Module 11 ENT Flashcards
What is the examination procedure to assess the ear and middle ear in infants and children?
- Test hearing
- Assess external ear visually
- Check external ear in not tender to touch before using otoscope
- Pull pinna posterior and inferior in the infant and laterally in the primary school aged child
- Gently insert otoscope looking at external canal first
- Assess tympanic membrane Intact
Colour
Contours
Movement
The motility of and presence of fluid cannot be assessed without using a pneumatic otoscope
What do you look at and comment on for the Otoscopic Inspection of the Drum?
the tympanic membrane should be examined for;
- Intactness
- Colour
- Contour
- Mobility
- intactness
intact
central perforation (usually benign)
marginal perforation (maybe associated with cholesteatoma)
- colour
normal pearly grey
red (associated with otitis media and other infections)
dull (serous otitis media)
blue (blood behind TM, may occur with fracture of base of skull)
- contour
normal
bulging (acute otitis media)
retraction (negative pressure in the middle ear, serous otitis media)
- mobility
normal
decreased
immobile (perforation, grommet, otitis media)
immobile and retracted (chronic secretory otitis media)
Comment on each of these images in regards to the tympanic membrane?
- A, Normal TM.
- B, TM with mild bulging.
- C, TM with moderate bulging.
- D, TM with severe bulging.
Note the
1. Intactness
2. Colour
3. Contour
4. Mobility
Of these 2 middle ears?
A blue or yellow appearance usually indicates a middle-ear effusion.
- Intactness
- Colour
- Contour
- Mobility
- intactness
intact
central perforation (usually benign)
marginal perforation (maybe associated with cholesteatoma)
- colour
normal pearly grey
red (associated with otitis media and other infections)
dull (serous otitis media)
blue (blood behind TM, may occur with fracture of base of skull)
- contour
normal
bulging (acute otitis media)
retraction (negative pressure in the middle ear, serous otitis media)
- mobility
normal
decreased
immobile (perforation, grommet, otitis media)
immobile and retracted (chronic secretory otitis media)
What is going on with these middle ears?
Note
Retraacted membrane due to Eustachian tube dysfunction
Retraction of the tympanic membrane occurs when the eustachian tube is blocked and air pressure within the middle ear cannot be equalised
- There will be no movement with positive pneumatic otoscopy but there maybe mild to moderate movement with negative pneumatic otoscopy
Is a red membrane of middle ear significant?
How about a light reflex?
A red tympanic membrane alone may not indicate pathology, because the blood vessels of the drum head may be engorged as a result of crying, sneezing, or blowing the nose.
- Assessment of the light reflex is generally not helpful, as a middle ear full of fluid reflects the light at least as well as a normal middle-ear space without fluid.
Note the Intactness, colour, contour and mobility of these inner ears?
Answer
Tympanometry
Is used for?
Results may be affected by?
What are the current guidelines around it?
Used to assess the compliance of tympanic membrane
Loss of compliance may indicate middle ear effusion
Loss of compliance will occur with tympanosclerosis and tympanic atrophy
Results may be affected by:
-ear wax
-crying
-moving
-not cooperating
-otitis externa
Readings may be influenced by the examiner or instrument
Current guidelines are:
- Pneumatic otoscopi is the primary tool for diagnosing middle ear effusion in acute otitis media with effusion
-Tympanometry is an optimal tool that can be used to confirm suspected otitis media
Tympanometry
-Useful to monitor child with chronic otitis media (middle ear effusion)
-helps to document response to chiropractic care
-Always compare tympanogram with pneumatic otoscope
-Often measured three monthly with chronic otitis media with effusion
-Used by ENT specialist to determine need for grommets
What is it?
Otitis Externa
An acute bacterial external otitis is characterised by:
-intense pain that is worsened by traction on the pinna
-purulent exudate
-intense canal wall inflammation
Otitis Externa
What are the main signs and symptoms?
- Ear pain! Made worse with pulling on pinna
- Itching
- Conductive hearing loss may result from edema of the skin and tympanic membrane, serous or purulent secretions,
- Swelling of ear canal , think and clumpy stuff in it
- White consistency throughout
- Thecanalfrequentlyissotenderandswollenthattheentireearcanaland tympanic membrane cannot be adequately visualized, and complete otoscopic examination may be delayed until the acute swelling subsides
- Otherphysicalfindingsmayincludepalpableandtenderlymphnodesinthe periauricular and, especially, preauricular areas.
- Rarely,facialparalysis,othercranialnerveabnormalities,vertigo,orsensorineural hearing loss is present.
What is the treatment and management for Otitis Externa?
