HEENT- Peds Flashcards
Mononucleosis: s/s
- Often begins with malaise, headache and low-grade fever before more specific sx develop
o Tonsillitis/pharyngitis
o Cervical LAD (typically posterior/occipital)
o Moderate to high fever
o Fatigue - LUQ abdominal pain
o Splenomegaly
Mononucleosis: supportive care
o Ibuprofen with food for swollen lymph nodes
o Warm compresses
o Rest
o Avoid contact sports d/t hepatomegaly
o Avoid sharing saliva: kissing, sharing utensils, sharing water bottles, etc…
o If co-contaminant strep A, do not treat with Amox/Penicillin: will develop a full body rash
If patient has both strep A and mono DO NOT TREAT WITH abx.. why?
full body rash will develop
Epiglottis: s/s
o Present with respiratory distress, anxiety, tripoding/sniffing posture (leaning forward at the trunk, hyperextending their neck/chin to maximize their obstructed airway).
o They may be reluctant to lay down
o Drooling is often present, but not always necessary
o Typically Hib
- Acute epiglottitis
o Above symptoms with accompanied acute onset, fever and stridor and hot potato (muffled) voice
tx of epiglottis
o Ensure no airway obstruction (intubate if necessary)
o Imaging: x-ray/CT (looking for Thumb sign)
o No laying down flat
o IV steroids
o ? IV antibiotics
o O2
PFAPA Syndrome: Periodic Fever with Aphthous Stomatitis, Pharyngitis, and Adenitis
- Fever begins abruptly with/without chills
- Prodrome: malaise, irritability, mood changes, sore throat or aphthous ulcers may occur during the preceding day. Fever ranges from 38.5C-41C for 2-7 days, then normalizes.
- Atypical symptoms: cough, inflamed nostrils, severe abdominal pain, vomiting/diarrhea, chest pain, rash, arthritis or significant neuromuscular symptoms
- Episodes last no greater than 7 days
- Periodic fever is the hallmark of PFAPA syndrome
- There is NO diagnostic lab test for PFAPA; it is based strictly on clinical hx and PE.
- Abnormal labs during flares potentially: leukocytosis, elevated ESR/CRP, neutrophilia, monocytosis and mild lymphopenia can be noted during flares, but normalize between attacks.
- You have to rule out other things to rule this in: strep, lyme, IBD, EBV, cyclic neutropenia.
- Careful documentation of the dates of fever episodes and PE during flares are IMPERATIVE for proper diagnosis.
- Primary features of PFAPA
o More than 3 documented stereotypical episodes of fever occurring at regular intervals
o Intervals between attacks are typically 2-8 weeks.
o Each episode lasts approximately 2-7 days
- Treatment of PFAPA
o Tylenol/Ibuprofen
o Fluids
o Rest
o 1-2mg/kg (max dose 60mg) PO Prednisolone given as a single dose OR 2 doses 12-48 hours apart
mumps
- Viral illness; affects saliva
*puffy/swollen cheeks
mumps: tx
- No definitive treatment: 1-2 weeks of symptoms typically; supportive treatment
o Rest
o Push fluids
o Tylenol/Ibuprofen (do not give aspirin to anyone under 16 years old)
o Warm/cool compresses
o Sucking on sour/lemon candy can help increase salivation which could help relieve some pressure from the parotid gland
mumps s/s
- Typically starts with a few days of: fever, headache, muscle aches, fatigue and loss of appetite, followed by swelling of their salivary glands
o This causes the jaw/cheek to become puffy/tender and a swollen jaw
o Parotitis: inflamed parotid gland
Stomatitis: Oral Mucositis
- Inflammation of the mouth; causes swelling and sores inside the mouth
- Post-viral (HFMD, HSV, Apthous Ulcers)
tx for stomatitis
- Push Fluids
- Tylenol/Ibuprofen
- “Magic mouthwash” combination of:
o Maalox
o Diphenhydramine
o Viscous Lidocaine
Peritonsillar Abscess/Retropharyngeal Abscess: s/s
o Rapid onset sore throat
o Unilateral
o With/without fever
o Can have neck swelling and referred ear pain
Peritonsillar Abscess/Retropharyngeal Abscess: presentation
o Tripoding
o Trismus
o potatoe/muffled voice
o unable to tolerate secretions
Peritonsillar Abscess/Retropharyngeal Abscess: exam
o Trismus
o Potato/muffled voice
o Extremely swollen/fluctuant unilateral tonsil with or without exudate
o Deviation of uvula to opposite side
o Erythematous pharynx
Peritonsillar Abscess/Retropharyngeal Abscess: tx
o Intra-oral Ultrasound
o Refer to ED for I&D and
* Augmentin: 45mg/kg/dose (max 875mg/dose) BID x 10 days
* Clindamycin: 10mg/kg/dose (max 600mg/dose) QID x 10 days
acute pharyngitis: tx
- Tylenol/Ibuprofen with food for pain/swelling
- Push fluids
- Warm salt water gargles
- Tea with honey and lemon
- Lozenges or Cepacol throat spray
acute pharyngitis: diagnosis
Modified Centor Criteria Score:
* fever: 1
* tonsillar exudate: 1
* absent cough: 1
* anterior cervial LAD: 1
* age 3-14 yrs: 1
* age 15-44 yrs: 0
* age > 44 yrs: -1
Streptococcal Pharyngitis: tx
- First line therapy
o Amoxicillin: 50mg/kg BID x 10 days (max 1gm/day) - If Penicillin/Amoxicillin allergy
o Cephalexin: 40mg/kg/day divided BID x 10 days (max 500mg/dose)
o Azithromycin: 12mg/kg/day (max 500mg/day) x 5 days
o Clindamycin: 7mg/kg/dose (max 300mg/dose) TID x 10 days - Ensure they change their toothbrush, wash pillowcases/towels/etc… after 24 hours on antibiotics.
