วันอาทิตย์ที่ 8 กรกฎาคม พ.ศ. 2555

ENT/eye in child

Acute otitis media

Dx: acute onset < 48h + middle ear efflusion (bulging, air-fluid level, limited TM mobility) + middle ear inflammation

**If cerumen impact: docusate 1 mL instill in ear canal, left 15 min then irrigate with warm saline or water

Tx:

• Analgesic (ibuprofen 10 mg/kg; paracetamol; hydrocordone or Antipyrine/benzocaine 2-4 drop q 1-2 h)

• ATB: amoxicillin 80-90 mg/kg/d x 5-7 d, ceftriaxone IM x 3d, azithromycin x 10d start immediately if high risk (<6 mo, ill appearing, other bacterial infection, recurrent within 2-4 wk, immunocompromised, limited access to medical care, craniofacial anomalies) or wait-and-see

• F/U if persist pain, fever > 72 h
Otitis media with efflusion

Tx: watchful waiting or start ATB/close F/U if permanent hearing loss, craniofacial anomalies, UD speech delays

Otitis externa

Malignant otitis externa: fever >38.9°C, severe pain, facial paralysis, meningeal signs

Tx: Ibuprofen, 2% acetic acid (VoSoL) 2-4 drop tid-qid for mild otitis externa or for prevention

• Neomycin-polymyxin B-hydrocortisone 2-4 drops qid or Fluoroquinolones(ofloxacin, ciprofloxacin) 2-4 drops bid

• Pope ear wick for extremely edematous

• For spreading infection: ceftazidime 50 mg/kg IV q 8 h + methicillin 50 mg/kg/dose q 6 h

• F/U if not improve in 48-72 h

Acute mastoiditis

Dx: abnormal tympanic membrane + erythema, tenderness, edema over the mastoid +/- CN involvement(VI, VII)

Tx: consult ENT

• Ampicillin-sulbactam 100 mg/kg IV q 6 h then switch to PO ATB total 14 d

Acute bacterial sinusitis

Dx: persistent symptoms (nasal/postnasal discharge or daytime cough > 10d) or severe symptoms(T > 39°C, purulent nasal discharge > 3d, ill appearing child)

Tx: amoxicillin (80 mg/kg/d PO) x 10-14d or 2nd-3rd generation cephalosporins (cefprozil, cefuroxime, cefpodoxime) or clarithromycin (7.5 mg/kg PO bid) or azithromycin (10 mg/kg PO on d 1, then 5 mg/kg PO daily for 5-7 d

If not improved in 48-72 h: add clavulanate: amoxicillin-clavulanate 22.5 mg/kg PO bid

• Intranasal steroids (fluticasone propionate 1-2 sprays/nostril daily, beclomethasone 1-2 sprays/nostril bid) if ATB do not result in improvement in the first 3-4 days of treatment

Cranial CT with contrast if suspected complications: preseptal/postseptal cellulitis, subperiosteal abscess, cavernous sinus thrombosis, osteomyelitis of the frontal bone (Pott puffy tumor), subdural empyema, epidural/brain abscess, meningitis

Chronic bacterial sinusitis

Tx: nasal saline irrigation + amoxicillin-clavulanate (22.5 mg/kg PO bid), clindamycin (8 mg/kg PO tid), moxifloxacin 400 mg PO daily) for adolescents x > 4 wks; consuit ENT if fail to medical tx

Allergic rhinitis

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Tx Nasal saline irrigation (or 3%NSS), 2nd generation antihistamines (loratadine (5 mg OD age 2-6 yrs; 10 mg OD >6 yrs), cetirizine (2.5-5.0 mg OD 2-6 yrs; 5-10 mg OD >6 yrs)), intranasal steroids

Nasal FBs

persistent, unilateral, purulent, foul-smelling nasal discharge

Tx: immobilization +/- sedation; kill insect before remove with 2% lidocaine or mineral oil

• Pretreated topically with 1% lidocaine and 0.5% phenylephrine (except button battery)

• Remove with alligator forceps, lubricated 5F or 6F Foley balloon catheter, positive pressure applied to the mouth while occluding the contralateral naris; suction catheter

Epistaxis

Tx: pinching the nostrils 5-10 mins with neck slightly extended

• Ice or phenylephrine applied to the nose to promote vasoconstriction

• Application of cotton gauze under the upper lip can be used to compress the labial artery

• Cautery with heat or silver nitrate

• Packed with absorbable gelatin foam, oxidized cellulose, preformed devices

Oral lesion

Apthous ulcer: Spontaneous resolution after 7-10 d; antimicrobial mouthwashes, topical analgesics (Kanistad gel)

