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Paediatrics > ENT and Ophthalmology > Flashcards

ENT and Ophthalmology Flashcards

1
Q

Why are children prone to Otitis media

A

Eustachian tubes are short, horizontal and function poorly.

The anatomy of the eustachian tube in younger children is immature, typically being short, straight, wide (only becoming more oblique as the child grows), meaning infection is more likely.

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2
Q

Symptoms Otitis Media

A

pain, malaise, fever, and coryzal symptoms, lasting for a few days.

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3
Q

Sign of acute otitis media

A

Tympanic membrane is red and bulging with loss of normal light reflection.

Occasionally acute perforation of eardrum with pus visible in the external canal.

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4
Q

Causes of Otitis media

A

Virus - RSV, Rhinovirus
Bacteria - Pneumococcus, H.influenzae, M.catarrhalis.

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5
Q

Complications Otitis Media

A

Uncommon.
Mastoiditis - can progress to necrosis and subperiosteal abscess
Meningitis

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6
Q

Management Otitis Media

A

Analgesic - paracetamol and ibuprofen
Regular is more effective than intermittent and for up to a week until acute inflammation resolves

Most resolve spontaneously

Antibiotics - give parents prescription and ask them to use it only if child is unwell after 3 days.
Amoxicillin

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7
Q

What is glue ear

A

Otitis media with effusion as a result of recurrent ear infections.

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8
Q

Symptoms of glue ear

A

Asymptomatic - possible decreased hearing.
There may be a sensation of pressure inside the ear that may be accompanied by ‘popping’ or ‘crackling’ noises.

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9
Q

Signs of glue ear

A

Eardrum is dull and retracted, often with fluid level visible. Loss of light reflection.

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10
Q

When is glue ear common

A

age 2-7 with peak 2.5-5 years

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11
Q

Complications glue ear

A

Resolves spontaneously but can cause conductive hearing loss as shown on pure tone audiometry.
Or a flat trace on tympanometry hearing testing in younger children.

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12
Q

Management glue ear

A

No abx, steroids or decongestants have been proven to work
In event of conductive hearing loss affecting speech and normal development use of ventilation tubes - grommets - but do not last more than 12 months.

If problem recurs after grommet removal, one is reinserted with adjuvant adenoidectomy.

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13
Q

Pathophysiology Otitis media

A

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

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14
Q

Most common causative pathogen of otitis media

A

S.pneumoniae

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15
Q

RF Otitis media

A

Age - 6-15 months
Gender - boys
Smoking
Bottle feeding
Craniofacial abnormalities

Recurrent - use of pacifiers, fed supine, first episode was <6 months.

Winter.

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16
Q

Ix Otitis media

A

On otoscopy, the tympanic membrane (TM) will look erythematous and may be bulging. If this fluid pressure has perforated the TM*, there may be a small tear visible with purulent discharge in the auditory canal. Patients may have a conductive hearing loss or a cervical lymphadenopathy.

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17
Q

What is important to assess in Otitis Media

A

function of the facial nerve (due to its anatomical course through the middle ear).

Examination should also include checking for any intracranial complications, cervical lymphadenopathy, and signs of infection in the throat and oral cavity.

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18
Q

Symptoms of ruptured tympanic membrane

A

Any extreme pain that suddenly resolves, followed by ear discharge

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19
Q

DDX of acute otitis media

A

Chronic Suppurative Otitis Media (CSOM), Otitis Media with Effusion (OME), and Otitis Externa (OE).

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20
Q

When to use Abx for OM

A

Systemically unwell children not requiring admission

Known risk factors for complications, such as congenital heart disease or immunosuppression

Unwell for 4 days or more without improvement, with clinical features consistent with acute otitis media

Discharge from the ear (ensure swabs are taken prior to commencing antibiotic therapy)

Children younger than 2 years with bilateral infections

Systemically unwell adult, provided not septic and with no signs of complications

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21
Q

When should inpatient admission be considered for OM

A

all children under 3 months with a temperature >38c, or aged 3-6 months with a temperature >39c, for further assessment.

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22
Q

Mastoiditis signs and symptoms and management

A

boggy, erythematous swelling behind the ear, which if left untreated progressing to pushing the pinna forward.

admitted for intravenous antibiotics and investigated further via CT head if no improvement is seen after 24 hours of intravenous antibiotics. mastoidectomy as definitive management if there is no improvement with IV antibiotics

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23
Q

RF glue ear

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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24
Q

Ix glue ear

A

Both pure tone audiometry and tympanometry are nearly always performed in such cases, which will reveal a conductive hearing loss and reduced membrane compliance (a type B tracing) respectively.

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25
Q

When to insert grommets

A

for those with > 3 months of bilateral OME and hearing level in better ear < 25-30dBHL

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26
Q

First line therapy for a pt with Down syndrome and OM with effusion

A

first line therapy may actually be a hearing aid, as complications from grommet can be common

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27
Q

Pathophysiology Otitis Externa

A

Otitis externa is an infection of the skin in the external auditory canal

Otitis externa is an inflammation of the external ear canal and can be either acute or chronic in nature. Acute otitis externa lasts less than 3 weeks whereas chronic otitis externa lasts more than 3 months.

