Pediatrics for EOR

Erythema Infectiousum

Etiology: Parvovirus B19
Sx: "slapped cheek appearance"
Tx: benign - resolves on its own. Most contagious prior to rash

Mumps

Etiology: tender swelling of one or more glands.
> parotid involvement is common
> orchitis and oophoritis.
Tx:supportive - fluids and analgesics.

Measles

Sx: high fever and lethargy, cold symptoms with cough
KOPLIK spots are pathognomonic
maculopapular rash noted on face and trunk - gone in 6 days
Labs: measles IgM antibody drawn at day three
Tx: supportive (resolution in 7-10 days)

Varicella

exposure occurs 2 weeks prior to rash .
Prodrome: 1-3 days of flu like illness - red macules rapidly become vesicles with surrounding erythema. "dew drops on a rose petal"
Tx: supportive: hydration - acetaminophen for discomfort.
Parenteral acyclovir for

Strep throat < 3 yrs

sx: insidious onset - mild low grade fever, discharge and pallor with otitis media.
posisble exudative pharyngitis. (uncommon)
Tx: PCN - V

strep throat > 3 years

fever - marked malaise - often with vomit
pharynx sore and edematous with tonsillar exudates
anterior cervical lymph nodes tender and enlarged
small petechia seen on soft palate.
Labs:
- rapid detection tests and cultures
- ASO titers
- high ASO titer and

Mononucleosis

EOD:
- malaise, fever, sore throat (posisble exudates)
- palatal petechiae, splenomegaly and maculopapular rash
- positive heterophil agglutination test (monospot)
- large lymphocytes in blood smear
Complications
- hepatitis, myocarditis, neuropathy
Consi

Reye's Syndrome

EOD:
- h/o URI with salicylate ingestion &Vomit & lethargy
Sx:
- irregular respirations, sluggish pupils
- liver may be enlarged
- positive babinski, hyperreflexia and posturing with high ICP
Labs: moderate to high AST/ALT with lactate dehydrogenase
- hyp

Pinworms

EOD: ANNAL PURITIS
sx: worms can be found in the bwoel wall, lumen of appendix, bladder, etc..
Labs: transparent tape test - with drop of xlene on slide to see ova
Tx: treat all household members with and repeat in 2 weeks
1) pyrantel pamoate
2) mebendazo

Influenza

Sx: fever, diarrhea, vomiting, and abdominal pain, headache, chills, infants have sepsis like symptoms
Prevention: all children 6-23 months of age = immunized
antivirals are of some benefit if started before 24 hr

Thrush

Findings:
creamy white patches on gingival surfaces
steroid inhalation for asthma = predispose
Labs: see budding yeast
Tx:
Infants = nystatin
oral azoles - fluconazole

Lyme disease

Caused:
burrelia burgdorferi from tick
Sx:
- erythema chronicum migrans - rash
- arthritis several weeks to months bite
- neuro manifents in 20% of cases. (bell's palsy, meningitis, polyradiculitis.
Dx: Elisa and immunoblot to confirm
Tx:
Rash <8 = amoxic

Chlamydia trachomatis

most common STD
Sx: PID like sx
NAAT is the most senstive test
Tx; doxy or azithromycin

Nesseria gonorrhea

2nd most common STD
Sx: mucopurulent cervicitis with yellow d/c
Labs: first void urine
Tx: tx for chlamydiaas well as gonorrhea
> CEFTRIAXONE

Legg Calve Perthes Disease

What: vascular supply to femur head is limited = necrosis
Who: 4-8 years old
Sx: persistent pain, limp or limited ROM
Labs: xray!
Tx: surgery and protection of the joint

Osgood-Schlatter's

What: from jumping and running sports - microfx of the tibial tubercle
Who: pre-teen boys 12-15 and girls 11-13 years old
Pain: local to tibial tubercle= get an xray!
Tx: resovles spontaneously - treat pain with NSAIDs

SCFE:

What: slipped femoral ephiphysis due to disruption of the growth plate
Who: obese males with an unknown cause. Association with hypothyroidism
Condition occurs: following acute fall or trauma, vague sx- pain referred to thigh or medial side of knee
Tx: Pi

Genu Varus/Valgum

varum is normal for infants through 2 years and changes to valgum until age 8 when adult alignment is obtained.
- varum - knees out
- valgum - knees in

