ENT (paeds) Flashcards
What is the newborn hearing screening programme (NHSP)?
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
What is otitis externa and how is it managed?
‘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
How do you take ear drops?
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
What is chronic otitis externa?
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
What is malignant otitis externa and how is it managed?
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
What is otitis media?
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
How does otitis media present?
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
What can reduce the risk of developing otitis media?
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
What are some complications of otitis media?
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
How is otitis media diagnosed?
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
How do you manage otitis media?
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
How do you treat OME/glue ear?
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
What are grommets?
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
What is chronic suppurative otitis media?
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
How do you manage foreign body in the ear?
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
How do you manage a foreign body in the nose?
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
What is choanal atresia?
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
What are the common causes and management of epistaxis?
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
How does sinusitis present in children?
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
What is periorbital cellulitis?
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
How does preorbital cellulitis present?
Acute swelling, warmth and tenderness of eye lid, ptosis, limited eye movement
Fever >38, malaise
How does orbital cellulitis present
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
How do you manage preorbital and orbital cellulitis?
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
How is a child’s upper airway different from an adults?
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
What are some congenital throat problems?
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
How do you differentiate where the pathology arises by listening to stridor?
Inspiratory = tracheal Biphasic = subglottis/trachea Expiratory = bronchi
What are some causes of stridor and how to you manage them?
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
What are tonsils and adenoids and how can they be involved in pathology?
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
How do you clinically assess for enlarged tonsils/adenoids?
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
How do you investigate obstructive sleep apnoeas?
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)
What is important when managing airway foreign bodies?
Using a rigid ventilating bronchoscope
Removing flat batteries fast - emergency
What is a feverPAIN score used for? How is it coded?
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
