → Exposure to daycare centers [Dr. Edquilag, 2021]

→ Tendency to touch many things [Dr. Edquilag, 2021]
I. Rhinitis (Common Cold) IV. Croup
A. Etiology A. Etiology → Because of the pandemic, there are less incidences since kids
B. Epidemiology B. Clinical Manifestations are kept at home [Dr. Edquilag, 2021]
C. Pathogenesis C. Diagnosis • Incidence decreases as child grows older (2-3 colds per year by
D. Clinical Manifestations D. Treatment adulthood)
E. Complications V. Epiglottitis (Supraglottitis) • Mannose-binding lectin deficiency with impaired innate immunity
F. Diagnosis A. Etiology may be associated with an increased incidence of colds in
G. Treatment B. Clinical Manifestations children [Nelson’s 20th ed]
II. Acute Sinusitis C. Diagnosis Treatment
A. Etiology VI. Bacterial Tracheitis C. PATHOGENESIS
B. Epidemiology VII. Retropharyngeal and Lateral Mode of Transmission
C. Pathogenesis Pharyngeal Abscess
D. Clincal Manifestations A. Etiology • Direct hand contact:
E. Complications B. Clinical Manifestations → Self-inoculation of one’s own nasal mucosa or conjunctivae
F. Diganosis C. Diagnosis after touching a contaminated person or object
G. Treatment D. Treatment → RSV and Rhinovirus
III. Acute Tonsillopharyngitis E. Complications • Inhalation of small-particle aerosols airborne from cough
A. Etiology VIII. Peritonsillar Cellulitis and/or → Influenza and coronavirus
B. Clinical Manifestations Abscess • Deposition of large-particle aerosols that are expelled during a
C. Pathogenesis A. Clinical Manifestations sneeze and land on nasal or conjunctival mucosa
D. Recurrent Pharyngitis B. Treatment • Infection of the nasal epithelium → with or without destruction of
E. Diagnosis IX. References
the epithelial lining/histologic damage
F. Treatment
→ Associated with an acute inflammatory response
I. ACUTE RHINITIS characterized by release of inflammatory cytokines (IL8)
• A viral illness attracting PMNs into the nasal submucosa and epithelium →
infiltration of the mucosa by inflammatory cells → most signs
• Often termed infectious rhinitis
and symptoms
• Also called the “common cold”
→ Rhinoviruses increase vascular permeability in the nasal
→ Acute viral URTI in which the symptoms of rhinorrhea and
submucosa → release albumin and bradykinin → signs and
nasal obstruction are prominent
symptoms
• Systemic symptoms and signs such as headache, myalgia, and
• Viral shedding peaks 3-5 days after inoculation
fever are absent or mild [Nelson’s 20th ed]
→ Coincides with symptom onset (1-3 days after)
• Onset of symptoms starts 1-3 days after viral infection
→ Low levels of viral shedding may persist for up to 2 weeks in
• Occasionally, a bacterial superinfection exists, and the patient
the otherwise recovering healthy host
develops rhinosinusitis
• Inflammation can obstruct the sinus ostia or eustachian tube,
• Rhinosinusitis
predisposing to bacterial sinusitis or otitis media, respectively
→ Includes self-limited involvement of the sinus mucosa
D. CLINICAL MANIFESTATIONS
A. ETIOLOGY
• In infants: fever and nasal discharge may predominate
• Most common pathogens associated with the common cold are
• Older children and adults: fever is uncommon
the more than 200 types of human rhinoviruses
• Onset of symptoms: 1-3 days after viral infection
• Rhinovirus (HRV)
• Sore or scratchy throat
→ Most common pathogen for colds
→ Usual first symptom noted
▪ Associated with more than 50% of colds in adults and
children [Nelson’s 20th ed] → Due to post-nasal dripping [Dr. Edquilag, 2021]
→ Prevalence is seasonal (rainy season) → Resolves quickly; by the 2nd and 3rd day of illness, nasal
▪ Early fall (Aug-Oct) and late spring (Apr-May) symptoms predominate
→ Most common trigger for asthma exacerbation • Cough
• Other viral etiologies: → Associated with two-thirds of colds in children and usually
begins after the onset of nasal symptoms
→ Respiratory syncytial virus (RSV)
→ Persists for an additional 1-2 weeks after resolution of
→ Human metapneumovirus (MPV)
symptoms (vs. allergic: 4-6 weeks)
→ Parainfluenza viruses (PIVs)
→ 10% lasts 2 weeks
▪ Peaks in the late fall and late spring
• Rhinorrhea – prominent
→ Adenoviruses
▪ Low prevalence throughout cold season → Do not mistake for allergic rhinitis because younger children
do not have sensitization or background yet for the
• RSV, Influenza, human coronavirus, and metapneumovirus
development of allergic rhinitis
→ Between December and April
• Nasal obstruction – prominent
• Nonpolio enterovirus
• Rhinosinusitis
→ Summer months or throughout the year
→ Includes self-limited involvement of the sinus mucosa
• Many viruses that cause rhinitis are also associated with other
• Other symptoms of a cold:
symptoms and signs such as cough, wheezing, and fever
→ Headache
B. EPIDEMIOLOGY → Hoarseness
• Common colds occur year-round → Irritability
• Young children: average of 6-8 colds per year, but 10–15% of → Difficulty sleeping
children have at least 12 infections per year [Nelson’s 20th ed] → Decreased appetite