SIDS

sudden infantdeath syndrome < 1 year that remains unexplained.
Peak age = 2-4 months usually occuring between midnight and 8am when both infant and parents are sleeping.
Risk: low birth weight, teenage or drug addicted mothers, maternal smoking, and famil

Juvenille Rheumatoid Arthritis

What: mono/poly arthropathy with a tendency to involve large joints or poximal interhapalngeal joints and lasting > 3 months
Sx: systemic with fever, erythematous rashes nodules, fatigue
Labs: HLA-DR5 associated with iritis and antinuclear antibodies
HLA-

Scoliosis

who: girls 8-10
associated disease: neurofibromatosis, marfan, CP, muscular dystrophy, poliomyleitis, myelodysplaisa
Sx: pain is present there is a strong chance that scoliosis is secondary to another disease
Treatment:
- < 20 degrees - not require
- 20-4

Hip dislocation

Ususally POSTERIOR dislocation (shoudler - anterior)
* leg is flexed, aDDucted, and externally rotated
**
emergency!
**
transport to ortho surgeon to reduce. protected weight bearing.
complications: severe bleeding, avn, and nerve damage.

hip dysplasia

what: abnormal growth or development.
Dx:
- ortolani (ouch) - pushing hip back into place
Barlow back - pressure with hip coming out of the joint
Tx: pavlik harness - first few eeks of life. Puts patietn in a flexed position
Hip Spica! - surgery

foreign bodies

Where: lodge at cervical esophagus, aortic arch, and LES
Sx: substernal chest pain, and increased salivation secondary to instability to swallow.
PE: normal unless perforation
Labs: xray of chest will normally identify foreign body (not if radiolucent lik

gastric and small bowel foreign bodies:

**most pass thorugh esophagus will go the rest of the way without difficulty
** if it doesn't pass within three days it should be removed via endoscopy
Obstruction:
> may occur if item becomes lodged at ileocecal valve
Small disk batteries: "button" batte

Juvenille DM- type 1

IDDM
associated with dimished isulin production with patients who are ketosis prone. Damage to islet producing B cells of pancreas.
Sx: polyuria, polydipsia, and weight loss, glycosuria on routine UA in office or random glucose > 300.
Tx: regular insulin

Type 2 DM

insulin 12-19 yrs old - < 7.5
insulin 6-11 yrs old - < 8%
< 5 yrs - 7.5-8%

PKU

D/T decreased activity of phenalalanine hydroxylase
Sx: pts with untreated PKU exhibit mental retardation, hyperactivity, seizures, light complexion and eczema
> screen for PKU 24 hrs post birth
Dx: high levels of serum phenylalanine
causes mental retarda

Hyperbilirubinemia

...

Syphillis

trans: in utero by tranplacental passage of treponema pallidum
Complications; still birth or prematurity
Sx in infant < 2 yrs - mucocutaneous lesions, lymphadenopathy, hepatosplenomegaly, bony changes,
Sx in >2 yrs- hutchinson teeth, mulberry molars, chor

Fetal Alcohol Syndrome

Dx: facial abnormaliteis (short palprebral fissures, thin upper lip and indistinctive or smooth philtrum) growth deficiency, and evidence of CNS damage and neuro abnormalities
Tx: Psychopharmacologic intervention needed to address issues like mood

Urinary Tract Infections

Cause - fecal flora (E. Coli)
Sx: newborns and infants, hypothermia, poor feeding, vomiting, strong, foul-smelling urine
Labs: midstream clean catch (pyuria > 5), urine function assessed with BUN/Cr
Imaging: U/S of kidneys if suspect pyelo/voiding cystour

Hemolytic Uremic Syndrome

What: most common glomerular vascular cause of acute renal failure in childhood (diarrhea = shigella or e.coli)
Source: ingestion of undercooked ground beef E. coli 157: h7
Presenting complaint: bloody diarrhea, hemolysis and renal failure
S&S: prodrome o

Testicular torsion

types
1) intravaginal torsion (bell-clapper deformity) - most common
2) extravaginal torsion - neonates and those with undescended testicles
S&S:
scrotal or testicular pain to lower abdomen
cremesteric reflex = absent
prehn sign (lifting of the testicles

phimosis

What: inability to retract foreskin to epxose the glans
can be d/t recurrent balanitis
Treatment: circumcision

paraphimosis

what: inability to reduce a previously retracted foreskin. Prepuce is fixed in a retracted position.
Tx: manual reduction (if fails - dorsal slit)

