Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 23

Sinus, Mouth, Throat, and Neck Disorders

Susan G. Rains

I. ALLERGIC RHINITIS

Allergic conjunctivitis, 372.14

Noisy breathing/snoring, 786.09

Allergic rhinitis due to other allergens, 477.8

Rhinorrhea, 478.1 Sneezing, 784.9

Allergic rhinitis due to pollen (seasonal rhinitis), 477.9

Stuffy nose, 478.1 Wheezing, 786.07

Cough, 786.2

 

Halitosis, 784.9

 

Nasal obstruction, 478.1

 

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.

Choanal atresia, 748

Rhinitis, drug or food induced, 477.1

Cystic fi brosis, 277

Rhinitis medicamentosus, 372.05

Dermatoid cyst, 706.2

Rhinorrhea, 478.1

Deviated septum, 470

Sinusitis, 473.9

Headache, 784

Sinusitis, chronic, 473.9

Nasal foreign body, 932

Upper respiratory infection, 465.9

Nasal glioma, 748.1

Vasomotor rhinitis, 477.9

Nasal polyp, 471.9

Viral URI, 465.9

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.

Dental malocclusion, 524.5

Loss of smell, 781.1

Hearing loss, 389.9

Otitis media, 382.9

Hoarseness, 784.49

Sinusitis, chronic, 473.9

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.

K. Education.

1. Chronicity of problem.

2. Avoidance of allergens (recent evidence that exposure to cats, dogs in first year of life decreases development of allergies later in childhood).

3. Medication administration and side effects.

II. APHTHOUS STOMATITIS

Aphthous stomatitis, 528.2

Fever, 780.6

Cheilitis

Lymphadenopathy, 785.6

Deficiencies of B12, 266.2

Malabsorption syndromes, 579.9

Deficiencies of folic acid, 266.2

Painful sores in mouth, 528.9

Deficiencies of iron, 280.9

 

A. Etiology.

1. Commonly known as canker sores, aphthous stomatitis is recurrence of painful, discrete, shallow ulcers on unattached mucous membranes of mouth.

2. Considered to be immune-mediated destruction of epithelium, cause is multifactorial, including infection, autoimmune disease, allergies, nutritional deficiencies, and trauma.

3. Associated risk factors.

a. Genetic: positive family history.

b. Deficiencies of iron, vitamin B12, folic acid.

c. Chronic illness such as IBD, celiac disease, immune suppression, lupus, JRA.

d. NSAID or ACE inhibitor usage.

e. Childhood: higher incidence (peak 10-19 years).

B. Occurrence.

1. Incidence: up to 20% of population.

2. Precipitating factors.

a. Stress/trauma: emotional, physical, hormonal.

b. Foods: chocolate, nuts, tomatoes.

c. Malabsorption syndromes.

C. Clinical manifestations.

1. Aphthous minor: 80% of cases: 1-5 mm lesions; heal in 5-12 days; no scarring.

2. Aphthous major: 15% of cases > 1 cm lesions; last 4 weeks; may scar.

3. Patient complains of single or multiple painful sores in mouth.

4. Tingling or burning may precede appearance of lesions.

D. Physical findings.

1. Painful, yellow, gray, ulcerative lesions with erythematous halo on mucosa.

2. 1-5 ulcerative oval or circular ulcers with an erythematous periphery and pale white/gray or yellow center.

3. Size: 2-10 mm.

4. Absence of systemic symptoms (i.e., fever, lymphadenopathy).

E. Diagnostic tests.

1. None.

F. Differential diagnosis.

Fever, 780.6

Herpes simplex, 054.9

Herpangina-ulcerative pharyngitis, 074

Lymphadenopathy, 785.6

1. Infections:

a. Herpes simplex (rare).

• Small, irregular vesicles that rupture and leave ulcers.

• Red at periphery with gray center.

• Patient often febrile with significant lymphadenopathy.

• Recurrent herpes infections remain localized to lips, rarely cross mucocutaneous junction.

• Primary infections sometimes involve oral mucosa.

b. Coxsackie–hand, foot and mouth disease.

• Sometimes ulcers in the mouth (and will have papules on hands and feet, perhaps buttocks).

2. Traumatic (injury).

3. Herpangina–ulcerative pharyngitis (not stomatitis); fever, lymphadenopathy.

4. Angular cheilitis–erythematous, painful fissures at corners of the mouth. May be caused by lipsucking, sensitivity to agent with which in contact. Treatment is topical with an antibiotic, anti-yeast or low-dose steroid ointment.

G. Treatment.

1. Supportive.

a. Oral analgesics such as acetaminophen or ibuprofen.

b. Topical anesthetics: especially prior to eating/drinking.

• Viscous Xylocaine dabbed on lesions with cotton swab.

• Mouthwashes.

i.  Diphenhydramine elixir: antacid suspension (aluminum and magnesium hydroxide combination): mix 1:1 (parent can do this).

ii. Pharmacist may add lidocaine 1% for older child to swish and spit.

• 0.1% Triamcinolone (Kenalog) in Orabase: dab on lesions qid.

c. Avoid acidic, salty foods and drinks.

d. Good oral hygiene.

• Rinse mouth frequently with clear water.

• Offer water to young children frequently, especially after eating or drinking other fluids.

H. Follow up.

1. None if healed.

I. Complications.

1. Generally none. Young child may refuse to drink.

2. Referral if persists 3 weeks or no urine output for 12 hours.

J. Education.

1. Avoidance of triggers/precipitating factors.

III. CAT-SCRATCH DISEASE

Cat-scratch disease, 078.3

Nonpruritic vesicle or papule(s), 216.3

Conjunctivitis, nonsuppurative, 372.3

Ocular granuloma, 376.11

Fever, 780.6

Skin lesion, 709.9

Lymphadenopathy, 785.6

 

A. Etiology.

1. Bacteria Bartonella henselae infects humans via cat saliva entering the body through a scratch or bite.

2. 87-99% of patients have had contact with kitten within the last 6 months; 50% have history of scratch.

