ENT, ophthalmology and audiology Flashcards
How common are ENT problems in children?
Up to 50% GP consultations in winter
Unique morbidity - different physiology and anatomy in children
Congenital problems prominent
What is the embryology of the face?
Formed from pharyngeal pouches/branchial arches, pouches, and clefts that go on to form different structures of the face/neck
Can predict which structures are going to be abnormal due to which arch is developing abnormally
What is the embryology of the ear?
External ear - pinna, 6 hillocks of his (mesoderm) from 1st and 2nd branchial arch
Ear canal - ectoderm of 1st branchial cleft
Tympanic membrane - outer ectoderm, middle mesoderm, and inner endoderm from 1st pouch
- Pars tensa (lower 2/3) mesoderm, ectoderm, and endoderm (tough as contains mesoderm)
- Pars falccida (upper 1/3) only endoderm and ectoderm so more prone to damage
What is the anatomy of the ear?
Outer cartilaginous and bony structures
Middle - bones of hearing, eustachian tube, promontory, facial nerve, chorda tympani (encased in temporal bone)
Inner - hearing and balance organs (cochlear, utricle, saccular, vestibule)
Name 3 examples of congenital problems with the ear
Absence of auricle/micotia Atresia of outer ear canal Pre-auricular sinus Accessory auricles Prominent ears
What might outer ear problems mean?
Middle ear problems
When does the inner ear develop relative to the outer and middle?
Earlier
Name 2 congenital abnormalities of the middle ear
Abnormal ossicles - disruption of sound amplification mechanisms - develop from 1st and 2nd branchial arteries
Craniofacial syndromes - also associated with 1st and 2nd branchial artery problems
Name 2 congenital abnormalities of the inner ear
Schiebe (cochleosaccular) dysplasia
Mondini (cochlear) dysplasia
Bing-Seibenmann (vestibulocochlear) dyplasia - membranous labyrinth affected
Michel aplasia - complete labryinthine aplasia
How are children with hearing loss identified?
Newborn hearing screening programme
- Within 4-5 weeks of birth, before 3 months
- Automated otoacoustic emission, auditory brainstem responses
Look out if risk factors in prenatal history
Neonatal check obvious structural abnormalities
Early referral to audiology - care and support
Early cochlear implantation
If in doubt send for hearing tests
What are the risk factors for deafness in newborns?
FHx - first degree relative needing hearing aids in childhood Illness in mother - hepatitis, rubella Prematurity Jaundice Anatomical abnormalities
What are the symptoms and what is the treatment for otitis externa?
Painful, inflamed external auditory meatus +/- pinna
Treat with microsuction, opical antibiotics
How common is otitis media?
90% of children at some point
What are the symptoms of otitis media?
Eustachian tube dysfunction Fluid in middle ear - mucoid vs serous Often painless (can be sudden perforation) OME persistent for > 3 months Self-limiting Risk of complications (mastoiditis) Chronic - OME, cholesteatoma
How is otitis media treated?
Controversy about antibiotics
- Can give prescription for later on if symptoms haven’t abaited
What is OME?
AKA glue ear
Otitis media with effusion in under 12s
Hearing loss 25-30dB on 2 occasions at least 3 months apart
What are the options for OME treatment?
Conservative - do nothing, Eustachian tube autoinflation (otovent balloon)
Ventilation tubes - Grommets
Hearing aids - alternative to surgical intervention where surgery is CI or not acceptable
What are the possible causes of the chronically discharging ear?
Perforation - close it
Retraction pockets - ear drum collapses inwards due to problem with Eustachian tube and decreased pressure in inner ear
Chronic suppurative otitis media
Cholesteatoma
What is a cholesteatoma?
'Greasy tumour' Present repeat infection Offensive discharge - really smelly Can see perforation White material Acquired vs congenital
What are the complications associated with cholesteatoma and why?
As it grows it locally erodes - intracranial complications, implications to inner ear and middle ear structures, implications to facial nerve
How is cholesteatoma treated?
Remove surgically preserving hearing if possible or leaving scope for reconstruction as may have to remove structures that might be encased in structure - mastoidectomy - refer to ENT surgeon
What does the removal of the middle ear bone lead to?