Cryptorchidism

what: undescended testicles is common. often unilateral and right sided. Infertility and testicular malignancy are risk factors
Findings: 2-6 mo
LH, FSH, and testosterone determine whether the testis are present
> HCG test is done to confirm teh asbence o

Acute glomerulonephritis (post strep)

post strepdisease in recent history (7-14 days) documented by culture of ASO titer
Presentation: gross hematuria (coffee/tea colored urine) with / without edema
abx therapy if strep inf is still present
acute abnormalities resolve in 2-3 wks

Enuresis

what: urinary incontinence in a child > 5 yrs of age
no real cause.
common in boys with FH of bed wetting issues
tx: fulis limited before bed.
Desmopressin acetate intranasally at bedtime

Wilm's tumor

WAGR synrome (wilms tumor, aniridia, ambiguous genitalia, mental retardiation) - most common in 2-5 yrs of age (not common after 6
Sx: increasing size of abdomen or asx abdominal mass incidentally discovered by parent or health care provider.
> smooth, fi

Down Syndrome

1:600 newborns (risk factor if mom is > 35)
mental retardation is characteristic
Physical findings: brachycephalic head, characteristic facies (up-slanting palprebral fissure, epicanthal folds, midface hypoplaseia, and small dysplatic pinna)
* 1/3 have co

Sickle Cell disease EOD

> neonatal screening test FS, FSC, or FSA
> african, middle eastern, idian, carribian, mediterranean
> anemia, elevated reticulocyte count, jaundice
> recurrent episodes of muskuloskeletal or abdominal pain.
> Hemoglobin electrophoresis with S > F
> splen

S&S of sickle cell

> children normal at birth and sx unusual before 4 mo b/c of high fetal hemoglobin that inhibits sickling
> increase chance of gall stones due to severe sickling
> slenomegaly resulting in functional asplenia = greater risk for infection with encapsulated

Tx of sickle cell

> pt and family education
> prophylactic PCN started at 2 mo and continued till age 5
> red cell transfusion
> daily hydroxyurea increases levels of fetal hemoglobin

ITP: idiopathic thrombocytopenia purpura

Decreased platelet count, petechiae, ecchymoses
> most common bleeding disorder of chidhood (2-5 yrs)
> follows viral infection
> petechiae on lips, bucal mucoasa and epistaxis
Labs
> platelet count is low, bleeding time prolonged.
Tx
> none, <10,000 uL r

Thrombocytopenia in a newborn

most common cause of purpura in a newborn.
> consider with petechiae or significant bleeding tendency
> platelet count less than 150,000 uL = dx
> Inf and intervascular coagulation syndormes are most common causes of thrombocytopenia

Disorders of platelet function

inherited or acquired (acquired is more common)
> acquired disorders may occur secondary to uremia, cirrhosis, sepsis, myeloproliferative disorders, acyonotic heart disease and viral infection
> Tx: desmopressin acetate

Factor 8 deficiency (hemophilia A)

CLASSIC
> BRUISING, BLEEDING, HEMARTHROSES
> prolonged PTT and reduced factor 8 activity
> males, x linked disorder
Tx
> attempt to prevent and stop bleeding, desmopressing, admin factor 8

Factor 9 deficiency (hemophilia B)

Christmas disease
> similar to factor 8
Treatment
> factor 9 concentrate

Factor 11 deficiency (hemophilia C)

> danger if trauma or surgery - need intervention
> treatment = FFP or desmopressin

Von Willebrand disease

easy bruising and epistaxis from early childhood. Also menorrhagia
> bleeding tim eusually prlonged
> platelet count usually normal
> reduced activity or abnormal structure of vonwillibrand factor
> abnormality in vWF a plasma protein that forms a multime

Acquired Bleeding disorders- DIC

> prolonged Pt, PTT or thrombin time, decreased fibrinogen and platelets> primary mediator of DIC is interleukin 6
> leads to thrombin generation, intravascular fibrin deposition, and platelet consumption.
> trigger DIC: endothelial cell damage, tisseu de

Acquried bleeding disorders and liver disease

> liver is the major synthetic site of prothrombin, fibrinogen, and many other factors
> it also produces plasminogen and three physiologic anticoagulants
Tx:
replace with FFP and platelets, desmopressin may shorten bleeding time

