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Otorhinolaryngologic Presentations of Infectious Mononucleosis
Nancy L. Snyderman
(Pediatric Clinics of North America, Vol 28, No 4, November 1981)
Infectious mononucleosis is frequently encountered in pediatric practice. Symptoms of malaise, fever, fatigue with sore throat, cervical adenopathy, and splenomegaly are wellknown manifestations of the disease. The otolaryngologist usually has minimal contact withthese patients. Most present with symptoms that are managed by their pediatricians and onlya small percentage of those affected children are hospitalized.
A review of admissions at Children's Hospital of Pittsburgh between 1970 and 1980 revealed 61 children whose presenting symptoms of infectious mononucleosis warrantedhospitalization. Thirty-three (55 per cent) presented with otolaryngologic complaints (Table1). One-third of those children admitted had some degree of airway obstruction. Theremaining presentations were peritonsillar cellulitis (1), facial paralysis (1), periorbitalcellulitis (3), epistaxis (2), suppurative lymphadenitis (1), external otitis (1), and sinusitis (2).
The reason for admission of the remainder is shown in Table 2.
Infectious mononucleosis has been known as a disease of young adults, usually affecting those between 15 and 35 years of age. The review of our series shows equaldistribution in children ≤ 5 years (19), 6 to 10 years (21), and ≥ 10 years (21). There was nosex predilection and 79 per cent were Caucasian. Sixty-seven per cent had splenomegalywhich concurred with the incidence of other series. Ten to 15 per cent of these children areknown to have group A beta-hemolytic streptococcal throat culture. Our finding is similarwith 18 per cent. Thirty-nine children had white blood counts greater than 10.000 per cu mm.
A lymphocytosis with atypical cells occurred in 78 per cent.
mononucleosis that are not frequently seen by the pediatrician. A recognition of these variouschief complaints and treatment modalities is important in managing this disease.
Case 1: Airway Obstruction
A three-year-old black girl presented with a four-day history of sore throat and progressive dysphagia. Examination revealed +4 hypertrophied tonsils with exudate,inspiratory stridor, and significant airway obstruction. There was marked cervical adenopathyand the tip of the spleen was palpable. The child appeared toxic and dehydrated. The whiteblood count was 19.200 with a lymphocytosis. A "monospot" was positive. The lateral x-rayfilm of the neck confirmed adenotonsillar enlargement and airway obstruction. A throatculture was negative for group A beta-hemolytic streptococcus.
Because of imminent obstruction, a nasopharyngeal airway was placed without difficulty and secured. An intravenous line was begun and dexamethasone (Decadron) wasgiven intravenously as a bolus (1 mg per kg) with a maximum dosage of 10 mg. One-half theinitial dose was then given every six hours for four doses. The airway was removed after 24hours without problem. Antibiotics were not administered. Oral intake gradually returned to normal and the child was discharged on the fourth day. Follow-up was uneventful.
Discussion
Waldeyer's ring is the mass of lymphoid tissue that encircles the oropharynx and nasopharynx: the palatine and lingual tonsils, adenoids, and lateral pharyngeal bands. Airwayobstruction in children with infectious mononucleosis is caused by hypertrophy of this tissue.
Most children present with nasal obstruction with snoring, mouth breathing, and inspiratorystridor. Tonsillar enlargement can obstruct the oral airway. Many patients have dysphagia andare dehydrated. Significant cervical adenopathy can cause poor neck mobility.
Twenty-two children presented with airway obstruction requiring an otolaryngologic consultation: 13 were ≤ 5 years of age, 5 ranged from 6 to 10 years of age, and 4 were ≥ 10years of age. Fifty-nine per cent were less than five years of age. Management varied overthe years. However, intravenous steroids have been used more frequently since 1975. In noinstance was a tonsillectomy performed. One tracheotomy was done in 1974 on a nine-year-old Caucasian girl who presented with airway obstruction.
Numerous modes of therapy have been proposed for treating airway obstruction in infectious mononucleosis. Tracheostomy was first suggested as a means of intervention in1949 by Jones and Jones. This received considerable support in the years following. Theprocedure is not always straightforward though, as described by lee in 1959. He reported a16-year-old Caucasian girl who presented with progressive airway obstruction. Atracheostomy was performed under local anaesthesia, but because the patient could not liestill, the airway became obstructed and the patient had a cardiac arrest. The procedure wascompleted under general anaesthesia.
Tonsillectomy has been supported by those who feel that the disadvantages of emergency tracheostomy in children outweigh the advantages. This treatment modality wasfirst reported in 1956 by Ranta of Finland. Since then, it has been a popular way of managingairway obstruction in infectious mononucleosis. The problems with this operation and generalanaesthesia should not be viewed lightly in these children. The tonsils are usually acutelyinfected and friable. Liver function abnormalities and prolonged coagulation times have beenreported. Consequently, bleeding may become a major issue.
