Objects in the mouth may be swallowed or breathed (aspirated) into the lungs

Objects in the ears and nose can make it hard to hear or breathe and can cause infection

FOREIGN BODIES IN THE EAR:

Foreign bodies in the ear canal be anything a child can push into his or her ear

Some of the items that are commonly found in the ear canal include

Food

Insects

Toys

Buttons

Pieces of crayon

Small batteries

« Some objects placed in the ear may not cause symptoms

« Other objects such as food and insects may cause pain in the air,redness or drainage

« Hearing may be affected if the object is blocking the ear canal

Techniques that may be used to remove the object from the ear canal:

Instruments such as long, thin tweezers or forceps may be put in the ear to grab and remove object

Magnets are sometimes used to remove the object if it is metal

The ear canal may be flushed with water

A machine with suction may be used to help pull the object out

After removal of the object, re-examine the ear to determine if there has been any injury to the ear canal

Antibiotic drops for the ear prescribed to treat any possible outer ear infections

FOREIGN BODIES IN THE NOSE:

Objects that are put into the childs nose are usually soft things

These include

Ÿ Tissue

Ÿ Clay

Ÿ Pieces of toys

Ÿ Erasers

« The most common symptom of a foreign body in the nose is nasal drainage

« Often has a bad odour

« In some cases, the child may also have a bloody nose

Techniques :

Sedating the child is sometimes needed to remove the object successfully

Suction machines with tubes attached may be used

Instruments may be inserted in the nose

The object may be blown out of the nose

After removal of the object, prescribe nose drops or Antibiotic ointment to treat any possible infections

FOREIGN BODIES IN THE THROAT :

A foreign body in the throat can cause choking and is a medical emergency that needs immediate attention. The foreign body can get stuck in many different places within the Airway.

According to the American Academy of Pediatrics death by choking  is leading cause of death and injury among children younger than 4 yrs of age

Ÿ Seeds                         

Ÿ Toy parts

Ÿ Grapes

Ÿ Hot dogs

Ÿ Pebbels

Ÿ Nuts

Ÿ Buttons

Ÿ Coins

Symptoms that may mean a child is choking

« Choking or gagging when the object is first inhaled

« Coughing at first

« Wheezing (A whistling sound usually made when the child breaths out)

 Symptoms may mean that the foreign body is still blocking an airway

« Stridor ( A high pitched sound usually heard when the child breathes)

« Cough that gets worse

« Child unable to speak

« Pain in the throat area or chest

« Hoarse voice

« Blueness around the lips

« Not breathing

« The child becoming unconscious

If the FB is visualised in the oropharynx and the patient can tolerate the procedure, removal may be attempted using Magill forceps. Otherwise, removal should be attempted with endoscopy under GA (either via pharyngoscopy / laryngoscopy or rigid oesophagoscopy).

The urgency of endoscopy is outlined below:

• Emergency endoscopy
  • Any red flag signs
  • Any sharp or long (>5cm) object in the oesophagus
• Urgent endoscopy (within 24 hours)
  • Oesophageal obstruction (unable to swallow saliva)
  • Blunt oesophageal FB
  • Magnets proximal to the duodenum
• Non-urgent endoscopy
  • Disc or cylindrical batteries which have passed into stomach without signs injury
  • coins may be observed for upto 24 hours before removal if asymptomatic

To prevent choking:

Cut foods into small pieces

Never let small children run, play or lie down while eating

Keep coins and small items out of reach of your children

Read warning labels on toys

Learn first aid for choking

Submitted by

P.Bharathi

Infection resulted in muscles due to intramuscular injection

Clinical identification:

• History of injection to the site
• Swelling at the site of injection
• Redness at the site of injection
• Fever
• Difficulty in moving the limb

Characterstics features:

• Along with above symptoms Tenderness may be present
• Fluctuations may be present in some cases

Lab diagnosis:

• Gold standard: High resolution ultrasonography
• Initial tests: CBP- Elevated WBC count

Warning signs:

• Persistent pain and fever
• Signs of sepsis
• Positive fluctuation test

PEM’S initial management:

• Local care
• Cold compress
• Antibiotics :

              AUGMENTIN 625mg TID

              CLINDAMYCIN 300mg TID

• Analgesics/ Anti inflammatory
• IV formulation in Diabetics and Immunocompromised patients

Definitive management

• Drainage of abscess, wound care
• Sensitivity based Antibiotics

Submitted by

P.Bharathi

Ø Tuberculosis or TB is a potentially serious infectious disease.

Ø It is caused by Bacteria called Mycobacterium Tuberculosis.

Ø TB mainly affects the Respiratory system but can affect other organ systems like Gastrointestinal system, the Lymphoreticular system, the skin, the Central nervous system, the Musculoskeletal system, Reproductive system and the liver.