Acquried bleeding disorders and Vitamin K def

all newborns have a depressed activity of vitamin K - if vit K is not given at birth a bleeding diathesis may occur

uremia

bleeding occurs in 50% of renal fialure patients
manifests as purpura, menorrhagia, or GI bleeding
Tx: infusion of desmopressin, red blood cells and FFP

Klinfelter's syndrome

tall, thin and long limbed obese adults (scoliosis)
> mild developmental delays, hypogonadism

Turner Sydrome

> monosomy X
> short stature, webbed neck, prominent earls, low hairline, broad chest with widely spaced nipples, amenorrhea, horsehoe kidney, CoA

Fragile X syndrome

pale blue irises, long narrowed facies, autism, MVP, protruding ears

iron def anemia

> pallor, fatigue, irritability, delayed motor developmen
> history of pica
Labs: decreased serum ferritin and low serum iron, elveated total iron binding capcity, and decreased transferring stauration
Tx:
> oral dose of elemental iron is 6 mg/kg/d in thr

ALL

acute lyphoblastic leukemia
> most common in kids (25% lymphoblasts) age 4 = peak
Sx:
pallor, petechiae, purpura
hepatosplenomegaly, lyphadenlpathy
Labs
multiple cytopenias (1/2 with leukocytosis)
Dx: confirmed by bone marrow examination
Induction therapy

AML- acute myeloid luekemia

more common in adults
> auer rods
Sx: fatigue, bleeding inf, adenopathy, hepatosplenomegaly, skin nodules
Cytopenia (neutropenia)
Long term survival = 50%
Overall < response to treatment and requires chemo

Chronic Myelogenous Leukemia

Philadelphia chromosome
> nonspecific complaints - massive splenomegaly, variable hepatomegaly
> Marked leukocytosis, elevated platelets, decreased to absent leukocytes alk phos
Tx:
> hydroxyuria used to reduce or elminate Ph+ cells
Hematopoietic stem cel

Lead poisioning (plubism)

Sx: vague. include weakness, irritability, weight loss, vomiting, personality changes, ataxia, constipation, colicky abdominal pain
late manifestations: include retarded development, convusions, and coma
Labs: blood lead levels , CBC, serrum ferritin, nor

Hemachromatosis

EOD
- dx b/c of elevated iron saturation or serum ferritin or FH
- most pts are asx, recognized ebfore the fourth decade
- hepatic abnormalities and cirrhosis, congestive heart failure, hypogonadism, and arthirtis
- HFE gene mutation found in most cases
-

HSP

- with strep infection and PCN
- small vessel vasculitis with purpura of LE/buttocks
- IgA depsoits in glomeruli
- palpable prupura - non blanchable red papules over extremiteis
Tx: systemic corticosteroids

Gastroesophageal Reflux

LES relaxation
GER vs. GERD - concerned for dz if there is wt loss, blood
Complications
> ALTE - baby turns blue post vomitus
Tx: keep baby upright (PPIs don't work as well)
* non-bilious vomiting is from above the ampulla

Pyloric Stenosis

Occurs b/t 4-6 wks of age, mostly males
> projectile nonbilious emesis = olive, peristalsis
> metabolic derangements- creates an alkalotic state, loss of K+ and HCl (hypokalemic, hypochloremic metabolic alkalosis)
> u/s diameter of pylorus 4-14mm
> pyloro

Congential obstructive lesions

> atresias - esophageal and duodenal
> annualar pancreas
> webs
> swallowed items: lactobeazor, coins, etc.
Dx: clinical or xray

Tracheoesophageal fistulas

most common - blind pouch
dx: feeding tube put in, visible on xray

Infections (that cause vomiting)

gastroenteritis - rotavirus most common
labrynthitis, otitis media
pancreatitis
UTIs or Pyelonephritis
appendicitis, helicobacter pylori
pneumonia, sinusitis (from post-nasal drip, post tussive
meningitis

Metabolic/endocrinologic
(inborn errors of metabolism)
& vomiting

diabetes: vomiting is a common complication of type 1
congenital adrenal hyperplasia
addison's disease

