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Year 4: Child Health > ENT > Flashcards

ENT Flashcards

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1
Q

What is Otitis Externa?

A

An inflammation of the external ear canal and can be either acute or chronic in nature

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2
Q

What is the difference in the history between acute OE and chronic OE?

A

Acute otitis externa lasts less than 3 weeks whereas chronic otitis externa lasts more than 3 months.

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3
Q

What are the 2 classifications of OE?

A

Localised otitis externa is an infection of a hair follicle in the ear which can develop into a boil. Diffuse otitis externa is widespread inflammation of the skin and subdermis.

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4
Q

What is malignant OE?

A

When the infection spreads to the mastoid and temporal bones causing osteomyelitis

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5
Q

Name some causes of OE.

A

Bacterial infection – most commonly Pseudomonas Aeruginosa or Staphylococcus Aureus. The bacteria usually enter the ear after 1 of 4 events:

Blockage of the canal
Absence of cerumen due to excess cleaning
Trauma
Alteration of pH within the canal.

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6
Q

Name some risk factors of developing OE.

A 
Hot and humid climates
Swimming
Older age
Diabetes Mellitus
Narrowing/obstruction of the auditory canal
Over-cleaning leading to a lack of wax in the canal
Wax build-up
Eczema
Trauma
Radiotherapy to the ear
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7
Q

What will a parent describe in the history of a child with OE?

A

Pain
Itching
Discharge
Hearing loss

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8
Q

What will an examination of OE reveal?

A

Oedema
Erythema
Exudate
Mobile tympanic membrane

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9
Q

How do you manage OE?

A

Avoid getting the ear wet use a cap for showering and swimming
Remove any discharge by gently using cotton wool, DO NOT put cotton buds into the ear
Remove any hearing aids and earrings
Use painkillers – paracetamol and ibuprofen

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10
Q

Name some complications of OE.

A

Abscesses
Stenosis of the ear canal due to a build-up of thick, dry skin
Perforated ear drum
Cellulitis
Malignant otitis externa – infection spreads to mastoid and temporal bones

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11
Q

What is acute mastoiditis a complication of?

A

Otitis media

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12
Q

How does acute mastoiditis occur?

A

It occurs due to otitis media infection spreading to involve the bone of the mastoid air cells directly.

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13
Q

In acute mastoiditis, where can the sub-periosteal abscess be found?

A
  1. Behind the pinna in an area known as Macewen’s triangle, or higher
  2. Superior to the pinna towards the zygomatic process
  3. Over the squamous temporal bone
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14
Q

Name 3 risk factors for developing acute mastoiditis.

A

More common in young children

Immunocompromised patients

Pre-existence of cholesteatoma

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15
Q

Name some investigations that could be performed in acute mastoiditis.

A

Ear swab – if discharging ear or post-aural abscess is oozing; sent for MC+S

Blood tests – raised inflammatory markers including WCC and CRP

CT head and mastoid with contrast is indicated in all cases of mastoiditis apart from cases of simple uncomplicated mastoiditis.

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16
Q

Describe the management of acute mastoiditis.

A

The initial management of acute mastoiditis is intravenous antibiotics as an inpatient. The choice of antibiotic will be based on local guidelines but should cover likely causative organisms including Streptococci and Staphylococcus aureus; high-dose co-amoxiclav or ceftriaxone are usually chosen.

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17
Q

Name some complications of acute mastoiditis.

A

Extracranial:

Facial nerve palsy
Hearing loss – conductive and sensorineural
Labyrinthitis
Subperiosteal abscess
Cranial osteomyelitis
Intracranial:

Intracranial infections including meningitis; epidural, temporal lobe or cerebral abscess; subdural empyema
Dural sinus thrombosis

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18
Q

Describe the pathophysiology of acute otitis media.

A

Bacterial infection of the middle ear results from nasopharyngeal organisms migrating via the eustachian tube.

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19
Q

Name the most common causative organisms of acute otitis media.

A

Common causative bacteria include S. pneumoniae (most common), H. influenza, M. catarrhalis, and S. pyogenes, all common upper respiratory tract microbiota. Common viral pathogens are respiratory syncytial virus (RSV) and rhinovirus.

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20
Q

Name some risk factors of acute otitis media.

A
  • Age (6-15 months)
  • Gender (boys)
  • Smoking
  • Bottle feeding
  • Craniofacial abnormalities
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21
Q

Describe the common symptoms of acute otitis media.

A

pain, malaise, fever, and coryzal symptoms

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22
Q

Why is it important to test and document the function of the facial nerve in acute otitis media?

A

due to its anatomical course through the middle ear

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23
Q

Describe the management of acute otitis media.