How would you support the Childs immune system?
- Only use ear drops if sure tympanic membrane is intact
- Can use 50/50 mixture of tea tree oil and olive oil heated to body temperature
- Avoid swimming (also called swimmer’s ear) or block external canal to prevent water entering.
- Adjust the subluxation
- Support child’s immune system
Luteolin (luteol plus -metegenics) + Quercetin (Allergese metegenics) Probiotics (flora care for kids ¼ teaspoon 2 x a day, in order to modulate endogenous flora of GI tract, reduce intestinal permeability, augment cellular and humoral immunity and modulate systemic allergy and inflammation.
How would you test for conductive hearing loss in your office?
Weber test: Place the base of a struck tuning fork on the bridge of the forehead, nose, or teeth. In a normal test, there is no lateralization of sound. With unilateral conductive loss, sound lateralizes toward affected ear. With unilateral sensorineural loss, sound lateralizes to the normal or better-hearing side.
Mastoiditis
A, This frontal photograph clearly shows the left auricle displaced anteriorly and inferiorly.
B, In another patient, viewed from the side, erythema can be appreciated over the mastoid process.
C, On otoscopy, erythema and edema of the canal wall are evident, and the posterosuperior portion of the canal wall sags inferiorly.
Mastoiditis
What is it and
What do we look for and test?
Mastoiditis is a rare condition where the mastoid air cells become infected.
Look for:
1. Head tilt (torticollis)
2. Ear prominence
3. redness and or swelling over mastoid process or behind ear
4. Tenderness of mastoid process
5. Unilateral cervical lymphadenopathy
Whats your knowledge on the research of Antibiotics for Otitis media or mastoiditis in Children?
Conclusions:
- Most children with mastoiditis have not seen their general practitioner for otitis media
-Antibiotics halve the risk of mastoiditis, but the high number of episodes needing treatment to prevent 1 case precludes the treatment of otitis media as a strategy for preventing mastoiditis.
-Although mastoiditis is a serious disease, most children make an uncomplicated recover after mastoidectomy or IV AB
Prevention and Management of Mastoiditis
Answer:
Treatment with antibiotics is indicated when mastoiditis is diagnosed but not indicated to reduce incidence of it.
Mastoiditis is a rare condition where the mastoid air cells become infected.
- Prophylactic treatment of otitis media with antibiotics to try to prevent mastoiditis has been shown to be unnecessary as well as not effective.
- Cochrane Summaries
Trusted evidence. Informed decisions. Better health. Published Online: January
31, 2013
There was not enough information to know if antibiotics reduced rare complications such as mastoiditis (infection of the bones around the ear).
Discuss the research on Antibiotic use and serious complications following acute otitis media and acute sinusitis
Results
Serious complications following AIM and acute sinusitis is rare. AB reduce the odd of developing complications, but odds ratio 0.54
- The incidence of brain abscess and acute mastoiditis following AOM were 0.03 and 5.62 per 10 000 AOM episodes, respectively.
- Antibiotic prescription for AOM was associated with lower odds of developing acute mastoiditis (odds ratio [OR] 0.54); NNT to prevent one case was 2181.
- The incidence of brain abscess and orbital cellulitis following AS was 0.11 and 1.50 per 10 000 AS episodes, respectively.
- Antibiotic prescribing for AS was associated with lower odds of subsequent brain abscess (OR 0.12); NNT to prevent one case was 19 988.
Conclusion
* Serious complications following AOM and AS are rare.
* Antibiotics are associated with lower odds of developing complications, but the NNT are large.
Whats this?
Basilar fracture * Basilar skull fracture.
A, The presence of a basilar skull fracture involving the temporal bone is often signaled by postauricular ecchymotic discoloration, termed the Battle sign.
B, The force of the blow may also cause tearing of the ear canal or, as shown here, middle ear hemorrhage with hemotympanum. Depending on timing of examination, this may appear red or blue.
Otitis Media can be further divided into??
What are the signs of Otitis Media with effusion and Acute Otitis Media? Acute Otitis Media (AOM) is when the ear is painful, or if the doctor looks into the ear and finds the ear drum is bulging with pus. Otitis Media with Effusion (OME) is when there is fluid in the middle ear but no acute infection.
- Acute OM (AOM) without effusion
with effusion - OM with effusion (OME) or serous otitis media
- Chronic suppurative OM with or without cholesteatoma
Cholesteatoma is an abnormal skin growth or skin cyst trapped behind the eardrum, or the bone behind the ear.
Other descriptions of OME include serous, secretory, mucoid, nonsuppurative, and “glue ear.”
