Paediatric Ear Nose and Throat

Question 1

Tonsillitis

Answer 1

Tonsillitis refers to inflammation in the tonsils.

The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.

The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The most common cause of otitis media, rhinosinusitis and the most common alternative bacterial cause of tonsillitis is Streptococcus pneumoniae.

Other causes:

Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus

Question 2

Waldeyer’s Tonsillar Ring

Answer 2

In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissues, making up the adenoid, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils at either side at the back of the throat.

Question 3

Features of Tonsillitis

Answer 3

A typical presentation is a child with a fever, sore throat and painful swallowing. Children aged 5 to 10 are most often affected, with another peak between ages 15 and 20.

Tonsillitis can present with non-specific symptoms, particularly in younger children. They may present with only a fever, poor oral intake, headache, vomiting or even abdominal pain.

Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.

Always examine the ears (otoscopy) to visualising the tympanic membranes and palpate for any cervical lymphadenopathy when assessing a child with suspected tonsillitis.

Question 4

Centor Criteria

Answer 4

The Centor criteria can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.

A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present:

Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)

Question 5

FeverPAIN Score

Answer 5

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis:

Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza

Question 6

Managing tonsillitis

Answer 6

It is important to exclude other serious pathology, such as meningitis, epiglottitis and peritonsillar abscess. When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score.

Educate patients or parents with likely viral tonsillitis, and give safety net advice about when to seek medical advice. Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. If this occurs you can start antibiotics or consider an alternative diagnosis.

Consider prescribing antibiotics if the Centor score is ≥ 3 or the FeverPAIN score is ≥ 4. Also consider antibiotics if they are at risk of more serious infections, for example young infants, immunocompromised patients or those with significant co-morbidity, or there is a history of rheumatic fever.

Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat, and providing a prescription that is to be collected only in the event that the symptoms do not improve or worsen in the next 2 – 3 days.

Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.

Choice of Antibiotic

Penicillin V (also called phenoxymethylpenicillin) for a 10 day course is typically first line. The trouble with penicillin V is it tastes bad, so young children requiring syrups are often reluctant to take it. Amoxicillin has a better taste but is not part of the guidelines.

Clarithromycin is the first line choice in true penicillin allergy.

Question 7

Complications of tonsillitis

Answer 7

Chronic tonsillitis
Peritonsillar abscess, also known as quinsy
Otitis media if the infection spreads to the inner ear
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis

Question 8

Quinsy

Answer 8

Quinsy is the common name for a peritonsillar abscess. Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.

Peritonsillar abscesses are usually a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis.

Quinsy can occur just as frequently in teenagers and young adults as it does in children, unlike tonsillitis which is much more common in children.

Question 9

Presentation of quinsy

Answer 9

Patients present with similar symptoms to tonsillitis:

Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen tender lymph nodes
Additional symptoms that can indicate a peritonsillar abscess include:

Trismus, which refers to when the patient is unable to open their mouth
Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
Swelling and erythema in the area beside the tonsils on examination

Question 10

Bacterial cause of quinsy

Answer 10

Quinsy is usually due to a bacterial infection. The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.

Question 11

Managing quinsy

Answer 11

Patients should be referred into hospital under the care of the ENT team for incision and drainage of the abscess under general anaesthetic.

Quinsy typically has an underlying bacterial cause, therefore antibiotics are appropriate before and after surgery. A broad spectrum antibiotic such as co-amoxiclav would be an appropriate choice to cover the common causes, but local guidelines will guide antibiotic choice according to local bacterial resistance.

Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.

Question 12

Tonsillectomy

Answer 12

Tonsillectomy is the name for the surgical removal of the tonsils. Removing the tonsils prevents further episodes of tonsillitis, although patients can still get a sore throat. The procedure is usually performed as a day case, and patients go home 6 – 8 hours after the operation, after a period of observation.