Maximal conductive hearing loss 60dB
What is acute mastoiditis?
Boggy swelling behind ear
Abscess
Complication of spreading otitis media
How is acute mastoiditis treated?
Surgery
How are ear foreign bodies treated?
Have one go if co-operative child, parent, good light, and equipment
If unable to remove do under general anaesthetic referral to ENT - often no harm if left in ear for few days
If battery - emergency immediate ENT referral
What is the embryology of the nose?
Starts to develop at week 5 from olfactory placodes
Median and lateral processes
Thickening of ectoderm above stomodeum
What is different about babies and adults in breathing?
Babies are obligate nose breathers so if they have blocked noses they really struggle to breath
What can affect breathing?
Facial abnormalities
What is a common cause of breathing problems in neonates?
Neonatal rhinitis - inflammation of nasal mucosa - clear nose with saline - self-limiting
What are the choanal holes?
Holes at back of nose allowing for breathing
What is choanal atresia?
Failure of nose to canalise - bony or membranous - blocked nose
Bilateral is rare but neonatal emergency
How does choanal atresia present?
Cyclical going blue, crying going pink (opened mouth so mouth breathing), stop crying go blue
Usually identified in early hours of life
Cold spatula - no misting
Failure to pass NG
How is choanal atresia treated?
Secure airway - Guedel or McGovern nipple
Tertiary referral for dilatation +/- stent insertion
Name 2 syndromic craniofacial abnormalities
Down's Apert Pfeiffer Crouzon Treacher collins All have midface abnormalities
What might midface abnormalities lead to in terms of ENT and how might they be treated?
Problems with airway - obstructive sleep apnoea, midfacial hypoplasia
Might require tracheostomy (last resort) - elective trachea to cover facial surgery
How might foreign bodies in the nose present?
Unilateral nasal discharge espec if smelly
How do you treat foreign bodies in the nasal passage?
Have one go - co-operative parents, good light, proper equipment otherwise refer to ENT
Be wary of organic foreign bodies - risk of infection
How common is epistaxis in children?
50-60% by age of 5 have suffered from recurrent nose bleed
What causes epistaxis?
Nose richly supplied blood
Nose picking, inflammation, foreign body, trauma, bleeding diatheses
How is epistaxis treated?
ABC
Medical - topical naseptin, silver nitrate cautery
Surgical - electrocautery
What should you look out for in teenage boys with persistent nose bleeds and nasal obstruction?
Juvenile nasopharyngeal angiofibroma
What is the embryology of sinuses?
Maxillary sinuses exist at birth, grows to full size after second dentition
Ethmoids only 2-3 cells at birth
Frontals rudimentary or absent at birth (develops by 7-8 years)
Sphenoid recognised at birth
How common is sinusitis in children?
Rare
What should you consider if sinusitis is associated with nasal polyps?
CF
What is the most common presentation of complications of sinusitis in children?
Periorbital cellulitis
What is periorbital cellulitis?
Medical emergency
URTI followed by painful swollen eye with proptosis
Red colour vision (sign of optic nerve compromise)
Will lose sight in eye if left
Who needs to care for a child with periorbital cellulitis?
ENT, paeds, ophthalmology
How is periorbital cellulitis treated?
IV Abx
Incision and drainage of abscess - open or endoscopic
What comprises the throat?
Oral cavity - teeth/tongue
Pharynx - naso-/oro-/hypopharynx
Tonsils - palatine (adenoids), pharyngeal (tonsils)
Larynx
What is he difference in airway from an adult to a child’s?
Child airway more funnel shape but adults more cylindrical
Absolutely and relatively smaller
Narrowest point is subglottis whereas is vocal chords in adults
Loose mucosae
Less reserve
Name 2 congenital problems associated with the throat
Laryngeal atresia
Laryngomalacia
How is laryngeal atresia treated?
EXIT - ex utero intrapartum treatment procedure - tracheostomy whilst umbilical cord still attached to mother
What is laryngomalacia?