Stomatitis(periodic fever, pharyngitis, cervical adenitis): oral steroids, will resolution of symptoms within 24 hrs

Herpangina

Dx: elliptical or oval-shaped papulovesicular lesions with erythematous rims on the posterior soft palate

Tx: resolution over 3-5 d; antipyretics and systemic analgesics aid with supportive care. (viscous lidocaine not recommended)

Hand foot and mouth disease

Dx: erythematous macules and develop small nontender vesicles at palate, buccal mucosa, gingiva, tongue, palm, sole, buttock

Tx: resolution over 4-7 d; antipyretics, topical and oral analgesics, oral rehydration

Herpetic gingivostomatitis

Dx: abrupt onset of high fever, irritability, decreased oral intake, vesicular lesions in the oral cavity, ulcerations, tender cervical lymphadenopathy < 1 wk(may up to 3 wks); Tzanck smear/viral culture of fluid from unroofed lesions 24-48 hours old; PCR

Tx: oral analgesics/antipyretics (acetaminophen, ibuprofen), topical analgesics, acyclovir 15 mg/kg PO divided five times a day for 7 days if severe disease (IV acyclovir for immunocompromised)

Pharyngitis

Viral: EBV, CMV, HIV

Dx: exudative pharyngitis, posterior cervical LN enlargement, splenomegaly, hepatomegaly

Ix: heterophile test (monospot), EBV IgM/IgG, CMV IgM/IgG, liver enzyme

Tx: supportive

Bacterial: β-hemolytic Streptococcus (GABHS)

Dx: Centor criteria for β-hemolytic Streptococcus: 1) Tonsillar exudates, 2) Tender anterior cervical lymphadenopathy, 3) Absence of cough, 4) History of fever

• If 0-1: GABHS is unlikely; > 2: rapid antigen detection test (RADT) +/- culture if RADT negative

• Other bacteria: gonorrhea, C. diphtheria, A. haemolyticum, Y. enterocolitica, Y. pestis, F. tularensis, M. pneumoniae, Chlamydia species, etc

Tx: symptoms markly improve at d3-4; ATB in GABHS, gonorrhea(cef-3), diphtheria; other bacteria: controversies

• Penicillin V or amoxicillin 250 mg (500mg for adolescent) PO bid x 10d

• Benzathine penicillin G 25,000–50,000 mg/kg IM singledose (max 1.2 mU)

• Azithromycin 12 mg/kg OD x 5d (500 mg d1 then 250 mg d2-5 for adolescent)

• Erythromycin 20-40 mg/kd/d PO x 10d (400-800 mg bid-qid for adolescent)

• Cephalexin 25-50 mg/kd/d PO x 10d

• Ceftriaxone 250 mg IM + azthromycin 1 gm PO for GC

Uvulitis

Infectious: if asso. with pharyngitis, epiglottitis

Noninfectious: allergic reaction, angioedema(ACEI)

Dental trauma

Subluxation: mobile tooth, sulcul bleeding

Tx: primary tooth: no tx; permanent teeth: splinting

Luxation: displacement and fix in new position

Tx: Primary teeth: passively reposition, dental consultation; Permanent teeth: active repositioning and splinting

Intrusion: displacing into alveolar bone

Tx: Primary teeth: extraction if apex is displaced toward the permanent tooth (by radiography), re-erupt in 2-6 mo; Permanent teeth with immature root formation may be allowed to re-erupt; mature teeth: orthodontic or surgical extrusion.

Avulsion/Root fx

Tx: Primary teeth: not replanted; Permanent teeth: urgent reimplantation within 5 min, gentle rinsing with water then store with Hanks' Balanced Salt Solution, cold milk, saliva, physiologic saline; temporary splint with a noneugenol zinc oxide periodontal dressing

Fracture

Tx: Ellis class I (enamel): no tx except sharp corner; Ellis class II (dentin): cover with glass ionomer dental cement. Refer < 24 h; Ellis class III (pulp): stop bleeding with sterile gauze, cover the exposed pulp with a calcium hydroxide base and glass ionomer dental cement, refer < 24 h

Soft tissue injuries in mouth

Most conservative Tx: except mandibular fenulum; Tongue lacerations > 1/3 of the total diameter or tip causing forking

Lacrimal system problems

Dacryostenosis: accumulate watery discharge, no sign of inflammation

Tx: gentle massage with a downward motion to the nasolacrimal duct 3-4 times a day; if > 6mo refer to ophthalmologist

 Dacryocystitis: chronic mucopurulent discharge followed by erythema and swelling inframedially to the eye

Tx: IV ATB for ill-appearing: cefuroxime 50 mg/kg/ IV q 8 h or cefazolin 33 mg/kg IV q 8 h or clindamycin 10 mg/kg IV q 6 h

Dacrycele: small, bluish-hued, palpable mass in the location of the nasolacrimal duct without conjunctival erythema

Tx: refer to ophthalmologist

 Dacroadenitis: soft tissue swelling of the lateral upper lid.