Question 13

Indications for tonsillectomy

Answer 13

A common question you will get from patients and parents is whether a child needs a tonsillectomy for recurrent tonsillitis. The NICE clinical knowledge summaries give the number of episodes required for a tonsillectomy:

7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
Other indications are:

Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring

Question 14

Complications of tonsillectomy

Answer 14

Pain, particularly a sore throat where the tonsillar tissue has been removed. This can last 2 weeks.
Damage to teeth
Infection
Post-tonsillectomy bleeding
Risks of a general anaesthetic

Question 15

Post Tonsillectomy Bleeding

Answer 15

Post tonsillectomy bleeding is the main significant complication after a tonsillectomy. Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy and it requires urgent management. This can happen up to 2 weeks after the operation. Bleeding can be severe and in rare cases life threatening, usually due to aspiration of blood.

Management:

Call the ENT registrar and get them involved early
Get IV access and send bloods including a FBC, clotting screen, group and save and crossmatch
Keep the child calm and give adequate analgesia
Sit them up and encourage them to spit the blood rather than swallowing
Make the child nil by mouth incase an anaesthetic and operation is required
IV fluids for maintenance and resuscitation as required
If there is severe bleeding or airway compromise, call an anaesthetist as intubation may be required.

Prior to going back to theatre there are two options for stopping less severe bleeds:

Hydrogen peroxide gargle
Adrenalin soaked swab applied topically

Question 16

Otitis media

Answer 16

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (ear drum) and the inner ear. This is where the cochlea, vestibular apparatus and nerves are found. It is a very common site of infection in children. The bacteria enter from the back of the throat through the eustachian tube. A bacterial infection of the middle ear is often preceded by a viral upper respiratory tract infection.

Question 17

Bacterial cause of otitis media

Answer 17

The most common bacterial causes of otitis media, as well as other ENT infections such as rhino-sinusitis and tonsillitis is streptococcus pneumoniae.

Other common causes include:

Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

Question 18

Presentation of otitis media

Answer 18

Otitis media typically presents with ear pain, reduced hearing in the affected ear and general symptoms of upper airway infection such as fever, cough, coryzal symptoms, sore throat and feeling generally unwell.

When the infection affects the vestibular system it can cause balance issues and vertigo. When the tympanic membrane has perforated there may be discharge from the ear.

It is worth noting that symptoms can be very non-specific, particularly in young children and infants. They may present with symptoms of fever, vomiting, irritability, lethargy or poor feeding. It is always worth examining the ears in unwell children.

Question 19

Examining otitis media

Answer 19

Always examine both ears and the throat of unwell children. These are common sites of infection and can produce non-specific symptoms. Use an otoscope to visualise the tympanic membrane whilst gently pulling the pinna up and backwards. It may be difficult to visualise the tympanic membrane if there is significant discharge or wax in the ear canal.

In a normal child the tympanic membrane should be “pearly-grey”, translucent and slightly shiny. You should be able to visualise the malleus through the membrane and a cone of light reflecting the light of the otoscope.

Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.

Question 20

Managing otitis media

Answer 20

Consider referral to paediatrics for assessment or admission if symptoms are severe or there is diagnostic doubt. Always refer for specialist assessment and to consider admission in infants younger than 3 months with a temperature above 38ºC or 3 – 6 months with a temperature higher than 39ºC.

Most cases of otitis media will resolve without antibiotics, and NICE guidelines from 2018 highlight the importance of not providing antibiotics for otitis media. They state that most cases of otitis media will resolve within 3 days without antibiotics, but it can last for up to a week. Complications (mainly mastoiditis) are rare. Give simple analgesia to help with pain and fever.

There are three options regarding prescribing antibiotics to patients with otitis media:

Immediate antibiotics
Delayed prescription
No antibiotics
Consider prescribing antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised. Children less than 2 years with bilateral otitis media and children with otorrhoea (discharge) are more likely to benefit from antibiotics.

Consider a delayed prescription that can be collected and used after 3 days if symptoms have not improved or have worsened at any time. This can be useful with patients that are very keen on antibiotics or where you suspect they might get worse.

The first line choice of antibiotic is amoxicillin for 5 days. Alternatives are erythromycin and clarithromycin.

Always safety-net, offering education and advice to patients and parents on when to seek further medical attention.