PEDIA 2 Cunanan, Diaz, Evangelista, Tiosin 1 of 10

• PE findings are limited to the upper respiratory tract
→ Systemic signs and symptoms (fever, headache, myalgia) are
absent or mild
→ Increased nasal secretion is usually obvious
▪ A change in the color or consistency of the secretions is
common during the course of the illness and does not
indicate sinusitis or bacterial superinfection but may
indicate accumulation of polymorphonuclear cells.
→ Examination nasal cavity: might reveal swollen, erythematous
nasal turbinates
▪ This finding is nonspecific and of limited diagnostic value
→ Abnormal middle ear pressure
▪ Common during the course of a cold
→ Anterior cervical lymphadenopathy or conjunctival injection
may also be noted on exam
▪ Manifestations of sinusitis which can happen when there is
clogged nose: headache and frontal pain
• Sinusitis
→ Self-limited sinus inflammation is a part of the pathophysiology
of common colds
→ 0.5-2% of viral URTI in adults and 5-13% in children are
complicated by acute bacterial sinusitis
• Asthma Exacerbation
• Antibiotic Resistance
→ Due to inappropriate use of antibiotics
• Acute Tonsillopharyngitis
→ Viral and bacterial pharyngitis present with same symptoms

Figure 3. Complications of common cold. (L) Otitis Media; (R) Sinusitis [Doc’s ppt]

Figure 1. Symptoms of a cold.
• Dr. Edquilag: In this time of pandemic, when everyone is very
wary of the presentation of COVID because it can overlap with
other disease conditions, wala dapat silang symptoms like fever,
body malaise, lower respiratory tract symptoms (see figure)
F. DIAGNOSIS
• Most important task of the physician: exclude other conditions
that are potentially more serious or treatable [Nelson’s 20th ed]
• Based on clinical symptoms
• Differential diagnoses:
→ Includes noninfectious disorders and other upper respiratory
tract infections
• Dr. Edquilag: it is important to distinguish common colds from
other significant URT disorders (see table)
Table 1. Other significant URT disorders [Doc’s ppt]

Condition Differentiating features

Allergic rhinitis • Prominent sneezing and itching
• Nasal eosinophilia
Foreign Body • Unilateral; foul-smelling discharge
• Bloody nasal secretions
Sinusitis • Headache
• Facial pain
• Periorbital edema
• Persistence of rhinorrhea or cough for
longer than 10-14 days
Streptococcal • Nasal discharge that excoriates the nares
nasopharyngitis
Pertussis • Onset of persistent or paroxysmal cough
• With the advent of vaccinations, this should
not be seen as often anymore (except for
those who may have missed vaccinations
because of certain conditions,
Figure 2. Coronavirus symptoms compared with other conditions
unavailability of vaccine in the area)
E. COMPLICATIONS Congenital • Persistent rhinorrhea (snuffles) with onset
syphilis in the first 3 months of life
• Acute otitis media (AOM)
→ Most common complication • Routine laboratory studies are not helpful for the diagnosis and
→ 5-30% of children with colds, increased risk if bottle-fed management of the common cold
→ Particularly in young infants • Nasal smear for eosinophils (Hansel stain) may be useful if
→ Dr. Edquilag: Also common in those with allergic rhinitis. If allergic rhinitis is suspected
otitis media is recurrent, check for the pattern. Baka allergic • Predominance of polymorphonuclear leukocytes in the
rhinitis [2022 trans] nasal secretion
→ With the intimate relationship to the eustachian tube, any → Characteristic of uncomplicated colds
inflammation in the tract can lead to otitis media [Dr. Edquilag, 2021] → Does not indicate bacterial superinfection
→ If <12y/o, other sinus functions are still limited to the maxillary • Viral pathogens associated with common cold
and ethmoidal sinuses [Dr. Edquilag, 2021] → Detected by culture, antigen detection, PCR, or serology