Normal voice, stridor worse on feeding and exertion
Congenital softening of the tissues of the larynx
Self-limiting - stridor lessens and gone by 2
What are the symptoms of laryngomalacia?
Normal voice Stridor worse on feeding and exertion Worse when supine Failure to thrive Increased work of breathing Normal child Work on breathing, tracheal tug, recession
How is laryngomalacia diagnosed?
Flexible nasoendoscopy examination - omega shaped epiglottis, short aryepiglottic folds, bulky, prolapsing arytenoids
How is laryngomalacia treated?
Close monitoring Weight - daily/weekly at first Antireflux If not coping NG ? surgery - microlaryngobronchoscopy + aryepiglottoplasty
What does the phase that stridor occurs in mean?
Helps detect location
- Inspiratory - laryngeal (high pitched/squeaky)
- Biphasic - subglottis/trachea
- Expiratory - bronchi (not ENT)
What should you do if a child presents with stridor?
Tertiary referral
How is the cause of stridor diagnosed?
Consider flexible nasendoscopy up to 1 or over 7 - children in between don’t understand and strong enough to fight back
General anaesthetic - microlaryngobronchoscopy
What can cause stridor?
Laryngomalacia Cysts Papilloma Haemangiomas Clefts Post intubation subglottic stenosis Tracheobronchomalacia
What are the grades of subglottic stenosis and what do they mean?
Grade 1 - 0-50% often asymptomatic
Grade 2 - stenosis 51-70% child struggling
Grade 3 - stenosis 71-99% child really struggling
Grade 4 - no life
What can cause inflammation in the throat?
Cold/URTI
How common is epiglottitis?
Rare age 2-5
What are the symptoms of epiglottitis?
Sudden onset v unwell
Drooling
Stridor
What can cause epiglottitis?
H influenza B
How is epiglottitis treated?
Medical emergency
Don’t agitate child
Theatre (intubate if poss)
What is croup?
Laryngotracheobronchitis
How common is croup?
Common
What are the symptoms of croup?
Low grade fever
Not v unwell
Stridor
What causes croup?
Parainfluenza viruses type 1 and 2
How is croup treated?
O2
Steroids
Adrenaline nebulisers
What are the tonsils and adenoids?
Collection of lymphoid tissue
What are the differences in the tonsils in children vs adults?
Large in children
What is obstructive sleep apnoea?
Cessation and breathing and desaturations
What might the history look like for a child with obstructive sleep aponea?
Snoring/stertor (upper airway noises) Restless Sweaty Poor eaters (drink milk copiously) Failure to thrive Pauses in breathing at night - gasping Behavioural problems - hyperactivity, tiredness
What examination should you do with a child with suspected obstructive sleep apnoea?
ENT exam - mouth breathing, adenoid facies
Large tonsils
Pes excavatum
What investigations might you do for a child with obstructive sleep apnoea?
?Domiciliary sleep study/polysomnography (EEG, ECG, O2 sats, infrared cameras, movement detectors)
Management based on Hx and examination
What is the treatment for obstructive sleep apnoea?
Adenotonsillectomy - intracapsular vs extracapsular
Monitor O2 sats overnight post op
- Most on surgical ward
- May need HDU
What investigations should you do with airway foreign bodies?
Rigid ventilating bronchoscope
What is important to remember with foreign bodies anywhere?
If battery - emergency!!!
What are the two types of strabismus?
Manifest - obvious deviation of one eye
Latent - eyes are straight when both eyes are open but a deviation of the visual axes can be elicited when each eye is covered, tendency for the eye to move
What are the 4 types of manifest strabismus?
Esotropia - deviation looks out
Exotropia - look in
Hypotropia - looks down
Hypertropia - looks up
What are the 4 types of latent strabismus?
Esophoria - turns in
Exophoria - turns out
Hypophoria - turns down
Hyperphoria - turns up
What can cause childhood strabismus?
Multifactorial
- Hereditary - 60% have close relative with strabismus
- Refractive errors - needing glasses but not corrected by glasses
- Most commonly uncorrected hypermetropia (long sighted) and accomodative esotropia
- Anisometropia - difference in refractive error between both eyes and development of ambylopia
- Unknown
- Secondary to loss of vision particularly if only one eye
- Neurological defects - cerebral palsy
- Neurological aetiology rare - acute onset esotropia, often have other signs/symptoms neurologically
- Anatomical/mechanical effects - craniofacial synostosis CN VI
What often occurs just before strabismus onset?