A

All patients should be treated with simple analgesics in the first instance. There is no need to treat with antibiotics in most cases and a ‘watch and wait’ approach can be taken provided there are no worrying features

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24
Q

For cases of mastoiditis, if the patient does not improve with IV antibiotics, what is the next line of management?

A

Mastoidectomy

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25
Q

Describe the aetiology of otitis media with effusion.

A

In children, otitis media with effusion is usually caused by a combination of chronic inflammatory changes and Eustachian tube dysfunction.

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26
Q

Name some risk factors of developing otitis media with effusion in children.

A

Bottle fed
Paternal smoking
Atopy (e.g eczema, asthma)
Genetic disorders
Mucociliary disorders, such as Cystic Fibrosis or Primary Ciliary Dyskinesia
Craniofacial disorders, such as Downs Syndrome

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27
Q

Describe some clinical features of otitis media with effusion in children.

A

The most common clinical feature of otitis media with effusion is difficulty hearing* (affecting one or both ears) and representing a conductive hearing loss.

There may be a sensation of pressure inside the ear that may be accompanied by ‘popping’ or ‘crackling’ noises. Less commonly, the patient can also experience disequilibrium and vertigo.

28
Q

Describe what you would see on examination of a child with otitis media with effusion.

A

On examination, the tympanic membrane will appear dull and the light reflex will be lost, indicating fluid in the middle ear. There may also be a bubble seen behind the TM. The external ear will be normal.

29
Q

Describe how otitis media with effusion is managed in children.

A

Otitis media with effusion in children can be managed in an outpatient setting. Approximately 50% of cases will resolve within 3 months; hence many cases are managed by ‘active surveillance’.

If no resolution is seen after 3 months, the management options can be divided into surgical and non-surgical:

Non-surgical – hearing aid insertion
Surgical – myringotomy and grommet insertion.

30
Q

Describe the spread of peri-orbital cellulitis.

A

Continguous spread from surrounding periorbital structures such as the paranasal sinuses

31
Q

What is the most common cause of per-orbital cellulitis?

A

Ethmoidal sinusitis is the most common cause of orbital cellulitis, especially in neonates who have not yet formed their frontal sinuses.

32
Q

Name the 2 categories into which peri-orbital cellulitis is divided.

A
  1. Pre-septal

2. Post-septal

33
Q

What is the most common pathogen that is responsible for causing per-orbital cellulitis?

A

Staphylococcus aureus

34
Q

Describe how a child with peri-orbital cellulitis would present.

A

eyelid oedema and erythema of the upper eyelid, with an absence of orbital signs. As such, patients with pre-septal cellulitis will present with normal vision, absence of proptosis, and full ocular motility without pain on movement.

35
Q

What is the classification used to define peri-orbital cellulitis called?

A

Chandler classification

36
Q

Describe the Chandler classification.

A 
Type I: Pre-septal cellulitis
Type II: Post-septal, orbital cellulitis.
Type III: Subperiosteal abscess
Type IV: Intra-orbital abscess
Type V: Cavernous sinus thrombosis
37
Q

Describe the treatment of peri-orbital cellulitis.

A

Mild pre-septal cellulitis in adults and children older than 1 year of age, treatment is typically rendered on an outpatient basis with empiric broad spectrum oral antibiotics, provided there is reliable access to close follow-up and no evidence of systemic toxicity. However, treatment of orbital cellulitis consists of hospital admission, intravenous antibiotics covering most gram positive and gram negative bacteria, which requires consultation with local guidelines, nasal decongestants, steroid nasal drops and nasal douching.

38
Q

What is the most coming cause of epistaxis in children?

A

Nose picking

39
Q

What area of of the nose does epistaxis result from?

A

Little’s area

40
Q

Where is little’s area found?

A

a confluence of blood vessels originating from the internal carotid arteries (anterior and posterior ethmoidal) and external carotid arteries (greater palatine, sphenopalatine, superior labial and lateral nasal arteries) This area sits on the anterior portion of the septum bilaterally.

41
Q

Name some risk factors of epistaxis.

A

Activities involving altitude e.g. skiing
Strenuous physical activities with risk of nasal trauma or straining/raising ICP e.g. rugby, gymnastics
Coagulopathies
Hayfever or regular URTIs
Medication use (rare)

42
Q

Describe the first aid management required in epistaxis.

A

-Lean the child forwards over a bowl and encourage them to spit any blood out of their mouth

–Pinch the soft part of the nose and hold for at least 15 minutes without releasing pressure

  • Try to keep children as calm as possible. This can be a frightening experience if happening for the first time
  • Check for cessation of bleeding. If not, pinch again for 15 minutes and apply an ice pack either to the nape of the neck or forehead. Alternatively the child can suck on an ice cube
  • Check for cessation of bleeding. If not, the child needs to be seen by a medical practitioner
43
Q

What treatment is used in A&E for epistaxis.