PEDIA 2 Upper Respiratory Tract Disorders 2 of 10

• Bacterial cultures or antigen detection
Useful only when group A Streptococcus, Bordetella pertussis,
→
or nasal diphtheria is suspected (acute bacterial rhinosinusitis)
• Self-limited radiographic abnormalities of the paranasal sinuses
are common during an uncomplicated cold
• Imaging is not indicated for most children with simple rhinitis
G. TREATMENT
• Consists primarily of supportive care and anticipatory guidance
• Usually symptomatic treatment with antipyretics
• Fluid hydration
→ To prevent dehydration, to thin secretions and soothe
respiratory mucosa
• Topical nasal saline may temporarily remove secretions
• Saline nasal irrigation may reduce symptoms
• Antivirals
→ Severe RSV infections: DOC is ribavirin
▪ However, no role in the treatment of the common cold
→ Influenza: Oseltamivir and zanamivir
▪ Oseltamivir: also reduces the frequency of influenza-
associated otitis media
→ Rhinovirus: N/A
▪ Pleconaril: still being developed
• Antibiotics are of no benefit since common colds are usually
caused by rhinoviruses
→ Should be avoided to minimize possible adverse effects and
the development of antibiotic resistance
• Zinc
→ Given as oral lozenges to previously healthy patients
→ Reduces the duration but not the severity of symptoms of a
common cold if begun within 24 hr of symptoms
→ No evidence of an antiviral effect of zinc in vivo
→ Side effects are common and include decreased taste, bad
taste, and nausea
• If patient presents with monthly colds
→ Need antibiotic coverage and hospitalization
II. ACUTE SINUSITIS
• A common illness of childhood and adolescence
• 2 common types: viral and bacterial
→ Fungal sinusitis: rare in immunocompetent patients but can
occur
Table 2. Sinuses at different ages
Description
At birth • Ethmoidal and maxillary sinuses are
present at birth but only the ethmoidal
sinuses are pneumatized
4 years old • Maxillary sinuses are pneumatized
5 years old • Sphenoidal sinuses are present
7-8 years old • Frontal sinuses begin development and
are not completely developed until
adolescence
• The ostia draining the sinuses are narrow (1-3 mm) and drain into
the ostiomeatal complex in the middle meatus
• The paranasal sinuses are normally sterile
→ Maintained by the mucociliary clearance system
A. ETIOLOGY
• Bacterial pathogens in children and adolescents
→ Streptococcus pneumoniae (30%)
▪ Approximately 25% of S. pneumoniae may be penicillin
resistant
→ Nontypable Haemophilus influenzae (20%)
→ Moraxella catarrhalis (20%)
• Commonly recovered in chronic sinus disease:
→ H. influenzae
→ α - and β -hemolytic streptococci
→ M. catarrhalis
→ S. pneumoniae
→ coagulase-negative staphylococci
PEDIA 2 Upper Respiratory Tract Disorders
B. EPIDEMIOLOGY
• Can occur at any age
• Predisposing conditions:
→ Viral upper respiratory tract infections
▪ Associated with pre-schools or school-aged siblings
→ Allergic rhinitis
→ Cigarette / Tobacco smoke exposure
• Acute <30 days; subacute 1-3 mos.; chronic >3 mos.
• Can develop chronic or recurrent sinus disease:
→ Children with immune deficiencies
▪ Particularly of antibody production (IgG, IgG subclasses,
IgA)
→ Cystic fibrosis
→ Ciliary dysfunction
→ Abnormalities of phagocyte function
→ Gastroesophageal reflux
→ Anatomic defects (cleft palate)
→ Nasal polyps
→ Cocaine abuse
→ Nasal foreign bodies (e.g. nasogastric tubes)
• Predisposing factors for severe fungal sinusitis (aspergillus,
mucor), often with intracranial extension:
→ Immunosuppression for bone marrow transplantation
→ Malignancy with profound neutropenia and lymphopenia
• Patients with nasotracheal intubation or nasogastric tubes:
→ May have obstruction of the sinus ostia
→ Resulting to sinusitis with multiple-drug resistant organisms of
the intensive care unit (ICU)
C. PATHOGENESIS
• Typically follows a viral upper respiratory tract infection
• Viral infection produces a viral rhinosinusitis
• Based on MRI, major abnormalities of the paranasal sinuses
(mucosal thickening, edema, and inflammation) occur in 68%
of healthy children in the normal course of the common cold
• Nose blowing
→ Generates sufficient force to propel nasal secretions into sinus
cavities
• Bacteria from the nasopharynx that enter the sinuses are
normally cleared readily
→ But during viral rhinosinusitis, inflammation and edema can
block sinus drainage and impair mucociliary clearance of
bacteria
D. CLINICAL MANIFESTATIONS
• Non-specific (in children and adolescents with sinusitis)
→ Nasal congestion
→ Purulent nasal discharge (unilateral or bilateral)
→ Fever
→ Cough
• Less common symptoms:
→ Bad breath (halitosis)
→ Decreased sense of smell (hyposmia)
→ Periorbital edema
→ Headache (rare)
→ Facial pain (rare)
• Additional symptoms:
→ Maxillary tooth discomfort
→ Pain or pressure exacerbated by bending forward
• PE findings:
→ Erythema and swelling of the nasal mucosa with purulent
