ENT (paeds)

Question 1

What is the newborn hearing screening programme (NHSP)?

Answer 1

Occurs within 4-5wks of birth/before 3m

Automated otoacoustic emissions - sounds of cochlear origin, caused by the motion of hair cells as they respond to auditory stimulation - non-invasive testing (often done on sleeping newborns)

Automated brainstem responses - brain’s response to sound - clicking noise conducted through ear and picked up on scalp electrodes

Question 2

What is otitis externa and how is it managed?

Answer 2

‘Swimmers ear’ - repeat exposure to water can increase likelihood; also any ear canal trauma or contact allergy to earplugs/hearing aids/earrings etc

1/10 lifetime prevalence; more common in women; most common in adults aged 45-75; atopic conditions may predispose, also immunocompromised

Bacterial infection most likely - usually Ps.aerguinosa or S.aureus; also possible fungal (Aspergillus - white balls - or Candida albicans - white strands)

Painful and inflamed (itchy, exudate) external acoustic meatus +/- pinna; some degree of temporary hearing loss; possible furunculosis = deep infection of hair follicle in ear, or cellulitis

Managed with: analgesia; antibiotic ear drops; corticosteroid ear drops to reduce inflammation; antifungal drops - clotrimazole; acetic acid spray (change pH - upset organism functioning)

Rarely, oral Abx are considered - severe/spreading/systemic disease - 7-day flucoxacillin or clarithromycin

Incision and pus draining also rarely required but possible if severe

Question 3

How do you take ear drops?

Answer 3

Remove any superficial earwax to ensure clean passage of drops into ear (if lots of wax, may need microsuction)

Warm drops by holding bottle in hand for few minutes (cold drops can make one dizzy)

Lie on side with affected ear facing up - add drops - push/pull on ear for 30s to work the drops into the ear canal and get trapped air out

Stay lying down for 3-5mins to ensure drops have a chance to work

Question 4

What is chronic otitis externa?

Answer 4

Where symptoms persist for several months (or years)

Constant itch around ear canal, ear pain and discomfort worse on movement (usually milder than acute form), ear discharge, buildup of thick/dry skin in canal (lichenification) causing a stenosis

Treat in the same way as acute but may need more trails of other things e.g. trying antifungals where only Abx tried previously

Question 5

What is malignant otitis externa and how is it managed?

Answer 5

Infection of bones of ear and/or skull base - usually Ps.aerguinosa or S.aureus

More common in those with DM, the elderly or immunocompromised

Severe pain - interferes with sleep, headaches, exposed bone in ear canal, facial nerve palsy - can be fatal

CT/MRI head to determine extent

Needs aggressive treatment with IV Abx and possible surgery

Question 6

What is otitis media?

Answer 6

Middle ear infection (often viral) +/- buildup of fluid behind the eardrum (= glue ear/otitis media with effusion/OME)

Most common in infants age 6-15m; 1/4 have had by age 10

Often follows a common cold + subsequent blockage of Eustachian tube and inability to drain mucous

Can also be blocked with large adenoid

Also associated with craniofacial abnormalities e.g. cleft palate; also Down’s syndrome

Question 7

How does otitis media present?

Answer 7

Acute onset + resolution - often self resolving (2-3 days, up to 7)

Earache, fever, vomiting, lethargy, hearing loss - if middle ear with effusion

May perforate eardrum + pus may exit ear

In young infants - pulling/tugging at ears, irritability/poor feeding/coryzal symptoms, diarrhoea,
loss of balance

If no resolution within 3days, lots of pain, pus/discharge or underlying CF/congenital heart disease then seek medical support

Question 8

What can reduce the risk of developing otitis media?

Answer 8

Breastfeeding 
Vaccination 
No smoking at home 
No dummies once older then 6-12 months 
Avoid others who are unwell 

Can have adenoids removed if repeat infections

Question 9

What are some complications of otitis media?

Answer 9

Mastoiditis - inflammation of the mastoid periosteum and air cells - high fever, swelling/redness/tenderness behind ear, ear discharge, headache, hearing loss - given IV Abx

Cholesteatoma - abnormal collection of skin cells in ear secondary to recurrent infection - hearing loss, diziness, tinnitus, possible facial nerve palsy - if significant and symptomatic then surgical removal

Labrynthitis - dizziness, vertigo, loss of balance, hearing loss - usually pass within a few weeks; sometimes Abx prescribed

Meningitis, brain abscess

Question 10

How is otitis media diagnosed?