B. Occurrence.

1. More common in children, (younger than 18 years), especially boys.

2. 20,000 cases/year in United States, primarily July-January.

C. Clinical manifestations.

1. Typical cat-scratch disease.

a. Primary skin lesion (papule) appears 3-10 days following inoculation.

b. Regional lymphadenopathy develops in about 2 weeks, persists sometimes for months. 85% have a single node.

c. Fever, which may be prolonged (up to 2 weeks) in two-thirds of patients.

d. 10% of nodes may suppurate spontaneously.

e. Hepatosplenic disease.

2. Less common clinical manifestations:

a. Parinaud oculoglandular syndrome.

b. Neuroretinitis-posterior segment ocular disease.

c. Encephalopathy.

d. Radiculopathy.

e. Facial nerve palsy.

f. Guillain-Barré syndrome.

g. Cerebral arteritis.

h. Transverse myelitis.

i. Glomerulonephritis.

j. Thrombocytopenia purpura.

k. Osteomyelitis.

l. Arthritis/arthralgia.

m. Endocarditis.

D. Physical findings (in typical CSD).

1. Nonpruritic vesicle or papule(s) over site of inoculation.

2. Lymphadenopathy of area that drains site of inoculation. Most commonly axillary and epitrochlear nodes, then head, neck, and groin in descending order of frequency.

3. Skin over affected nodes is warm, taut, tender, indurated.

E. Diagnostic criteria: (3 of the following 4):

1. Cat or flea contact regardless of presence of inoculation site.

2. Negative serology for other causes of adenopathy, sterile pus aspirated from a node, a positive PCR assay, and/or liver/spleen lesions seen on CT scan.

3. Positive enzyme immunoassay or IFA with a titer ratio of > 1:64.

4. Biopsy showing granulomatous inflammation consistent with CSD or positive Warthin-Starry silver stain.

F. Differential diagnosis.

Cytomegalovirus, 078.5

Lymphadenopathy, 785.6

Epstein-Barr virus, 075

Mycobacterium, 031.9

Group A streptococcus, 041.01

Neck masses, 784.2

Group B streptococcus, 041.02

Staphylococci, 041.1

HIV, V08

Toxoplasmosis, 130.9

Infectious mononucleosis, 075

 

1. Other causes of lymphadenopathy.

a. Common viral and bacterial infections such as Group A betahemolytic streptococci (GABHS), staphylococci, cytomegalovirus (CMV), Epstein-Barr virus (EBV; infectious mono), HIV.

2. Subacute and chronic lymphadenopathy more likely associated with mycobacterium and toxoplasmosis.

3. Neck masses from other sources.

G. Treatment.

1. Symptomatic.

a. Antipyretics and analgesics.

b. Moist wraps/compresses.

c. Aspiration of painful nodes (avoid I&D).

d. Antimicrobial treatment for severely ill patients or those with other chronic condition. Not suggested for regional CSD.

e. For patients with significant lymphadenopathy: Azithromycin (Zithromax): 500 mg day 1, 250 mg days 2-5; younger children 10 mg/kg day 1, 5 mg/kg days 2-5.

f. Other antibiotics with anecdotal evidence of efficacy: ciprofloxacin, rifampin, trimethoprim-sulfamethoxazole.

H. Follow up.

1. Every week until resolution of symptoms, dependent on severity of symptoms.

I. Complications.

Aseptic meningitis, 047.9

Osteomyelitis, 730.28

Encephalitis, 323.9

Parinaud oculoglandular syndrome, 378.81

Erythema nodosum, 695.2

Pneumonia, 486

Hepatosplenomegaly, 571.8

Submandibular lymphadenopathy, 785.6

Neuroretinitis, 363.05

Thrombocytopenia purpura, 287.3

1. Parinaud oculoglandular syndrome: inoculation of conjunctiva results in ipsilateral preauricular or submandibular lymphadenopathy.

2. Less commonly: encephalitis, aseptic meningitis, neuroretinitis, thrombocytopenia purpura, erythema nodosum, pneumonia, hepatosplenomegaly, osteomyelitis, endocarditis.

J. Education.

1. Avoid scratches by decreasing rough play with kittens.

2. Immediately cleanse wounds from cats.

IV. CERVICAL LYMPHADENITIS

Adenopathy, 785.6

Hepatosplenomegaly, 571.8

Arthralgias, 719.4

Infectious mononucleosis, 075

Kawasaki disease 446.1

Lymphoma, 202.8

Cat-scratch disease, 078.3

Malnutrition, 263.9

Cervical lymphadenitis, 289.3

Mycobacterial infections, 031.9

Cervical lymphadenitis, acute, 683

Night sweats, 780.8

Cervical lymphadenopathy, 785.6

Pharyngitis, 462

Collagen vascular disease, 459.9

Rubella, 056.9

Cough, 786.2

Sore throat, 462

Enlargement of lymph glands, 785.6

Staphylococci, 041.1

Epstein-Barr virus, 075

Staphylococcus aureus, 041.11

Fatigue, 780.79

Toxoplasmosis, 130.9

Fever, 780.6

Upper respiratory infections, 465.9

Group A streptococcus, 041.01

Weight loss, 783.21

Group B streptococcus, 041.02

 

A. Etiology.

1. Enlargement of lymph glands of neck generally due to:

a. Infection, which causes proliferation and invasion of inflammatory cells.

