Nose/Throat Flashcards
1
Q
Nose Assessment
External Nose
A
- Does child have unusual shape
- Saddle shaped nose
- Symmetry, size, normal variations, abnormalities
- Discharge
- Flaring
- Allergic crease or nasal pleat
2
Q
Nose Assessment
Internal Nose
A
- Septum – central, deviated, intact
- Patent nares
- Mucosal edema, erythema, discharge
3
Q
Physical Assessment of the Nose
A
- Look at the nose
- Palpate the soft tissue and ridge of the nose
- Tilt the child head back
- Check each nare separately using the otoscope light
- Note the color of the mucosa
- Push the tip of the nose upward and hold the light with the other hand
- You should be able to see up the nose
- Do not touch the nares
- Turbinates
- Equal
4
Q
Color of Mucosa/Secretions
Red inflamed mucosa
A
Infection
5
Q
Pale Boggy Mucosa
A
Allergy
6
Q
Swollen grayish mucosa
A
Chronic rhinitis
7
Q
Purulent Secretion
A
- Common with any nasal infections
- If the secretions are from high up in the nose, may indicate sinus infection
- Discharge and crusty nose indicates streptococcal infection
8
Q
Water nasal secretions indicate
A
- Allergy
- Common cold
- Ilicit drug use
- Rarely skull fracture
9
Q
Purulent foul smelling secretions
A
Foreign body
10
Q
NOSE
Toddler, school age child, adolescent
A
- Foreign bodies
- Epistaxis
- Sinusitis/Purulent rhinitis
- Allergic rhinitis
- Nasal Polyps
11
Q
Epistaxis
History and Physical Exam
A
- History
- Duration and amount
- Efforts at home
- Prior history
- Medication use
- Physical Exam
- Is patient hemodynamically stable
- Posterior bleeding rare in pediatrics
12
Q
Epistaxis
Location
A
Typically anterior in origin in childhood
Little’s area = Kiesselbach’s area or plexus
13
Q
Causes of Epistaxis
A
- Trauma
- Digital, foreign body, air pollution
- Inflammation
- URI
- Anatomic
- Nasal septal deviation
- Vascular abnormalities
- Hemangioma
- Malignant neoplasm
- Phabdomyosarcoma, lymphoma
- Platelet dysfunction
- NSAID use, especially aspirin
- ITP
- Leukemia
- Coagulopathy
- Von Willebrand disease
- Hemophilia
- Liver Disease
- Benign masses
- Pyogenic granuloma
- Papilloma
14
Q
Management of Epistaxis
A
- Digital pressure for 10-15 minutes
- Silver nitrate cautery
- Topical vasoconstrictors
- Neo-synephrine
- Nasal sponge: must be removed in 48 hours
- Antibiotic RX
- Nosebleed QR
- Treatment is use of bactroban tid for one week
- If posterior bleed must have ENT consult
15
Q
Nose: Quantifying blood loss
A
- When mothers/teachers get worried about the amount of blood lost due to nose bleeds, it is helpful to quantify how much blood the child actually lost
- Blood that would saturate a 4x4 gauze is only about 1 tsp of blood
- Reassurance
16
Q
Nose Problems
Nasal
A
Unilateral foul smelling discharge
Can sometime visualize
17
Q
Nose problems
Allergic Rhinitis
A
Inflammation
Edema
Weeping of nasal mucosa
18
Q
Assessment following midface trauma
A
- Observe for deviation of the nasal septum
- Evaluate the septal hematoma
- Bulding of nasal septum into the nasal cavity
- Can deprive cartilage and overlying mucoperichondrium of blood supply
- Is there any clear fluid leak of CSF as a result of skull fracture through the cribriform plate
- Do vision screening
- Do extraocular movements to evaluate for orbital fracture
- Check for pupil reactivity to light
- Look in the oral cavity for injury from the trauma
19
Q
MOUTH and THROAT
Intro
A
- Defer until last
- Note the color around the mouth
- Inspect lips
- Look for symmetry when open
20
Q
Angular cheilitis VS. Cheilosis
A
- Look for angular cheilitis
- Fissures that occur after exposure to wind, sun
- Look for cheilosis
- Occurs with nutritional deficiency
- Riboflavin deficiency
21
Q
Clinical Eval of the Oral Cavity
Lips, buccal mucosa, gums
A
- Lips
- Moist, symmetry, color
- Mouth breathing
- Shape of philtrum
- Buccal mucosa (inside cheek)
- Color
- Lesion
- Gums
- Color, swelling, bleeding
22
Q
Clinical Eval of the Oral Cavity
Tongue, teeth, palate, pharynx
A
- Tongue
- Size
- Color
- Mobility
- Lesions
- Frenulum
- Teeth
- Palate: color, symmetry, closure
- Pharynx
23
Q
Eval of the Oral Cavity
Assessment tips
A
- Save the posterior pharynx exam for the last in young children
- Ask child to open their mouth and show you their teeth (appropriate for older toddler/child)
- Moisten the tongue blade
- An alternative is to be flexible and look in the mouth when the child is crying for some other reason!!!
