ENT Flashcards by Daiyan Haider

Paediatric ENT epidemiology

ENT problems common
-Up to 50% of GP consultations in winter months

Unique morbidity
- different physiology and anatomy

Congenital problems prominent

How well did you know this?

Not at all

Perfectly

Ear embryology

Head and neck structures develop from pharyngeal (branchial) arches, pouches and clefts
External ear – pinna: 6 Hillocks of His (mesoderm) from 1st and 2nd branchial arch
Ear canal: ectoderm of 1st branchial cleft
TM: 3 layers - outer ectoderm, middle mesoderm and inner endoderm from 1st pouch

How well did you know this?

Not at all

Perfectly

Basic ear anatomy

Outer cartilaginous and bony shorter
Middle; bones of hearing, Eustachian tube, promontory, facial nerve and chorda tympani
Inner: hearing and balance organs (cochlea, utricle, saccule and vestibule

How well did you know this?

Not at all

Perfectly

Congenital problems of the ear

Absence of auricle/ microtia
Atresia of outer ear canal - dont have ear canal
Pre auricular sinus
Accessory auricles - body tried to make more than one ear
Prominent ears - bat ear
Outer ear abnormalities may herald middle ear problems
Inner ear develops earlier than middle/outer ear

How well did you know this?

Not at all

Perfectly

Middle ear problems

Abnormal ossicles
- disruption of sound amplification mechanisms

Craniofacial syndromes

How well did you know this?

Not at all

Perfectly

Inner ear problems

Scheibe (cochleosaccular) dysplasia
Mondini (cochlear) dysplasia
Bing-Siebenmann (vestibulocochlear) dysplasia – membranous labyrinth affected
Michel aplasia – complete labyrinthine aplasia

How well did you know this?

Not at all

Perfectly

What does a malformed inner ear cause?

Profound hearing loss

How well did you know this?

Not at all

Perfectly

How do we identify children with hearing loss

Newborn Hearing Screening Programme NHSP (2006)
Within 4-5 weeks of birth, before 3 months
Automated otoacoustic emissions, auditory brainstem responses
Look out if risk factors in the prenatal history
Neonatal check obvious structural abnormalities
Early referral to audiology; care and support
Early cochlear implantation
IF IN DOUBT- SEND FOR HEARING TESTING

How well did you know this?

Not at all

Perfectly

RFs for deafness in newborns

FH
Illness in mother
Prematurity
Jaundice
Anatomical abnormalities

How well did you know this?

Not at all

Perfectly

Ear infections

Otitis externa
Painful, inflamed EAM +/- pinna
Treat with microsuction, topical antibiotics

How well did you know this?

Not at all

Perfectly

Otitis media features

Otitis media 90% of children at some point
- infection
- Eustachian tube dysfunction
- Fluid in middle ear: mucoid vs serous
- Often painless (can be sudden pain if perforation)
- OME persistent for >3/12
Self limiting
But risks of complications (mastoiditis)
Controversy about antibiotics (Finland prescription to fill if not better)
Chronic otitis media
- OME, cholesteatoma

How well did you know this?

Not at all

Perfectly

Features of OME/Glue ear

NICE Guidelines CG60: Otitis media with effusion in under 12s: surgery (2008)
Hearing loss 25-30dB on 2 occasions 3/12 apart
Options
1. Conservative: Do nothing, Eustachian tube autoinflation (Otovent balloon)
2. Ventilation tubes (Grommets)
3. Hearing aids: alternative to surgical intervention where surgery is contraindicated or not acceptable

How well did you know this?

Not at all

Perfectly

Features of a chronically discharging ear

Perforation
Retraction pockets
Chronic supparative otitis media
Cholesteatoma
- Present repeated infections
- Offensive discharge
- Can see perforation
- White material

How well did you know this?

Not at all

Perfectly

What are the 2 types of Cholesteatoma

Acquired
Congenital

How well did you know this?

Not at all

Perfectly

What happens in cholesteatoma

As cholesteatoma sac grows, it locally erodes.

Damage to middle ear/inner ear structures

How well did you know this?

Not at all

Perfectly

What is the treatment for Cholesteatoma?

Rationale: Dry, safe ear
Perforation - Close it
Cholesteatoma remove it preserving hearing if possible or leaving scope for reconstruction
Mastoidectomy

How well did you know this?

Not at all

Perfectly

What is the boggy swelling in ear known as?

Acute mastoiditis

How well did you know this?

Not at all

Perfectly

Issues with foreign bodies in the ear

Have one go (cooperative child, parent, good light and equipment)-
If unable to remove: GA
- Foreign bodies often no harm if in for a few days in ear

How well did you know this?

Not at all

Perfectly

What happens if there are button batteries in your ear, nose or has been swallowed?

IMMEDIATE EMERGENCY REFERRAL TO ENT

Embryology of the nose

Starts to develop at week 5 (olfactory placodes)
Median and lateral processes
Thickening of ectoderm above stomodeum

Issues with nose

Babies obligate nasal breathers
Facial anomalies can affect breathing

What is choanal atresia and what are its features?