Mastoiditis: s/s
o Postauricular tenderness
o Erythema
o Swelling
o Fluctuance or mass
o Protrusion of the auricle
o Ear pain, which is a nonspecific finding and may manifest as irritability in young children
Mastoiditis: tx
This should be ED referral, as they likely need to be admitted for aggressive IV antibiotics and potential surgery.
Otitis Externa (Swimmer’s Ear)
- Inflammation/infection of the external ear canal
o Often will be associated with tragal tenderness
o Green/black discharge in the edematous/erythematous canal
Otitis Externa (Swimmer’s Ear): tx
o Ciprodex (Ciprofloxacin 0.3% and dexamethasone 0.1% otic solution): 2 drops QID x 7 days
o Cortisporin (Neomycin 0.35%, polymyxin B 10,000units/mL, and hydrocortisone 0.5% otic solution)
Considering placing a wick if extremely swollen to allow for more drops to get into the ear
Rule out concern for mastoiditis
chronic otitis media
- Clear fluid in the Tympanic Membrane
- Feels pressure/pain
- Often associated with seasonal allergies.
chronic otitis media: tx
o Claritin/Zyrtec (5mg QAM)
o Flonase nasal spray (1 squirt in each nostril twice daily)
o Benadryl (1mg/kg) at night before bed
o Vicks vapoRub/peppermint oil behind the ears to help open the eustachian tube; fluid will drain down the throat.
acute otitis media: age limits
- Children over 2 years of age with a fever, treat; if afebrile, can watch and wait and discuss this with caregivers
- Children under 6 months-2 years, treated if infection
- If 2 years old or under, treat for 10 days
o If not responding to amox after 48-72 hours, switch to augmentin - Tougher on the GI system
- Can start with Augmentin in hx of resistant AOM to amox or with co-contaminant purulent conjunctivitis or if on amox in the past 30 days.
acute otitis media: first line tx
- First line: Amoxicillin 80-90mg/kg
o Augmentin: 90mg/kg per day of amox and 6.4mg/kg per day of clavulanate divided BID (max 3gm/day) - Alternatives for penicillin allergy:
o Cefdinir/Omnicef (once or twice daily dosing): 14mg/kg/day divided BID (max 600mg/day)
o Ceftriaxone: 50mg/kg (max 1 gm/day) IM QD 1-3 days
o Azithromycin: 10mg/kg per day orally (max 500mg/day) on day one, then 5mg/kg per day orally (max 250mg/day) days 2-5
o Clindamycin: 20-30mg/kg divided TID (max 1.8g daily
Perforated Tympanic Membrane
- Can happen d/t infection or trauma (loud noises, loud music, explosions, q-tips in the ear)
Perforated Tympanic Membrane: tx
- Oral therapy recommended d/t ototoxicity of drops
o Amoxicillin 90mg/kg/day divided BID x 10 days
o Augmentin 90mg/kg per day of Amoxicillin and 6.4mg/kg per day of clavulanate divided BID x 10 days.
o Cefdinir: 14mg/kg per day in 1-2 doses (max 600mg/day)
o Ceftriaxone: 50mg/kg IM once per day (max 1g/day) for 1-3 doses
o Azithromycin: 10mg/kg/day (max 500mg) on day 1, then 5mg/kg/day (max 250mg) on days 2-5
o Clindamycin: 20-30mg/kg/day divided TID (max 1.8g/day)
Special Considerations
- 4 or more ear infections in 6 months OR 5 or more ear infections in 12 months
- If a child has cochlear implant, treat with Augmentin to target H. influenzae.