Question 21

Complications of otitis media

Answer 21

Otitis media with effusion
Hearing loss (usually temporary)
Perforated eardrum
Recurrent infection
Mastoiditis (rare)
Abscess (rare)

Question 22

Glue ear

Answer 22

Glue ear is also known as otitis media with effusion. The middle ear becomes full of fluid, causing a loss of hearing in that ear.

The Eustachian tube connects the middle ear to the back of the throat. It helps drain secretions from the middle ear. When it becomes blocked, this causes middle ear secretions (fluid) to build up in the middle ear space.

The main symptom of glue ear is a reduction in hearing in that ear. The main complication of glue ear is infection (otitis media).

Otoscopy can show a dull tympanic membrane with air bubbles or a visible fluid level, although it can look normal.

Question 23

Managing glue ear

Answer 23

Referral for audiometry to help establish the diagnosis and extent of hearing loss. Glue ear is usually treated conservatively, and resolves without treatment within 3 months. Children with co-morbidities affecting the structure of the ear, such as Down’s syndrome or cleft palate may require hearing aids or grommets.

Grommets

Grommets are tiny tubes inserted into the tympanic membrane by an ENT surgeon. This allows fluid from the middle ear to drain through the tympanic membrane to the ear canal. Usually grommets are inserted under general anaesthetic as a day case procedure. The procedure is relatively safe with few complications. Grommets usually fall out within a year, and only 1 in 3 patients require further grommets to be inserted for persistent glue ear.

Question 24

Causes of hearing loss

Answer 24

Hearing loss can be congenital, occurring prior to birth, or acquired, as the result of an illness during childhood.

Common Causes

Congenital

Maternal rubella or cytomegalovirus infection during pregnancy
Genetic deafness can be autosomal recessive or autosomal dominant
Associated syndromes, for example Down’s syndrome
Perinatal

Prematurity
Hypoxia during or after birth
After birth

Jaundice
Meningitis and encephalitis
Otitis media or glue ear
Chemotherapy

Question 25

Presentation of hearing loss

Answer 25

The UK newborn hearing screening programme (NHSP) tests hearing in all neonates. This involves special equipment that delivers sound to each eardrum individually and checks for a response. This can identify congenital hearing problems early.

Children with hearing difficulties may present with parental concerns about hearing or with behavioural changes associated with not being able to hear:

Ignoring calls or sounds
Frustration or bad behaviour
Poor speech and language development
Poor school performance

Question 26

Audiometry and audiogram

Answer 26

Audiometry

Younger children (under 3 years) are tested by looking for a basic response to sound (i.e. turning towards a sound). Older children can be tested properly with headphones and specific tones and volumes. The results of audiometry testing are recorded on an audiogram, which can help identify and differentiate conductive and sensorineural hearing loss.

Audiogram

Audiograms are charts that document the volume at which patients can hear different tones. The frequency in hertz (Hz) is plotted on the x-axis, from low to high pitched. The volume in decibels (dB) is plotted on the y-axis, from loud at the bottom to quiet at the top. It is worth noting that the lower down the chart, the higher the decibels and the louder the volume.

Hearing is tested to establish the minimum volume required for the patient to hear each frequency, and this level is plotted on the chart. The louder the sound required for the patient to hear, the worse their hearing is and the lower on the chart they will plot. For example, a 1000 Hz sound will be played at various volumes until the patient can just about hear the sound. If this sound is heard at 15 dB, a mark is made on the chart where 1000 Hz meets 15 dB. If this sound can only be heard at 80 dB, a mark is made where 1000 Hz meets 80 dB.

Hearing is tested in both ears separately. Both air and bone conduction are tested separately. The following symbols are used to mark each of these separate measurements:

X – Left sided air conduction
] – Left sided bone conduction
O – Right sided air conduction
[ – Right sided bone conduction
When a patient has normal hearing, all readings will be between 0 and 20 dB, at the top of the chart.

In patients with sensorineural hearing loss, both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart. This may affect only one side, one side more than the other or both sides equally.

In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB), however air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. In conductive hearing loss, sound can travel through bones but is not conducted through air due to pathology along the route into the ear.

In patients with mixed hearing loss, both air and bone conduction readings will be more than 20 dB, however there will be a difference of more than 15 dB between the two (bone conduction > air conduction).

