Pediatric Primary Care (52 page)

Gunasekera H, Morris P, McIntyre P, et al. Management of children with otitis media: A summary of evidence from recent systemic reviews.
J Pediatr Child Health.
2009;45(10):554-563.

Leo G, Piacentini E, Incorvaia C, et al. Sinusitis and eustachian tube dysfunction in children.
Pediatric Allergy Immunol.
2007;18(Suppl. 18):35-39.

Meropol S. Valuing reduced antibiotic use for pediatric acute otitis media.
Pediatrics.
2008;12:669-673.

Rosenfeld RM. Antibiotic use for otitis media: Oral, topical, or none?
Pediatr Ann.
2004;33:833-842.

Stool SE, et al. Managing otitis media with effusion in young children. In:
Quick Reference Guide for Clinicians.
AHCPR Publication 94-0623. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.

Takata G, et al. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion.
Pediatrics.
2003;112:1379.

Vernacchio L, Vezina R, Mitchell A. Management of acute otitis media by primary care physicians: Trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline.
Pediatrics.
2007;120:281-287.

CHAPTER 23

Sinus, Mouth, Throat, and

Neck Disorders

Susan G. Rains

I.  ALLERGIC RHINITIS

A.  Etiology.

1.  Atopic predilection.

a.  Very common atopic disease of childhood, second only to asthma.

b.  Often same mediators that produce asthma.

c.  Genetic factors: increased IgE production in response to allergens.

2.  Environmental factors.

a.  Common allergens.

• Seasonal (rare in children younger than 3 years of age).

   i.   Nonflowering, wind-pollinated plants.

   ii.  Tree pollens: early spring.

   iii. Grasses: late spring and early summer.

   iv.  Weeds: fall.

• Perennial: animal dander, dust (mites), molds (spores), mildew, feathers, cockroaches.

B.  Occurrence.

1.  Affects about 40% of children and 30% of adolescents.

2.  If one parent affected, child has 30% chance of developing allergies; both parents, 70% chance.

3.  The incidence in males is slightly higher.

C.  Clinical manifestations.

1.  Stuffy nose, sneezing, itching, runny nose, noisy breathing/snoring, cough, halitosis, frequent clearing of throat, plugged ears, wheezing.

2.  Possibly associated signs of allergic conjunctivitis: itchy, injected conjunctiva, puffy lids, tearing or clear mucous drainage in eye.

3.  Has significant decrement on measurements of vigilance and a broad range of cognitive functioning.

D.  Physical findings.

1.  Nasal mucosa is usually pale, edematous, boggy.

2.  Thin, watery rhinorrhea.

3.  Allergic salute may cause external, transverse crease near end of nose.

4.  Nasal obstruction may cause mouth breathing.

5.  Allergic shiners (dark circles under eyes), due to venous pooling.

E.  Diagnostic tests.

1.  Nasal smear for presence of eosinophils: 10% is positive (intranasal steroids may decrease percentage).

2.  Skin testing.

F.  Differential diagnosis.

1.  Infection.

a.  Viral upper respiratory infection (URI): red and swollen turbinates, thicker, more purulent rhinorrhea; duration 10-14 days, clustered fall-spring.

b.  Sinusitis: possibly symptoms of URI, also headache, facial pressure; duration longer than viral URI but more limited than solely allergic rhinitis.

2.  Nasal foreign body: unilateral purulent nasal discharge, foul odor.

3.  Nasal polyp, dermatoid cyst, nasal glioma.

4.  Cystic fibrosis (patients often have nasal polyps and chronic sinusitis).

5.  Choanal atresia, deviated septum.

6.  Vasomotor rhinitis: sudden appearance and disappearance of symptoms in response to irritants.

7.  Rhinitis medicamentosus: abuse of nasal spray/drops.

8.  Drug- or food-induced rhinitis.

G.  Classification.

1.  Mild, moderate, severe.

2.  Intermittent or persistent.

H.  Treatment.

1.  Avoidance.

a.  Minimize exposure to dust mites, especially in child's bedroom: remove wall-to-wall carpets, curtains, bed ruffles, stuffed animals; wash cotton bedding in hot water frequently, use nonallergenic bedding covers.

b.  Minimize exposure to animal dander.

c.  Minimize exposure to pollens: close windows, use air conditioning, filters on air systems, keep humidity low in home, remove house plants.

d.  Avoid activities such as leaf raking, lawn mowing, furniture dusting.

e.  Avoid talcs, perfumes, cigarettes, wood smoke.

2.  Pharmacotherapy.

a.  Antihistamines.

•  First generation (sedating unless child has adverse hyperactive response). Diphenhydramine (Benadryl), chlorpheniramine, combined products: 5 mg/kg/day, divided qid.

•  Second generation. Loratadine (Claritin, generic and brand preparations now available OTC), age 2-5 years: 5 mg PO daily; older than 6 years: 10 mg. Cetirizine (Zyrtec, generic and brand preparations now available OTC), age 2-5 years: 2.5-5 mg PO daily; older than 6 years: 10 mg. Fexofenadine (Allegra); age 2-11 years: 30 mg bid; older than 12 years: 60 mg tab bid or 180 mg daily. Desloratidine (Clarinex): age 6-11 months: 1 mg/day, 12 months to 5 years: 1.25 mg/day, 6-11 years: 2.5 mg/day, 12 years and older 5 mg/day. Levoceterizine (Xyzal): 6-11 years: 2.5 mg HS, 12 years and older 5 mg HS.

b.  Intranasal steroids, e.g., fluticasone propionate (Flonase 0.05%–only one available generically); mometasone furoate (Nasonex); triamcinolone acetonide (Nasocort AQ); budesonide (Rhinocort Aqua).

•  4-12 years of age: 1 spray each nostril daily.

•  Older than 12 years of age: 2 sprays/nostril.

c.  Topical cromolyn (NasalCrom): 1 spray tid-qid, 2-4 weeks for effect (available OTC).

d.  Nonsedating nasal anti-histamine: Patanse (Olopatadine), ages 6-11 years: 1 spray/nostril q day; 12 years 2 sprays/nostril q day.

e.  Nasal decongestants (not recommended due to rebound effect secondary to abuse).

•  Oral often combined with antihistamines.

•  Topical not recommended due to rebound and abuse potential.

3.  Immunotherapy (hyposensitization): “allergy shots,” especially recommended for children who suffer perennially and do not respond to medications.

I.  Follow up.

1.  2-4 weeks after initial treatment, sooner if needed, then 3-6 months.

J.  Complications.

1.  Chronic sinusitis.

2.  Recurrent otitis media.

3.  Hoarseness.

4.  Loss of smell or hearing.

5.  High-arched palate, dental malocclusion from chronic mouth breathing.