• Viruses:

i. Upper respiratory: respiratory syncytial virus (RSV), adenoviruses, influenza, parainfluenza, rhinoviruses–which usually resolve more quickly than other etiologies.

ii. EBV.

iii. CMV–rare.

iv. Rubella, rubeola, roseola–rare.

v. Varicella zoster–rare.

vi. HSV.

vii. Coxsackie.

viii. HIV–rare.

• Bacteria:

i. Staphylococcus aureus and GABS: 40-80% of cases.

ii. Anaerobes–rare.

iii. Corynebacterium diphtheriae.

iv. Bartonella henselae (cat-scratch disease).

v. Gram-negative rods: Haemophilus influenzae, pseudomonas, salmonellae, shigellae, Francisella tularensis (tularemia).

• Mycobacterium.

i. Mycobacterium tuberculosis.

ii. Nontuberculous mycobacteria (NTM).

• Spirochetes.

• Rickettsiae.

• Fungi, including Histoplasma capsulatum (histoplasmosis)–rare.

• Protozoa, including Toxoplasma gondii (toxoplasmosis)–rare.

b. Other causes.

• Neoplasms that cause infiltration of neoplastic cells–rare.

• Histiocytosis.

• Collagen vascular diseases: juvenile rheumatoid arthritis (JRA), lupus.

• Sarcoidosis.

• Kawasaki disease.

• Postvaccination: DTaP, polio, typhoid.

• Drugs-phenytoin, INH.

B. Occurrence.

1. About 40% of all children have palpable cervical lymph nodes.

2. Most cases of cervical lymphadenitis resulting from common bacterial and viral infections occur in toddler and preschool age groups.

3. Etiologic and age-related occurrence.

a. Neonate.

• Acute unilateral cervical lymphadenitis: S. aureus.

• “Cellulitis-adenitis” syndrome: late-onset Group B streptococcus.

b. Younger than 5 years of age.

• Acute pyogenic cervical lymphadenitis: S. aureus and GABHS.

• NTM lymph node infection.

• Kawasaki disease (also usually unilateral).

c. School-aged and adolescents: more likely chronic cervical lymphadenitis than acute pyogenic disease.

C. Clinical manifestations.

1. Acute bilateral cervical lymphadenopathy generally caused by URI or strep pharyngitis. Generally associated with EBV (infectious mononucleosis).

2. Acute unilateral cervical lymphadenitis variably associated with fever and suppuration, most often caused by staph and Group A streptococcus.

3. Subacute and chronic lymphadenitis are found in cat-scratch disease, toxoplasmosis, and mycobacterial infections. Nodes become fluctuant and are generally nontender.

4. Painless, possibly matted nodes and especially those in supraclavicular area are more likely malignant.

5. Associated symptoms.

a. With URI: fever, sore throat, cough.

b. Lymphoma, TB: fever, night sweats, weight loss.

c. Collagen vascular disease or serum sickness: fever, fatigue, arthralgias.

D. Physical findings.

1. General.

a. Signs of malnutrition, including poor growth: suggestive of chronic disease.

b. Generalized adenopathy and hepatosplenomegaly: suggestive of malignancy or other noninfectious illnesses and some infectious diseases such as EBV, HIV, TB, histoplasmosis.

2. Enlargement of the lymph nodes: > 1 cm.

a. Node-bearing areas: occipital, cervicofacial, axillary, epitrochlear, inguinal, popliteal.

b. Nodes may be warm, mobile, fixed, fluctuant, solid, smooth.

3. Presentation, distribution, associated diseases.

a. Acute posterior cervical lymphadenopathy: rubella, infectious mononucleosis.

b. Supraclavicular or posterior cervical lymphadenopathy: risk for malignancy.

c. Cervical lymphadenopathy, associated generalized lymphadenopathy: viral infection.

d. Generalized lymphadenopathy: associated with leukemia, lymphoma, collagen vascular disease.

e. Nodes bilateral and soft (not fixed): viral infection.

f. Tender nodes, possibly fluctuant, not fixed: bacteria.

g. Redness and warmth: acute pyogenic process.

h. With fluctuance: abscess formation.

i. Matted or fluctuant nodes, skin overlying red but not warm: TB.

j. Nodes hard and fixed, without signs of acute inflammation: associated malignancy.

4. Associated physical signs.

a. Markedly red pharynx, possibly exudates, soft palate petechiae: GABHS.

b. Swelling, redness, tenderness of gums: periodontal disease.

c. Edema of the soft tissues of the neck: diphtheria.

d. Sinus tract formation: TB.

e. Gingivostomatitis: HSV.

f. Herpangina: coxsackievirus.

g. Rash: infectious mono, scarlet fever.

h. Pallor, petechiae, bruises, sternal tenderness.

i. Hepatosplenomegaly: leukemia.

E. Diagnostic tests.

1. Appropriate for suspicion of specific entity.

2. Throat culture.

3. PPD.

4. CBC.

5. Erythrocyte sedimentation rate (ESR) or (CRP) C-reactive protein

6. Blood cultures.

7. Liver enzymes.

8. Serology for specific microorganisms.

9. Chest X-ray.

10. Ultrasound of nodes.

11. Echocardiogram, ECG.

12. Fine-needle aspiration for Gram stain and culture.

13. Biopsy: if malignancy suspected.

F. Differential diagnosis.

Neck masses, 784.2

1. Neck masses.

a. Congenital lesions are generally painless and most likely identified in infancy.

• Thyroglossal duct cyst: midline between thyroid bone and suprasternal notch, moves upward.

• Branchial cleft cyst: smooth, fluctuant, proximal, anterior border of sternocleidomastoid muscle.

• Sternocleidomastoid tumor: mass in belly of the muscle caused by perinatal injury; associated torticollis.

• Cervical ribs: bony anomaly.

• Cystic hygroma: fluid filled, easily transilluminated.

• Hemangioma.

• Laryngocele: cystic mass extending through the thyrohyoid membrane.