Neurologic issues & vomiting

>> increased ICP, hydrocephalus
>> meningitis: babies are born with only two sinuses (maxillary and ethmoid)
>> brain abscess
>> encephalitis
>> brain tumors

bilious vomiting

always pathological

duodenal atresia

usually second portion of the duodenum
1 in 7500 births
failure of recanalization of intestines during early gestation

malrotation

during embyrology, fibers attach to liver instead of attaching to spleen

volvulus

twisting of bowel on itself
it is a medical emergency, may become necrotic and lead to short gut syndrome

Hirshbrung disease

absence of ganglionic cells
- CLINICALLY suspect if they have not had a BM within the first 48 hrs of life
Transition zone - area without ganglionic cells will always be in contraction, shows "STRING sign"
Diagnosis - barium swallow
Tx: pull through proce

Intussusception

telescoping of one portion of the bowel into its distal segment
> MC terminal ileum into the cecum
> result of lymphatic hypertrophy in the pyer's patches from a recent viral infection
Age: 2 yrs is average.
Clinical - severe abdominal pain and vomitting

Necrotizing entercolitis

deadly disease seen in premature babies whose intestines are not yet fully developed. Wall is susceptible to infx. Stomach appears purpuric

Hematemesis

usually benign in chlidren
> naspharynx, resp.
> esophageal
> gastroduodenal - from H. pylori
> maternal - not a problem, swallowed during birth
> maternal - not a porblem, swallowed during birth
> coagulopathy

History of vomitus

character of vomiting
> degree
> force
> frequency
> duration
> timing
> appearance
associated sx - fever, h/a dizzy, pain, jaundice, nasuea, change in mental status

Malrotation

> midgut extends from duodenojejunal junction to the mid transverse colon (suppled by SMA) which runs root of the mesentary
Sx:
infants present within first three weeks with bile stained vomit
> ascites or meconium peritonitis
> malsabsorption, protein lo

Umbilical Hernia

more common in preterm infants and black
> if it persitsafter four yearsof age it should be repaired surgically

Inguinal Hernia

Indirect - process vaginal remains open - peritoneal fluid may go into it. *most common
Direct - less common
Sx: most cases - painless inguinal swelling. "fullness" with periods of standing or coughing.
Tx: incarceration of hernia is likely to occur in bo

Protein deficiency

Causes: severe skin disease and burns, CF
Impaired growth, lethargy, irritability, edema, hepatomegaly
Tx: adjust treatment

carb deficiency

causes: diarrhea, malabsorption, improper diet, excess results in DM and obesity
Tx: diet adjust

Vitamin K deficiency

aids in formulation of coagulation
hemorrhagic purpura
vitamin K levels, prolonged PT time
Tx: IM, vitmain K injection

Fluroide deficiency

Incorporated into tooth matrix, resistance to dental caries
> found in most public water sources.
> increased dental caries, discolored, teeth
Tx: supplementation after 6 mo

Iron deficiency

Causes: breast fed infants, untreated maternal aemia
pallor, fatuge, pica, increased ferritin, TIBC, decreased iron
Tx: food high in iron, supplementation

Gastroenteritis

viruses are the most common cause
> rotavirus is the most common (affects small intestine causing voluminous watery diarrhea
> trasnmitted fecal oral route
Sx: low grade fever, watery diarrhea

Diagnosis and treatment of rotavirus gastro

> incubation for 24-48 hrs
> vomiting is the first symptom in most pateints followed by low grade fever and watery diarrhea
> diarrhea lasts 4-8 days (no blood or white cells)
> metabolic acidosis results from bicarb loss in the stool
> rotavirus identifi

E. Coli Gastroenteritis

E. coli may cause diarrhea of varing types
Tx: seldom requires antimicrobial treatment
fluid and electrolyte therapy
bismuth subsalicylate reduces stool volume by 1/3 in infants with watery diarrhea
traveler's diarrhea with bactrim in chidlren with fluroq

enterotoxigenic e. coli

mild self limiting illness without sig fever or systemic toxicity
> known as traveler's diarrhea

HUS - short cut

hemolytic uremic syndrome
> 2-5% of children and is characterized by microangiopathic hemolytic anemia, thrombocytopenia and renal failure

Salmonella Gastroenteritis

Sx: n/v/headache, meningismus
fever, diarrhea, abdominal pain
culture or organism from stool, blood or other specimens
Consider: > fowl and reptiles carry transmit to humans by fecal oral route
Sx:
> fever, vomiting, diarrhea
> stools watery and have mucu