Failure of the nose to canalise
Bony or membranous
Bilateral rare but a neonatal emergency
Cyclical going blue, crying-going pink, stop crying going blue again
Cold spatula: no misting
Failure to pass an NG tube
If confirmed secure airway (Guedel or McGovern nipple)
Tertiary referral for dilatation +/- stent insertion (SCH)

What are some types of craniofacial abnormalities?

Syndromic
Down, Apert, Pfeiffer, Crouzon, Treacher Collins
May have problems with airway
OSA, midfacial hypoplasia
Tracheostomy may be required (last resort)
Elective trache to cover facial surgery

Features in foreign bodies of the nose

Nose contains erectile tissue…
( honeymoon rhinitis)
Unilateral discharge is a foreign body unless proven otherwise
Have one go (cooperative parents, good light, proper equipment) otherwise refer to ENT
Be wary of organic foreign bodies: risk of infection

Features of nosebleeds (Epistaxis)

Nose richly supplied with blood Little's area Nose picking, inflammation, foreign body, trauma, bleeding diathesis ABC Medical treatment: Topical naseptin, silver nitrate cautery Surgical treatment Electrocautery BEWARE teenage boy with persistent nosebleeds and nasal obstruction: ?juvenile nasopharyngeal angiofibroma

When are the sinuses morphed?

Maxillary sinuses exists at birth, grows full size after second dentition Ethmoids 2-3 cells at birth Frontals rudimentary or absent at birth (develops by 7-8 years) Sphenoid recognised at birth

Sinusitis in children

Rare in children If associated with nasal polyps consider cystic fibrosis Complications most common presentation - Periorbital cellulitis

What is periorbital cellulitis?

Medical emergency URTI followed by painful swollen eye Proptosis Red colour vision: sign of optic nerve compromise Needs joint care between ENT, paeds and ophthalmology IV Abx Incision and drainage of abscess – open or endoscopic

What needs to happen if there is periorbital cellulitis

IMMEDIATE REFERRAL TO ENT/PAEDS/OPTHALMOLOGY

Anatomy of the throat

Oral cavity Teeth, tongue Pharynx: naso-/ oro-/ hypopharynx Tonsils Palatine (adenoids) Pharyngeal (tonsils) Larynx

Anatomy of the airway

Absolutely and relatively smaller Narrowest point is subglottis (vs VC in adults) Loose mucosa Less reserve

Anatomy of the larynx

Find in ent slide 42

What are some congenital larynx issues?

Laryngeal atresia – EXIT (ex utero intrapartum treatment) procedure Tracheostomy while umbilical cord still attached to mother Laryngomalacia

What is laryngomalacia

Most common abnormality Normal voice, stridor worse on feeding and exertion Worse when supine Failure to thrive Increased work of breathing

What is found on examination of laryngomalacia?

Normal child Stridor WOB, tracheal tug, recessions Flexible nasendoscopy examination: omega shaped epiglottis, short aryepiglottic folds, bulky, prolapsing arytenoids

What is the treatment of laryngomalacia?

Close monitoring Weigh (?daily/weekly at first) Antireflux If not coping NG tube ?surgery – microlaryngobronchoscopy + aryepiglottoplasty Is self limiting stridor lessens and gone by 2 years old

Why is stridor important?

Phase important to detect location Inspiratory: laryngeal Biphasic: subglottis/trachea Expiratory: bronchi Tertiary referral Consider flexible nasendsocopy (up to 1 year old, or over 7 years of age) GA: Microlaryngobronchoscopy

What are the causes of stridor

Laryngomalacia, cysts, papilloma, haemangiomas, clefts, post intubation subglottic stenosis, tracheobronchomalacia

Inflammation of the larynx

Colds/URTIs Epiglottitis rare age 2-5: sudden onset v unwell, drooling, stridor Haemophilus influenzae B (HiB) Medical emergency Do not agitate child Theatre (intubate if poss)

What is croup and its features

Laryngotracheobronchitis Common Low grade fever Not v unwell Parainfluenza virus types 1 and 2 Stridor O2, steroids, adrenaline nebulisers

Features of Tonsils, adenoids and OSA

Tonsils and adenoids: collection of lymphoid tissue (Waldeyer’s ring) Large in children Obstruction sleep apnoea - Apnoeas: cessation of breathing + desaturations

History of Tonsils, adenoids and OSA

Snoring/stertor (upper airways noises) Restless Sweaty Poor eaters (drink milk copiously) Failure to thrive Pauses in breathing at night, gasping – apnoeas Behavioural problems: hyperactivity, tiredness

Assessments

ENT exam (mouth breathing, adenoid facies) Large tonsils Pes excavatum

Tests

Domiciliary sleep study/polysomnography (EEG, ECG, O2 sats, infra red cameras, movement detectors) Management based on history and examination

Treatment

Adenotonsillectomy Intracapsular vs. extracapsular Monitor O2 sats overnight post op Most on surgical ward May need HDU

Airway foreign bodies

Rigid ventilating bronchoscope Button batteries: emergency!