24
Q
Clinical Eval – INSPECTION
A
- Inspect the teeth
- Count the number of teeth and note position
- Note any defects or discolorations
- Inspect the gums, mucosal surfaces and posterior pharynx
- Inspect the buccal mucosa and gums looking for ulcers, candida, or trauma
25
How to see the Posterior Pharynx
* You may have to use the tongue blade and gag the child
* Alternative tricks you can use include asking the child to -- roar like a lion; pant like a dog
* HAH-HAH Test
* Sing LA-LA-LA
* Pretending your tongue is stuck down and out
26
Tonsils
* Note tonsillar size
* Tonsils enlarge to their peak size at 7 and then will disappear slowly behind the tonsillar pillars
27
Tonsil Grading
* Tonsils are +1 if they are visible only slightly beyond the tonsillar pillars
* Tonsils are +2 if they are midway between tonsillar pillars and uvula
* Tonsils are +3 if they are nearly touching the uvula
* Tonsils are +4 if they are touching at midline and occluding view of oropharynx
28
Geographic Tongue
Geographic tongue (benign migratory glossitis) is a painless condition characterized by in amed, irregularly shaped areas on the dorsum of the tongue that are devoid of liform papil- lae.
Lesions are red, slightly depressed, and bordered by a whitish band
29
Causes of Painful Mouth Ulcers
* Aphthous ulcers of unknown etiology
* Immune deficiency
* Erythema Multiforme
* Leukemia
* Folic Acid
* B 12 deficiency
* Inflammatory Bowel disease
* Neutropenia
* Niacin deficiency
30
Clinical Presentation of Streptococcal Tonsilitis
* Nausea and fever may be the only presenting symptom of strep throat
* Always examine the throat of a child with abdominal pain especially on the right side since you can get lymphoid tenderness in the right lower quadrant pain
* Epigastric tenderness and headache is another sign of strep
31
Pastia's Lines
After generalization the rash becomes accentuated in skin folds and creases, and 1 to 3 days after its appearance, petechiae may appear in a linear distribution along the creases, forming Pastia lines
32
Peritonsillar Abscess
* Most common deep infection of neck
* Typical complication of tonsillitis
* Extension of infection from tonsil
* Abscess form between tonsil capsule and superior constructor muscle
* Obstruction and infection of weber gland
33
Dental Health Assessment: History
* Changes in teeth or mouth
* Oral hygiene practices (frequency, problems)
* Use of fluoridated water for drinking or cooking
* Fluoride use (fluoridated toothpaste, fluoride supplements)
* Dental sealant use
* Eating practices
* Illnesses or infections
* Medications
* Physical activity and sports participation
* Injuries to teeth or mouth
* Use of tobacco by adolescent
34
Preventative Counseling
Dental care/Dental caries
Gingivitis begins in early childhood
9-17% of children aged 3-11 years have gingivitis
If chronic, most common complaint is bleeding gums
35
Caries risk assessment
Low risk
* No carious teeth in past 24 months
* No enamel demineralization (enamel caries “white-spot lesions”)
* No visible plaque; no gingivitis
36
Caries Risk Assessment
Moderate
* Carious teeth in the past 24 months
* 1 area of enamel demineralization (enamel caries “white-spot lesions”)
* Gingivitis\*
37
Caries Risk Assessment
High Risk
* Carious teeth in the past 12 months
* More than 1 area of enamel demineralization (enamel caries “whitespot lesions”)
* Visible plaque on anterior (front) teeth
* Radiographic enamel caries
* High titers of mutans streptococci
* Wearing dental or orthodontic appliances†
* Enamel hypoplasia‡
38
CAT -- Environmental
Low Risk
* Optimal systemic and topical fluoride exposure
* Consumption of simple sugar or foods strongly associated with caries initiation primarily at mealtimes
* High care giver socioeconomic status
* Regular use of dental care in an established dental home
39
CAT -- Environmental
Moderate
* Suboptimal systemic fluoride exposure with optimal topical exposure
* Occasional (i.e., 1-2) between-meal exposures to simple sugars or foods strongly associated with caries
* Midlevel caregiver socioeconomic status (i.e., eligible for school lunch program or SCHIP)
* Irregular use of dental services
40
CAT -- Environmental
HIGH
* Suboptimal topical fluoride exposure
* Frequent (i.e., 3 or more) between meal exposures to simple sugars or foods strongly associated with caries
* Low-level caregiver socioeconomic status (i.e., eligible for Medicaid)
* No usual source of dental care
41
CAT -- general health conditions
HIGH
Children with special health care needs
Conditions impairing saliva composition/flow
42
Maxillary Sinus
Present at birth
Rapid growth from birth to 4 and 6-12
Final growth
43
Frontal Sinus
Last sinuses to develop
Begins between 4-8 years of age
Fully until late adolescence
44
Ethmoid
Present at birth but not developed
Grow rapidly during the first 4 years
Fully developed by 12 year
45
Sphenoid
Undeveloped at birth
Does not begin to grow rapidly until after 5 years of age
Complete between 12-15 years of age.
46
Sleep Problem
Must do physical assessment of HEENT
47
NASAL POLYP NEED TO RULE OUT
CF
SWEAT TEST
48
STREP -- MOUTH
PETECHIAE ON PALATE
49
TWO UVULA
BIFID UVULA
SUB-MUCOSAL CLEFT