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28
Q

Causes of Otitis Externa

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

Fungal infection

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29
Q

RF Otitis Externa

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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29
Q

Symptoms Otitis Externa

A

Pain
Itching
Discharge
Hearing loss

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30
Q

Examination Otitis Externa

A

Otoscopy may show the following features:

Oedema
Erythema
Exudate
Mobile tympanic membrane
Other features may include:

Pain on movement of tragus or auricle
Pre-auricular lymphadenopathy (4)

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31
Q

Management Otitis Externa

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
Specific management:

Antibiotic or antifungal ear drops are generally the mainstay of treatment
A pope wick can be used to get the drops into the ear if the canal is closed.

If there is cellulitis or lymphadenopathy then oral antibiotics are indicated

In cases of chronic otitis externa, acetic acid and corticosteroid ear drops are used

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32
Q

Symptoms Periorbital cellulitis

A

Unilateral Fever with erythema, tenderness and oedema of the eyelid or other skin adjacent to the eye

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33
Q

Causes of Periorbital cellulitis

A

Trauma of the skin
Paranasal sinus infection or dental abscess

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34
Q

Treatment Periorbital cellulitis

A

IV Abx - ceftriaxone

35
Q

Complication of peri orbital cellulitis and symptoms

A

Orbital cellulitis
Proptosis, painful or limited ocular movement with or without reduced visual acuity.

CT or MRI to assess posterior spread of infection

36
Q

Types of Peri-orbital cellulitis

A

Peri-orbital cellulitis is divided into two forms; namely pre-septal and post-septal cellulitis.

Infection anterior to the orbital septum is pre-septal and posterior is post-septal. The orbital septum is the only barrier impeding spread of infection from the eyelid into the orbit.

37
Q

Most common cause of orbital cellulitis

A

Ethmoidal sinusitis

38
Q

Why does peri-orbital cellulitis occur in young children more commonly

A

thinner and dehiscent bone surface of their lamina papyracea and increased diploic venous supply. in addition to incomplete immunologic development

39
Q

Most common bacteria for peri-orbital cellulitis

A

S.pneumoniae and S.aureus

40
Q

Why is there swelling in peri-orbital cellulitis

A

an impedance to drainage through ethmoid vessels. Due to the superficial nature, erythema may spread to upper cheek and brow area.

41
Q

Type 1 orbital cellulitis

A

Cellulitis in pre septal region

Cellulitis confined to the eyelid

42
Q

Type 2 orbital cellulitis

A

Post septal cellulitis
Inflammation extends into orbital tissue, no abscess formation.

43
Q

Type 3 orbital cellulitis

A

Lateral pus in post septal region

Abscess forms deep to the periosteum of the orbit.

44
Q

Type 4 orbital cellulitis

A

Pus in all of post septal region

Collection of pus inside or outside the muscle cone due to progressive and untreated orbital cellulitis.

45
Q

Type 5 orbital cellulitis

A

Cellulitis in deepest part of post septal region

Extension of orbital infection into the cavernous sinus that can lead to bilateral marked eyelid edema and involvement of the third, fifth, and sixth cranial nerves.

46
Q

Treatment 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

47
Q

Treatment orbital cellulitis

A

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.

Urgent drainage is also recommended for intracranial complications at the time of presentation and in frontal sinusitis

48
Q

What is strabismus

A

is a misalignment of the visual axis. This means that the eyes are not directed at an object at the same time

49
Q

Esotropia

A

Other eye looks in

50
Q

Exotropia

A

Other eye looks out

51
Q

Hypertropia

A

Other eye looks up

52
Q

Hypotropia

A

Other eye looks down

53
Q

What is a pseudo squint

A

the impression of misaligned eyes when no squint is present.

54
Q

RF of squint

A

low birth weight, prematurity, maternal smoking throughout pregnancy, hypermetropia, family history of squint, and assisted or Caesarean delivery.

55
Q

Management of squint

A

Glasses to correct any refractive error.
Occlusion or penalization therapy to treat amblyopia.
Surgery (or in some cases injection of botulinum toxin) to correct misalignment of eyes.

56
Q

When is a squint common

A

Up to 3 months of age

57
Q

Most common cause of squint

A

Refractive error

58
Q

Concomitant squint

A

Non-paralytic and common.
Correction with glasses.
Squinting eye most often turns inwards but there can be outward deviation

59
Q

Paralytic squint

A

varies with gaze direction due to paralysis of the motor nerves.
Sinsister due to possibility of space-occupying lesion such as brain tumour.

60
Q

Nystagmus and cause

A

Repetitive involuntary movement of the eye usually horizontal.