nasal discharge
→ Sinus tenderness may be detectable in adolescents and
adults
→ Transillumination reveals opaque sinus
• Versus common cold, bacterial sinusitis may manifest with:
→ Persistence of nasal congestion, rhinorrhea (of any quality),
daytime cough ≥10 days without improvement;
→ Severe symptoms of temperature ≥39°C with purulent nasal
discharge for 3 days or longer;
3 of 10
 → Worsening symptoms either by recurrence of symptoms after • Treatment:
an initial improvement or new symptoms of fever, nasal → Broad-spectrum intravenous antibiotics (usually cefotaxime or
discharge, and daytime cough ceftriaxone combined with vancomycin)
→ In 50%, the abscess is a polymicrobial infection which is
treated by surgical drainage
F. DIAGNOSIS
• Clinical diagnosis is based on history
• Sinus aspirate culture
→ Only accurate method of diagnosis
→ Not practical for routine use for immunocompetent patients
→ May be a necessary procedure for immunosuppressed
patients with suspected fungal sinusitis
• In children:
→ Transillumination is difficult to perform and unreliable before
12 y/o
• Signs and symptoms suggesting a complicating acute
bacterial sinusitis:
→ Nasal discharge and cough for longer than 10 days without
improvement
Figure 4. Criteria for the Diagnosis of Sinusitis [Nelson’s 20th ed] → Severe respiratory symptoms
▪ Temperature of at least 39°C (102°F)
E. COMPLICATIONS ▪ Purulent nasal discharge for 3-4 consecutive days
• Intracranial complications • Children with chronic sinusitis have a history of persistent
→ Due to the close proximity of the paranasal sinuses to the brain respiratory symptoms, including cough, nasal discharge, or nasal
and eyes congestion for >90 days
• Differential diagnostic considerations:
Orbital complications
→ Viral upper respiratory tract infection
• Most often secondary to acute bacterial ethmoiditis ▪ Characterized by clear and usually nonpurulent nasal
• Periorbital cellulitis discharge, cough, and initial fever
→ Produces erythema and swelling of the tissues surrounding ▪ Symptoms do not usually persist beyond 10-14 days,
the globe although a few children (10%) have persistent symptoms
• Orbital cellulitis even at 14 days
→ Involves the intraorbital structures → Allergic rhinitis
→ Produces: ▪ Can be seasonal
▪ Proptosis ▪ Evaluation of nasal secretions should reveal significant
▪ Chemosis eosinophilia
▪ Decreased visual acuity → Nonallergic rhinitis
▪ Double vision → Nasal foreign body
▪ Impaired extraocular movements
▪ Eye pain G. TREATMENT
• Infection can spread directly through the lamina papyracea, the • Antimicrobial treatment for acute bacterial sinusitis to promote
thin bone that forms the lateral wall of the ethmoidal sinus resolution of symptoms and prevent suppurative complications
• Evaluation: (American Academy of Pediatrics)
→ CT scan of the orbits and sinuses with ophthalmology and → 50-60% of children with acute bacterial sinusitis recover
otolaryngology consultations without antimicrobial therapy
• Treatment • Initial therapy with amoxicillin (45 mg/kg/day)
→ IV antibiotics → Adequate for majority of children with uncomplicated mild to
→ Orbital cellulitis may require surgical drainage of the moderate severity acute bacterial sinusitis
ethmoidal sinuses → Alternative for the penicillin-allergic patient:
Intracranial complications ▪ Cefdinir, cefuroxime axetil, cefpodoxime, or cefixime
▪ Levofloxacin for older children
• Meningitis • Azithromycin and trimethoprim-sulfamethoxazole are no
• Cavernous sinus thrombosis longer indicated
• Subdural empyema → High prevalence of antibiotic resistance
• Epidural abscess • High-dose amoxicillin-clavulanate (80-90mg/kg/day of
• Brain abscess amoxicillin)
• Osteomyelitis of the frontal bone (Pott puffy tumor) → For children with risk factors:
→ Edema and swelling of the forehead ▪ Had antibiotic treatment in the preceding 1-3 months
• Mucoceles: chronic inflammatory lesions ▪ Daycare attendance
→ Commonly in the frontal sinuses that can expand and cause ▪ Age <2 yrs
displacement of the eye with resultant diplopia → For those non-responsive to amoxicillin within 72 hours
• Evaluation for the presence of intracranial complications of • Ceftriaxone (50 mg/kg, IV or IM) may be given to children who
acute bacterial sinusitis which require immediate CT scan of the are vomiting or who are at risk for poor compliance
brain, orbits, and sinuses: → It should be followed by a course of oral antibiotics
→ Children with altered mental status • Frontal sinusitis can rapidly progress to serious intracranial
→ Nuchal rigidity complications
→ Severe headache → Necessitates the initiation of parenteral ceftriaxone until a
→ Focal neurologic findings substantial clinical improvement
→ Signs of increased intracranial pressure (headache, vomiting) • Saline nasal washes or nasal sprays can help to liquefy
secretions and act as a mild vasoconstrictor