Chronic suppurative OM implies a nonintact tympanic membrane (perforation or tympanostomy tube present) with 6wk or more of middle-ear drainage.
Describe what you see here for a normal tympanic membrane?
What do we assess the ear drum for?
- A normal tympanic membrane.
The drum is thin and translucent, and the ossicles are readily visualized.
It is neutrally positioned with no evidence of bulging or retraction.
Describe the epidemiology so you know and for parents of Acute Otitis Media?
- After respiratory tract infections, inflammation of the middle ear, otitis media (OM), is the most prevalent disease of child hood.
- The natural history is that about 85% will resolve spontaneously after 2 to 7 days.
- Nearly two thirds of children have at least one episode of AOM by 3yr of age; 50% of children have two or more episodes .
- Infants and young children are at highest risk for OM, with the peak between 6 and 13mo of age.
- After a single episode of AOM,about
1. 40% of children have OME that persists for 4wk,
2. 10% have an effusion that is still present at 3mo. - The incidence of the disease tends to decrease as a function of age, with a marked decrease after age 6yr.
- The incidence is higher in:
1. Boys
2. children in large day care settings
3. those exposed to second hand smoke
4. non–breast-fed infants
5. those with HIV or biologic siblings or parents with a significant history of OM - OM is most common during the winter months because many episodes are associated with an upper respiratory tract infection (UR I).
Describe the research of Otitis media and AB for yourself and for parents
-Will likely spontaneously recover within a day with or without AB (60% of cases)
Pain: Research to see it improves pain is limited.
Adverse events was reported in every 13th case who received AB. Some of these can cause greater harm to child than the infection itself ie diarrhoea, vomiting, oral thrush or skin rash.
Treatment of acute otitis media in children <2 years pf age - 4 outcomes:
1. No difference in time to resolution of symptoms in children with or without AB
2. The 2nd outcome’
Bla bla
basically don’t give it to them, as research doesn’t support it. Your at risk of doing more harm than good.
There is massive over prescribing of antibiotics in children which led to antibiotic resistant bacteria.
GPs doing a bad job- not following guidelines/
PERSISTANT AB PRESCRIPTION CAN BE THE DRIVER OF decreased IMMUNE and INCREASE IN RECURRENT EAR INFECTIONS.
WHAT IS THE EFFECT OF ANTIBIOTICS ON The immune system and GIT
-* Use of antibiotics destroys the helpful intestinal bacteria which affects digestion, immune function and synthesis of certain vitamins.
* Use of antibiotics inhibits immune function, increasing the likelihood of further infections.
- Antibiotics prevent white blood cell movement to the site of infection,
- Antibiotics reduce the ability of white blood cells to attack bacteria and suppress the
activity of bacteria killing neutrophils. - Antibody production is also decreased for up to 20 days after use.
Certain antibiotics reduce the absorption of nutrients such as vitamin K, B12, folic acid, calcium and magnesium.
◼ In a study of 3,660 children with Otitis media, antibiotic treated children recovered at a slightly slower rate than children not receiving antibiotics.
TELL ME a bit about anti-biotic resistance? What is the cause for concern?
What is common myth?
BS –> “u must finish a course of antibiotics otherwise u get antibiotic resistant bacteria’
Truth: Actually opposite- as soon as symptoms improve - stop AB
The concern is if kid develop AB resistant bacteria- say they develop pneumonia - which Ab can no longer kill - they are more at risk of dying.
Should give parents this fact sheet on ear infections - In reader apparently
How do children Eustachian tubes differ from adults?
They are more horizontal
Their nasopharyngeal opening, is likely to have numerous lymphoid follicles surrounding it.
Also in a child, adenoids may fill the nasopharynx, mechanically blocking the nose and eustachian tube orifice or acting as a source of infection that may contribute to edema and dysfunction of the eustachian tube.
o The eustachian tubes protect the middle ear from nasopharyngeal secretions, provide drainage into the nasopharynx of secretions produced within the middle ear, and permit equilibration of air pressure with atmospheric pressure in the middle ear.
How will a child with an acute otitis media present?
Children with an URI often develop the symptoms of AOM
1. Otalgia
2. fever
3. Hearing loss
4. generalised malaise
Other symptoms:
- irritability
-lethargy
-anorexia, nausea, vomiting, diarrhoea + headache.
ANY CHILD with a fever without focus should be evaluated for a middle ear infection.
What is this?
Bullous Myringitis
Acute otitis media with bullous myringitis.
The bullous lesion commonly ruptures spontaneously, providing immediate relief of pain.
Google: Bullous myringitis, sometimes called infectious myringitis, is a condition where painful blisters (“bullae”) form in the ear, specifically along the tympanic membrane inside the ear.
