Page 1 of 7

PULMONOLOGY LECTURE
MARIA CONSUELO MARAMAG-MANUEL MD

Diseases of the NOSE

CHOANAL ATRESIA
most common congenital anomaly of
the nose.
often diagnose by the in ability to pass a 5.0 French
feeding tube from the nose to the nasopharynx.

Acquired Disorders:
FOREIGN BODIES
- common in childhood
- presence of mucopurelent discharge from one of the nares
- the foreign body can be visualized by nasal speculum
- remove with forceps or nasal suction.

EPISTAXIS
- can be seen with congenital vascular abnormalities,
platelets disorders or hypertension.
- Commonly seen following trauma or URTI.
- Source of bleeding anterior nares or the turbinates.
- Tx; local compression , use of vasoconstrictors.

COMMON COLD
Often termed rhinitis; rhinosinusitis is more correct term
Most common infectious condition in children
Syndrome more extensive in children

Common Pathogens :
Association Pathogens Frequency
primarily
associated
with colds
Rhinoviruses
Coronaviruses
Frequent
Occasional
other clinical
syndromes
that also
cause
common cold
symptoms
RSV
Human
pneumometavirus
Influenza viruses
Parainfluenza virus es
Adenovirus es
Enterovirus es
Bocavirus
Occasional

Occasional
Uncommon
Uncommon
Uncommon
Uncommon
Uncommon

Epidemiology:
universal susceptibility
occur throughout the year
average in children = 6-8 colds/year; highest number
during 1
st
2 years of life.

Period of Infectivity: few hours to 1-2 days after illness
appeared

MOT:
inhalation or droplet nuclei
direct inoculation/contact
Re-infection occurs because protective immunity does not
develop after an infection
Clinical Manifestations
Symptoms of rhinorrhea and nasal obstruction are
prominent
Systemic s/s myalgia & fever are absent/mild
Onset 1-3 days after viral inf. sore throat nasal
obstruction & rhinorrhea
Usual cold last about 1 week
P.E. swollen erythematous nasal turbinates
A change in color or consistency of the secretion is
common during the course of illness and is NOT indicative
of sinusitis or bacterial superinfection.

Differential Diagnosis
Etiology Key Points on Hx or PE
Sinusitis
Age (>2 years)
duration (>14d) high fever,
unilateral headache,
facial tenderness or nasal d/c
Strepto-
coccosis
Nasal discharge that excoriates the nares
Allergic
Rhinitis
Hx of atopy,
itchy watery eyes, allergic facies,
nasal eosinophils; prominent itching/sneezing
FB
Unilateral, foul smelling D/C,
bloody nasal secretion
Pertussis Onset of persistent/severe cough
Congenital
Persistent rhinorrhea w/ onset in 1
st
3 months
of life

Diagnosis
Routine lab studies not helpful
Nasal smear for eosinophils only if allergic rhinitis is
suspected
Viral studies generally not indicated; useful only when
anti-viral agent contemplated

Complications
Otitis media most common; 5-30% of children
Sinusitis self limited sinus involvement
- part of pathophysiology
- occurs in 5-13% of cases
Asthma exacerbation relatively uncommon but
potentially serious complications
Inappropriate use of antibiotics
- important consequence antibiotic resistant of
pathogenic respiratory bacteria;
- 30% of MDs prescribe antibiotics

Treatment :
Primarily symptomatic
Antibiotics of no benefit
Antiviral
- specific for rhinovirus not available
- Ribavirin for RSV no role in tx
- Oseltamivir/zanamivir modest effect on
duration of influenza/s; beneficial if started w/in 2
days of onset
Page 2 of 7
SYMPTOMATIC TREATMENT
- No studies have demonstrated a significant effect in
children
- Decision to use must be balanced against potential
adverse effects