Ø Tuberculosis that affects lungs is called Pulmonary tuberculosis.

Ø Tuberculosis that affects organs other than lungs is called Extrapulmonary tuberculosis.

TYPES OF TB

Latent TB

Many of those who are infected with TB bacteria do not develop disease ,the bacteria in their body are inactive that cause no symptoms and their chest X ray will be normal. Latent TB also called inactive TB, isn’t contagious. Latent TB can turn into active TB, so treatment is important in certain group of people. This latent TB only diagnosed through Tuberculin skin test or Interferon gamma release assay (IGRA).

Active TB

It is an illness in which the TB bacteria are rapidly multiplying and invading different organs of the body.

• Coughing for two or more weeks
• Expectoration
• Hemoptysis (sometimes)
• Fever – mostly low grade, evening raise of hemoptysis
• Chills
• Chestpain
• Loss of apettite
• Unintentional weight loss
• Fatigue

In case of Extrapulmonary tuberculosis, signs and symptoms vary according to the organs involved. For example, TB of the spine cause back pain and TB of the kidneys might cause blood in urine, TB of the intestine cause abdomen pain, diarrhea.

MODE OF TRANSMISSION

Tuberculosis is transmitted between person to person through air. When people with PTB cough , snneze, or spit, microscopic droplets released into air. IF the healthy people inhale only a few of these germs present in the droplets, they will get infected.

Although TB is contagious, its not easy to catch. It is much more likely to get TB from someone you live or work with than from a stranger.

Most people with Active TB who have had appropriate drug treatment for atleast two weeks are no longer contagious.

PATHOPHYSIOLOGY

                                M.Tuberculosis starts replication inside macrophages

                                                                    ê

                                                  Primary infection occurs

                                                                    ê

Cell mediated immunity gets activated , surrounds the cell to forms granuloma (3 weeks)

                                                                   ê

                                  Leads to necrosis of tissues at infection site

                                                                   ê

                                      Involve nearby lymph nodes (Gohn’s complex)

                                                                   ê

                                    Calcification of Gohn’s complex (Latent T.B)

Incubation period:  Approximately 2 to 12 weeks. However, the risk for developing active disease is highest in the first two years after infection.

DIAGNOSIS

Physical exam

 Check  lymphnodes for swelling and use a stethoscope to listen to the sounds lungs make when breathe, patients with PTB have abnormal breath sounds, especially over the upperlobes or involved areas.

Sputum microscopy

• Sputum for AFB
• Early morning sputum sample should be tested
• May need to repeat 2-3 times

CBNAAT/Genexpert

• Early morning sputum
• It is more sensitive than microscopy
• It can diagnose TB and also give Rifampicin sensitive/resistance status

Imaging tests

• Chest X ray
• CT chest

Other tests

• Sputum for MTB culture-MGIT
• LPA- Lime probe assay

Tuberculin skin test/montoux test and IGRA/TB gold test

• These tests are used mainly to diagnose latent TB
• Their role in diagnosing active TB is very low

TREATMENT

For drug sensitive TB,treatment include 8 weeks of intensive phase with Isoniazide(H), Rifampicin(R), Ethambutol(E), Pyrazinamide(Z) followed by 16 weeks of continuation phase with Isoniazide(H), Rifampicin(R), Ethambutol(E)

If patient had a history of PTB and ATT intake in the past, then drug sensitivity for latest TB infection should be carefully assess and treated accordingly

T.Benadon 20-40mg OD should be added ATT

Can use other symptomatic medication along with ATT

For drug resistance TB, treatment is complicated which include combination of first and second line Anti tubercular medication which depends on the resistance pattern

First line drugs                                                  Side effects

H-Isoniazid  5mg/kg  – change in memory, Hallucination, Psychosis, Anemia, Neuropathy,  

                                     Gynecomastia, Euphoria

 R-Rifampicin 10mg/kg- Interstitial nephritis, flu, anemia, orange coloured urine, pulmonary

                                        syndrome, contraception failure

E-Ethambutol 15mg/kg – Eye toxicity, Ooptic neuritis, red green colour blindness,

                                         hyperurecimia

Z-Pyrazinamide 25mg/kg – Hepatotoxic, neuropathy, hyperuricemia, arthralgia

Second line drugs:

Levofloxacin

Moxifloxacin

Bedaquiline

Linezolid

Amikacin

Ofloxacin

Ciprofloxacin 

If the patient have latent TB, recommend treatment with medication if the patient at high risk of developing active TB. For active tuberculosis, patient must take ATT drugs for at least six to nine months. The exact drugs and duration of treatment depends on the patient age, overall health, possible drug resistance and where the infection is in the body.