• Dermoid cyst: midline cyst, also contains solid components.

• Parotitis: swelling crosses angle of jaw; mumps.

2. To summarize: It is reasonable to safely observe nodes that are bilateral, < 3 cm in size, nonerythematous nor exquisitely tender. Treat empirically if: no accompanying systemic symptoms, node > 2-3 cm, unilateral, or erythematous and tender.

G. Treatment.

1. Acute cervical lymphadenitis.

a. Staphylococcus or Group B streptococcus.

• Patient nontoxic, no abscesses or cellulitis.

i.  Cephalexin–for 10 days; child: 40 mg/kg/day divided bid or qid; adult: 250-500 mg bid or qid.

ii. Amoxicillin-clavulanate (based on amoxicillin component): 40 mg/kg/day divided bid for 10 days; adult 500-875 mg bid.

iii. Clindamycin: child older than 1 month of age: 8-25 mg/kg/day in divided doses q6-8h; adult: 150-450 mg q6h, max: 1.8 g/day.

• Patient toxic or immunocompromised.

i.  IV cefazolin, nafcillin, or clindamycin.

b. Anaerobes: seen with periodontal/dental disease.

• Penicillin or clindamycin.

c. Oral analgesia, warm compresses.

d. Incision and drainage for suppurative, fluctuant nodes.

2. Consider referral for biopsy if significant lymphadenopathy (> 2 cm in diameter) persists 2 weeks, or no decrease in size after 4-6 weeks or node(s) are supraclavicular, lack inflammation, are firm or rubbery, develop ulceration, fail to respond to antibiotic treatment or there are systemic symptoms (e.g., fever, weight loss, hepatosplenomegaly).

3. Cervical lymphadenitis abscess: refer for finenveedle aspiration or excision (I&D).

H. Follow up.

1. Call if node enlarges, becomes markedly tender, erythematous, indurated.

2. Call if child appears toxic, has difficulty breathing or swallowing.

3. If being treated for bacterial infection, call if not better in 48 hours (fever down, tenderness decreased, size of node stable).

4. Recheck at end of treatment.

5. Recheck if node(s) persist longer than several weeks.

I. Complications.

1. Bacterial: suppuration, bacteremia.

2. Undiagnosed infectious process or malignancy.

J. Education.

1. Address family's fears: primarily those of malignancy.

2. Compliance with medications.

3. Observation: when to call, return to clinic.

4. Hydration.

V. EPISTAXIS

Allergies, unspecified, 477.9

Lymphadenopathy, 785.6

Epistaxis, 784.7

Nosebleeds, 784.7

Hepatomegaly, 789.1

Pale skin, 709.9

Hypertension, 401.9

Petechial rashes, 782.1

Hypovolemia, 276.5

Upper respiratory infections, 465.9

A. Etiology.

1. Bleeding from the nose can be anteriorly from nares (commonly Kiesselbach plexus) or posteriorly into nasopharynx. The nasal mucosa has rich, yet relatively unprotected blood supply. The mucosa is thin, especially in children.

2. Causative factors.

a. Inflammation.

• Infectious processes.

• Allergies.

b. Neoplasms, polyps.

c. Trauma.

• External injury.

• Nose picking.

• Foreign bodies.

• Chemical or caustic agents (including drugs).

3. Rarely.

a. Systemic illnesses.

• Hematologic diseases.

• Hypertension.

B. Occurrence.

1. Very common in children.

2. Highest incidence 2-10 years of age.

3. Often familial history.

C. Clinical manifestations.

1. Complaints of persistent, recurrent nosebleeds.

2. May have history of:

a. Recent or current URI.

b. Allergies (especially nasal).

c. Tarry stools.

d. Medication or drug use.

e. Persistent bleeding or bruising.

f. Family history of epistaxis or bleeding disorders.

g. Trauma: nose picking or foreign body insertion.

D. Physical findings.

1. Vital signs may reflect hypovolemia or underlying cause such as hypertension.

2. Inspection of nose, nasopharynx, and oropharynx may reveal:

a. Bleeding most commonly from medial anterior nares.

b. Dry, crusted mucosa.

c. Excoriation of mucosa, site of bleeding.

3. General exam may find lymphadenopathy, hepatomegaly, petechial rashes, or pale skin, mucosa, nail beds.

E. Diagnostic tests.

1. Vital signs, including blood pressure.

2. Hematocrit or CBC with platelets.

3. If severe and persistent:

a. CBC with platelets.

b. Prothrombin and partial thromboplastic bleeding time.

F. Differential diagnosis.

Bleeding disorders, 289.9

Polyps, 471.9

Foreign body, nose, 932

Renal disease, 593.9

Hypertension, 401.9

Vascular abnormalities, 785.9

1. Bleeding disorder: if severe and recurrent, child younger than 2 years, positive family history.

2. Polyps, vascular abnormalities.

3. Foreign body.

4. Hypertension, renal disease.

G. Treatment.

1. Elevate head and lean forward.

2. Pinch nares together for at least 10 minutes.

3. Ice to nasal dorsum may be added.

4. Packing (preferably absorbable), topical vasoconstrictive drugs may be needed.

5. Referral to ENT if unmanageable or prolonged or abnormalities of nose.

H. Follow up.

1. Hct, 6-12 hours after bleed if concern for anemia.

2. Return if unmanageable and/or persistent.

I. Complications.

1. Possibly mild anemia.

2. Rare: airway obstruction, aspiration, vomiting.

J. Education.

1. Prevention.

a. Humidification of air in home, especially bedroom.

b. Nasal saline sprays, drops.

c. Petroleum jelly applied sparingly to anterior nares.

d. Protective athletic gear.

e. Discouragement of nose-picking behaviors and vigorous blowing.