Yeager reported performing a tonsillectomy on a 4.5-year-old Caucasian girl with infectious mononucleosis in 1964. During induction, a rubber airway was passed because oflabored respirations and these were relieved. The operation proceeded with a blood loss of150 to 200 mL. It was necessary to place suture ligatures in both tonsillar fossa. This casesupports tonsillectomy in airway obstruction in patients with infectious mononucleosis.
However, it illustrates the potential for compromise of the patient because of the significantblood loss seen with acutely infected tonsils. In addition, the airway may be successfullymanaged by use of a nasopharyngeal airway alone.
While our method of managing these children is more conservative, we feel that it is safe and still solves the problem of impending airway obstruction. Initially, these childrenreceive intravenous hydration with total fluid losses being taken into account. Decadron, 1 mgper kg, with a maximum dose of 10 mg, is given initially. One-half of the loading dose is then given every six hours for 48 hours. A soft rubber nasopharyngeal airway is placed andsecured. All tubers are removed within 48 hours. Several children were maintained on dosesof oral prednisone for a few days following the tube removal at the discretion of the attendingphysician. None of these children has returned to Children's Hospital with mononucleosis,airway obstruction, or recurrent tonsillitis. This review describes our success in managingacute airway obstruction in these patients without subjecting them to the increased risks ofanesthesia and surgery. We propose that this regimen is a safe and reasonable way of treatingacute airway obstruction in the pediatric patient with infectious mononucleosis.
Case 2: Facial Paralysis
A 2.5-year-old Caucasian girl presented to Children's Hospital of Pittsburgh with a three-day history of fever, sore throat, and bilateral otalgia. One day prior to admission, hermother noticed that the right side of her face was not moving well. Examination confirmedbilateral otitis media and right facial peripheral paralysis. Splenomegaly and hepatomegalywere present. Tonsils were +3 enlarged with exudate and there was cervical adenopathy. A"monospot" was positive. White blood cell count was 10.400 with a lymphocytosis. The childwas begun on prednisone, 2 mg per kg per day, and ampicillin, 250 mg orally every sixhours. A myringotomy was performed. The paralysis began to resolve within 24 hours andthe child was completely well by the end of the week.
Discussion
Infectious mononucleosis has been associated with dysfunction of all the cranial nerves causing anosmia, parosmia, unilateral deafness, and facial paralysis most often. Therelationship with facial paralysis was first described by Osell in 1937. In otitis media, it is feltthat the facial nerve becomes involved secondary to swelling and compression in the fallopiancanal. Complete recovery in the young patient with a viral illness is common and is relatedto the length of time it takes for function to begin to return.
Myringotomy is frequently used for treatment of facial nerve paralysis in otitis media.
Steroids are controversial in the management of facial paralysis with a viral or idiopathiccause but were employed here with apparently good results. Patients should be followed withfacial nerve stimulation and watched carefully for signs of degeneration. Because the facialnerve is frequently involved in viral infections, other causes such as mumps, chickenpox,herpes zoster, influenza, and polio should be considered. The course is one of rapid onset withslow but usually complete resolution. No topographic studies have been performed in thesepatients, but the course appears similar to that of Bell's palsy.
Case 3: Epistaxis
A five-year-old Caucasian girl presented to Children's Hospital of Pittsburgh with a left epistaxis of several hours' duration. She was taking erythromycin for an upper respiratoryinfection. Examination revealed +3 tonsillar hypertrophy, and a palpable spleen tip. Whiteblood cell count was 8.700 with a lymphocytosis. "Monospot" was positive. A platelet counton admission was 20.000 but fell to 4.000 by the next day. A bone marrow confirmed thediagnosis of idiopathic thrombocytopenic purpura. The nose was packed with Surgicel and bleeding was controlled. The platelet count returned to normal over the following week. Nofurther intervention was necessary.
Discussion
Infectious mononucleosis has been associated with autoimmune hemolytic anemia and viral etiologies have been proposed for idiopathic thrombocytopenic purpura. Here, the lowplatelet count secondary to the idiopathic thrombocytopenic purpura was the obvious causeof the epistaxis. Cautery, nasal packing, or other routine ways of managing nosebleeds cannotovercome the basic coagulation defect. Therefore, the manipulation and trauma of theseprocedures must be minimized. Packing with an absorbable coagulant such as Oxycel orSurgicel will usually suffice until the underlying hematologic defect can be corrected. Thechild's activity should be kept to a minimum and anything that increases circulatory pressuresuch as leaning over, straining, nose blowing, and sneezing should be avoided.
Conclusion
We have described the significant, potentially life-threatening complications of infectious mononucleosis for which the pediatrician may require the assistance of theotolaryngologist. Recognizing the various presentations of infectious mononucleosis is ofparticular importance. Our approach to the pediatric airway is conservative, safe, and avoidsoperative intervention. Managament of facial paralysis and epistaxis involves treatment of theunderlying disease.

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