ENT Flashcards
OSA symptoms in children? ALWAYS ask these symptoms in SNORERS
snoring paradoxical chest movement apnoeas (usually hypopnoeas ) restlessness cough / choking / gagging (esp in sleep) / reflux enuresis waking frequently daytime tiredness SEVERE Sx - cyanotic episodes, failure to thrive
normal physiology of adenoids in children
adenoids located at back of nose - enlarge age 3-4 then involute by age 12
what are nasal obstructive symptoms + causes
SNORING (normal ~10% habitually, 20% intermittently - largely due to adenoids - other causes: allergic rhinitis, septal deviation - rarely: FB, macroglossia, max hypoplasia etc - will improve as child grows + adenoid involutes - HOWEVER, chronic nasal obstruction will affect maxillary growth → high arched palate + narrow dental arch CHRONIC MOUTH BREATHING HYPONASALITY
SNORING Mx?
Do nothing - most kids outgrow it if due to adenoids CONSERVATIVE - trial 1 month of topical steroid eg: Rhinocort - trial 1 month of low dose ABx (incase due to adenoiditis) SURGICAL - adenoidectomy if loud + chronic + due to large adenoids (could be the turbinates!) IF due to inferior turbinates (snuffly nose of newborn) - Rx w saline drops, vasoconstrictor drops (eg: Drixine) + topical steroids eg: Rhinocort ALTERNATING for 3 - 6 weeks w tapering
Allergic rhinitis Sx/Mx
snoring, itch, sneezing associated strongly w asthma - most allergic to house dust mites (worse in mane) Mx - house dust mite protectors for pillow +/- other bedding - rhinocort/nasonex - De-mister (for children >12 yo) - has anti-histamine + steroid - salt water spray (FESS) - gets rid of some of the histamine +/- anti-histamine nasal spray (often added initially to gain control then stopped) +/- oral anti-histamine (esp if children dont tolerate nasal spray) eg: clarytine SURGERY - for reduction of inferior turbinates
OSA in children features + Ix
a more common reason for T&A prevalence 2%, peak age 2 - 5yo T&A cure for most, but w complex craniofacial issues etc → it improves it SEVERE Sx - cyanotic episodes, failure to thrive RF - 63% of Downs syndrome children have OSA (recommend annual sleep studies in these children due to risk on heart/neurological) O/E - FTT vs obesity - cold metal fogging pattern either nasal opening - tonsil size OSA consequences - growth (sleep effects disordered GH release → FTT) - daytime performance (school issues, 40% behaviour changes either end of spectrum, developmental delay) - cardiac (eg: cor pulmonale) - neurological VIDEO (eg: crescendo snoring then stops ) hyperextending neck Ix +/- lateral XR (for adenoids) +/- has-endoscopy (adenoid size) +/- sleep study – borderline Sx, possible central component (eg <2yo), other abnormalities, at parents request – apnoea >1/hypopnea >5 index is abnormal in children (for 6 seconds or 1.5 to 2 breaths), O2 <92%, highest CO2 lvl
When to refer to ENT re: OSA
Snoring - if loud and chronic mouth breather if OSA symptoms or suspected if sleep study shows OSA
OSA Mx
OSA tonsillectomy + adenoidectomy - cures majority of children - helps kids w other issues eg: craniofacial abnormalities post tonsillectomy care - pain relief - up to 4% bleeding risk in first 2 weeks post op (need to not be far away from hospital) Other - CPAP - craniofacial surgery, palate surgery - septoplasty/tracheostomy
Tonsilitis features
peak incidence age 5-8 yo Predisposed if - prev recurrence, Lowrys resistance, viral phargynitis ETIOLOGY Viral (50 -85%) - EBV, adenovirus, echovirus, simplex, coxsacie, measles, varicella etc Bacterial (15- 50%) - Beta haemolytic strep - staph aureus - pneumococci - H.influenza etc (corynaebacterium diphtheriae) SYMPTOMS - sore throat - fever - dysphagia - odynophagia - hot potato voice - malaise in young kids - ear ache, stomach ache, vomiting Pseudomembrane (grey fishy) - diphtheria + EBV (IMN) Other signs - cellulitis uf uvula/soft palate - petechiae (coxackie/IMN) - lymphadenopathy (hepatosplenomegaly in IMN) inflamed lingual tonsils - hot potato voice (painful if protrude tongue)