2. Reassurance: amount of blood always looks greater than it is.

VI. FOREIGN BODY, NASAL

Choking, 784.9

Foreign body, nose, 932

Cough, 786.2

Vomiting, 787.03

Dysphagia, 787.2

 

A. Etiology.

1. Small objects are often inserted into nose by children, causing full or partial obstruction of nares.

B. Occurrence.

1. Frequent, especially in young children age 3-6 years.

C. Clinical manifestations.

1. Child may have been observed.

2. Initially, local symptoms of obstruction: swelling, sneezing, mild discomfort.

3. Subsequently, persistent, purulent, unilateral discharge; may be bloody or foul smelling.

D. Physical findings.

1. Dependent on length of time obstruction has been present: see above symptoms. Obstruction is almost always unilateral.

2. Examiner may be able to visualize object with nasal speculum or otoscope.

3. Common objects include beads, buttons, toy parts, pebbles, candle wax, food, paper, cloth, button batteries.

4. Tend to locate in floor of nasal passage or in the upper nasal fossa.

E. Diagnostic tests.

1. None.

F. Differential diagnosis.

Adenoiditis, 474.01

Nasal tumors, 471.9

Rhinosinusitis, 473.9

1. Infection.

a. Rhinosinusitis.

b. Adenoiditis.

2. Polyps.

3. Nasal tumors.

G. Treatment.

1. Purulent discharge may need to be suctioned in order to visualize object.

2. An older child may be told to occlude one side of nares and blow vigorously.

3. A parent may blow gently through the child's mouth while occluding one side of the nose or an Ambu bag may be used.

4. Removal requires:

a. Good lighting.

b. Topical anesthesia (generally lidocaine).

c. Vasoconstrictor drugs (0.5% epinephrine to reduce mucosa edema).

d. Alligator forceps, cerumen spoon (curved, wire ones best).

e. Narrow tip suction.

f. Passing a thin, lubricated, 5-6 Fr, balloon-tipped catheter past the foreign body, inflating balloon and pulling forward.

H. Follow up.

1. None, if successful removal and signs of infection clear within 1-2 days.

2. Referral to ENT if unable or unlikely to remove easily.

3. Consider behavioral/emotional assessment if is recurrent problem or developmentally inappropriate behavior.

I. Complications.

1. Chronic infection if undetected and/or not removed.

2. Trauma to nares from removal procedure.

J. Education.

1. Close observation of children by caregivers.

2. Limit access by small children to small objects.

3. Note: If child swallows foreign body, especially coin, radiographic survey must be done to ensure object is in stomach. Child must be observed closely for hoarseness, dysphagia, drooling, gagging, vomiting, coughing, choking, and airway compromise including inspiratory stridor.

VII. INFECTIOUS MONONUCLEOSIS

Abdominal pain, 789

Mild hepatitis, 573.3

Fatigue, 780.79

Myalgia, 729.1

Fever, 780.6

Myocarditis, 429.01

Group A streptococcus, 041.01

Palatal petechiae, 782.7

Group B streptococcus, 041.02

Pharyngitis, 462

Hemolytic anemia, 283.9

Rash, 782.1

Infectious mononucleosis, 075

Splenomegaly, 789.2

Lymphadenopathy, 785.6

Thrombocytopenia, 287.5

Lymphocytosis, 288.8

Tonsillitis, 463

Malaise, 780.79

 

A. Etiology.

1. Epstein-Barr (which is a herpesvirus) virus: 90% of cases.

2. Clinical symptoms result from proliferation of b-lymphocytes in the epithelial cells of the pharynx, parotid duct, lymph nodes, spleen.

3. Spread primarily in saliva.

4. Latent, lifelong infection occurs and may be reactivated during immunosuppression.

B. Occurrence.

1. Humans.

a. Endemic worldwide in younger children, especially third world countries.

b. One-third of cases in adolescents in more affluent populations of developed countries.

c. Almost all adults in United States are seropositive for EBV.

C. Clinical manifestations.

1. Primary EBV infection.

a. Incubation is 30-50 days.

b. Primary EBV infection in adolescents presents in > 50% of cases with:

• Fatigue, malaise, myalgia.

• Generalized lymphadenopathy.

• Pharyngitis.

• Possibly fever or prodrome of malaise and fever.

c. Younger children may experience mild febrile episode, rash, abdominal pain.

D. Physical findings.

1. Tonsillitis, pharyngitis: possibly exudative.

2. Palatal petechiae (transient).

3. Lymphadenopathy.

a. Anterior and posterior cervical nodes, also axillary or inguinal nodes.

b. Large, mildly tender.

c. Epitrochlear nodes highly indicative.

4. Splenomegaly.

a. Frequent false negatives, if done too early in 50% of cases.

b. 2-3 cm below costal margin.

c. Persists for 2-4 weeks past resolution of other symptoms.

E. Diagnostic tests.

1. “Monospot” (mononucleosis rapid slide agglutination test for heterophile antibodies disease process) 25% false negative in the first week of the disease. In children younger than 12 years of age monospot detects 25-50% of cases.

2. CBC with differential.

a. Lymphocytosis with up to 20,000 WBCs.

b. Up to 40% atypical lymphocytes. Note: 50% lymphocytes with 10-20% atypical lymphocytes diagnostic.

c. Mild thrombocytopenia 50% of cases.

d. Positive monocytes on differential.

3. Liver enzymes.

a. Mild hepatitis common.

b. Usually asymptomatic.

4. EBV serology: indicated in acutely ill patient.

a. If monospot negative and strong suspicion.

b. VCA-IgM test if monospot negative and urgent diagnosis needed such as in a competitive athlete.

5. Throat culture.

a. Rule out other causes.

b. 5-25% cases have concurrent GABHS infection.

