Nose, Throat, Mouth Flashcards
External Nose Assessment (6)
- Does child have unusual shape
- Saddle shaped nose
- Symmetry, size, normal variations, abnormalities
- Discharge
- Flaring
- Allergic crease or nasal pleat
Internal Nose Assessment (3)
- Septum—central, deviated, intact
- Patent nares
- Mucosal edema, erythema or discharge
Physical Assessment of the Nose (9)
- 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 other hand
- You should be able to see up the nose
- Do not touch the nares.
- Check that turbinates are equal
Never leave speculum on!
Nasal Fractures and Hematoma
In children, there is only a loose attachment of the upper lateral cartilages to the nasal bones, so it is possible to develop hematomas in this area as well. Untreated hematomas cause pressure necrosis to the septal cartilage, leading to a saddlenose deformity
Red inflamed nasal mucosa…
Infection
Pale boggy nasal mucosa…
Allergy
Swollen grayish nasal mucosa…
Chronic rhinitis
Purulent secretion nasal mucosa…(5)
- Common with any nasal infections
- If the secretions are from high up the nose, may indicate sinus infection
- Discharge and crusty nose indicates streptococal infection.
- Water nasal secretions indicate
- Allergy
- Common cold
- Illicit drug use
- Rarely skull fracture - Purulent foul smelling secretion suggestion foreign body
Common Nasal Problems (5)
- Foreign bodies
- Epistaxis
- Sinusitis/purulent rhinitis
- Allergic rhinitis
- Nasal polyps
History of epistaxis (4)
- Duration and amount
- Efforts at home
- Prior history
- Medication use
Physical of epistaxis (3)
- Is patient hemodynamically stable
- Posterior bleeding rare in pediatrics
- Typically anterior in origin in childhood
A. Little’s area
B. Kiesselbach’s area or plexus
*Look at kiesselbach’s plexus; picking nose will cause scratch of those vessels and then bleeding
Trauma causes of epistaxis (3)
- Digital
- Foreign body
- Air pollution
Inflammation cause of epistaxis
URI
Anatomic cause of epistaxis
Nasal septal deviation
Vascular abnormality leading to epistaxis
Hemangioma
Malignant Neoplasm causing epistaxis (2)
- Rhabdomyosarcoma
2. Lymphoma
Platelet dysfunction leading to epistaxis (3)
- NSAID use, especially aspirin
- ITP
- Leukemia
Coagulopathy cause of epistaxis (3)
- Von Willebrand disease
- Hemophilia
- Liver disease
Benign mass cause of epistaxis (2)
- Pyogenic granuloma
2. papilloma
Management of Epistaxis (5)
- Digital pressure for l0 to l5 minutes
- Silver nitrate cautery
- Topical vasoconstrictors
- - Neo-Synephrine
- - Nasalsponge:mustberemovedin48hours
- - AntibioticRX
- - NosebleedQR - Treatment is use of Bactroban tid for one week
- If posterior bleed must have ENT consult
Nose Bleed Amount (2)
- 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 4*4 gauze is only about 1 tsp of blood. This helps to reassure them that their child is okay.
Allergic Rhinitis Signs (3)
- Inflammation
- Edema
- Weepingofnasal mucosa
Nasal Foreign Body Signs (2)
- Unilateralfoul smelling discharge
2. Can sometimes visualize the object
Nasal polyps
Nasal polyps are seen in children with cystic fibrosis; if you see stringy secretions, think about allergies first, but if there are nasal polyps do sweat test to check for cystic fibrosis
If nasal polyp is blocking the turbinate, the patient will complain of feeling unable to breath through the nose
Assessment Following Midface Trauma (4)
- Observe for deviation of the nasal septum.
- Evaluate the septal hematoma
- - bulging 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 movement to evaluate for orbital fracture
- - Check for pupil reactivity to light. - Look in the oral cavity for any injury from the trauma.
Mouth and Throat Assessment
- Defer until last
- Note 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
*Angular cheilitis usually from strep or candidiasis
Look for cheilosis: Occurs with nutritional deficiency
*Vitamin deficiencies can cause angular cheilosis
Clinical Evaluation of the Lips (3)
- Moist, symmetry, color
- Mouth breathing
- Shape of philtrum
Clinical Evaluation of Buccal Mucosa
Color and lesion
Clinical Evaluation of Gums
Color, swelling, bleeding
Clinical evaluation of the tongue (5)
- Size
- Color
- Mobility
- Lesions
- Frenulum
Clinical Evaluation of Oral Cavity (8)
- Save the posterior pharynx exam for the very last in young children
- Ask child to open their mouth and show you their teeth (appropriate for an 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!!! ! - Inspect the teeth
- -Count the number of teeth and note position
- -Note any defects or discolorations - Inspect gums, mucosal surfaces and posterior
pharynx - Inspect the buccal mucosal and gums looking for ulcers, candida or trauma
- To see the posterior pharynx, you may have to use the tongue blade and gag the child.
