兒童急性鼻竇炎(Acute sinusitis)

急性鼻竇炎常見病原體包括病毒和細菌，而真菌引起的鼻竇炎在免疫功能正常者身上不常見。大約2％的病毒性上呼吸道感染會併發細菌性鼻竇炎。急性細菌性鼻竇炎的病原體有肺炎鏈球菌（約30％）、嗜血桿菌（約30％）和卡他莫拉菌（約10％）。四分之一的肺炎鏈球菌可能是具有青黴素抗性。金黃色葡萄球菌、其他鏈球菌和厭氧菌少見於兒童急性細菌性鼻竇炎。

Common pathogens of acute sinusitis include viruses and bacteria, while fungal sinusitis is uncommon in immunocompetent individuals. About 2% of viral upper respiratory infections are associated with bacterial sinusitis. The pathogens of acute bacterial sinusitis are Streptococcus pneumoniae (about 30%), Haemophilus (about 30%) and Catamonas (about 10%). One quarter of Streptococcus pneumoniae may be penicillin resistant. Staphylococcus aureus, other streptococci, and anaerobes are less common in children with acute bacterial sinusitis.

急性細菌性鼻竇炎常發生在病毒性上呼吸道感染、過敏性鼻炎和菸霧暴露有關。急性鼻竇炎定義為持續時間小於三十天，慢性鼻竇炎持續時間超則過三個月。在上呼吸道感染過程中，七成的兒童鼻竇會出現異常，包括黏膜增厚、水腫和發炎，這些將阻礙鼻竇引流，減少黏膜纖毛清除細菌，導致細菌大量生長。

Acute bacterial sinusitis often occurs in association with viral upper respiratory tract infections, allergic rhinitis and smoke exposure. Acute sinusitis is defined as lasting less than 30 days, while chronic sinusitis lasts longer than three months. During an upper respiratory infection, 70% of children have sinus abnormalities, including thickening, edema and inflammation of the mucous membranes, which can block sinus drainage and reduce the ability of mucous membrane cilia to clear bacteria, leading to bacterial growth.

急性鼻竇炎的症狀包括鼻塞、膿鼻涕、發燒和咳嗽。少見的症狀包括口臭、嗅覺減退、眼眶周圍水腫、頭痛和上頜牙齒不適。理學檢查可能會發現鼻黏膜紅腫伴隨膿鼻涕。青少年和成人可能有鼻竇壓痛。

Symptoms of acute sinusitis include nasal congestion, runny nose, fever and cough. Less common symptoms include bad breath, decreased sense of smell, periorbital edema, headache, and maxillary dental discomfort. Physical examination may reveal redness and swelling of the nasal mucosa with pus. Adolescents and adults may have sinus tenderness.

急性細菌性鼻竇炎的臨床診斷乃是根據病史。持續性流鼻涕和咳嗽超過十天未見改善，或嚴重的呼吸道症狀(包括體溫超過39°C及連續三至四天的膿鼻涕)，我們都需要懷疑急性細菌性鼻竇炎。鼻竇吸出培養是唯一準確的診斷方法，但對於免疫功能正常的患者常規使用並不實際。鑑別診斷考慮因素包括病毒性上呼吸道感染、過敏性鼻炎和鼻腔異物。病毒性上呼吸道感染的鼻涕通常清澈無膿，有咳嗽，一開始發燒，但症狀通常不會持續十至十四天。

The clinical diagnosis of acute bacterial sinusitis is based on history. A persistent runny nose and cough that does not improve for more than 10 days, or severe respiratory symptoms (including a temperature over 39°C and a purulent runny nose for three to four days in a row) warrant suspicion of acute bacterial sinusitis. Sinus aspirate culture is the only accurate diagnostic method, but is impractical to use routinely in immunocompetent patients. Identifying diagnostic considerations include viral upper respiratory tract infections, allergic rhinitis, and nasal foreign bodies. Viral upper respiratory tract infections usually have a clear, pus-free nasal discharge, a cough, and an initial fever, but the symptoms usually do not last more than ten to fourteen days.

現今尚不清楚急性細菌性鼻竇炎的抗菌治療是否提供實質益處。在成人進行的研究顯示，治療七天症狀將得到改善。主要指引建議，急性細菌性鼻竇炎嚴重發作或病情惡化需給予抗生素，雖然一半的急性細菌性鼻竇炎患兒童可能在沒有抗菌治療的情況下恢復。對於有風險因素的兒童，包括最近三個月內的抗生素治療、托兒所或年齡小於二歲的兒童，應考慮給予抗菌治療。適當治療時間尚未確定，個別化治療是合理的。一般建議至少十天或在症狀消退後至少七天。

It is not clear whether antimicrobial therapy for acute bacterial sinusitis provides substantial benefit. Studies in adults have shown that symptoms improve with seven days of treatment. The main guideline suggests that antibiotics should be given for severe exacerbations or worsening of acute bacterial sinusitis, although half of children with acute bacterial sinusitis may recover without antimicrobial treatment. Antimicrobial therapy should be considered for children with risk factors, including antibiotic treatment within the last three months, in daycare or for children younger than two years of age. The appropriate duration of treatment has not been determined and individualized treatment is reasonable. A minimum of ten days or at least seven days after symptoms subside is generally recommended.

最好的預防方式是經常洗手和避免感冒，並且每年接受流感疫苗注射。

The best prevention is frequent hand washing and avoiding colds, and getting a flu shot every year.