A

Silver nitrate

44
Q

Once the bleeding has stopped, what medication should patient experiencing an epistaxis be discharged with?

A

Naseptin ointment BD for 2 weeks

45
Q

Name some red flags for foreign bodies.

A

Any signs of airway compromise, such as stridor, dysphonia, or drooling

Any signs of oesophageal perforation, such as chest pain, features of sepsis, or surgical emphysema

Any history of button battery ingestion

46
Q

Name 2 causative bacteria that cause epiglottis.

A

Haemophilus influenzae and streptococcus pneumoniae

47
Q

Name 3 risk factors of epiglottis.

A

Children not receiving the HiB vaccine

Male gender

Immunosuppression

48
Q

Describe how a child with epiglottis would present.

A

Symptoms less than 12 hours

Dyspnoea
Dysphagia
Drooling
Dysphonia (muffled “hot potato” voice in 54%)

49
Q

Name some differential diagnoses to epiglottis and there defining differences.

A

Laryngotracheobronchitis (Croup)
Distinctive, seal-like barking cough
May have drooling, stridor and tripod position
May have a prodrome of non-specific viral URTI symptoms
Neck X-Ray: Steeple sign of subglottis

Inhaled foreign body
History: Sudden onset e.g. whilst eating/playing with small toys
No fever initially
Neck X-Ray: May see radio-opaque foreign bodies (Note: Button battery is TIME CRITICAL EMERGENCY)

Retropharyngeal abscess
Clinical features very similar (immediate management is the same as epiglottitis)
CT: Abscess
Laryngoscopy/Flexible Nasendoscopy: Normal epiglottis, swollen retropharyngeal space

Tonsillitis
Bilateral erythematous tonsils with exudate (if bacterial)
Longer clinical history

Peritonsillar Abscess
Unilaterally displaced tonsil with peritonsillar erythema and swelling
Deviated uvula
CT: Collection of fluid with enhanced rim

Diphtheria
Thick membrane over posterior pharynx
Unvaccinated child
Corynebacterium diphtheria found on microbiology assay

50
Q

What would you see on a lateral x-ay of a child suffering with epiglottis?

A

Thumb-print sign

51
Q

What tonsils is tonsillitis inflammation of?

A

The palatine tonsils

52
Q

Name a risk factor os tonsillitis

A

Smoking

53
Q

Describe how a child with tonsillitis would present.

A

Between 5-7 day history of:
Odynophagia (in severe cases, patient is unable to even take liquids orally)
Fever
Reduced oral intake
Halitosis
New onset snoring (or even apneic episodes in severe cases)
Shortness of breath ­­

54
Q

What criteria is used to differentiate between bacterial and viral tonsillitis?

A

The Centor criteria was developed to try and differentiate between bacterial and viral tonsillitis based on clinical symptoms. There are four key criteria:

Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
Fever or history of fever
Absence of cough
A score of 3 or more is highly suggestive of bacterial infection (40-60% likelihood) and a score of 2 or less suggests bacterial infection is unlikely (80% likelihood)

55
Q

What criteria is used to determine whether a tonsillectomy is appropriate?

A

SIGN criteria:
In 1 year 7 or more episodes of tonsillitis
In 2 years 5 or more episodes per year
In 3 years 3 or more episodes per year

56
Q

A complication of tonsillitis is quinsy – this is due to a spread of infection into which space?

A

Peritonsillar

57
Q

What age are tonsils at their largest?

A

Ages 4-8

58
Q

When is the peak incidence of peritonsillar abscess?

A

20-40 years

59
Q

What is the most common causative organism for peritonsillar abscess?

A

Strep A

However: Fusobacterium necrophorum is more commonly isolated in 15-24 year olds, whilst group A Streptococcus is more common in 30-39 year olds

60
Q

Name 2 risk factors of developing a peritonsillar abscess.

A

Recurrent episodes of tonsillitis or partially treated episodes following multiple antibiotics

Significantly increased risk in smokers

61
Q

What is glandular fever also known as?

A

infectious mononucleosis (IM)

62
Q

What is glandular fever caused by?

A

Epstein-Barr virus

63
Q

How would a child with glandular fever present?

A

sore throat with associated fever and lymphadenopathy.

64
Q

What is the most common age group to suffer with glandular fever?

A

teenager and young adults

There are two peaks in primary infection: the first is age 1-6 and the second is 18-22, where individuals not previously exposed to the virus are suddenly exposed to it through mixing at either school or university.

65
Q

What is the most common transmission route of glandular fever?

A

Exchange of saliva

66
Q

Name what the monospot test relies on.

A

Non-specific heterphile IgM autoantibody

67
Q

What lymphomas is EBV associated with?

A

Burkitts
Hodgkins
T cell
Nasopharyngeal carcinoma

Year 4: Child Health (16 decks)

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