Febrile illness
What are you more at risk of with a constant unilateral strabismus?
Amblyopia
What is amblyopia?
A lazy eye
Defective visual acuity which persists after correction of refractive error and removal of any pathology
What questions should you ask in the history?
Age of onset
Check not sudden onset - urgent referral espc if have other neurological symptoms
Type
Constant/intermittent
Family history - associated with family history
Birth history - associated with low birth weight and prematurity
General health
What is a common differential for strabismus often in babies?
Transient neonatal misalignment
Reduces by 2 months and stopped by 4 months
Just eyes getting stronger
What should you do in an examination for strabismus?
Corneal reflections
Cover test
Visual acuity - test each eye separately
Ocular movements - needs to exclude paralytic strabismus
What is different about the corneal reflections in strabismus?
Not on pupils where they should be
Why do we do the cover test for strabismus and how is it done?
Determine presence of strabismus Direction of strabismus Where it is manifest Approximate size Light and detailed target 33cm and 6m, and cover
What is childhood strabismus associated with in terms of ocular movements?
Defective eye movements
Often have associated features to aid diagnosis
Eg moebius syndrome
Can you get 2 different types of strabismus in the same eye?
Yes
Eg exotropia for distance and exophoria for near
What is pseudostrabismus and what could it be instead?
Where a child may look like they have strabismus but actually don't Epicanthus Narrow or wide interpupillary distance Facial asymmetry Unilateral ptosis Deep set or prominent eyes
What are the different types of ambylopia?
Strabismic ambylopia Anisometropic amblyopia Ametropic amblyopia Meridional ambylopia Stimulus deprivation ambylopia
What is anisometropia amblyopia?
Difference in refractive error in eyes
What is ametropic amblyopia?
Reduced vision in both eyes, high level of refractive error in both
What is meridional amblyopia?
Associated with astigmatism
What is stimulus deprivation amblyopia?
Something getting in the way of the stimulus reaching the back of the eye ball, ptosis, tumour in eye, capillary hemangioma
Can you have more than one type of amblyopia?
Yes
What should you do for patients with amblyopia?
Refraction and a fundus and media check under cycloplegia
How do you treat amblyopia?
Refractive adaptation - wear appropriate glasses for 16-18 weeks
Occlusion of better seeing eye (patches) - full/part time, allows vision to develop in worse eye
Atropine drops/ointment - in better seeing eye, dilates pupil and paralyses accomodation, blurs vision
What is the prognosis for amblyopia?
The younger the child, the better the prognosis for vision, usually prescribed before 7
What is the aim of strabismus management?
To restore comfortable binocular single vision - eyes working together
To eliminate diplopia
To achieve/restore good alignment of the two eyes
To restore alignment for psychosocial problems, anxiety, and depression
Intermittent or late onset - to restore binocular single vision - functionally better vision
What are the conservative treatment options for strabismus?
Optical - glasses/contact lenses
Prisms
Orthoptic exercises - better for latent strabismus
What are the surgical treatment options for strabismus?
Esotropia - bilateral medial rectus recession or medial rectus recession and lateral rectus resection (weaken medial rectus)
Extropia- bilateral lateral rectus recession or lateral rectus recession and medial rectus recession (weaken lateral rectus)
Vertical strabismus - surgery depends on type and ocular movements
What is another treatment option for strabismus and why is it rarely used?
Gradually wears off after a few months
Inject muscle
- Medial rectus in esotropia
- Lateral rectus in exotropia
May need repeat injections as effect wears off
Can be excellent diagnostic tool pre-operatively
In children under ketamine anaesthesia
How common is hearing loss?
10 million in UK with some form of hearing loss 1 in 5
800,000 severely or profoundly deaf
2 million have hearing aids, 1.4 million use regularly
Incidence of hearing loss in children 1:1000
Criteria for hearing loss in children - moderate/greater hearing loss in both ears
Prevalence doubles at age 10-11
In Sheffield around 700 children with hearing aids
Of those with hearing loss, what are the different types?