兒童急性咽炎(Acute pharyngitis)

最近天氣炎熱，卻有不少兒童因急性喉嚨疼痛來到門診就醫。父母來到門診總以為小孩大概是得到感冒，然而，喉嚨疼痛並不等於感冒。我們所稱的感冒是指急性上呼吸道的病毒感染，三分之一患者有喉嚨痛，或者說急性咽炎的表現，但引起急性咽炎卻有許多原因。

While the weather has been hot lately, many children have come to the outpatient clinic with acute sore throat. Parents always think that their children probably have a cold, but a sore throat is not the same as a cold. What we call a cold is an acute viral infection of the upper respiratory tract. One-third of the patients have a sore throat, or acute pharyngitis, but there are many causes of acute pharyngitis.

急性咽炎是指咽部的急性發炎，包括紅斑、水腫、滲液、潰瘍或水泡。咽炎可能與環境暴露有關，如香菸、空氣污染、過敏原、腐蝕性物質、熱食、熱湯和傳染性病原體。

Acute pharyngitis is an acute inflammation of the pharynx that includes erythema, edema, oozing, ulcers or blisters. Pharyngitis may be associated with environmental exposures such as cigarette smoke, air pollution, allergens, corrosive substances, hot foods, hot soups and infectious agents.

病毒是急性咽炎的主要原因，常通透過口腔接觸或飛沫傳染，常發生在秋天至春天。可能引起急性咽炎的病毒包括：鼻病毒、呼吸道融合病毒、冠狀病毒、腸病毒、流感病毒、腺病毒、EB病毒、巨細胞病毒、單純皰疹病毒。大多數病毒引起的咽炎常在後來伴隨流鼻水或咳嗽症狀，另外，病毒性染也易導致細菌性中耳感染和細菌性鼻竇炎。對多數病毒引起的咽炎採症狀治療，包括退燒和止痛藥物。麻醉噴霧劑可以提供局部緩解作用。雖然類固醇常用於患有咽炎的成人，但在兒童身上仍缺乏大規模研究在安全性和療效性的證實。

Viruses are the main cause of acute pharyngitis, which is often transmitted through oral contact or droplet infection and often occurs in the fall to spring. Viruses that may cause acute pharyngitis include: rhinovirus, respiratory fusion virus, coronavirus, enterovirus, influenza virus, adenovirus, EBV, cytomegalovirus, and herpes simplex virus. Most viral pharyngitis is often followed by a runny nose or cough, and viral infections can also lead to bacterial middle ear infections and bacterial sinusitis. Symptomatic treatment for most viral pharyngitis includes medications to reduce fever and relieve pain. Anesthetic sprays can provide local relief. Although steroids are commonly used in adults with pharyngitis, there is a lack of large-scale studies in children to confirm safety and efficacy.

細菌引起的急性咽炎不容忽視，特別是A型鏈球菌。鏈球菌咽炎在二至三歲前相對少見，在五至十五歲兒童卻相當常見。全年都有機會感染，其中冬天至春天最為普遍。腹瀉、咳嗽、流鼻水、潰瘍、聲音嘶啞、結膜炎與鏈球菌性咽炎無關，若有以上症狀，應懷疑病毒感染引起。鏈球菌咽炎採用抗生素治療，早期抗生素治療能加速恢復十二至二十四小時，減少化膿或併發症，以及預防急性風濕熱。

Acute pharyngitis caused by bacteria, especially Streptococcus A, should not be ignored. Streptococcal pharyngitis is relatively uncommon before the age of 2 to 3 years, but is quite common in children aged 5 to 15 years. It is a year-round infection, with winter to spring being the most common. Diarrhea, cough, runny nose, ulcers, hoarseness, and conjunctivitis are not associated with streptococcal pharyngitis, but viral infection should be suspected. Streptococcal pharyngitis is treated with antibiotics. Early antibiotic therapy speeds recovery by 12 to 24 hours, reduces suppuration or complications, and prevents acute rheumatic fever.

黴漿菌肺炎(Mycoplasma pneumonia)

一位年輕女性，因反覆咳嗽一個月而至本院看診。最近否認發燒，但咳嗽症狀逐漸加劇，由乾咳轉為帶有淡黃色痰液。她的工作為小學行政人員，一個月內無出國旅遊紀錄，家中成員除孩子這二週感冒外，無其他特別接觸史或群聚史。第一次至門診時，診斷為社區性肺炎，給予經驗性抗生素安滅菌和短效氣管擴張劑。三天後返診時，咳嗽更加厲害，並出現胸痛及呼吸困難之情形，故建議住院治療。入院後，聽診發現略有喘音，X光片未見明顯實質化。除原有安滅菌外，再加以巨環類抗生素，並使用吸入型氣管擴張劑。隔日，她覺得症狀改善，追蹤血清報告，證實為黴漿菌感染。建議繼續服用完巨環類抗生素療程，並安排支氣管激發試驗，釐清是否有氣喘。第三日，因病況大幅好轉，完整留完痰液後，建議出院，並回門診追蹤。

黴漿菌感染常表現為咽炎、支氣管炎或喘息。一成的感染者可能發生肺炎。它的發病常是漸進的，發生在幾天內，或者更突然。雖然黴漿菌肺炎可能以喉嚨痛開始，但最常見的症狀是咳嗽。咳嗽通常是乾咳，部分患者仍會伴隨痰液。

理學檢查時，八成的患者有喘息或濕囉音。然而，更多患者的肺炎藉由X光片進行診斷。最常見的是支氣管周圍肺炎、支氣管標記增厚和間質浸潤。臨床上二成的患者有胸腔積液。

臨床表現常無法區分黴漿菌肺炎與其他類型的社區性肺炎。當社區性肺炎對青黴素或頭孢類抗生素無效時，應考慮黴漿菌感染的可能性。儘管黴漿菌肺炎通常是自限性，但適當的抗菌治療可顯著縮短持續時間。一些患者在急性肺炎治癒後，可能伴隨長期反覆喘息。慢性感染可能與氣喘有關，需要積極追蹤複查。