F. Differential diagnosis.

Adenovirus, 079

Leukemias, 208.9

Cytomegalovirus, 078.5

Pharyngitis, 462

Group A streptococcus, 041.01

Rubella, 056.9

Group B streptococcus, 041.02

Tonsillitis, 463

HIV, V08

Toxoplasmosis gondii, 130.9

Human herpes virus, 054.9

 

1. Other causes of infectious mononucleosis-like syndrome (in descending order of incidence):

a. Cytomegalovirus.

b. Toxoplasmosis gondii.

c. HIV-mucocutaneous lesions, diarrhea, nausea and vomiting, weight loss.

d. Human herpesvirus.

e. Rubella.

2. Pharyngitis/tonsillitis.

a. GABHS–absence of hepatosplenomegaly; fatigue less prominent.

b. Other bacterial causes.

c. Viruses other than EBV.

3. Leukemias.

4. Infectious mononucleosis should be suspected in any febrile patient with sore throat plus palatal petechiae, splenomegaly, posterior cervical, and possibly axillary or inguinal adenopathy.

G. Treatment.

1. Supportive.

a. Analgesics and antipyretics.

b. Hydration support if needed.

c. Corticosteroids may be indicated if:

• Impending airway obstruction or dehydration secondary to severe tonsillopharyngitis.

• Massive splenomegaly.

• Myocarditis.

• Hemolytic anemia.

• Hemophagocytic syndrome.

H. Follow up.

1. Fatigue may persist months after recovery. Patient should be allowed to resume school and activities as energy level permits.

2. Splenomegaly.

a. Risk of rupture is estimated at 0.1% (50% are spontaneous).

b. Recheck at weekly intervals.

c. Avoid contact sports at least 3-4 weeks until fully recovered and spleen no longer palpable.

d. Consider selective ultrasonography such as when an athlete would like to return to competitive sports in < 4 weeks.

I. Complications.

Airway obstruction, 519.8

Dehydration, 276.5

Antibiotic-induced rash, 693

Splenic rupture, 289.59

1. Additional complications are rare, but include:

a. Dehydration.

b. Antibiotic-induced rash (most commonly when ampicillin or amoxicillin antibiotic used for concurrent bacterial infection).

c. Thrombocytopenia.

d. Airway obstruction.

e. Acute interstitial nephritis.

f. Hemolytic anemia.

g. Myocarditis.

h. Neurologic abnormalities.

i. Cranial nerve palsies.

j. Encephalitis.

k. Retrobulbar neuritis.

J. Education.

1. Close personal contact is required for transmission.

2. Recovery often biphasic, with worsening of symptoms after period of improvement.

3. Full recovery may take months.

4. Patient should not donate blood.

VIII. PHARYNGITIS

Adenovirus, 079

Neisseria gonorrhoeae, 032.9

Coxsackievirus, 079.2

Peritonsillar abscess, 475

Epstein-Barr virus, 075

Pharyngitis, 462

Group A streptococcus, 041.01

Rheumatic fever, 390

Group B streptococcus, 041.02

Rhinovirus, 079.3

A. Etiology.

1. Inflammation of mucous membranes and underlying structures of pharynx and tonsils, usually caused by infection.

2. Causative agents.

a. Respiratory viruses, including rhinovirus, adenovirus, coxsackievirus, Epstein-Barr virus.

b. GABHS.

c. Group C beta-hemolytic strep (not a cause of rheumatic fever), Neisseria gonorrhoeae rarely.

d. Mycoplasma pneumoniae: possibly 10% occurence in adolescents.

e. Corynebacterium diphtheriae.

B. Occurrence.

1. Peak incidence late fall through early spring.

2. Younger children more commonly present in winter months and with viral pharyngitis.

3. GABHS has proclivity for 5- to 15-year age group, also peaking in winter.

C. Clinical manifestations.

1. Viral pharyngitis.

a. Gradual onset.

b. Cough, coryza, diarrhea more common.

2. Coxsackievirus (see “Physical findings”–next section)

3. Streptococcal.

a. Rapid onset.

b. See “Physical findings”–next section.

D. Physical findings.

1. Viral pharyngitis.

a. Sore throat, dysphagia.

b. Low-grade fever.

c. Possibly diarrhea.

2. Coxsackievirus.

a. Fever, headache.

b. GI complaints.

c. Possibly papular rash of hand, foot, mouth disease.

d. Possibly ulcerative lesions in mucosa of mouth.

3. Streptococcal GABHS.

a. Moderate to high fever, headache.

b. Red pharynx: beefy red, swollen uvula and tonsils.

c. Yellow, blood: tinged exudates.

d. Petechiae on soft palate, strawberry (coated) tongue.

e. Tender cervical lymphadenopathy.

f. Multiple GI complaints.

g. Accompanying scarlatiniform rash: red, sandpaper-like, clustered in body's “hot spots” (axillae, neck, inguinal, anticubital, popliteal areas).

E. Diagnostic tests.

1. Throat swab for rapid antigen detection test for GABHS. Negative should also have follow-up throat culture (can also identify carrier state).

2. Heterophile antibody test for EBV.

3. CBC.

F. Differential diagnosis.

Allergic rhinitis, generalized, 477.9

Group G streptococcus, 041.05

Group C streptococcus, 041.03

Infectious mononucleosis, 075

1. Viral vs. bacterial entity.

a. Infectious mononucleosis.

b. Group C or G streptococcus.

2. Allergic rhinitis.

G. Treatment.

1. Nonpharmacologic.

a. Encourage fluids: may prefer hot or cold for pain relief.

2. Pharmacologic.

a. Topical and oral analgesics and antipyretics.

b. Antimicrobials: penicillin V recommended.

• Children < 27 kg: 250 mg bid or tid for 10 days.

• Children > 27 kg: 500 mg bid or tid for 10 days.