1. Nasal Obstruction
a. Topical adrenergic agents
- XYLOMETAZOLINE, OXYMETAZOLINE,
PHENYLEPHRINE
- not approved for <2 yrs;
- systemic absorption rarely associated with
bradycardia, hypotension & coma;
- prolonged use avoided to prevent RHINITIS
MEDICAMENTOSA
b. Oral adrenergic agents less effective
- associated with CNS stimulation, hypertension &
palpitation
2. Cough
- If due to URT irritation associated w/ PND
treatment w/ 1
st
gen AH helpful
- If due to virus-induced reactive airway dse
bronchodilator tx
*Codeine, Dextromenthorphan, guiafenesinnot
effective

3. Rhinorrhea
1
st
gen AH induce it by 25-30%; effect due to
anticholinergic property
2
nd
gen AH non-sedating; no effect on symptom
Ipratropium Bromide topical anticholinergic
- not associated with sedation
- most common SE : nasal irritation & bleeding

NO SIGNIFICANT EFFECT on cold symptoms:
- Vitamin C
- Guiafenesin
- warm humidified air
- zinc
- echinacea

Prevention:
chemoPx not available
protective face shields
good hand washing


ACUTE PHARYNGITIS
All infections of the pharynx, including tonsillitis and
pharyngotonsillitis; part of most URTI
Most important agents: viruses & GABHS
Strictly it refers to conditions in which principal
involvement is throat

MOT:
- person to person contact
- airborne dissemination
- indirect through contaminated hands


Clinical Manifestations

1. Viral Pharyngitis

Adenovirus pharyngoconjunctival fever
Cosxackievirus herpangina/acute lymphonodular
pharyngitis
EBV prominent tonsillar enlargement, exudative,
CLAD, hepatomegaly, rash, fatigue IM syndrome
1 herpes simplex high fever Gradual onset

Symptoms: rhinorrhea, cough & diarrhea &
gingivotomatitis
viral etiology is suggested by the presence of:
- Conjunctivitis
- Coryza
- Cough
- Hoarseness

2. Streptococcal Pharyngitis
- Rapid onset with prominent sore throat
- (-) of cough and fever
- Headache and GI/s are frequent
- Red pharynx, enlarged tonsils w/ yellow, blood-
tinged exudate
- Petechiae / donut lesions on the soft palate and
post. pharynx;
- uvula red, stippled & swollen
- enlarged & tender CLAD
- Additional stigmata of scarlet fever: circumoral
pallor, strawberry tongue & red finely popular rash

Diagnosis : goal is to identify GABHS infection; considerable
overlap with clinical presentation
Throat culture imperfect gold std. (false +/-results)
Rapid test for GAS Ag
- High specificity so if (+), throat c/s is unnecessary
- Less sensitive, so a (-) test must be confirmed by
throat c/s

Treatment:

1. Acute Pharyngitis
Early antibiotic treatment hastens clinical recovery by
12-24 hours
1 benefit of tx prevention of acute RF
Antibiotics recommended even w/o c/s in:
- Children w/ symptomatic pharyngitis & a (+)
rapid streptococcal Ag test
- Clinical Dx of scarlet fever
- Household contact w/ documented strep.
pharyngitis
- Past history of acute RF
- Recent history of acute RF in a family member
GABHS remains universally susceptible to penicillin
Penicillin V BID or TID x 10d
250 mg/dose for children
500 mg/dose for ado/adults

Page 3 of 7
Amoxicillin
750 mg OD x 10d = 250 mg Penicillin TID x 10d
50 MKD BID x 6d = TID Penicillin V x 10d
Benzathine Penicillin Single IM dose
600T u for child <27 kg (60 lbs)
1.2 M u for bigger child
Erythromycin MKD TID/QID x 10d
(max dose = 1 gm/d)
Azithromycin
- Convenient
- more expensive
- associated w/ R to erythromycin among GAS
1
st
gen cephalosphorins
- as effective as penicillin;
- more effective in eradicating strep carriage

Follow-up cultures not necessary unless symptoms
recur
For eradicating strep. carriage:
clindamycin 20 MKD TID x 10d
(adult = 150 450 mg TID/QID) most effective