Question 27

Managing hearing loss

Answer 27

Establishing the diagnosis is the first step. After the diagnosis is established, input from the multidisciplinary team is required for support with hearing, speech, language and learning:

Speech and language therapy
Educational psychology
ENT specialist
Hearing aids for children who retain some hearing
Sign language

Question 28

Nosebleeds

Answer 28

Nosebleeds are also known as epistaxis. They originate from Kiesselbach’s plexus, which is also known as Little’s area. This is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels. When the mucosa is disrupted in this area and the blood vessels are exposed, for example due to trauma from a child picking their nose, they are prone to bleeding.

TOM TIP: Little’s area (the area most affected by Little fingers) is a popular topic in exams. Remember the name of this area as examiners like to ask “what is the most likely location of the bleeding?”

Question 29

Presentation of nosebleeds

Answer 29

Nosebleeds are common in otherwise healthy children. They can be triggered by nose picking, colds, vigorous nose blowing, trauma and changes in the weather. If children swallow blood during a nosebleed, they may present with vomiting blood. Bleeding is usually unilateral. Bleeding from both nostrils may indicated bleeding posteriorly in the nose.

Question 30

Managing nosebleeds

Answer 30

Nosebleeds will usually resolve without needing any medical assistance. Recurrent and significant nosebleeds might require investigations to look for an underlying cause, such as thrombocytopenia or clotting disorders.

You may have to advise patients and parents on how to manage a nosebleed:

Sit up and tilt the head forwards. Tilting the head backwards is not advised as blood will flow towards the airway.
Squeeze the soft part of the nostrils together for 10 – 15 minutes
Spit any blood in the mouth out rather than swallowing
When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, from both nostrils or they are unstable, patients may require admission to hospital. Treatment options are:

Nasal packing using nasal tampons or inflatable packs
Nasal cautery using a silver nitrate stick
After treating a nosebleed consider prescribing naseptin (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.

Question 31

Cleft lip

Answer 31

Cleft lip is a congenital condition where there is a split or open section of the upper lip. This opening can occur at any point along the top lip, and can extend as high as the nose.

Cleft palate is where a defect exists in the hard or soft palate at the roof of the mouth. This leaves an opening between the mouth and the nasal cavity. Cleft lip and cleft palate can occur together or on their own.

Most cases of cleft lip and cleft palate occur randomly. Having a relative with cleft lip or palate makes it slightly more likely, however it does not follow a traditional inheritance pattern like conditions such as cystic fibrosis. 3 in 10 cases of cleft lip or palate are associated with another underlying syndrome.

Question 32

Complications of cleft lip

Answer 32

Cleft lip or cleft palate is not life threatening, although it can lead to significant problems with feeding, swallowing and speech. It can also have significant psycho-social implications, including affecting bonding between mother and child. Surgery generally resolves these problems. Children with cleft palates can be more prone to hearing problems, ear infections and glue ear.

Question 33

Managing cleft lip

Answer 33

Patients should be referred to the local cleft lip services. This involves the specialist multi-disciplinary team:

Specialist nurses to support and coordinate care
Plastic, maxillofacial and ENT surgeons
Dentists
Speech and language therapists
Psychologists
General practitioners
The first priority is to ensure the baby can eat and drink. This may involve specially shaped bottles and teats. The specialist nurse will follow the child up through surgery and beyond to ensure good development.

The definitive treatment is to surgically correct the cleft lip or palate. This leaves a subtle scar, but is generally very successful, giving full functionality to the child. Cleft lip surgery is usually performed at 3 months, whilst cleft palate surgery done at 6 – 12 months.

Question 34

Tongue tie

Answer 34

Tongue tie is also known as ankyloglossia. This is when a baby is born with a short and tight lingual frenulum, the attachment of the tongue to the floor of the mouth. This prevents them properly extending their tongue out of the mouth and makes it difficult for them to latch onto the breast. It usually presents as poor feeding or when noticed by the mother, midwife or doctor on newborn checks.

Question 35

Managing tongue tie

Answer 35

Mild tongue tie can be monitored and would not be expected to cause any issues.

