ENT Flashcards
Paediatric ENT epidemiology
ENT problems common
-Up to 50% of GP consultations in winter months
Unique morbidity
- different physiology and anatomy
Congenital problems prominent
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
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
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
Middle ear problems
Abnormal ossicles
- disruption of sound amplification mechanisms
Craniofacial syndromes
Inner ear problems
Scheibe (cochleosaccular) dysplasia
Mondini (cochlear) dysplasia
Bing-Siebenmann (vestibulocochlear) dysplasia – membranous labyrinth affected
Michel aplasia – complete labyrinthine aplasia
What does a malformed inner ear cause?
Profound hearing loss
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
RFs for deafness in newborns
FH
Illness in mother
Prematurity
Jaundice
Anatomical abnormalities
Ear infections
Otitis externa
Painful, inflamed EAM +/- pinna
Treat with microsuction, topical antibiotics
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
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
Features of a chronically discharging ear
Perforation
Retraction pockets
Chronic supparative otitis media
Cholesteatoma
- Present repeated infections
- Offensive discharge
- Can see perforation
- White material
What are the 2 types of Cholesteatoma
Acquired
Congenital
What happens in cholesteatoma
As cholesteatoma sac grows, it locally erodes.
Damage to middle ear/inner ear structures
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
What is the boggy swelling in ear known as?
Acute mastoiditis
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
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!