2. Recurrent Pharyngitis
a. Relapse with an identical strain
- If poor antibiotic compliance = IM Benz.
Penicillin suggested
- Possibility of resistance if non-penicillin tx
(erythromycin) was given
b. Caused by a different strain
- New exposure or another cause + strep. carriage (esp.
if mild illness & a typical for strep)

*Tonsillectomy
- lowers incidence of pharyngitis for 1 2 years among:
a. Children with recurrent culture (+)
b. GABHS pharyngitis that is severe
c. Frequent episodes = > 7 episodes in previous
year or >5 in each of the preceding 2 years
- Undocumented histories of recurrent pharyngitis
inadequate basis for tonsillectomy

Complications
1. Viral pharyngitis > bacterial middle ear infections
2. Strep pharyngitis
a. local suppurative complications: parapharyngeal
abscess
b. non-suppurative illnesses: acute RF, acute post-infx
GN


Retropharyngeal Abscess, Lateral Pharyngeal
Abscess, Peritonsillar Cellulitis/Abscess
Neck contains deeply located lymph nodes ~
retropharyngeal/lateral pharyngeal nodes that drain upper
airway and digestive tracts
Infection usually an extension from a localized infection
of the oropharynx



Retropharyngeal & Lateral Pharyngeal Abscess

DDx:
- acute epiglottitis
- FBA
- Meningitis
- Lymphoma
- Hemathoma
- vertebral osteomyelitis
Dx :
- I and D for c/s definitive dx;
- CT scan useful but accurate only in 63%; soft tissue
neck films - width, air-fluid level in the
retropharyngeal space

Tx:
- IV Antibiotics w/ or w/out surgical drainage
- 3
rd
gen cephalosporin + Sulbactam Ampicillin or
Clindamycin for anaerobic coverage
- Drainage if with respiratory distress or failure to
improve with IV antibiotics

Complications:
- Significant UAO
- Rupture aspiration pneumonia
- Extention of mediastinum

Peritonsillar Cellulitis / Abscess

Etiology:
- caused by bacterial invasion through capsule of tonsil;
- typical pt ado w/ recent hx of ATP;
- grp A streptococcus and oral anaerobes most
common pathogens

Clinical mainfestations:
- sore throat
- fever
- trismus
- dysphagia
- P.E. : asymmetric tonsillar bulge with displacement of
the uvula

Tx:
- antibiotics against GAS/anaerobes;
- surgical drainage
- Tonsillectomy if with:
a. Failure to improve w/in 24 hrs of antibiotic
therapy & needle aspirations
b. Hx of recurrent peritonsillar abscess/recurrent
tonsillitis
c. Complications from peritonsillar abscess


Sinusitis

Maxillary and ethmoid present at birth
- ethmoidal pneumatized
- maxillary not until 4 yrs of age
Page 4 of 7
Frontal sinus begin to develop by age 7 8 yrs and are
not completely developed until adolescence
Sphenoidal sinus present by 5
th
year life
Paranasal sinuses normally sterile, maintained by
mucociliary system
Typically follows a viral URTI
Nose blowing can be generate sufficient force to propel
nasal secretions into sinus cavities
2 types: viral / bacterial

1. Viral rhinosinusitis inflamation/edema
- Block sinus drainage and impair mucociliary clearance
of bacteria

2. Acute Bacterial Sinusitis

Etiology:
a. M. catarrhalis (100%),
b. H. influenzae (50%),
c. S. pneumoniae (25%)
- May occur at any age
- Predisposing condition:
a. viral URTI
b. allergic rhinitis
c. cigarette smoke exposure
- Persistent/s of URTI (nasal discharge & cough) > 10 14
days w/o improvement
- Severe respiratory /s, including temperature of at least
39C
- Purulent nasal discharge x 3-4 consecutive days
suggestive of acute bacterial sinusitis

Clinical Manifestations
Nonspecific: nasal congestion / purulent nasal discharge,
fever & cough
Less common: halitosis, sense of smell & periorbital
edema
Rare : headache & facial pain
Additional/s: maxillary tooth discomfort, pain/P
exacerbated by bending forward, hyposmia
P.E.: mild erythema & swelling of nasal mucusa w/
purulent nasal discharge; sinus tenderness in adolescents