When it affect feeding they may benefit from treatment. Tongue tie can be cured with a frenotomy. This involves a trained person cutting the tongue tie. This can usually be done on the ward or in the clinic without any anaesthetic. Complications are very rare, and include excessive bleeding, scar formation and infection.

Question 36

Cystic hygroma

Answer 36

A cystic hygroma is a malformation of the lymphatic system that results in a cyst filled with lymphatic fluid. It is most commonly a congenital abnormality and is typically located in the posterior triangle of the neck on the left side.

It may be seen on antenatal scans, picked up on routine baby checks or discovered later when noticed incidentally.

Question 37

Features of cystic hygroma

Answer 37

Cystic hygromas most commonly present in the neck or armpit. They:

Can be very large
Are soft
Are non-tender
Transilluminate
To transilluminate the cystic hygroma, hold a pen torch flat against the skin and watch as the whole thing lights up like a bulb.

Question 38

Complications of cystic hygroma

Answer 38

Depending on the location and size, cystic hygromas can interfere with feeding, swallowing or breathing. It can become infected, in which case it will turn red, hot and tender. There can be haemorrhage into the cyst.

Question 39

Managing cystic hygroma

Answer 39

Treatment varies based on the size, location and complications. Watching and waiting can be appropriate as it is a benign condition. They do not resolve spontaneously, but can show some regression.

Aspiration (giving temporary improvement), surgical removal and sclerotherapy are treatment options.

Question 40

Thyroglossal cysts

Answer 40

During fetal development, the thyroid gland starts at the base of the tongue. From here it gradually travels down the neck to its final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists it can give rise to a fluid filled cyst. This is called a thyroglossal cyst.

Ectopic thyroid tissue is a key differential diagnosis, as this commonly occurs at a similar location.

The main complication is infection of the cyst, causing a hot, tender and painful lump.

Question 41

Features of thyroglossal cyst

Answer 41

Thyroglossal cysts usually occur in the midline of the neck. They are:

Mobile
Non-tender
Soft
Fluctuant
Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.

TOM TIP: Remember the key feature of thyroglossal cysts moving with movement of the tongue. This is a unique fact examiners like to use to test your knowledge. Look out for a thyroglossal cyst as a differential of a neck lump in your MCQ exam. If you come across a midline neck lump in a young child in your OSCEs, ask them to stick their tongue out and look for the lump moving upwards.

Question 42

Managing thyroglossal cyst

Answer 42

Ultrasound or CT scan can confirm the diagnosis.

Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the full thyroglossal duct is removed.

Question 43

Branchial Cyst

Answer 43

A branchial cyst is a congenital abnormality arising when the second branchial cleft fails to properly form during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much more rare.

Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.

Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected.

TOM TIP: Branchial cysts may appear in exams as a differential of neck lumps in teenagers or as part of a neck examination in an OSCE. Remembering the key features will help you differentiate them in your exams. They are just anterior to the sternocleidomastoid muscle, round, soft and non-tender. If the lump transilluminates, it is more likely to be a cystic hygroma. They might ask you where it was most likely to originate, and the answer would be the second branchial cleft.

Question 44

Sinuses and Fistulas

Answer 44

A sinus is a blind ending pouches. A fistula is an abnormal connection between two epithelial surfaces.

A branchial cleft sinus describes when the branchial cyst is connected via a tract to the outer skin surface. There will be a small hole visible in the skin beside the cyst. There may be a noticeable discharge from the sinus.

A branchial pouch sinus describes when the branchial cyst is connected via a tract to the oropharynx.

A branchial fistula describes when there is a tract connecting the oropharynx to the outer skin surface via the branchial cyst.

Sinuses and fistula pose an increased risk of infections in the branchial cyst, as they are a way for pathogens to get in.

Question 45

Managing branchial cyst

Answer 45

Where the branchial cleft is not causing any functional or cosmetic issues, conservative management may be appropriate.

Where recurrent infections are occurring, there is diagnostic doubt about the cause of the neck lump or it is causing other functional or cosmetic issues, surgical excision may be appropriate.