Answer 10

Otoscopic examination:
Bulging tympanic membrane
Change in membrane colour (usually grey) - red, yellow; or appearing cloudy
Possible perforation/hole

May need tympanometry - uses air pressure waves to see how membrane responds to pressure; or audiometry - if hearing loss

Question 11

How do you manage otitis media?

Answer 11

Paracetamol/ibuprofen for pain

Often viral so supportive treatment but sometimes Abx needed - Amoxicillin (or erythromycin/clarithromycin) - 5-7 days - usually only when chidlren are <3m, <2yrs with bilateral infection, if discharging ear, other complicating condition e.g. CF, congenital heart disease

Admit when: severe systemic infection or other acute complications, if child <3m with temp >38oC

Question 12

How do you treat OME/glue ear?

Answer 12

If recurrent and severe + age under 12 + hearing loss 25-30dB on 2 occasions 3/12 apart = surgery - grommets

In the mean time - conservative management = do nothing (should self resolve anyway) or Eustachian tube autoinflation (Otovent balloon = a balloon you blow up with your nose)

Hearing aids - where surgery is contraindicated or not wanted

Question 13

What are grommets?

Answer 13

Tiny tubes placed into tympanic membrane to help draining of fluid

For children with recurrent severe middle ear infections with concomitant glue ear (OME)

Inserted under GE, takes about 15 mins and same day release

Kept in for 6m-5yrs (but most commonly <1yr) then are naturally discharged from eardrum

Question 14

What is chronic suppurative otitis media?

Answer 14

Chronic inflammation of the middle ear and mastoid cavity and discharge through a perforated tympanic membrane for >2-6wks +/- conductive hearing loss of varying degrees

Can be with or without cholestetoma

Investigated with: CT/MRI - may show occult cholestetoma and extent of bone involvement/erosion

Managed with: referral to specialists, microsuction - to remove debris and maximise topical Abx drop efficacy = Pseudomonas (G-ve), S.aureus (G+ve) - aminoglycosides and fluroquinolones (though used with caution due to their ototoxicity - but still outweighs risks of untreated disease)

Treatment failure often likely due to debris rather than resistance

Question 15

How do you manage foreign body in the ear?

Answer 15

Have one go with a cooperative child and parent with good lighting and equipment

If failure - GA and surgical removal

They will do no harm if left in the ear for a few days

Question 16

How do you manage a foreign body in the nose?

Answer 16

Have one go with a cooperative child and parent with good lighting and equipment

If failure - GA and surgical removal

Beware organic foreign body - as increased risk of infection

Batteries stuck in the nose need emergency removal

Question 17

What is choanal atresia?

Answer 17

Failure of the nose to canalise - can be bony or membranous blockage

Bilateral is rare but a neonatal emergency - as they are obligate nasal breathers, will present with cycles of going blue, crying, going pink, stopping, going blue again

Will have failures to pass an NG tube, no misting on cold spatulas

Secure airway temporarily - oropharyngeal airway or McGovern nipple (bottle teat with tip cut off and placed in mouth - forcing mouth breathing)

Surgery - dilatation and stent insertion

Question 18

What are the common causes and management of epistaxis?

Answer 18

Nose is particularly vascular - especially in Little’s area = Kiesselbach’s plexus where 4x arteries anastomose on the anterioinferior part of the nasal septum

Bleeding mostly is due to picking, facial trauma, foreign body, inflammation and bleeding disorders

Boy age 10-25 boy with persistent nose bleeds and nasal obstruction - think juvenile nasopharyngeal angiofibroma

Check that patient isn’t anaemic or hypovolaemic from blood loss

Treat with: education, silver nitrate cautery, topical naseptin (Abx + disinfectant); electrocautery

Question 19

How does sinusitis present in children?

Answer 19

Is rare because sinuses are much smaller - maxillary sinuses grow to full size after second dentition; ethmoids are only 2-3 cells at birth; frontal are developed by 7-8yrs

If associated with nasal polyps then consider CF

Most commonly presents with periorbital cellulitis as a complication of sinusitis

Question 20

What is periorbital cellulitis?