Complications
1. Orbital periorbital / orbital cellulitis
2. Intracranial meningitis, cavernous sinus thrombosis,
subdural empyema, epithelial/brain abscess

Diagnosis : Sinusitis
Transillumination of sinus cavities difficult to perform
& unreliable
Sinus plain films & CT Scan
- opacification, mucosal thickening, presence of air-
fluid level;
- not diagnostic;
- can confirm presence of sinus inflammation
Sinus aspirate culture the only accurate method for
Dx; not practical for routine use



DDx:
- viral URTI - /s <10-14d, clear nasal d/c
- Allergenic rhinitis seasonal, nasal eosinophilia
- Non-allergic rhinitis
- Nasal foreign body

Tx:
Amoxicillin = 45 MKD for uncomplicated acute bacterial
sinusitis
- Appropriate duration has yet to be determined ~ tx
for 7 days after resolution of /s
For penicillin allergic: cefuroxime, cefpodoxime,
clarithromycin or azithromycin
High dose Amoxicillin Clavulanic acid:
(80-90 MKD) 6.4 MKD)

1. For children with risk factors
- Antibiotic tx in preceding 1-3 months
- Daycare attendance
- <2 yrs
2. Resistant bacterial species
3. Tx failure w/ amoxicillin after 72 hours
Azithromycin/Levofloxacin (older children)
alternative

Otolaryngology referral for Co-amoxiclav failure
maxillary sinus aspiration

Treatment : Sinusitis
Symptomatic Tx: decongestants, AH, mucolytics and
intranasal CS not adequately studied & is not
recommended
Saline nasal wash / sprays liquify secretions & act as mild
vasoconstrictor


Ear Infections
OTITIS EXTERNA (swimmers ear)
Results from chronic irritation & maceration from
excessive moisture in the canal; loss of protective
cerumen; cerumen impaction w/ trapping of water
Etiology:
- P. aeroginosa is most common
- gm (-) bacilli,
- Staph aureus
- Klebsiella
- Streptococci may be isolated

Clinical manifestations:
- ear pain aggravated by movement of tragus is
presenting complaint
- itching
- if chronic, conductive hearing loss;
- thick clumpy otorrhea/periauricular edema s/ of
acute dse

Tx:
- cleansing and drying of external ear canal;
- otic drops w/ mixture of polymyxin, neomycin and
corticosteroid;
Page 5 of 7
- analgesics
- antibiotics (oxacillin or any penicillinase-resistant
penicillin for staph and aminoglycosides for GN
bacilli) for severe cases

OTITIS MEDIA
Inflammation of middle ear
highest in the 1
st
2 years of life and declines thereafter
Peak incidence: 6 20 months of age
Anatomic predisposition:
- eustachian tube is shorter, wider, straighter and more
horizontal ~ facilitate invasion of middle ear by
nasopharyngeal bacteria;
- bottle-fed babies in supine position > breastfed
infants in semi-upright position

Acute Otitis Media
Definition: recent, usually abrupt onset of s/s of MEE
& middle ear infammation
MEE: bulging of TM, limited/absent motility of TM,
air-fluid level behind TM, otorrhea
Middle ear inflammation: distinct erythema of TM or
distinct otalgia
Diagnosis requires:
- History of acute onset of s/s
- Presence of MEE
- s/s of middle ear inflammation

2 Main Components
1. Supurative or Acute (AOM)
2. Nonsupurative or secretory or with effusion
(OME)
*Middle ear effusion (MEE) is a feature of BOTH
AOM & OME and may persist for 3 months or more

Etiology :
a. AOM:
- Strep. Pneumoniae 40%
- Non-typable H. influenza 25-30%
- M. Catarrhalis 10-15%
- Viruses - rhinovirus & RSV most often
b. OME: usually sterile but pathogens in AOM are
also seen in 30%