Chronic dacryoadenitis: Sjögren syndrome, sarcoidosis, thyroid disease

Acute dacryoadenitis: viral less severe than bacterial infection

Tx: cephalexin 25 mg/kg PO q 6 h, IV ATB for more severe infection(nafcillin)

Periorbital/orbital cellulitis

Differentiated periorbital from orbital cellulitis: conjunctival injection, VA drop, proptosis, limit EOM, pain with eye movement, RAPD positive, +/- orbital, sinus CT scan

Tx: Amoxicillin clavulanate (20 mg/kg PO bid; IV ATB if severe periorbital cellulitis, hematogenous spread (< 18 mo + prior URI), orbital cellulitis: cefuroxime 50 mg/kg IV q 8 h, ceftriaxone 50 mg/kg IV q 12 h, ampicillin-sulbactam 50 mg/kg IV q 6 h, add clindamycin 10 mg/kg IV q 6 h if suspected anaerobe, consult EYE, ENT

Red eye

DDx bacterial, viral, allergic conjunctivitis, iritis, keratitis, uveitis, glaucoma, corneal abrasion, Kawasaki disease, pediculosis of the eyelashes

Corneal abrasion

Tx: erythromycin ophthalmic ointment; ciprofloxacin/ofloxacin ophthalmic solutions are safe in children >1 year old

• Cyclopentolate 1% drops may alleviate pain by reducing ciliary spasm

• F/U pediatrician in 48 h; F/U ophthalmologist next day if large abrasions, involved visual axis, use contact lenses, hx of herpes

Opthalmia neonatorum

Chemical: hx use sliver nitrate ointment, resolve in 48 h

Gonococcal: d2-7 of life with intense bilateral bulbar conjunctival erythema, chemosis, copious purulent discharge

Tx: G/S, C/S; ceftriaxone 50 mg/kg IV or cefotaxime 50 mg/kg IV q 8 h, eye irrigation

Chlamydia: d5-14 with unilateral or bilateral purulent discharge with intense erythema of the palpebral conjunctiva

Tx: Giemsa stain, C/S, nucleic acid amplification of conjunctival scrapings; erythromycin 12.5 mg/kg PO q 6 h x 14 d; F/U in 24 h if no pneumonia

Other bacteria: hyperemia, purulent discharge, edema

Tx: G/S, C/S; tropical therapy with bacitracin, polymyxin, or neomycin ointment

Viral: d6-14 with bilateral lid edema, conjunctival erythema, associated mucocutaneous lesions or maternal history of herpes

Tx: keratitis or corneal dendrites on fluorescein examination, viral C/S, nucleic amplification tests; full sepsis evaluation (LP with herpes PCR), acyclovir 20 mg/kg IV q 8 h x 14-21 d + topical antivirals (1% trifluridine, 0.1% iododeoxyuridine, 3% vidarabine)

Childhood conjunctivitis

Viral conjunctivitis

- Pharyngoconjunctival fever: conjunctivitis, pharyngitis, preauricular adenopathy

- Epidemic keratoconjunctivitis: pain, photophobia, subepithelial defects, pseudomembranes over the conjunctiva

- Follicular conjunctivitis: FB sensation, erythema of the conjunctiva, appearance of follicles

- Acute hemorrhagic conjunctivitis: hyperemic conjunctiva, subconjunctival hemorrhages, chemosis, swelling, photophobia, pain

Tx: cool compression, artificial tears, topical vasoconstrictors, +/- topical antibiotics

Bacterial conjunctivitis: normal vision, mucopurulent matting of the lashes (esp. after sleep), eyelid edema, no photophobia and eye pain; if concomittent otitis media = conjunctivitis-otits syndrome

Tx:FQ (ciprofloxacin/ofloxacin ophthalmic), bacitracin-polymyxin, trimethoprim-polymyxin; refer ophalmologist if not improve in 7d

Allergic conjunctivitis: bilateral itchy eyes, tearing, thin mucoid discharge, mild redness, eyelid edema

Tx: topical antihistamine, mast cell stabilizer (Ketotifen (1 drop q 8-12 hrs), olopatadine (1-2 drops OD)), topical NSAIDs, vasoconstrictor; oral antihistamine not recommmended

Glaucoma

cloudy and edematous cornea; Children <1 yr should not have a corneal diameter >12 mm, no child should have a corneal diameter >13 mm; blepharospasm, red infected eye, myopia, IOP > 20, cupping optic disc

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