PEDIA 2 Upper Respiratory Tract Disorders 4 of 10

 → The effects have not been systematically evaluated in children • Discrete papulovesicular lesions or ulcerations in the
• The use of decongestants, antihistamines, mucolytics, and posterior oropharynx, severe throat pain, fever (characteristic of
intranasal corticosteroids has not been adequately studied in herpangina, caused by enteroviruses)
children and is not recommended for the treatment of acute
C. PATHOGENESIS
uncomplicated bacterial sinusitis
T/N: this part is lifted from 2022 Trans, Dr. Edquilag did not discuss this.
III. ACUTE TONSILLOPHARYNGITIS • Colonization of the pharynx by S. pyogenes can result in either
• Pharyngitis asymptomatic carriage or acute infection
→ Inflammation of the pharynx, including erythema, edema, • M protein
exudates, or an enanthem (ulcers, vesicles) → Major virulence factor of S. pyogenes
• Spread by close contact → Facilitates resistance to phagocytosis by PMNs
• Streptococcal pharyngitis • Type-specific immunity develops during infection
→ Uncommon before 2-3 years old → Provides protective immunity to subsequent infection
• Incidence increases among children • Scarlet fever
• Declines in late adolescents and adulthood → Caused by S. pyogenes
→ Peak age of adenoid hypertrophy is 5-7 y/o, thus prone to ▪ Produces 1 of 3 streptococcal erythrogenic exotoxins (A,
develop tonsillopharyngitis. This is questionable in older B, and C) that can induce a fine popular
patients [Edquilag, 2019]. → Exotoxin A: most strongly associated with scarlet fever
• Beefy red, inflamed, engorged tonsils and uvula [Edquilag, 2021] D. RECURRENT PHARYNGITIS
→ In some patients: isthmus is narrowed [Edquilag, 2021] T/N: this part is lifted from 2022 Trans, Dr. Edquilag did not discuss this.
• Hyperemic pharyngeal walls [Edquilag, 2021] • Occurs with:
• Erythematous, popular rash on palate → petechial hemorrhage → Reinfection with the same M type if type-specific antibody has
• Hypertrophic tonsillar formation not developed
• Exudative formation → Macrolide resistance if a macrolide was used for treatment
• Difficulty to distinguish between EBV infection and ATP → Infection with a new M type
→ Poor compliance with oral antibiotic therapy
▪ IM benzathine penicillin is the suggested alternative
treatment
• May represent relapse with an identical strain
• Can also be caused by a different strain from new exposures or
another cause accompanied by streptococcal carriage
→ If illnesses are mild and atypical for streptococcal pharyngitis
• If S. pyogenes is detected by repeat culture a few days after
completing treatment
→ Therapy to eliminate carriage is recommended
• Recurrent GAS pharyngitis is a rarely a sign of an immune
disorder
→ But it can be part of a recurrent fever or auto inflammatory
syndrome such as PFAPA syndrome
• Prolonged pharyngitis (>1 – 2 weeks) suggests another
disorder
→ Such as neutropenia or recurrent fever syndromes aside from
Figure 5. Appearance of acute tonsillopharyngitis [Doc’s ppt 2021]
infectious mononucleosis and Lemierre syndrome
A. ETIOLOGY • Tonsillectomy
→ Lowers the incidence of pharyngitis for 1-2 years among
• Most important agents:
children with recurrent, culture positive GABHS pharyngitis
→ Viruses
that has been severe and frequent (more than 7 episodes in
▪ Adenovirus, Coronavirus, Enterovirus, Rhinovirus, RSV,
the previous year, or more than 5 in each of the preceding 2
EBV, HSV, and metapneumovirus [Trans 2022]
years)
→ Group A-beta hemolytic streptococcus (GABHS)
→ Undocumented history of recurrent pharyngitis is an
→ H. influenzae inadequate basis for recommending tonsillectomy
→ S. pneumoniae
E. DIAGNOSIS
B. CLINICAL MANIFESTATIONS
• The goal is to identify GABHS
Table 3. Acute Tonsillopharyngitis clinical manifestations → Throat culture: imperfect
Pharyngitis Tonsilitis → Group A Streptococcus rapid test: impractical
• Prominent sore throat • Odynophagia → CBC: to detect atypical lymphocytes in EBV
• Fever: • Dysphagia
From 2022 Trans
→ Infection with Group A • Dry throat
• Rely on clinical manifestations
beta hemolytic strep • Malaise
• Goal: identify S. pyogenes, but not to isolate them
shows dramatic rise of • Fever
• Throat culture not routinely done
fever (Edquilag, 2021) • Chills
• Headache and GI • CBC
• Referred otalgia
→ Atypical lymphocytes and lymphocytosis in EBV-caused
symptoms (frequent) • Headaches
tonsillopharyngitis
• Enlarged lymph nodes
• Throat culture and rapid antigen-detection tests
• Yellowish exudate covering
→ Diagnostic tests for Group A Streptococcus (GAS)
tonsils [Trans 2022]
• Throat culture plated on blood agar
• Gingivostomatitis and ulcerating vesicles (primary oral HSV → Gold standard for diagnosing streptococcal pharyngitis
infection) • Gas molecular tests: highly sensitive and specific (≥98%)