- Allergic/Viral conjunctivitis
o Allergic/Viral/Bacterial
o If associated URI symptoms, likely viral/allergic
o Allergic: clear discharge from eyes
* Antihistamines: Zyrtec/Claritin 5mg PO QD
* Zaditor eye drops: 1 drop in each eye BID
* Benadryl at night before bed
Viral/Bacterial Conjunctivitis
can both have crusting/mucopurulent discharge
o Erythromycin ointment (1 thin ribbon four times daily) x 5-7 days
* The easiest for pedi patients (drops can work, but they often cause burning/stinging temporarily, which is not ideal for pedi patients)
* Can cause temporary blurriness
* Avoid touching eyes (tough in children)
* Contagious for 24 hours, once starting treatment; after 24 hours of treatment, please wash pillowcases, towels, etc….
* Trimethoprim-Polymyxin B drops (1-2 drops four times daily) x 5-7 days
Traumatic Hyphema
- Blood in the anterior chamber of the eye
Traumatic Hyphema: hx
vision loss, eye pain, nausea and vomiting, blunt trauma
o Rule out orbital compartment syndrome or open globe
o Needs Intraocular pressure done
Traumatic Hyphema: PE
visual acuity, pupillary response, extraocular movement, visual fields by confrontation, slit lamp, direct fundoscopic exam
Traumatic Hyphema: tx
- Requires a head CT and ENT
corneal abrasion
- Superficial scratch on the cornea
o Caused by some irritant/scratch on eye - Contact lens wearer, makeup,
- Getting something into eye
- Foreign body sensation even once the object is removed
- With/without photophobia
- Increased lacrimation
- Inability to open eye fully
- Pain even with the eye closed/blinking
o Fluorescein stain can confirm (can add Tetracaine drops as well
corneal abrasion: tx
o Avoid direct contact with light (sunglasses)
o Avoid wearing contacts/makeup
o If significantly large, may require a corneal patch (refer to Ophthalmologist/Optometrist)
o If contact wearer tx:
* Ofloxacin drops: 2 drops QID x 7 days
o If not a contact lens wearer:
* Erythromycin ointment: 3-4 applications QID x 5-7 days
Retinoblastoma
- Most common type of eye cancer in children; rare cancer, most common in children 5<; can be inherited
Retinoblastoma: s/s
o A white color in the center circle of the eye (pupil) when light is shone in the eye, such as when someone takes a flash photograph of the child
o Eyes that appear to be looking in different directions
o Poor vision
o Eye redness
o Eye swelling
o Absence of red reflex
o Often caught with families taking pictures with cameras/cell phones
Primary Infantile Glaucoma
- Characterized by a progressive optic neuropathy, manifested by cupping of the optic disc, and usually, but not always, associated with increased intraocular pressure (IOP)
- Onset within the first YOL
- First sign, peripheral vision loss and if not treated can lead to central vision loss
- Early diagnosis and referral and necessary for optimal treatment/timely outcomes
o Refer to the ED
Preseptal/Orbital Cellulitis: s/s
- Infection surrounding the orbit (posterior to the orbit)
- Pain with eye movement
- Proptosis
- Ophthalmoplegia
Preseptal/Orbital Cellulitis: tx
o Refer to the ED for IV antibiotics (Vancomycin/Ceftriaxone)
nasal trauma
- Stop the bleeding
- Concern for concussion/LOC
- Rule out a fracture
o Deviated septum
o Patency of nares - Refer to Pedi ENT
foreign body
- Can try to grab with alligator forceps/clamps
- Close unaffected nostril; have parent blow into the patients mouth very forcefully
- Fogarty Balloon
o Insert the catheter past/through the object, then inflate the balloon and pull out
Epistaxis (Nosebleed)
- How long have they been bleeding?
- Hx of bleeding disorder?
- Trauma?
- Hot/dry air (common in winter d/t forced hot air and summer with AC’s)
Epistaxis (Nosebleed): tx
o Pressure
o Ice (Nose Buddy)
o Nasal saline/Ayr gel/humidifier in room
o Refer for Heme workup if constant and lasting greater than 20 minutes
sinusitis
- With/without fever
- Timeline
- Other symptoms
sinusitis: tx
o Claritin/Zyrtec (5mg QD)
o Flonase
o Benadryl at night before bed
o Saline rinses/Neti pots
o Augmentin: 45 mg/kg/day (max 1.75g/day) divided BID x 10 days
o Cefdinir: 14mg/kg/day (max 600mg/day) divided BID x 10 days
o Levofloxacin: 10-20mg/kg/day (max 500mg/day) divided BID x 10 days