PREVENTION

As TB is an airborne infection, TB bacteria released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by using a few simple precautions

Good ventilation: As TB can remain suspended in the air for several hours with no ventilation

Natural light: UV light kills off TB bacteria

Good hygiene: covering the mouth and nose when coughing or sneezing reduces the spread of TB bacteria

Use of protective masks: wearing a facemask when you are around other people during the first three weeks of treatment may help lessen the risk of transmission

Stay home: Don’t go to work or school or sleep in a room with other people during the first few weeks of treatment

RED FLAGS:

• Weight loss
• Anorexia
• Evening rise of temperature
• Productive cough over 2 weeks
• Hemoptysis

PIT FALLS:

• Bronchogenic carcinoma
• Lymphomas

PEARLS:

• Always sent for CBNAAT when suspecting TB
• Do not prescribe levofloxacin when suspecting TB

Submitted by

P.Bharathi

• It is an infectious disease caused by the SARS -Cov 2 ( severe acute Respiratory syndrome- Corona virus 2)
• Corona virus derive their name from the Latin word “corona” meaning crown

• The name refers to the unique appearance of the virus under an electron microscope as round particles with a rim of projections resembling the solar corona
• They are enveloped , positive sense, single stranded RNA viruses which were first isolated from humans in 1965.
• Corona virus belongs to the family coronaviridae which is known to produce mild respiratory disease in humans.

Variants

• In the last 2 years, we have seen 5 variants of concerns- Alpha, Beta, Gama, Delta and Omicron
• WHO has said that omicron won’t be the last variant .

• SARS-Cov 2 is the seventh known corona virus to infect people after 229E, NL63, OC43, HKUI, MERS-Cov and the original SARS- Cov

EPIDEMIOLOGY

• On 31 Dec 2019, WHO was informed of cases of Pneumonia of unknown cause in Wuhan city, China.
• A novel coronavirus was identified as the cause by chinese authorities on 7 jan 2020 and was temporarily named “2019-nCov”.
• Recently, there have been 3 major corona virus leading to disease outbreaks, beginning with the (SARS- COV) in 2002, followed by the Middle east respiratory syndrome coronavirus (MERS-Cov) in 2012 , and now the SARS- Cov 2
• Since the initial report from china, the disease spread rapidly, and the number of causes increased exponentially.
• On Jan 11, the 1st case was reported outside mainland china in Thailand, within months the disease spread to all the continents except Antarctica.

• India reported its 1st case of COVID-19 on Jan 30, 2020. This rose to 3 cases by Feb 3 2020, by mid march. The number of infected cases started to increase. The first COVID 19 related to death in India was reported on March 12, 2020.

INCUBATION PERIOD

• The mean or median incubation period of disease ranges from 5 to 6 days

• The median duration of virus shedding was 20 days , mild cases tend to clear the viruses early, while severe cases can have prolonged viral shedding.

MODE OF TRANSMISSION

• Commonly through droplets/ Airborne transmission
• Sometimes by surface/fomite transmission

CLINICAL MANIFESTATIONS

COVID 19 affects different people in different ways. Most infected people will develop mild to moderate illness and recover without hospitalization.

Most common symptoms:

• Fever
• Cold

• Cough

• Sorethroat

• Headache

• Body pains

• Tiredness

• Loss of taste or smell

Less common symptoms

• Diarrhoea
• Skin rash
• Conjuctivitis

Serious symptoms:

 seen in small proprtions of patients

• Difficulty breathing or shortness of breath

• Chest pain

People with mild symptoms should manage their symptoms at home. On average it takes 5-6 days from when someone is infected with the virus for symptoms to show, however it can take upto 14 days.

DIAGNOSTIC TESTS

Rapid antigen test -Nasal /Throat swab

                                                              Less sensitive, more specific

RT PCR –   Nasal /Throat swab

                   Less sensitive, more specific

HRCT scan – Helps in diagnosis and also in assessing severity of the disease

                       More sensitive and specific

                       Timing is important

     Routine blood tests

• CBC
• RFT
• Blood sugars etc

Inflammatory markers: Helps to assess severity and to monitor treatment

• CRP
• D- Dimer
• LDH
• IL-6 –Can be sent in rapidly detoriating  patients

TREATMENT

Mild disease: Fever, upper respiratory tract symptoms without SOB or Hypoxia

Symptomatic management- Hydration

                                             Paracetamol

                                             Anti tussives

Monitor vitals regularly

Moderate disease

If SOB is present, Tachypnea present or SPO2 < 94% room air

• Low dose steroids (Dexamethasone/ Methylprednisolone)
• Anticoagulant prophylaxis : If there is no contraindication or high risk of bleeding