Answer 20

Nasal sinus or skin infection - H.infuenzae, S.pneomioniae, Staphlococci; possible haematogenous spread from other sites

Most common in children under 10yrs (also common in elderly and immunocompromised)

Medical emergency - as can progress to orbital cellulitis and meningitis or eye loss

Commonly follows an URTI or blunt trauma to the face

Question 21

How does preorbital cellulitis present?

Answer 21

Acute swelling, warmth and tenderness of eye lid, ptosis, limited eye movement

Fever >38, malaise

Question 22

How does orbital cellulitis present

Answer 22

Bacterial infection of the tissues lying posterior to the orbital septum

Proptosis and painful eye movements are present here where they aren’t in preorbital; in severe cases - acuity, changes in colour vision (e.g. red is absent? Optic nerve compromise) and relative afferent pupillary defect (RAPD) (pupils constrict less when bright light swung from unaffected eye to affected)

CT head needed to identify

Question 23

How do you manage preorbital and orbital cellulitis?

Answer 23

Initially presume orbital cellulitis until proved otherwise (following repeat examination - 4hrly tests of pupillary reaction/acuity/colour/light brightness appreciation - good response to Abx in 24hrs and normal CT)

ENT, paeds and ophthalmology MDT

Oral or IV Co-amox - clinical improvement 24-48hrs; for orbital - cefotax + flucox + metronidazole in patients >10yrs; alternatively clindamycin or vancomycin + quinalone

Abx for 7-0 days

Possible incision and drainage of any abscesses

Question 24

How is a child’s upper airway different from an adults?

Answer 24

In children:

Tongue = larger in mouth

Pharynx = smaller

Epiglottis = larger + floppier

Larynx = more anterior and superior

Narrowest at the cricoid (compared to the vocal cords in adults)

Trachea = narrower + less rigid

Question 25

What are some congenital throat problems?

Answer 25

Laryngeal atresia - failure to develop - have an EXIT procedure (Ex utero intrapartum treatment) = a tracheostomy whilst umbilical cord still attached to mother

Laryngomalacia - most common, normal voice, stridor worse on feeding + exertion + when supine, increased WOB, failure to thrive; omega shaped epiglottis on examination

Question 26

How do you differentiate where the pathology arises by listening to stridor?

Answer 26

Inspiratory = tracheal 
Biphasic = subglottis/trachea 
Expiratory = bronchi

Question 27

What are some causes of stridor and how to you manage them?

Answer 27

Laryngomalacia
Cysts
Papilloma
Haemangiomas 
Clefts 
Post intubation subglottic stenosis 
Tracheobronchomalacia 

Weights frequently to monitor growth - if not growing then can NG tube them

Possible surgery - microlaryngobronchoscopy to visualise then make relevant excisions

Question 28

What are tonsils and adenoids and how can they be involved in pathology?

Answer 28

Collections of lymphoid tissue in the naso- and oropharynx

Can be especially large in children - obstruct Eustachian tube (glue ear), can lead to obstructive sleep apnoeas (cessations of breathing + desaturations), can become infected themselves

Question 29

How do you clinically assess for enlarged tonsils/adenoids?

Answer 29

Snoring
Restless or tired 
Sweaty 
Poor eaters - may drink lots of milk 
Failure to thrive 
Apnoeas and gasping at night 

Mouth breathing and visualisable large tonsils - ‘kissing’ if especially large

Question 30

How do you investigate obstructive sleep apnoeas?

Answer 30

Domiciliary sleep study/polysomnography - involves: EEG, ECG, O2 sats, infraredd cameras and movement detectors

Having had sleep studies are essential for removal of tonsils/adenoids (even if results come back negative for apnoeas if there a strong Hx)

Question 31

What is important when managing airway foreign bodies?

Answer 31

Using a rigid ventilating bronchoscope

Removing flat batteries fast - emergency

Question 32

What is a feverPAIN score used for? How is it coded?

Answer 32

Used to assess risk of streptococcal throat infection in a sore throat

Fever in the past 24hrs (1)
Absence of cough or coryza (1)
Symptoms <3days (1) 
Purulent tonsils (1)
Severely inflamed tonsils (1) 

/5:
0-1 = bacterial unlikely - reassure
2-3 = bacterial possible - delayed antibiotics (given and told to take if not resolving)
4-5 = bacterial likely - consider antibiotics now