PEDIA 2 Upper Respiratory Tract Disorders 5 of 10

 F. TREATMENT IV. LARYNGOTRACHEOBRONCHITIS (LTB)” CROUP”
• Most untreated episodes of streptococcal pharyngitis resolve • Most common form of upper respiratory tract obstruction in
uneventfully in a few days children
• Early antibiotic therapy • Viral infection of the glottic and subglottic regions
→ Hastens clinical recovery by 12-24 hours • Refers to a heterogenous group of mainly acute and infectious
→ Reduces supportive complications of GAS pharyngitis such as processes that are characterized by a bark-like or brassy cough
peritonsillar abscess and cervical adenitis and maybe associated with:
→ Prevention of acute rheumatic fever → Hoarseness
▪ Highly effective when started within 9 days of onset of → Inspiratory stridor
illness → Respiratory distress
→ Antibiotic therapy does not prevent acute post streptococcal • Typically affects: larynx, trachea, bronchi
glomerulonephritis (APSGN) → Involvement is centered on larynx and major bronchus
• Antibiotic therapy should be started immediately without culture • Most common: 6 months to 3 years old
for children with: → Peak incidence: 2 years old [Pedia Plat]
→ Symptomatic pharyngitis → More common in males [Pedia Plat]
→ Positive rapid streptococcal antigen test • Incidence varies depending upon respiratory viral epidemic
• Presumptive antibiotic treatment (with (+) diagnostic test for
A. ETIOLOGY
GAS) is started for patients with:
→ Clinical diagnosis of scarlet fever • Most common etiology: parainfluenza virus [Pedia Plat]
→ Household contact with documented streptococcal pharyngitis • Parainfluenza (types 1,2,3): 75% of cases
→ Past history of acute rheumatic fever • Other etiologies:
→ Recent history of acute rheumatic fever in a family member → RSV
• Antibiotics are discontinued if GAS are not identified → Influenza A and B
• Follow-up testing for GAS is unnecessary after completion of → Adenovirus
therapy and is not recommended unless symptoms recur → Measles
• Tonsillectomy B. CLINICAL MANIFESTATIONS
→ For recurrent/chronic cases
Table 5. Symptoms and signs of croup
→ Indication remains uncertain [Pedia Plat]

→ >3 infection of tonsils or adenoids per year despite medical Symptoms Signs
management (American Academy of Otorhinolaryngology) • URTI and fever 1-3 days • Coryza and rhinorrhea
→ If patient develops rheumatic fever → sleep study prior to upper airway • Normal to moderately
obstruction inflamed pharynx
Table 4. Antibiotic treatment for Acute Tonsillopharyngitis [Trans 2022 with updates from Dr. Edquilag]
• “Barking cough” • Slight tachypnea
Antibiotic Notes
• Hoarse voice • Inspiratory stridor
Penicillin V • Possible hypersensitivity • Symptoms worse at night
(x 10 days) • Not present in market any longer T/N: this part below is lifted from Nelsons 21st ed..
(Edquilag, 2021) • Agitation and crying greatly aggravate symptoms and signs
Amoxicillin • Often preferred for children • Symptoms worsen at night, and often recur with decreasing
(x 10 days) because of taste, availability as intensity for several days and resolve completely within a week
chewable tablets, convenience of → Child may prefer to sit up in bed or be held upright
once-daily dosing (750 mg fixed • Croup is a disease of the upper airway and alveolar gas
dose or 50 mg/kg, maximum 1 g) exchange is usually normal
given orally for 10 days → Hypoxia and low oxygen saturation are seen only with
• Amoxicillin is given instead of complete airway obstruction
Penicillin V nowadays (Edquilag, → The child who is hypoxic, cyanotic, pale, or obtunded needs
2021) immediate airway management
IM benzathine Pen G • Ensures compliance • The pattern of severe LTB is occasionally difficult to differentiate
(Single dose: 600,000 • Very painful, G19 needle (viscous; from epiglottitis
IU TIM) usually laced with lidocaine)
or • Diphtheria prophylaxis C. DIAGNOSIS
Benzathineprocaine • Diagnosis of croup is mainly clinical [Pedia Plat] and does not require
penicillin G a radiograph on the neck [Nelson’s 21st ed]
combination
• Findings on neck radiograph:
Narrow-spectrum, 1st • For patients allergic to penicillins
→ Subglottic narrowing or “steeple sign”
generation • If the previous reaction to penicillin
cephalosporin – ▪ Hourglass-shaped
was not an immediate (type I)
cephalexin or ▪ Subglottic narrowing in area of cricoid cartilage
hypersensitivity reaction
cefadroxil ▪ Narrowing due to inflammation
(x 10 days) → X-rays do not correlate well with disease severity
Erythromycin, • Frequently for those penicillin- • CBC
clarithromycin, or allergic patients and/or cannot → Leukocytosis is uncommon, and if present, it may suggest
clindamycin tolerate GI upset bacterial tracheitis or epiglottitis
(x 10 days) Table 6. Westley Croup Score: rating Severity of croup [Pedia Plat]

or Sign Degree Score

Azithromycin • None 0
(x3-5 days) Stridor • At rest on auscultation 1
• At rest without auscultation 2
• None 0
Chest wall • Mild 1
retractions • Moderate 2
• Severe 3