Myringitis: The term myringitis is used to denote an inflammatory condition of the tympanic membrane (TM), involving its lateral surface with or without the involvement of the adjacent bony external auditory canal.
What is this?
Traumatic tympanic membrane perforation
A, This 8-year-old boy’s tympanic membrane was perforated by a forceful slap on the ear.
(jagged edges- may heal and close up)
B, Even more severe damage with thickening and hemorrhage is seen in this victim of a blast injury caused by an explosion.
(rounded tissue = healed- won’t close up)
What has happened here? How should it be managed?
Sequelae of perforation - Dimerism
= consisting of or divided into two parts.
Otoscopy demonstrates a severely retracted atrophic segment of the eardrum that also has multiple white scars.
The thinned portions are the result of abnormal healing of perforations and tend to be hypermobile on otoscopy.
This will occur post grommets- it will affect sound transmission. Poor connective tissue healing because nutritionally deficient.
Serous Otitis media
This patient has a chronic serous middle ear effusion.
The tympanic membrane is retracted, thickened, and shiny.
Behind it is a clear yellow effusion.
Mobility was decreased and primarily evident on negative pressure.
The child was not acutely ill but did have decreased hearing
What has occurred here? what are the consequences?
Focal thickening of the membrane associated with chronic infections and prior ventilation tube placement is called
tympanosclerosis. This is a hyaline degeneration of the middle fibrous layer of the tympanic membrane that may be calcified
A, Much of this child’s tympanic membrane is scarred and thickened, and a thinned dimeric area balloons out of the inferior central
portion.
B, The eardrum is markedly thickened, scarred in an arc from 12 to 5 o’clock, and has a large chronic perforation.
What is happening here
Cholesteatoma
G: Cholesteatoma is an abnormal skin growth or skin cyst trapped behind the eardrum, or the bone behind the ear.
Causes G:
Besides repeated infections, a cholesteatoma may also be caused by a poorly functioning eustachian tube, which is the tube that leads from the back of the nose to the middle of the ear.
The eustachian tube allows air to flow through the ear and equalize ear pressure. It may not work properly due to any of the following:
chronic ear infections
sinus infections
colds
allergies
If your eustachian tube isn’t working correctly, a partial vacuum might occur in your middle ear. This may cause a section of your eardrum to be pulled into the middle ear, creating a cyst that can turn into a cholesteatoma. The growth then becomes larger as it fills with old skin cells, fluids, and other waste materials.
A, Congenital cholesteatoma noted in a young child with spontaneous ear
drainage. There had been no previous history of ear infections
.
B and C, Acquired cholesteatomas, which generally present after a long history of chronic middle ear disease.
What has occurred here?
Granuloma
- Granulomas and polyps of the tympanic membrane.
A, Growth of this polypoid granuloma was stimulated by the inflammatory process of chronic middle ear infection.
B, These polyps, which protrude through a tympanic membrane perforation, have enlarged to entirely fill the external ear canal. Because of the possible attachment of the polyp to the facial nerve or the ossicles of the middle ear, removal of polyps requires extreme caution.
What are the recommendations around treatment of sinusitis
Treatment of Sinusitis
- NewInfectiousDiseaseSocietyofAmerica(IDSA) guidelines state that most cases of acute rhinosinusitis are caused by viruses and should not be treated with antibiotics
- Up to 98% of cases are caused by viruses and therefore would not be responsive to antibiotics.
- Treat as for general Th1 decreased activity
- Assess for allergy both inhaled and dietary
Most likely to have an issue with cow’s milk protein If signs of hayfever use Luteol Plus (Metagenics) - Treat locally with
Nasoclear (Metagenics) nasal spray – effective
against biofilm
Colloidal silver - effective against biofilm
Inhalation of vaporised tea tree oil, eucalyptus oil, lavender oil etc
What are these? give some info?
Gingival cysts:
Firm, greyish-white mucous gland cysts ion the buccal aspect of the alveolar ridges- called Bohn nodules.
Bohn nodules are small developmental anomalies located along the buccal and lingual aspects of the mandibular and maxillary ridges and in the hard palate of the neonate
These lesions arise from remnant of mucous gland tissue.
Treatment is not necessary, because nodules disappear within a few weeks.
What are these?
Oral Abscess
Dental abscesses. This abscess above the right central incisor has ruptured through the gingiva and began to drain. T
What is this?
What causes it?
Geographic tongue
It is a chronic and often recurring condition affecting the filiform papillae of the tongue.
Lesions are red, slightly depressed, and bordered by a whitish band.