Clinical Manifestations:
a. AOM signs referable to ear: sense of fullness,
deafness, ear pain, in infants or neonates head
rolling, ear tugging and irritability; malaise, high grade
fever, purulent ear discharge if with rupture of tm or
NO symptoms
b. OME usually w/ NO symptoms
- With associated conductive hearing loss
- Older child: mild discomfort or sense of fullness
- Dx confirmed by otoscopy; absent light reflex,
decreased motility, retraction or bulging are
diagnostic





Treatment :
a. First-Line:
- Amoxicillin DOC for uncomplicated AOM
= 80-100 MKD effective against penicillin I &
some penicillin R strain
- Allergic children azithromycin (TMP-SMZ-
high clinical failure rate bec of resistance of H
influenzae and S. pneumoniae), or cefdinir (if
w/ no cross-rxn to ceph)
- Duration of Tx: 10 days
- Factors Contributing to Failure of First-Line
Treatment
1. Poor compliance
2. Concurrent viral infection
3. Persistent middle ear under aeration
4. Re-infection from other sites
5. Impaired host defenses

b. Second-Line: Co-amoxiclav, cefuroxime, IM
Ceftriaxome

c. Indications for myringotomy:
- Severe, refractory pain
- Hyperpyrexia
- AOM complications facial paralysis,
mastoiditis, CNS infection
- Immunologic compromise
- Failure of 2
nd
line tx

Otitis Media with Effusion
Determine course by monthly examination & hearing
assessed if effusion is for 3 months
Antimicrobial tx: w/ evidence of associated bacterial URTI;
chronicity &/or hearing loss w/ consideration of
tympanostomy; given for 2-4 weeks


CROUP & EPIGLOTTITIS

Croup refers to a heterogeneous grp of acute/infectious
processes characterized by: barklike/brassy cough, associated
with hoarseness, inspiratory stridor & respiratory distress;
- typically affects larynx, trachea and brochi

Epiglottitis (supraglottitis) included in acute infections
producing upper airway obstruction

Stridor harsh, highly pitched sound, usually
inspiratory/biphasic; NOT a diagnosis but a sign of UAO

Epiglottitis Distinction from Viral LTB
- Lack of history of URTI
- Speed of progression
- Degree of toxicity
- Extent of drooling
- Use of tripod position
- Minimal cough



Page 6 of 7
Mainstay of Tx airway management
Placement of child in mist tent ~ may anxiety & worsen
respiratory distress; controlled trial failed to show benefit;
no longer recommended
Decision on feeding must relate to severity of respiratory
distress
Nebulized racemic epinephrine
- Accept tx for moderate-severe croup
- MOA: constriction of pre-capillary arterioles fluid
resorption from interstitial space laryngeal
mucosal edema; rapid onset 30 min; effects last x 2-
3 hrs
- Dose: 0.25-0.75 ml of a 2. 25% soln in 3 ml NSS q 20
minutes
- L-epinephrine: 0.4-0.5 ml/kg (max 5 ml) of 1:1000
soln
- No risk of AE
- Should be nebulized in oxygen w/ cardiac monitoring;
d/c if with arrythmia

Nebulized racemic epinephrine Indications:
1. Moderate to severe stridor at rest
2. Possible need for intubation
3. Respiratory distress
4. Hypoxia

Recommending in Kendig: single dose of 0.15 to 0.6
mg/kg dexamethasone po, IV or IM; if nebulized
budesonide is available, give 2 mg nebulized dose;
both have additive beneficial effect
Discharge: w/ no stridor at rest, w/ minimal to no
other symptoms
Racemic ephinephrine/corticosteroids are
INEFFECTIVE for epiglottitis/tracheitis

Indications for Rifampicin prophylaxis (20 mk OD x 4 days, max
dose 600 mg/d):
1. Any contact < 48 months old w/ incomplete
immunization
2. Any contact < 12 months old w/ NO 1 vaccination
series
3. Immunocompromised child in HH