PEDIA 2 Upper Respiratory Tract Disorders 6 of 10

 • Normal 0 • Other agents that cause acute epiglottitis in vaccinated pediatric
Air entry • Decreased 1 patients: S. pyogenes, S. pneumoniae, S. aureus, and non-
• Severely decreased 2 typeable H. influenzae
• None 0 B. CLINICAL MANIFESTATIONS
Cyanosis • With agitation 4
• At rest 5 • Acute, rapidly progressive, and potentially fulminating course of
Consciousness • Normal 0 high fever, sore throat, dyspnea, and rapidly progressing
level • Altered 5 respiratory obstruction
• Interpretation of Results (total score can be 0-17 points) • Degree of respiratory distress at presentation is variable
• Mild: ≤2 → Lack of respiratory distress can deceive an unwary clinician
• Moderate: 3-7 → Can also be the 1st manifestation
• Severe: equal or >8 • Often, the otherwise healthy child suddenly develops a sore
• Impending respiratory failure: equal or >12 throat and fever
→ Within a matter of hours, patient appears toxic, swallowing is
D. TREATMENT difficult, and breathing is labored
• Aqueous epinephrine (1:1000) diluted in plain NSS (0.3 ml • Drooling is usually present, and neck is hyperextended in an
aqueous epinephrine: 2.7 ml plain NSS) attempt to maintain the airway
→ Available in the Philippines • Preference for sitting
→ Not available in the Philippines: aerosolized racemic (D- and → Child may assume the tripod position
L-) or L-epinephrine → Sitting upright, leaning forward with chin up, mouth wide open
→ Steroids while bracing on the arms
• Brief period of air hunger with restlessness may be followed by
Table 7. Management of Croup based on Severity (Westley Croup Score) [Pedia Plat]
rapidly increasing cyanosis and coma
Severity Intervention
→ “Anticipate intubation for the patient” [Doc Edquilag, 2021]
• Dexamethasone 0.6 mg/kg/dose PO/IV/IM
Mild • Stridor (rapid onset and progression)
(max dose: 16 mg)
→ Late finding and suggests near-complete airway obstruction
• Dexamethasone 0.6 mg/kg IV/IM
• Complete obstruction of the airway and death can ensue unless
• Humidified oxygen (if O2 saturation <92%)
adequate treatment is provided
Moderate to • Give nothing by mouth
• Barking cough typical of croup is rare
Severe • Nebulize epinephrine over 15 minutes (0.5
• Pulmonary edema can be associated with acute airway
mL/kg/dose max 5 mL using 1:1000
obstruction
dilution)
• No other family members are ill with acute respiratory symptoms
• High concentration of oxygen
Impending (nonrebreathing mask preferred) From the lecture:
respiratory • Dexamethasone IV/IM • Muffled (rather than hoarse) voice
failure • ET intubation as indicated (use smaller ET • Dysphagia and drooling: most pronounced manifestations
tube size) • Refusal to eat, drink or sleep
It is strongly recommended that a single dose of glucocorticoids → Patient refuses to sleep as it is uncomfortable to lie down
be administered to children presenting to the emergency • High anxiety
department with croup. • Most patients have concomitant bacteremia
Table 8. Summary table for Croup vs. Epiglottitis Pedia Plat] → Occasionally, other infections may be present such as
Feature Croup Epiglottitis pneumonia, cervical adenopathy, otitis media
Age Younger children Older children • Manifestations are worrisome for the patient and the doctor
Narrowing Subglottic Supraglottic • Expect to see impending respiratory failure in patients at ER
Stridor 88% 8%
Pathogen Parainfluenza H. influenza type B
Rapid onset (4-12
Onset Prodrome (1-7 days)
hours)
Fever Low grade High grade
Associated Barking cough,
Muffled voice, drooling
symptoms hoarseness
Response to
Improvement of
racemic None
stridor
epinephrine Figure 6. Tripod position
CXR Steeple sign Thumbprint/leaf sign
Secure airway, C. DIAGNOSIS
Management Supportive
antibiotics • Requires visualization by laryngoscopy
V. EPIGLOTTITIS (SUPRAGLOTTITIS) → Large, cherry red, swollen epiglottis
• Occasionally, the other supraglottic structures, especially the
• Life-threatening upper airway obstruction caused by infection of
aryepiglottic folds, are more involved than the epiglottis itself
epiglottis
• In a patient in whom the diagnosis is certain or probable based
→ Compared to croup – Epiglottitis has a morbid feature
on clinical grounds
• A medical emergency that warrants immediate treatment with
→ Laryngoscopy should be performed expeditiously in a
placement of an artificial airway in controlled situations
controlled environment such as OR or ICU
• Generally, occurs in children between 1 and 5 years of age
• Anxiety-provoking interventions
A. ETIOLOGY → Phlebotomy, intravenous line placement, placing the child
supine, or direct inspection of the oral cavity
• Haemophilus influenza type B (HiB)
→ Should be avoided until the airway is secure
→ Most commonly identified etiology in the past
• If epiglottitis is thought to be possible but not certain in a patient
→ Incidence reduced by 99% since widespread use of HIB
with acute upper airway obstruction
vaccine
PEDIA 2 Upper Respiratory Tract Disorders 7 of 10
 → Patient may undergo lateral radiographs of upper airway first VI. BACTERIAL TRACHEITIS
• Classic radiographs of a child who has epiglottitis T/N: This section was not discussed. All information is from 2022 trans and Nelson’s 21st ed.
→ Show the “thumb sign”
• Potentially life-threatening
▪ “Parang thumb nan aka-press sa neck” [Doc Edquilag, 2021]
• Mean age: 5-7 years old
• Proper positioning of the patient for the lateral neck radiograph is
crucial in order to avoid some of the pitfalls associated with • Incidence and severity do not differ by sex
interpretation of the film • Often follows viral respiratory infection
→ Adequate hyperextension of the head and neck is necessary → Especially laryngotracheitis
→ Epiglottis can appear to be round if the lateral neck is taken → May be considered as a bacterial complication of a viral
at an oblique angle disease rather than a primary bacterial illness
• If the concern for epiglottitis still exists after the radiographs • More common than epiglottitis in vaccinated populations
→ Direct visualization should be performed A. ETIOLOGY
• A physician skilled in airway management and use of intubation
• Most common pathogen: Staphylococcus aureus
equipment should accompany patients with suspected epiglottitis
• Others include:
at all times
→ MRSA
• An older cooperative child might voluntarily open the mouth wide
enough for a direct view of the inflamed epiglottis → Streptococcus pneumoniae
→ Moraxella catarrhalis
Summary: → Non-typable H. influenza
• Lateral x-ray of the neck: Thumb sign → Anaerobic organisms
→ Thickened and bulging epiglottis
→ Thickened aryepiglottic folds B. PATHOGENESIS
• Laryngoscopy: Direct observation of a large, cherry red, • Major pathologic feature
swollen epiglottis and inflamed supraglottic structures → Mucosal swelling at the level of cricoid cartilage
→ Done in a controlled environment such as an operating ▪ Swelling is complicated by copious, thick purulent
room or ICU, with a surgeon and anesthesiologist secretions sometimes causing pseudomembrane
formation
C. CLINICAL MANIFESTATIONS
• Brassy cough
• High fever
• Toxicity with respiratory distress
• Can lie flat
• Does not drool
• No dysphagia associated with epiglottitis
D. COMPLICATIONS
• On chest radiograph: patchy infiltrates, focal densities
Figure 7. Thumb sign in lateral x-ray • Subglottic narrowing, rough and ragged tracheal air column
• If airway management is not optimal
→ Cardiorespiratory arrest
• If due to staphylococcal and group A streptococcal tracheitis
→ Toxic Shock Syndrome
E. DIAGNOSIS
• Based on evidence of bacterial upper airway disease:
→ High fever
→ Purulent airway secretions
→ Absence of classic findings of epiglottis
• During endotracheal intubation: copious purulent material
below the cords
Figure 8. Normal (left) and Cherry Red Swollen Epiglottis (right)
• Lateral x-ray may not be needed but may show classic findings
D. TREATMENT • In laryngoscopy, thick tracheal membranes can be seen. The
distal tracheobronchial tree is unremarkable.
• Warrants immediate treatment with an artificial airway → In contrast to croup, tenacious secretions are seen throughout
• All patients should receive oxygen en route the trachea
→ Unless the mask causes excessive agitation → In contrast to bronchitis, the bronchi are not affected
→ Double set-up
• Endotracheal or nasotracheal intubation
→ Done regardless of the degree of apparent respiratory distress
→ As many as 6% of children with epiglottitis without an artificial
airway die compared with <1% of those with an artificial airway
→ Tracheostomy is an alternative
→ In general, children with acute epiglottitis are intubated for 2 to
3 days because the response to antibiotics is usually rapid
• Antibiotics should work in 48-72 hours
→ Ceftriaxone, cefotaxime, or a combination of ampicillin-
Figure 9. (L): Thick tracheal membrane and (R): Adherent membranous
sulbactam should be given parenterally pending culture and secretions
susceptibility reports because 10-40% of H. influenza type B
cases are resistant to ampicillin
→ Continue antibiotics for 7-10 days

