Nose/Throat Flashcards
Nose Assessment
External Nose
- Does child have unusual shape
- Saddle shaped nose
- Symmetry, size, normal variations, abnormalities
- Discharge
- Flaring
- Allergic crease or nasal pleat
Nose Assessment
Internal Nose
- Septum – central, deviated, intact
- Patent nares
- Mucosal edema, erythema, discharge
Physical Assessment of the Nose
- 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
Color of Mucosa/Secretions
Red inflamed mucosa
Infection
Pale Boggy Mucosa
Allergy
Swollen grayish mucosa
Chronic rhinitis
Purulent Secretion
- 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
Water nasal secretions indicate
- Allergy
- Common cold
- Ilicit drug use
- Rarely skull fracture
Purulent foul smelling secretions
Foreign body
NOSE
Toddler, school age child, adolescent
- Foreign bodies
- Epistaxis
- Sinusitis/Purulent rhinitis
- Allergic rhinitis
- Nasal Polyps
Epistaxis
History and Physical Exam
- History
- Duration and amount
- Efforts at home
- Prior history
- Medication use
- Physical Exam
- Is patient hemodynamically stable
- Posterior bleeding rare in pediatrics
Epistaxis
Location
Typically anterior in origin in childhood
Little’s area = Kiesselbach’s area or plexus
Causes of Epistaxis
- 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
Management of Epistaxis
- 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
Nose: Quantifying blood loss
- 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
Nose Problems
Nasal
Unilateral foul smelling discharge
Can sometime visualize
Nose problems
Allergic Rhinitis
Inflammation
Edema
Weeping of nasal mucosa
Assessment following midface trauma
- 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
MOUTH and THROAT
Intro
- Defer until last
- Note the color around the mouth
- Inspect lips
- Look for symmetry when open
Angular cheilitis VS. Cheilosis
- Look for angular cheilitis
- Fissures that occur after exposure to wind, sun
- Look for cheilosis
- Occurs with nutritional deficiency
- Riboflavin deficiency
Clinical Eval of the Oral Cavity
Lips, buccal mucosa, gums
- Lips
- Moist, symmetry, color
- Mouth breathing
- Shape of philtrum
- Buccal mucosa (inside cheek)
- Color
- Lesion
- Gums
- Color, swelling, bleeding
Clinical Eval of the Oral Cavity
Tongue, teeth, palate, pharynx
- Tongue
- Size
- Color
- Mobility
- Lesions
- Frenulum
- Teeth
- Palate: color, symmetry, closure
- Pharynx
Eval of the Oral Cavity
Assessment tips
- 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!!!
Clinical Eval – INSPECTION
- 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
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
Tonsils
- Note tonsillar size
- Tonsils enlarge to their peak size at 7 and then will disappear slowly behind the tonsillar pillars
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
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
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
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
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
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
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
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
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
Caries Risk Assessment
Moderate
- Carious teeth in the past 24 months
- 1 area of enamel demineralization (enamel caries “white-spot lesions”)
- Gingivitis*
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‡
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
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
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
CAT – general health conditions
HIGH
Children with special health care needs
Conditions impairing saliva composition/flow
Maxillary Sinus
Present at birth
Rapid growth from birth to 4 and 6-12
Final growth
Frontal Sinus
Last sinuses to develop
Begins between 4-8 years of age
Fully until late adolescence
Ethmoid
Present at birth but not developed
Grow rapidly during the first 4 years
Fully developed by 12 year
Sphenoid
Undeveloped at birth
Does not begin to grow rapidly until after 5 years of age
Complete between 12-15 years of age.
Sleep Problem
Must do physical assessment of HEENT
NASAL POLYP NEED TO RULE OUT
CF
SWEAT TEST
STREP – MOUTH
PETECHIAE ON PALATE
TWO UVULA
BIFID UVULA
SUB-MUCOSAL CLEFT
