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PEDIATRIC MANAGEMENT PROBLEMS.

Max, an 8-year-old, white male, is accompanied by his mother and older brother to the family practice clinic. He is being seen for a 2-week history of nasal congestion.

History of Present Illness

Max's mother states that the whole family had a cold 2 weeks ago but, "Max can't seem to shake his." His mother reports that in the past week he has had an intermittent, thick, green nasal discharge and has been breathing through his mouth. Max has been frequently clearing his throat and "snorting" because of excess posterior pharyngeal drainage. A nonproductive cough has been present. The cough occurs both night and day but is worse at night. Max has complained of having a sore throat for the last 5 to 6 days. He describes the sore throat as moderate in intensity, worse in the morning but getting progressively better throughout the day. His mother states Max's breath has a foul odor. She has also noticed puffiness around both eyes in the mornings for the past week. Max has complained of his right ear hurting "a little" for the past 2 days. He denies discharge or drainage from the right ear.

Max's appetite is slightly diminished, but he is taking fluids well. There is no history of headache, fever, malaise, abdominal pain, nausea, vomiting or diarrhea, facial tenderness or pain, tooth pain, or shortness of breath. The child denies inserting a foreign body into the nose.

Past Medical History

Max has had about four to five ear infections since age 2, a "handful" of upper respiratory infections (URIs), and one episode of strep throat. All infections have been successfully treated with a single course of antibiotics. There have been no major accidents, injuries, or hospitalizations. Max's immunizations are all current including the second MMR and Hepatitis B. He has not been immunized against varicella.

Family/Social History

Max lives with his mother, father, and older brother; both parents smoke in the home. There is a family history of environmental allergies. Both parents have hayfever, and Max's older brother has asthma triggered by tree pollen, dust, and animal dander. Max's only known allergy is to amoxicillin; from which he developed a rash. Max attends the third grade at a local public school. He enjoys school, is making satisfactory progress, and has many friends. He is able to read, write in cursive, and dress himself completely. He enjoys riding his bicycle. Max wears a helmet while riding his bicycle, uses his seat belt regularly, and puts on appropriate protective equipment when participating in sports. He is a member of the local cub scout troop and plays soccer and baseball. Max eats three balanced meals a day. Max consumes some high calorie, high fat snacks typical of children his age.

Physical Examination

General: Alert and cooperative; in no acute distress. Well-nourished, well-developed male. Appears stated age. Behavior, dress, and speech appropriate.

Weight: 70 lb (50th percentile).

Height: 55.5 in. (75th percentile). Vital Signs: T: 99/6 [degrees] F; HR:100; RR: 24; BP: 96/60.

Skin: Warm, dry. Hair evenly distributed. No masses, lesions, or rash.

HEENT: Normocephalic; no tenderness over sinuses upon palpation; no periorbital edema. Vision screening--OS- 20/20; OS- 20/25; sclerae white; conjunctivae clear; EOM intact; PERRLA; Fundi-unremarkable. Nasal mucosa edematous and beefy red in color; small amount of thick, green, purulent discharge present bilaterally. Left tympanic membrane (TM) WNL; right TM erythemic at inferior border; light reflex intact; no bulging or retraction. Teeth in good repair; oral mucosa pink, moist without lesions; pharynx slightly reddened; no exudate; green discharge present in the posterior pharynx.

Neck: Supple without lymphadenopathy or thyroid enlargement.

Heart: Regular rhythm and rate without murmurs. Femoral pulses intact bilaterally.

Lungs: Lungs CTA bilaterally. No tactile fremitus. No egophony. Diaphragmatic excursion equal.

Abdomen: Unremarkable.

Extremities: No deformities. No atrophy or weakness.

Neurologic: DTR 2+ bilaterally. Romberg negative.

Laboratory: Rapid strep negative.

What is Your Assessment?

The following differential diagnoses should be considered for this 8-year-old male.

1. Viral URI. This diagnosis usually presents with a low-grade fever, pharyngitis, conjunctivitis, and is generally limited to 7-10 days duration. This diagnosis can be ruled out since Max's symptoms have continued for 14 days.

2. Allergic rhinitis. While Max does have a strong family history of allergy, this diagnosis is unlikely since it usually presents with pale, boggy nasal mucosa. Sneezing and pruritis are also typical symptoms.

3. Group A strep infection. Max does not have the typical presentation of strep pharyngitis (i.e., abrupt onset, severe sore throat, high fever, and absence of rhinorrhea). Nevertheless, a rapid direct antigen test was performed. This test is reported to be 95%-99% specific and 85%-95% sensitive resulting in some false negatives and necessitating a follow-up tradition culture (Boynton, Dunn, & Stephens, 1998). This diagnosis is unlikely but cannot be completely ruled out until the traditional throat culture is read as negative.

4. Nasal foreign body. This diagnosis can be ruled out. The nares are patent and there is no history of foreign body insertion. The nasal discharge is bilateral not unilateral as is seen with nasal foreign body.

5. Cough variant asthma. This diagnosis is unlikely since the child has no respiratory involvement other than the cough. In addition, the sore throat, ear pain, and green, purulent nasal discharge imply an infectious agent.

6. Otitis media. This is a valid diagnosis. The erythema of the inferior right tympanic membrane coupled with subjective complaints of right ear pain necessitate treatment for this condition. The rhinorrhea, cough, and sore throat are not explained by this diagnosis.