90% born to hearing parents - 1/2 passed on by recessive genes
70% non-syndromic
30% syndromic
What syndromes are associated with hearing loss?
Usher's syndrome Wardenbergs syndrome Treacher Collins Pendred syndrome Dilated vestibular aqueducts SN loss Alport syndrome
What are the types of Ushers syndrome?
T1 - profound loss, congenital absent vestibular response
T2 - sloping audiogram, congenital and normal vestibular system
T3 - progressive variable system and onset
What is Wardenberg’s syndrome?
Eyes often different colour and look wider apart but due to slant of eyelids
Congenital SN
White forelock
What is Treacher Collins?
Autosomal dominant
Underdevelopment of cheek bones
Abnormal outer and middle ear
Conductive loss
What congenital infections can cause hearing loss?
CMV 30%
Rubella
Syphilis
Herpes
What is the personal impact of hearing loss?
Major unrecognised long term condition Associated with increased chronic health conditions eg diabetes, sight loss, increased fall risk Unaddressed - Communication difficulties - Social isolation - Depression x2.5 more likely - Reduced QoL and loss of independence - Increased risk of dementia
Why is hearing important?
Spoken language primary measure of communication for humans
Hearing needed for speech development
Hearing loss can result in delays in
- Speech and language development
- Emotional and social interaction difficulties
- Academic underchievement
- Mental health difficulties
When is hearing tested?
Newborn hearing screening programme
School screening programme when start full time school
Also tested when hearing concerns from parents, education or health
What are the aims of the newborn hearing screening programme?
Aim to identify moderate, severe, or profound deafness and hearing impairment in newborns
May miss mild/sloping losses
How is hearing tested?
Depends on age and development of child
Objective
- Otoacoustic emission - performed on babies in newborn screens
- Auditory brainstem response performed for more detailed information after OAE test
Subjective - behavioural testing
- Performed subject to developmental age
- Requires patient to perform an action in response to sound
- Distraction test 6-18 months - pitfalls visual cues, auditory cues, olfactory cues
- Visual reinforcement audiometry 6-30 months - pitfalls rhythmical play in associated with stimulus presentation, toys or behaviour or tester/parent too distracting, attempting to condition to sub-threshold stimuli, additional behavioural cues given by parent/testers
- Performance testing 24+ months old
- Pure tone audiometry 3+ years
Typanometry - measures middle ear pressures
In what groups is hearing monitored long term?
CF Chemotherapy before and after treatment CMV Syndromes associated with hearing loss Head trauma Cleft lip/palate Downs
Why is early identification important?
Shown to benefit
- Receptive and expressive language
- Educational outcomes
- Mental health issues
- Employment problems
What are the aims of a hearing test?
Measure hearing threshold (dB)
Frequency specific Hz
Test for hearing threshold for speech sound
Obtain single ear information
Differentiate between conductive, sensorineural, and mixed losses
Compare aided and unaided responses
Monitor fluctuating or progressive hearing loss
Audiogram - graphical representation of hearing thresholds
What is conductive hearing loss?
Middle ear problem
Bone conduction better than air conduction
What are the potential causes of conductive hearing loss?
Glue ear Ear wax Otitis media Perforated eardrum Abnormality of outer ear Eustachian tube dysfunction
How is conductive hearing loss treated?
Most will resolve themselves over time - infections clear up, perforations that heal, glue ear clears
Some are operable - Grommet’s for glue ear
Hearing aids offered for persistent losses
Bone anchored hearing aid
What is sensori-neural hearing loss?
Inner ear problem
Degree and shape of loss varies depending on severity of damage and where it occurs in cochlear
Tends to be permanent
How is sensori-neural hearing loss managed?
Hearing aids
Raise level of hearing so that as much speech is as audible as possible
Cochlear implants
What is the other type of hearing loss?
Mixed - both sensori-neural and conductive
How is mixed hearing loss managed?
Address conductive element first
Hearing aid issued to make parts of speech audible especially at high frequencies