• IM benzathine penicillin G: if compliance, vomiting issues.

i.  Children < 27 kg: 600,000 units.

ii. Children > 27 kg: 1.2 million units.

• Amoxicillin: substituted for taste issues (may benefit 40% of children with adenotonsillar disease, who yield beta-lactamase-producing bacteria).

i.  Once daily dosing of amoxicillin at 50 mg/kg for 10 days is as effective as penicillin V or amoxicillin given in multiple doses for 10 days.

• Penicillin (PCN) allergic options:

i.  Clindamycin (20 mg/kg/day in 3 divided doses, max 1.8 g/ day). In the United States, macrolide resistant rates to group A streptococci (GAS) have been 5-8%.

ii. Erythromycin estolate or ethylsuccinate: 40 mg/kg/day in 2-4 divided doses.

iii. Clarithromycin: Child: 15 mg/kg/day, max: 1000 mg divided q12h for 10 days. Adult: 500 mg q12h for 10 days.

iv. Azithromycin: 12 mg/kg/day for 5 days.

• First-generation cephalosporin such as cephalexin: also appropriate if retreatment necessary.

• Note: As many as 5% of penicillin-allergic people are also allergic to cephalosporins. People with type 1 allergy to PCN should not be treated with a cephalosporin.

• Due to increased treatment failure with PCN, some clinicians are using a first generation cephalosporin in all nonallergic patients.

i. Cephalexin (25-40 mg/kg/day in 2 divided doses for 10 days).

• Other cephalosporins also have indication for GAS treatment:

i.  Cefprozil (second generation).

ii. Cefpodoxime, cefdinir (third generation).

• If illness recurs shortly after treatment:

i.  May be retreated with same drug.

ii. IM penicillin if compliance an issue.

iii. Narrow-spectrum cephalosporin (cephalexin).

iv. Amoxicillin-clavulanate potassium.

H. Follow up.

1. Routine reculturing is not necessary.

2. Encourage patients to call if:

a. Unable to complete course of medication or retain medication.

b. Siblings complain of sore throat within 2-5 days: amoxicillinxclavulanate 90 mg/6.4 mg per kg/day. If allergic: 6 months to 12 years of age, cefdinir 7 mg/kg bid or 14 mg/kg daily; 13 years, 300 mg bid 10 days.

c. No improvement in patient in 48 hours.

d. Signs and symptoms of renal complications.

e. Drug reaction.

3. Possible assessment of carrier state which is common and patients are low risk to transmit and develop invasive disease. Most common scenario is a carrier who is experiencing repeated intercurrent episodes of viral pharyngitis. (In true GAS pharyngitis response to antimicrobial therapy is rapid.) Treatment of carriers is indicated only in very specific cases such as those involving rheumatic fever or glomerulonephritis outbreaks or recurrent, symptomatic GAS pharyngitis in a family after appropriate therapy.

a. Clindamycin most effective treatment (20 mg/kg/day in 3 divided doses; max 1.8 g/day).

b. ENT referral for possible tonsillectomy and adenoidectomy, though currently poorly understood and risks of surgery often do not outweigh possible benefits.

• Multiple bouts of tonsillitis in 1 year despite adequate treatment.

• Significant upper airway obstruction.

• Peritonsillar abscess.

I. Complications.

Cervical lymphadenitis, 683

Poststreptococcal glomerulonephritis, 580

Mastoiditis, 383

Rheumatic heart disease, acute, 391.9

Peritonsillar abscess, 475

Streptococcal pharyngitis, 034

1. Streptococcal pharyngitis.

a. Suppurative.

• Peritonsillar abscess.

• Cervical lymphadenitis.

• Mastoiditis.

b. Acute rheumatic fever.

c. Post-strep glomerulonephritis.

J. Education.

1. Transmission is person to person via respiratory tract secretions.

2. Medication compliance is essential.

3. May return to school/daycare 24 hours after beginning antibiotic therapy.

IX. RHINOSINUSITIS

Allergic rhinitis, 477.9

Immunodefi ciency, 279.2

Ciliary dyskinesia, 781.3

Nasal obstruction, 478.1

Cough, 786.2

Nasal speech, 784.5

Cystic fibrosis, 277

Postnasal secretions, 473.9

Dental pain, 529.6

Proptosis, 376.3

Ear pressure, 388.7

Rhinorrhea, 478.1

Fatigue, 780.79

Rhinosinusitis, bacterial, 473.9

Gastroesophageal reflux, 530.81

Smoke exposure, 987.9

Halitosis, 784.9

Snoring, 786.09

Headache, 784

Upper respiratory infection, 465.9

A. Etiology.

1. Each case of viral rhinitis is also rhinosinusitis, because mucous membranes of nasal passages, sinus cavities are identical.

2. Sinusitis is inflammation of mucous membranes lining paranasal sinuses, commonly used to describe bacterial rhinosinusitis.

3. Factors that increase risk of sinusitis are:

a. Smoke exposure.

b. Cold and dry inspired air.

c. Preceding or concurrent URI.

d. Allergic rhinitis.

e. Swimming.

f. Gastroesophageal reflux.

g. Cystic fibrosis.

h. Immunodeficiency.

i. Ciliary dyskinesia.

j. Factors associated with nasal obstruction.

4. Stagnation of secretions occurs within sinus cavities, becoming culture medium for bacteria.

5. Common pathogens.

a. Streptococcus pneumoniae.

b. Haemophilus influenzae.

c. Moraxella catarrhalis (becoming most common in children).