Structural eye problem but also a consequence problems at a cortical level

61
Q

Test for squints

A

Corneal light reflex test and Cover test

62
Q

Corneal light reflex test

A

Pen touch help at distance to produce reflections on both corneas simultaneously

If the light reflection does not appear in the same position in the two pupils a squint is present. Minor ones are hard to detect.

63
Q

Cover test

A

Could encouraged to look at a. toy or light.
Cover the fixated eye and the squinting eye will move to take up fixation.
With both near 30cm and distant 6m objects.

64
Q

Hypermetropia

A

Long sight

Most common refractive error.

65
Q

Management of hypermetropia

A

Convex lenses.

66
Q

Myopia

A

Children born preterm. Concave lenses. Short sightedness

67
Q

Amblyopia

A

Permanent reduction of visual acuity in an eye that has not received a clear image.

Normally unilateral

68
Q

Causes of amblyopia

A

Squint
Refractive errors
Obstruction of visual pathway

69
Q

Treatment amblyopia

A

Patching the good eye to force lazy eye to work.
Early treatment essential as after 7 YO treatment success is unlikely.

70
Q

Genetic causes of visual impairment

A

Cataract
Albinism
Retinal dystrophy
Retinoblastoma

71
Q

Antenatal and perinatal causes of visual impairments

A

Congenital infection
Retinopathy of prematurity
Hypoxic-ischaemic encephalopathy
Cerebral abnormality or damage
Optic nerve hypoplasia

72
Q

Post natal causes of visual impairments

A

Trauma
Infection
Juvenile idiopathic arthritis.

73
Q

Pharyngitis and pathogens

A

Pharynx and soft palate inflammation and local lymph nodes are enlarged and tender. Usually due to viral infection - adenoviruses, enteroviruses and rhinoviruses.

74
Q

Tonsillitis

A

Form of pharyngitis where intense inflammation of the tonsils, often with purulent exudate

Common pathogens - Group A B- haemolytic streptococci and EBV (infectious mononucleosis)

75
Q

Symptoms tonsillitis

A

Bacterial - more common
Swollen tonsils,
Sore throat
Headache,
Apathy,
Abdominal pain
Tonsilar exudate and cervical lymphadenopathy

76
Q

Management of severe pharyngitis and tonsillitis

A

Penicillin V or erythromycin if allergy - even though only 1/3 caused by bacteria.

10 days abx treatment required.

Severe - admission for IV fluid and analgesia if unable to swallow

77
Q

Why no amoxicillin for pharyngitis and tonsillitis

A

Can cause widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis.

77
Q

Consequence of pharyngitis and tonsillitis and its features

A

Scarlet fever - most common in age 5-12

Fever precedes headache and tonsillitis by 2-3 days.

Sandpaper like maculopapular rash with flushed cheeks and perioral sparing.

Tongue white coated and swollen.

Abx - penicillin V and erythromycin to prevent complications.

78
Q

Epiglottitis quick summary

A

Caused by Haemophilus Influenzae Type B
Clinical Presentation
- Rapid onset
- High temperature
- Stridor
- Drooling and saliva
- Patient finds it easier to breathe leaning forward and extending neck (tripoding
position)

Diagnosis
- Clinical
- CXR - Thumb sign and acute epiglottis swelling
- Do not examine throat

Management
- O2
- Nebulised adrenaline
- IV Abx - 3rd gen cephalosporins e.g. Ceftriaxone

79
Q

Otitis media quick summary

A

OTITIS MEDIA

  • Infection of the middle ear

Aetiology
- Viral
- Pneumococcus/Haemolytic Streptococcus/Hib

Clinical Presentation
- Ear pain
- Fever
- Bulging tympanic membrane
- Discharge

Secondary otitis media (glue ear)
- Child may have hearing loss
- Retracted eardrum
- > 3 months: referral for grommets and adenoidectomy

Management
- 5 days Amoxicillin/Erythromycin

80
Q

Concomitant squint

A

differences in the control of the extra ocular muscles

81
Q

Esotropia

A

inward position squint -> affected eye deviated towards the nose

82
Q

Exotropia

A

outward position quint -> affected eye deviated towards the ear

83
Q

Periorbital cellulitis summary

A

An eyelid and skin infection in front of the orbital septum where the inflammation and infection remains confined to the soft tissue layers superficial to the orbital septum.
It is important to differentiate this from orbital cellulitis which is where the muscles of the orbit are affected and is usually due to bacterial sinusitis and is a life threatening condition.

Risk factors
Boys
Previous sinus infection
Lack of Hib infection
Recent eyelid injury

Clinical Presentation
- Swelling, redness and hot skin around the eyelids and the eye

Investigations
- Clinical examination
- CT sinus and orbits with contrast will help to differentiate between periorbital and
orbital

Management
Empirical antibiotics either an inpatient or outpatient depending on severity e.g Cefotaxime/Clindamycin

Paediatrics (17 decks)

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