Caused/ associated with stress
What is this?
What is the treatment?
Oropharyngeal Candidiasis
ommon in neonates from contact with the organism in the birth canal or breast.
The diagnosis is confirmed by direct microscopic examination on potassium hydroxide smears and culture of scrapings from lesions
.
OPC is usually self-limited in the healthy newborn infant, but topical application of nystatin to the oral cavity of the baby and to the nipples of breast-feeding mothers will hasten recovery.
Treatment:
Tea tree oil and components exert their anti fungal actions by altering membrane properties.
Tonsilar grading
How would you grade these tonsils?
Answer -probably exam question
What is it? Describe each image and what causes it/
- Tonsillopharyngitis. This common syndrome has a number of causative pathogens and a wide spectrum of severity.
A, The diffuse tonsillar and pharyngeal erythema seen here is a nonspecific finding that can be produced by a variety of pathogens.
B, This intense erythema, seen in association with acute tonsillar enlargement and palatal petechiae, is highly suggestive of group A b-streptococcal infection, though other pathogens can produce these findings.
C, This picture of exudative tonsillitis is most commonly seen with either group A streptococcal or Epstein-Barr virus infection.
Tonsillectomy alone is usually performed for recurrent or chronic pharyngotonsillitis.
What is this diagnosis?
Uvulitis
A, The uvula appears markedly erythematous and edematous, with pinpoint hemorrhages, in this case caused by b-streptococci.
B, In this child with mononucleosis the tonsils are enlarged and covered with a gray membrane and the uvula is edematous and erythematous. The patient had respiratory compromise because of the severity of his tonsillar and adenoidal hypertrophy.
C, The vesicular lesions on the swollen, painful uvula of this patient suggest a viral etiology, probably involving an enterovirus.
Treat as for Th1 suppression
What is this?
Tonsillar Lymphoma
Tonsil cancer may be of the Lymphoma type and usually arise from the lymphatic cells which are found in the wall of the tonsils.
A patient comes in with Stridor: what is the cause?
- An 18 month old female presented with a history of fever, noisy breathing, a harsh cough, and drooling.
- The fever and coughing began yesterday, but tonight the fever is higher and the cough sounds very harsh.
- The sound of this cough was alarming to the parents.
- The highest temperature measured was 39.5 degrees rectally.
- She was noted to be drooling more than usual, but this was attributed to teething.
- Her cry was more raspy than her normal cry.
- She was not taking in solids well, but she was taking liquids well.
- The epiglottis is normal in shape. The pre- epiglottic (vallecular) space is preserved. The airway is patent. There is pre-vertebral soft tissue swelling noted. This radiograph is consistent with a retropharygeal abscess, not croup.
- The retropharyngeal space is a pocket of connective tissue that extends from the base of the skull approximately to the tracheal carina.
- It harbors two chains of lymphoid tissue that drain the nasopharynx, adenoids, and posterior paranasal sinuses. Bacterial infections of the areas drained may result in suppuration of the nodes and abscess formation.
- These lymphatic chains begin to atrophy about the third or fourth year of life. Thus, 50% of the cases of retropharyngeal abscess occur between 6 and 12 months of age, and 96% of cases occur in children under 6 years of age (prior to lymphatic atrophy).
A, This infant had high fever, toxicity, and marked, exquisitely tender anterolateral neck swelling with overlying erythema. These manifestations followed a week of upper respiratory tract symptoms and decreased feeding.
B, His CT scan reveals an encapsulated abscess in the right parapharyngeal area.
Parapharyngeal abscess
Croup
https://www.youtube.com/watch?v=8TBKMn0I9Tk
An upper airway infection that blocks breathing and has a distinctive barking cough.
Croup generally occurs in children.
In addition to a barking cough, symptoms include fever, hoarseness and laboured or noisy breathing.
Most cases clear up with home care in three to five days. A doctor may prescribe a steroid for a persistent case. Rarely, a severe case may need hospital care.
Epiglottitis:
Epiglottitis is a potentially life-threatening condition that occurs when the epiglottis — a small cartilage “lid” that covers your windpipe — swells, blocking the flow of air into your lungs
What is this cause of Stridor in this patient?
- This radiograph shows evidence of epiglottitis (also called supraglottitis).
- The epiglottis is thumb-like in appearance (instead of triangular or flat in shape) and the aryepiglottic folds are thickened.
- The pre-epiglottic space is preserved to some degree, but it is not as large as it should be.
- In many cases of epiglottitis, the pre-epiglottic space is obliterated (replaced by edematous tissue). The retropharyngeal space (pre-vertebral tissue) is not widened.