(eg. Enoxaparin 0.5mg/kg/day subcutaneous route)

• Antiviral

Inj. Remdesivir 200mg for 1^st day followed by 100mg for 5 days

• Oxygen supplementation and other supportive medication

Severe disease

If SOB is present, severe tachypnea or SPO2 < 94% room air

Need ICU admission

• Parenteral steroids  -should ruleout sepsis
• Anticoagulants – If there is no contraindication or high risk of bleeding
• Anti viaral

Inj .Remdesivir for 5 days

• Oxygen supplementation or NIV or Invasive ventilation depending on patient clinical condition

Red flags

• Pulmonary embolism is a complication during and after Covid which can cause rapid deterioration of patient condition
• Mucormycosis or other fungal infections can occur during or after Covid

Pearls

Monoclonal antibodies: Different combinations of monoclonal antibodies are being tried for treatment of infection with different strains

PREVENTION

Protect yourself and those around you:

• Get vaccinated as soon as it’s your turn and follow local guidance on vaccination.
  • Keep physical distance of at least 1 metre from others, even if they don’t appear to be sick. Avoid crowds and close contact.
  • Wear a properly fitted mask when physical distancing is not possible and in poorly ventilated settings.
  • Clean your hands frequently with alcohol-based hand rub or soap and water.
  • Cover your mouth and nose with a bent elbow or tissue when you cough or sneeze. Dispose of used tissues immediately and clean hands regularly.
  • If you develop symptoms or test positive for COVID-19, self-isolate until you recover.

To properly wear your mask:

• Make sure your mask covers your nose, mouth and chin.
  • Clean your hands before you put your mask on, before and after you take it off, and after you touch it at any time.
  • When you take off your mask, store it in a clean plastic bag, and every day either wash it if it’s a fabric mask or dispose of it in a trash bin if it’s a medical mask.
  • Don’t use masks with valves.

   Submitted by

P.Bharathi

Tonsillitis is of two types:

1. Acute tonsillitis
2. Chronic tonsillitis

Acute Tonsillitis:

Aetiology:

• Streptococci, Pneumococci and Hemophilus influenzae.
• Haemolytic streptococcus- most common organism.
• Mainly seen in school-going children but also affects children.

Symptoms:

• Sore throat
• Difficulty in swallowing
• Fever
• Ear ache

Signs:

• Often breath is foetid and tongue is coasted
• Hyperaemia of pillars, soft palate and uvula

Examination:

• Endoscopy
• Culture test

Clinical management:

• Pt should take bed rest.
• Plenty of fluids must be taken.
• PCM-650 must be taken thrice a day for pain relief & fever.
• Gargle with warm salt water or betadine solution (1:3 dilution).

Antimicrobial therapy:

Adult dosage:

• Penicillin V 500mg PO BD for 10 days or 250mg PO QID for 10 days.
• Benzathine penicillin G 1.2 million units IM once or
• Amoxicillin 500-875mg PO q12h or 250-500mg PO q8h for 10 days
• Cefuroxime axetil 500mg PO BD for 5 days

Paediatric dosage:

• Penicillin V 25-50mg/kg/day divided q6h for 10 days or
• Benzathine penicillin G 25,000 units/kg IM once or
• Amoxicillin 50mg/kg/day PO in 2 or 3 divided doses for 10 days or
• Amoxillin clavulanate 500-875mg PO q12h for 10 days
• Cefuroxime axetil 10mg/kg PO BD for 7 days

Differential diagnosis:

• Diphtheria, Pharyngitis

Chronic Tonsillitis:

• Complication of acute tonsillitis.
• Mostly affects children & young adults.
• Rarely occurs after 50 years.
• Caused by chronic infection in tooth or sinuses.

Signs:

• Enlarged tonsils
• Yellowish beads of pus

Complications:

• Peritonsillar abscess
• Parapharyngeal abscess
• Intratonsillar abscess
• Tonsilloliths
• Tonsillar cyst

Clinical management:

• Tonsillectomy

Preventive measures:

• The best way to prevent tonsillitis is by washing hands and good hygienic practices.
• Good oral care must be maintained.
• Avoid sharing food, dishes, water bottles or utensils.
• Replace tooth brushes after infection.
• Avoid having low quality ice creams and juices.

Red flags:

• Teeth and skeletal abnormalities of teeth

Pit falls:

• Confused with Ricketts

Pearls:

• Defluorination of water & fluoride paste

References:

• PL Dhingra, Shruti Dhingra (7^th edition) Diseases of Ear, Nose and Throat & Head and Neck Surgery, Elsevier publications.
• Tonsillitis and Diphtheria- Centres for Disease Control and prevention (CDC)