B. Occurrence.

1. Complication of 5-10% of viral upper respiratory illnesses in children.

2. In young children, occurs primarily in maxillary sinuses, ethmoids secondly.

3. Frontal sinusitis is rare prior to age 10 years.

C. Clinical manifestations.

1. Acute and persistent nasal and sinus symptoms for 10-30 days.

a. Subacute: clinical symptoms for 4-12 weeks.

b. Chronic: symptoms lasting at least 12 weeks.

c. Recurrent: 4+ incidents/year with complete resolution in interim.

d. Mild: 10-14 days of persistent anterior or posterior rhinorrhea (discharge)–of any quality, without improvement and fatigue.

e. Moderate: 10 days of nasal congestion, fever, increased maxillary or frontal tenderness/pressure.

f. Severe-high fever > 102°F and purulent nasal discharge for at least 3 days in a child who seems ill.

2. May complain of cough (daytime, often worsening at night), rhinorrhea, postnasal secretions, halitosis, dental pain, headache, fatigue, ear pressure, snoring, nasal speech.

D. Physical findings.

1. Fever.

2. Nasal speech.

3. Halitosis.

4. Purulent drainage in posterior pharynx and/or nose.

5. Nasal mucosa may be erythematous and swollen.

6. Face over paranasal sinuses may be tender to palpation.

7. Headache, especially when bending over.

8. Sinuses opaque, especially in older children.

9. Puffiness around eyes.

10. Proptosis, impaired extraocular movements: associated with orbital infection.

E. Diagnostic tests.

1. X-rays–findings on plain radiographs correlate poorly with disease and should not be used.

2. CT scan of paranasal sinuses: indicated in complicated, severe, or recalcitrant cases.

F. Differential diagnosis.

Adenoidal hypertrophy, 474.12

Foreign body, nose, 932

Allergic rhinitis, 477.9

Septal deviation, 470

Choanal atresia, 748

Viral URI, 465.9

1. Viral URI.

2. Allergic rhinitis.

3. Drug induced (rhinitis medicamentosa).

4. Tumors: polyps, neoplasms, adenoidal hypertrophy.

5. Foreign body.

6. Septal deviation, choanal atresia.

G. Treatment.

1. Acute bacterial rhinosinusitis (ABRS) in children.

a. Mild symptomatology and no antibiotics within past 4-6 weeks.

• Amoxicillin (90 mg/kg/day) for 10 days.

• High-dose amoxicillin-clavulanate ES: 90 mg/kg/day, (based on amoxicillin component) divided bid.

• Cefpodoxime proxetil, cefuroxime axetil, cefdinir, cefprozil.

b. Mild disease and have received antibiotics within previous 4-6 weeks or in moderate disease.

• High-dose amoxicillin-clavulanate ES (same dose).

• Cefdinir if allergic.

• Azithromycin or clarithromycin if severely allergic.

c. Consider switch in medications if no response in 72 hours.

2. Chronic sinusitis: may need to treat for 4 weeks.

3. Normal saline nasal sprays: assists drainage and ventilation.

4. Topical nasal steroids: may decrease swelling of turbinates and aid ostia to drain.

5. Mucolytics: may help mucous clearance.

6. Antihistamines: helpful if allergic component.

7. Decongestants: controversial benefit.

8. Humidified air.

9.  Encourage fluids.

H. Follow up.

1. Patient to call if no response to medications in 72 hours.

2. Recheck in 2 weeks.

3. Referral to ENT or allergist if indicated or refractory.

I. Complications.

Brain abscess, 324

Orbital cellulitis, 376.01

Cavernous sinus thrombosis, 325

Osteomyelitis of maxilla or frontal bone, 730.28

Exacerbation of asthma, 493.92

Subdural empyema, 324.9

Optic neuritis, 377.3

 

1. Orbital cellulitis.

2. Intracranial complications such as cavernous sinus thrombosis, subdural empyema, brain abscess.

3. Exacerbation of asthma.

4. Optic neuritis.

5. Osteomyelitis of maxilla or frontal bone.

J. Education.

1. Prevention: Avoid allergens and treat allergies when appropriate.

2. Encourage humidified air at home unless it exacerbates mildew, mold allergies.

3. Emphasize that most rhinitis and sinusitis are viral in etiology and antibiotics are not indicated.

4. Encourage compliance with prescribed antimicrobial agents.

5. Advise patient against diving (including scuba).

BIBLIOGRAPHY

American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis. Pediatrics. 2001;108(3):798-808.

American Academy of Pediatrics. 2009 red book: report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Choby B. Diagnosis and treatment of streptococcal pharyngitis. Am Family Physician. 2009;79(5):383-390.

Clark M, Krol D. PACT module: protecting all children's teeth, oral health initiate. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Dulin M. Management of cervical lymphadenopathy in children. Am Family Physician. 2008;78(9):1097-1098.

Ebell M. Epstein-Barr virus infectious mononucleosis. Am Family Physician. 2004;70(7):1279-1287.

Feder HM. Periodic fever, aphthous stomatitis, pharyngitis, adenitis: a clinical review of a new syndrome. Clin Opin Pediatr. 2000;12:233-236.

Florin T, Zaoutis T, Zaoutis L. Beyond cat scratch disease: widening spectrum of Bartonella henslae infection. Pediatrics. 2008;121:e1413-e1425.

Hayden G, Hendley J. An up-to-date approach to pharyngitis in children. Resp Dis Pediatr J. 2001;3:125-131.

Heims S. Foreign bodies in the ear, nose and throat. Am Family Physician. 2007;76(8):1185-1189.

Leung A, Robson L. Childhood cervical lymphadenopathy. JPed Health Care. 2004;18:3-7.

Mahr T, Sheth K. Update on allergic rhinitis. Pediatrics in Rev. 2005;26:284-289.

Margileth M. Recent advances in the diagnosis and treatment of cat scratch disease. Current Infectious Dis Rep. 2000;2(2):141-146.

Ownby DR, et al. Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. JAMA. 2002;288:963-972.

Platts-Mills TAE. Allergen avoidance in the treatment of asthma and rhinitis. N Engl J Med. 2003;349:207-208.

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