-trismus if quinsy
MODIFIED CENTAUR score for if tonsillitis due to GBS
one point for:
temp >38
tender cervical lympadenopathy
enlarged tonsils or exudate
NO cough age 3 to 14 (age = minus if over 44)
score 4 or more = >50% chance GBS score 2-3 = 20 - 35% GBS
Tonsilitis complications
OSA quinsy - abscess outside tonsil btw phargyngeal muscles + tonsil - extremely painful - 20% 1st recurrence rate, 50% 2nd recurrence rate - so offer tonsillectomy Retro or para-phargyneal abscess (as spreads to LNs) Suppurative cervical adenitis subacute bacterial endocarditis Lemierre’s syndrome (anaerobes w symptoms of tonsillitis but can get thrombosis of internal jugular vein) Tonsilloliths Tonsil cyst tonsil haemorrhage Scarlet fever rheumatic fever (0.5/100,00 in western society vs 650/100,000 in aboriginal)
Tonsilitis Ix
usually none THROAT SWAB - tells us if bacterial BUT may not show causative organism (INSIDE tonsil) strep carrier rate 40% pop surface organism dont necessarily represent core BLOODS - FBE, monosopt, serology for EBV (LFTs) ASOT (antistreptolysis O titre) Rapid strep test - 75 - 80% sensitive, Dx within 5-10 min
Tonsilitis Mx
TLC - bed rest, fluids, panadol antibiotics - penicillin, if failed, augmentin - if allergic erythromycin, or clindamycin (has good anaerobic cover) steroids if IMN (1-2 days)
infectious mononucleosis (IMN) features + Mx
often presents w tonsilitis lymphadenopathy, palpable spleen/liver monospot/FBE w differential (+/- EBV IgM + IgG tires) Rx - TLC - steroids stat dose - penicillin for secondary bacterial infection (amoxil causes a rash w IMN)
INDICATIONS FOR TONSILLECTOMY + C/I
OSA Suspected malignancy (unilateral enlargement) recurrent tonsilitis - 6 attacks in 1 year - 4-5 attacks per year for 2 years - 3 attacks per year for 3 years NB: consider severity off attacks, response to treatment, complications of episodes, general health chronic tonsilitis peritonsilar abscess/quinsy (20% recurrence risk w 1st) systemic infection a/w tonsilitis C/I bleeding diathesis acute infection (higher bleeding risk) lack of facilities
Complications of tonsillectomy
Haemorrhage - 1-4% chance within 1st 2 weeks voice change (resonance chamber) eg: if professional singer
Types of stridor
Largynomalacia
very common in children
FEATURES
- inspiratory stridor
- as get excited or at rest or constant
- onset: 1-2 months, outgrow @ 18 months
- most parents just need reassurance
- if FTT, cyanotic episodes, difficulty feeding - then surgery
tall, omega shaped epiglottis
short aryglottic folds + tal areutenoids
posteriorly placed epiglottis
all of the above
definition recurrent AOM + Rx
3+ AOM in 6 months
or 4 AOM in 1 year
or complications
Rx
if recurrent within 1 month → Rx broader spectrum ABx (likely to be resistant)
if 3+ episodes or complications
- Abx: low dose for 1 month, if STILL recurrent → grommets
Causes of conductive hearing loss?
wax
exostoses
otitis externa
FB
atresia
stenosis
Tell me about otitis externa
Swimmers ear
common organisms - pseudomonas, staph aureus
features
very painful, smelly ear
swelling of skin external aud cannal
Ix
swab MCS + fungal culture
Rx
keep ear dry when washing/swimming (cotton wool + vasaline or blue tack)
clean debris (tissue spears, Ear Clear- has peroxide component which bubbles ear wax ot)
topical ear drops ciloxin or ciproxin HC (steroid component)
if suspect concurrent otitis media → Rx w PO ABx (augmentin)
NB: if suspect perforation OR pt has grommets in situ → dont use ciproxin HC as preservative can be toxic to middle/inner ear. Ciloxin safe.
if fungal otitis media
black spores - aspergillus nigra
wet blotting paper - candida
itchy, generally not very painful
conductive hearing loss
Rx
topical antifungals
- IF EAR DRUM INTACT:locacortin-viofrom drops, nilstrat, kenacomb (antifungal, candida, bacterial, steroid)
keep ear dry, can take ~1 month to settles
What pathologies in the middle ear cause conductive hearing loss (CHL)?