Peritonsillar Cellulitis or Abscess (Quinsy)

Most common pathogen: B hemolytic strep
C/O: severe sore throat, high fever, tonsil bulges and anterior tonsillar pillar is prominent, uvula displaces towards uninvolved side, fullness and tenderness, can cause airway obstruction
Tx: aspirate, admit w/ IV

Acute Viral Pharyngitis & Tonsillitis

90% due to viral infections

Infectious Mononucleosis

exudative tonsillitis, generalized cervical adenitis, and fever (older than 5 yrs) w/ palpable spleen or axillary adenopathy.
Labs
> positive monospot (false - in children less than 5)
> EBV shows elevated IgM
> amoxicillin is contraindicated in patietns

Herpangina

What:
> 3 mm in size surrounded by a halo found on anterior tonsillar pillars, soft palate and uvula.
> anterior mouth and tonsils are spared
Caused by Coxsackie A group of viruses, and a patient may have several bouts of ulcers.
Tx: self limiting

Hand, Foot and Mouth Disease

D/t Enteroviruses
> vesicles, pustules or papules found in palms, soles, interdigital areas and butt, mouth and face

Pharyngoconjunctival fever

> d/t adenovirus - can be epidemic
Sx: exudative tonsillitis, conjunctivitis, lyphadenopathy, and fever
Tx: symptomatic

Acute Bacterial Pharyngitis

10% with sore throat & fever =group A strep infection
Untx strep can result in = acute rheumatic fever, glomerulonephritis, and suppurative complciations.
Sx: > SOre throat, odynophagia, fever, h/a, cervical node,s palatal petechiae, beefy red uvula, and

Epiglottitis

D/T = H. influenzae type B
Sx: sudden onset of fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis and soft stridor, sit in the "sniffing dog position"
Dx: made by inspection of the epiglotitis = cherry red
Imaging: lateral radiog

Otitis Externa

> inflammation of the skin lining the ear canal. loss of protective function of cerumen. swimming is common culprit
> Staph aureus or pseudomonas aeruginosa
Sx: pain and itching when chewing or pressure on tragus. swollen
Tx: topical treatment with floqro

Otitis Media

Most common ear infection in young chidlren
Sx: pain, fever, decreased hearing often happens after a cold
Tx: abx, decongestants, nasal irrigation, steroid
amoxicillin - covers Strep pnumo, H. influ, moraxella ?
Augmentin
Surgery: myringotomy

Myringotomy limitations

> average tube stays in 9-12 months, comes out on own
> enlarged adenoids
- adenoidectomy - proven to decrease incidence of OM

Indications for tonsillectomy and adneoidectomy

> seven epsidoes of tonsillitis in the past year
> five episodes of tonsillitis each year for teh past two years
> three episodes of tonsillitits each year for the past three years

Indications for myringotomy

>> severe oitits media (middle ear inf)
> hearing loss greater than 30dB with effusion present for greater than three months
> poor response to abx
> impending mastoiditis or intracranial complications
> recurrent AOM (> 3 eipsodes in 6 mo or more than 4

anterior epistaxis

Cause: kisselbach's plexus
Dx: H&H, CBC, bleeding time
Management:
> ABC
> direct pressure. Pinch nostrils and sit forward
> cautery - chemical, electric, thermal, silver nitrate sticks
> use of vasoconstrictors sprays, anesthetic agets.
> atnerior packin

Posterior epistaxis

Cuase: branch of the sphenopalatine artery
Dx: H&H, CBC, bleeding time
Management:
> attempt to locate source
> vasocnstrictive agetns
> posterior nasal packing
> otolaryngologist referral
> prophylactic abx
> hospitalziation and monitoring
> surgery / em

acute viral rhinitis (common cold)

What; virual upper respiratory infection) - most common pediatric infectious disease
> children younger than 5 yrs typically have 6-12 colds per year
EOD
> clear or mucoid rhinorrhea, nasal congestion, sore throat
> possible fever, particfularly in young

Rhinorsinusitis

sinusitis

Acute bacterial Rhinosinusitis

> ALWAYS proceeded by viral URI
> diagnosis made hwen child does not improve 10-14 days
> maxillary and ethmoid isnuses are most commonly invovled
> S pneumoniae, H. flu, M catarrhalis, and B hemolytic strep
Complications
> eyelid edema, restricted EOM, p