7. Sinusitis. The diagnosis of sinusitis may not be considered in children because of the belief that sinuses do not become clinically important until the age of 10. While this is true for frontal sinuses, both maxillary and ethmoid sinuses are present at birth and are capable of becoming infected any time during childhood.

The most important factor in the clinical diagnosis of sinusitis is chronic cold symptoms for more than 10 days (Kenna & Reilly, 1993). The classic symptoms of sinusitis (e.g., headache, facial pain/tenderness) are usually not present in children. Rhinorrhea of any quality (clear, cloudy, mucoid, or purulent) may be present. Postnasal drip and cough are common. Fever may or may not be present. Periorbital swelling, mild sore throat, and slight nausea due to gastric irritation from infected sinus drainage may be seen.

Otitis media occurs concurrently with sinusitis about 50% of the time (Schwartz, 1994). Sinusitis has also been associated with asthma. In fact, 79% of children studied were able to discontinue their asthma medication once they were appropriately treated for sinusitis (Slavin, 1993).

There are many risk factors for sinusitis. They include: URI, allergic rhinitis, overuse of topical decongestants, hypertrophied adenoids, deviated nasal septum, nasal polyps, swimming and diving, cigarette smoking, barotrauma, dental extraction/injection, immune deficiency, cystic fibrosis, bronchiectasis, and immotile cilia syndrome (Slavin, 1993).

What is Your Management Plan?

Most of the time the diagnosis of sinusitis can be made without diagnostic testing. Plain x-ray films, which have been used for years, may overrepresent or underrepresent sinus abnormalities and, therefore, are not encouraged (Kenna & Reilly, 1993). Currently, computerized tomography (CT) is the gold standard for diagnosis of paranasal sinus disease of children (Kenna & Reilly, 1993). A CT is indicated when a child does not improve significantly after medical treatment (e.g., after 6 weeks), when a complication of sinusitis is suspected, or when a child is severely ill (e.g., those with severe headache, blurred vision, limitation of ocular mobility, lethargy, or confusion). A CT will also be needed in children requiring surgery for anatomic problems, progressive infection, or a protracted chronic illness (Kenna & Reilly, 1993).

There are three physiologic processes important to the proper functioning of the paranasal sinuses: (a) the patency of the ostia, (b) the function of the cilia, and (c) the quality of mucous secretion (Schwartz, 1994). Ostia can become obstructed from inflammation caused by a viral URI or allergic inflammation. Cold, dry air; viral or bacterial infections; or chemicals or drugs can impair ciliary function. Overproduction of purulent sinus secretions can overwhelm or even damage cilia and prevent removal of infected secretions. Therefore, management goals involve controlling infection, decreasing tissue edema, facilitating drainage, and maintaining patency of sinus ostia.

The typical causative pathogens of sinusitis include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; the same organisms that cause otitis media. Amoxicillin 20-40 mg/kg/day in three divided doses is a good first line therapy. Children sensitive to penicillin may take trimethoprin/sulfamethoxazole or erythromycin and sulfisoxazole if older than 2 months of age. Other effective agents include clarithromycin, cefprozil, loracarbef, and amoxicillin and clavulanic acid.

Unless symptoms are recurrent or chronic, 2 weeks of antibiotic therapy is generally sufficient. A 3-week course may be needed if symptoms continue. Most sinusitis in children will resolve spontaneously or after a 1- to 2-week course of antibiotics.

Several medications may be useful to decrease inflammation, facilitate drainage, and maintain patency of ostia. Decongestant nasal drops or spray may be used cautiously in infants. Oral decongestants may be helpful in children older than 6 months. Combined oral antihistamines/decongestants maybe beneficial in children with allergies or allergic rhinitis.

Since Max has an allergy to amoxicillin, he was placed on trimethoprin/sulfamethoazole pediatric suspension, 15 mi orally twice a day for 14 days. This antibiotic will treat both sinus and ear infections. He is also given a prescription for a decongestant. Max may take ibuprofen, 200 mg every 6 hours as needed, for ear pain.

Max is encouraged to take prolonged showers to help promote sinus drainage. He is told to avoid diving or jumping into deep water when he has a URI, to gently blow his nose to evacuate the nasal cavity, and to increase his fluid intake. Max's mother is instructed on the consequences of passive smoking. She is also encouraged to humidify the air in the child's room, especially at night. Max and his mother are also told that sinus inflammation occurs as part of a normal cold, and antibiotics are not usually indicated.

Follow-Up

Max and his mother are told to follow-up in 2 weeks for a recheck of the infected ear. She is asked to call in 48 hours if Max is not improved or if central nervous system (CNS) complications occur (e.g., difficulty in balance, clumsiness, change in mental status, or lethargy).

References

Boynton, R.W., Dunn, E.S., & Stephens, G.R. (1998). Manual of ambulatory care. Philadelphia: J.B. Lippincott Company.

Kenna, M.A., & Reilly, J.S. (1993). Childhood sinusitis: A practical plan for office management. Consultant, 33(11), 62-64.

Schwartz, R. (1994). The diagnosis and management of sinusitis. Nurse Practitioner, 19(12), 58-63.

Slavin, R.G. (1993). Sinusitis: Ten questions physicians often ask. Consultant, 33(2), 65-68.

Contributed by: Bethany Jagers, MS, RN Hocking College School of Nursing Nelsonville, OH
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Author:Belkengren, Richard; Sapala, Shirley
Publication:Pediatric Nursing
Date:Jan 1, 1999
Words:1815
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