- glue ear (otitis media w effusion)
- perforation
- ossicular chain disruption or fixation eg: tympanosclerosis
- mass in middle ear
- acquired cholesteatoma
OME - features, Ix, when to treat, Cx, Mx
OME
- very common, esp daycare ~80% preschool children
- 50% get OME post episode of AOM
- most resolve spontaneously - 60% cleared by 1 month, 90% cleared by 3 months
- if OME >3 months = chronic and needs Mx
- biofim created, often polymicrobial
RF
- season
- FHx
- URTI
- cleft palate/downs syndrome, muscopolysaccharidoses
- childcare centres
O/E
dull drum, amer fluid behind, airlfuid lvlsdrum retraction or bulging
pneumatico-otoscopy useful to see if drum moves (absent movment)
or tympanometry (flat line)
Chronic OME = > 3 months → risk of complications
- hearing loss
- behavioural difficulties
- speech delay *controversial
- damage to drum → secondary damage to ossicles/erosion
- drum retraction (precursor to cholesteatoma)
Mx
antibiotics - full orlow dose (daily dose of abx) for 1 month to remove biofilm
DONT use steroids
otovent to drain ET
if drum retraction = atelectasis
- grommets if drum retracted but not stuck down
- surgery: exploration, dissection of drum off ossicles
When to treat OME?
persistent bilateral OME w effusion present for >3 months
WITH
bilateral hearing loss OR damage to drum or ossicles
How do grommets work?
allow aeration of middle ear
- stops negative middle ear pressure
- stops bugs tracking up from nose (as vacuum removed)
- stops TM retraction + Cx from this
- aeration reverses metaplasia
- ie: 80% goblet cells (creating mucoid) return to 20% goblet cells
- O2 tension, disrupts biofilm
20% of kids will need second set of gromets
last 6-18mo
keep dry
small chance perforation + retention
they will come out themselves
shouldnt have discharge through grommet
Cx of AOM
Cx of AOM
- facial palsy (need to drain middle ear + insert grommet + ABx)
- mastoiditis → abx if early, surgery
- TM perforation
- labrynthitis
- abscesses (brain, sub+extradurral)
- lateral sinus thrombosis
- meningitis
AOM features + Mx
AOM
peak incidence: 6 - 12 months, smaller peak 4 to 5yo
common (2/3 of children by age 3, 50% have 3+ episodes by age 3)
cant tell if bacterial or viral, but most are bacterial ( s.pneumo, Hib, moraxella, 25% viral
features (can progress VERY quickly)
- fever
- erythema in TM w bulging pus behind it
painful → 60% painfree in 24hrs w/o Abx
hearing loss
Rx
watch an wait w most pt before Rx, EXCEPT FOR
children <2 yo (complications hrder to pick up)
if pt unlikely to come back for F/U in next few datys
cochlear implant children
Abx choice
- amoxil, augmentin, ceclor (shorter courses <5 days have more treatment failures.relapses = re-infections than longer 8 to 10 day courses)
less AOM -. chronic OME w conjugate penumococcal vaccine (prevenar) - ;)
TM perforation
better outcomes if in middle of TM
per
If acute perf - likely to heal on own
- keep dry to prevent contamination
- F/U in 1-3 months
Myringoplasty (patch hole)
hearing aid (if conductive loss)
When to refer OME/ recurrent AOM to ENT?
- OME - bilateral for >3 months, w hearing loss or drum changes
- Speech/language delay or cognitive issues w OME
- Frequent episodes AOM 3-4 per 6 months
- chronic ear discharge (needs cholesteatoma ruled out)
- unusual otoscopic findings eg: atelectasis of drim or if suspect cholesteatoma
- hearing loss w possile sensori-neural component
cholesteatoma
often occurs at ant-sup segment
presenting features
- CHL
- chronic ear discharge
- polyp
- scaly skin from one area of drum
- deep retraction pocket that cant see edges of
recurrent ear infections
O/E old dry skin, attic retraction
Ix: CT scan (specific slices), audiogram
Mx: surgical removal (tympanoplasty, mastoidectomy)
all of the above