Tonsil Evaluation
Note tonsillar size; Tonsils enlarge to their peak size at 7 and than will disappear slowly behind the tonsillar pillars
*By the time puberty is hit, tonsils start to get smaller
Tonsil Grading (1-4)
- 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
Causes of Painful Mouth Ulcers (9)
- Aphthous ulcers of unknown etiology
- Immune deficiency
- Erythema Multiforme
- Leukemia
- Folic Acid
- B 12 deficiency
- Inflammatory Bowel disease
- Neutropenia
- Niacin deficiency
Bifid Uvula
double or notched (bifid) uvula that, when present, serves as a clue to the existence of the palatal abnormality, but may also be asymptomatic
*More common in Caucasians
Clinical Presentations of Strep Tonsilitis (4)
- Nausea and fever may be the only presenting symptom of strep throat
* Strep pharyngitis presents with a lot of systemic symptoms; may even look like appendicitis due to right sided pain can have hives, headache, vomiting, etc. - 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
- May have petechiae on the palate
Scarlet Fever
Strep can secrete a toxin that causes scarlet fever (an exotoxin); will see rash on skin as a result
Scarlet fever isn’t more serious than strep throat; it is just a different stereotype in the same family of strep
Clinical Evaluation of Peritonsillar abscess (4)
- 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
Evolution of how the mouth looks with strep (Day 1-4)
Day 1: My throat hurts
Day 2: Fever
Day 3: begin to see the bulge starting to form (tonsilar abcess) on the side
Day 4: fiery red color of tonsils
*May get worse before getting bettter
Dental Health Assessment: History (11)
- Changes in the teeth or the 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 the teeth or the mouth
- Use of tobacco by adolescent
Dental Care (2)
- Gingivitis begins in early childhood -9-17% of children
aged 3-11 years have gingivitis - If chronic, most common complaint is bleeding gums
Low risk for Dental Caries (3)
- No carious teeth in past 24 months
- No enamel demineralization (enamel caries white-spot lesions )
- No visible plaque; no gingivitis
Moderate risk for Dental Caries (3)
- Carious teeth in the past 24 months
- 1 area of enamel demineralization (enamel caries white-spot lesions )
- Gingivitis
High Risk for Dental Caries (8)
- Carious teeth in the past 12 months
- More than 1 area of enamel demineralization (enamel caries white- spot lesions )
- Visible plaque on anterior (front) teeth Radiographic enamel caries
- High titers of mutans streptococci
- Wearing dental or orthodontic appliances
- Enamel hypoplasia
- Children with special health care needs
- Conditions impairing saliva compositio n/flow
Environmental Characteristics Low Risk for Dental Caries (4)
- 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
Environmental Characteristics Moderate Risk for Dental Caries (3)
- 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
Environmental Characteristics High Risk for Dental Caries (4)
- 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
Dental Diseases (6)
- A tooth surface without caries.
- The first signs of demineralization, a small “white spot” has been formed (initial caries, incipient caries). It is not yet a cavity, the surface is still hard. It is not calculated as “D” (Decayed) according to WHO criteria. With proper measures, the caries process can be halted here and even reversed.
- The enamel surface has broken down. We have got a “lesion” with a soft floor. It is now calculated as a “D” tooth or surface.
- A filling has been made, but as can be seen, the demineralization has not been stopped and the lesion is surrounding the filling.
- The demineralization proceeds and undermines the tooth.
- The tooth has fractured - an effect of a process which could have been stopped at an
early stage!
Maxillary Sinuses (3)
- Present at birth
- Rapid growth from birth to 4 and 6-12
- Final growth
Frontal Sinuses
Last sinuses to develop, begins between 4-8 years of
age
*Fully there until late adolescence
Ethmoid Sinuses (3)
- Present at birth but not developed
- Grow rapidly during the first 4 years
- Fully developed by 12 year
Sphenoid Sinuses (3)
- Undeveloped at birth
- Does not begin to grow rapidly until after 5 years of
age - Complete between 12-15 years of age.