PEDIA 2 Upper Respiratory Tract Disorders 8 of 10

 → Retropharyngeal nodes involute after 5yr of age and,
therefore, infection in older children and adults is much less
common
• 67% of patients have a history of recent ear, nose, or throat
infection
A. ETIOLOGY
• Caused by:
→ Extension from a localized infection of the oropharynx
→ Penetrating trauma to the oropharynx
→ Dental infection
→ Vertebral osteomyelitis
• Most often polymicrobial
→ Group A streptococcus
▪ Studies have documented an increased incidence of group
A streptococcus recovered from such abscesses
→ Oropharyngeal anaerobic bacteria
→ Staphylococcus aureus
→ Other pathogens: Haemophilus influenzae, Klebsiella, and
Figure 9. Pseudomembrane detachment in the trachea Mycobacterium avium-intracellulare
F. TREATMENT B. CLINICAL PRESENTATION
• Antimicrobial therapy • Clinical manifestations of Retropharyngeal abscess are
→ Anti-staphylococcal agents nonspecific:
→ Instituted in patient whose course suggest bacterial tracheitis → Fever
• Current empiric therapy recommendations: → Irritability
→ Beta lactamase-resistant beta lactam antimicrobial → Decreased oral intake
agents (Nafcillin or Oxacillin) given first → Drooling
→ Vancomycin → Neck stiffness
▪ If no improvement noted after 24h of nafcillin or oxacillin
→ Torticollis
→ Nelson’s: vancomycin or clindamycin + a 3rd generation
→ Refusal to move the neck
cephalosporin (e.g., cefotaxime or ceftriaxone)
→ Child might complain of sore throat and neck pain
• Artificial airway
→ Other signs: muffled voice, stridor, respiratory distress,
• Supplemental oxygen (usually necessary)
obstructive sleep apnea
• Usual treatment for croup (racemic epinephrine) is ineffective
• Physical examination of Retropharyngeal abscess:
• Intubation or tracheostomy may be necessary
→ Bulging of the posterior pharyngeal wall
→ Younger patients are more likely to need intubation ▪ Present in <50% of infants with retropharyngeal abscess
G. PROGNOSIS → Cervical lymphadenopathy
• Clinical presentations of Lateral pharyngeal abscess
• Excellent for most patients
→ Fever
• Becomes afebrile within 2-3 days of antimicrobial therapy
→ Dysphagia
→ But prolonged hospitalization may be necessary
→ Prominent bulge of the lateral pharyngeal wall
• Decrease in mucosal edema and purulent secretions:
→ Medial displacement of the tonsil
→ Extubation may be accomplished safely
• Careful observation while antibiotics and oxygen therapy are C. DIAGNOSIS
continued
• Timely diagnosis important since because of airway compromise
VII. RETROPHARYNGEAL AND LATERAL PHARYNGEAL and posterior mediastinitis
ABSCESS • Definitive Diagnosis is based on incision for drainage and
culture of an abscessed node
From Doc Edquilag: • Differential diagnosis
• Quite rare but a few cases can still be observed which should → Acute epiglottitis
not be the case since it is preventable → Foreign body aspiration
• Much more morbid outcome and can lead to death without → Meningitis
adequate intervention ▪ Considered in children with limited neck mobility
• Due to poor hygiene and severe cases of gingivostomatitis → Lymphoma
• Retropharyngeal nodes and lateral pharyngeal nodes → Hematoma
→ Drain the mucosal surfaces of the upper airway and digestive → Vertebral osteomyelitis
tracts Imaging Findings
→ Located in Retropharyngeal space and Lateral pharyngeal • CT Scans
space
→ Useful in identifying the presence of a retropharyngeal, lateral
• These nodes communicate with each other, allowing bacteria pharyngeal, or parapharyngeal abscess
from either cellulitis or node abscess to spread to other nodes
→ Deep neck infections can be accurately identified and
→ Result in airway compromise or posterior mediastinitis localized,
• Three stages: ▪ CT accurately identifies abscess formation in only 63% of
→ Cellulitis patients
→ Phlegmon → CT with contrast medium enhancement can reveal central
→ Abscess lucency, ring enhancement, or scalloping of the walls of a
• Occurs most commonly in children < 3-4 yr of age lymph node.
→ Boys affected more often than girls. ▪ Scalloping is thought to be a late finding and predicts
abscess formation.

PEDIA 2 Upper Respiratory Tract Disorders 9 of 10

 • Physical examination
→ Asymmetric tonsillar bulge with displacement of the
uvula
▪ Diagnostic, but it may be poorly visualized because of
trismus.
▪ CT is helpful for revealing the abscess
B. TREATMENT
• Treatment includes surgical drainage and antibiotic therapy
• Antibiotic therapy
→ Against group A streptococci and anaerobes.
• Surgical drainage
→ Needle aspiration
▪ Can involve aspiration of the superior, middle, and
inferior aspects of the tonsil to locate the abscess
▪ 95% of peritonsillar abscess cases resolve using this
Figure 11. Sequential CT slice exhibiting ring-enhancing lesion treatment
• Soft tissue neck films ▪ A small percentage of these patients require a repeat
→ Taken during inspiration with the neck extended needle aspiration
→ Can show increased width or an air-fluid level in the → Incision and drainage
retropharyngeal space. ▪ Cases that fail to resolve after needle aspiration (~5% of
cases) require incision and drainage
D. TREATMENT → Tonsillectomy
• Intravenous antibiotics with or without surgical drainage ▪ Should be considered if there is failure to improve within 24
→ >50% of children can be successfully treated without surgical hours of antibiotic therapy and needle aspiration
drainage ▪ History of recurrent peritonsillar abscess or recurrent
tonsillitis, or complications from peritonsillar abscess
→ Drainage is necessary in the patient with respiratory distress
or failure to improve with intravenous antibiotic treatment • General anesthesia may be required for the uncooperative
patient
→ Therapy for several days with intravenous antibiotics until the
patient has begun to improve
▪ Optimal duration is unknown IX. REFERENCES
→ Followed by a course of oral antibiotic is typically used. American Academy of Allergy, Asthma & Immunology. (n.d.). Coronavirus
symptoms [Image].
• Provide anaerobic coverage via https://www.aaaai.org/Aaaai/media/MediaLibrary/Images/Promos/Coronaviru
→ 3rd-generation cephalosporin s-Symptoms.pdf
→ Ampicillin-sulbactam or clindamycin Kliegman, R. (2020). Nelson textbook of pediatrics (21st ed..). Philadelphia, PA:
• Staphylococcus aureus Elsevier.
→ Increasing prevalence of methicillin-resistance Dr. Edquilag’s lecture (2021)
2022 trans
→ Can influence empiric antibiotic therapy
-END OF TRANSCRIPTION-
D. COMPLICATIONS
• Significant upper airway obstruction
• Rupture leading to aspiration pneumonia
• Extension to the mediastinum
• Thrombophlebitis of the internal jugular vein
• Erosion of the carotid artery sheath
VIII. PERITONSILAR CELLULITIS/ABSCESS
• Relatively common compared to the deep neck infections
• Etiology
→ Group A streptococci
→ Mixed oropharyngeal anaerobes
• Pathogenesis
→ Bacterial invasion through the capsule of the tonsil
→ Leading to cellulitis and/or abscess formation in the
surrounding tissues.
• Typical patient is an adolescent with a recent history of acute
pharyngotonsillitis.
• Complications
→ Rupture of the abscess with resultant aspiration pneumonitis
→ 10% recurrence risk for peritonsillar abscess.
A. CLINICAL PRESENTATION
• Clinical Manifestations
→ Sore throat
→ Fever
→ Trismus
→ Dysphagia

PEDIA 2 Upper Respiratory Tract Disorders 10 of 10