Other Disorders Of URT

Tonsils and Adenoids
Tonsils 2 faucial tonsils
Adenoids nasopharyngeal tonsil
Part of lymphoid tissues that circle the pharynx; known
collectively as Waldeyers ring (lymphoid tissue on base of
tongue [lingual tonsils], 2 faucial tonsils, adenoids,
lymphoid tissue on posterior pharyngeal wall)
Most immunologically active bet. 4-10 yrs old, after
puberty
Principal disturbances are:
- Acute infection
- Chronic infection
- Airway obstruction
- Tonsillar neoplasm
Acute Infection
Most viral; GABHS most common bacterial cause
/S dry throat, malaise, fever & chills, odynophagia,
dysphagia, reffered otalgia, headache, myagia, CLAD
/S dry tongue, erythematous enlarged tonsils, exudate,
palatine petechiae, enlarged tender nodes

Chronic Infection
Polymicrobial streptococci, H. influenzae, anaerobes
predominate
Chronic / cryptic tonsillitis
/S halitosis, chronic sore throats, foreign body sensation,
Hx of expelling foul-tasting / smelling cheesy lumps
S/ - tonsils any size, copious debris w/in crypts

Airway Obstruction
Typically manifested in sleep-disordered breathing OSA,
obstructive sleep hypopnea, UA resistance syndrome
Daytime /s: chronic mouth breathing, nasal obstruction,
hyponasal speech, hyposmia, appetite, poor school
performance, /s of right sided heart failure
Nighttime /s: loud snoring, choking, gasping, frank apnea,
restless sleep, sleep walking / talking, night terrors,
enuresis

Tonsillar Neoplasm
Rapid enlargement of 1 tonsil highly suggestive
lymphoma
Especially if with night sweats, fever, weight loss and
lymphadenopathy

Medical Management
- Tx for acute pharyngitis / GABHS
- Celophosporin or clindamycin for chronic

Tonsillectomy
7 or > throat infections in the preceding yr
5 or > in each of the preceding 2 yrs
3 or > in each of the preceding 2 yrs

Tonsillectomy is effective in:
Decreasing the # of infections
Decreasing /s of chronic tonsillitis: halitosis,
persistent/recurrent sore throat, recurrent cervical
adenitis

Adenoidectomy
For tx of chronic nasal infection (chronic adenoiditis)
Chronic sinus infection that have failed medical Mx
Recurrent AOM
Chronic or recurrent OME
OSA
UAO is suspected of causing cranio-facial or occlusive
developmental abnormalities

T & A
Same criteria as tonsillectomy alone
UAO 2 to adenotonsillar hypertrophy OSA, FTT,
craniofacial / occlusive developmental abnormality,
speech abnormality, cor pulmonale
Page 7 of 7
CONGENITAL LOBAR EMPYSEMA
Most common cogenital anomaly of the lungs.
Irreversible distention and rupture of the alveoli
resulting from the partial obstruction of a bronchus or
bronchiole
Diagnos by xray- overinflated lobe with mediastinal
shift.

ATELECTASIS
Imperfect expansion or collapse of lung parencyma.
May occur with restrictive or obstructive pulmonary
diseases.
May present with dyspnea, shallow breathing,
tachypnea or cyanosis.

EMPHYSEMA
Condition of the lungs in which there is irreversible
distention and the rupture of the alveoli.
Results from ball-valve obstruction of a primary or
secondary bronchus
Commonly seen with foreign bodies, tuberculosis.
Chest examination decrease breath sound in the
affected lobe and hyper resonance on percussion
Chest x-ray reveals hyperlucency on the affected lobe
and shift of mediastinal contents to the contralateral
side.

DISEASES OF THE PLEURA
Typically accompanies underlying destructive lung
disease.
Small pneumothoraces may resolve spontaneously.
Moderate pneumothoraces utilizing inspiration of
100% oxygen.
Large pneumothoraces requires thoracentesis with
closed vacuum assisted drainage.
Persistent pneumothoraces requires evacuation and
surgical or chemical adhesion of the plural surfaces.