Paediatric ENT Flashcards
What is the most common causative organism of scarlet fever?
Strep pyogenes
How does scarlet fever present?
Fine, pinhead erythema
Rough sandpaper like texture to the skin
Strawberry tongue
Fever, malaise, lethargy
Sore throat
Can be febrile seizures
How is scarlet fever managed?
Penicillin V - need a prolonged course of 10 days
How long does a child with scarlet fever need to be kept off school?
Until 24 hours after commencing Abx (scarlet fever)
What are complications of scarlet fever?
Otitis media
Rheumatic fever
Acute glomerulonephritis
What is the most common bacterial cause of otitis media?
Strep pneumoniae
-Other common bacterial pathogens that can cause otitis media include Haemophilus influenzae and Moraxella catarrhalis.
It’s worth noting that viral infections, such as respiratory syncytial virus (RSV) and rhinovirus, are also frequent contributors to otitis media.
What is glue ear?
Acute otitis media with effusion
Middle ear becomes full of fluid and leads to hearing loss
Due to blockage of the Eustachian tube
How is glue ear seen on otoscopy?
Dull tympanic membrane
Air bubbles
Visible fluid level
How is glue ear managed?
Gommets may be needed if there is a structural abnormality e.g. Down syndrome/cleft palate
What are congenital causes of hearing loss?
Maternal Rubella/cytomegalovirus
Genetic deafness
Down syndrome
What are post-birth causes of hearing loss?
Jaundice (kernicterus)
Meningitis/encephalitis
Otitis media/glue ear
Chemotherapy
What is cleft lip and cleft palate?
Cleft lip = split/open section of upper lip
Cleft palate = defect in hard/soft palate with opening in between mouth and nasal cavity
When does surgery for cleft lip and palate occur?
Lip = 3months Palate = 6-12 months
Which type of congenital neck lump transilluminates? Where does this neck lump usually sit?
Cystic hygroma
Posterior to sternocleidomastoid
What is the most appropriate hearing test in newborns? What do you do if this test is abnormal?
Otoacoustic emission test – should be done as part as the newborn hearing screening programme
If abnormal – auditory brainstem response test
What hearing test is usually done at schools?
Pure tone audiometry
Summary of hearing tests in children:
A 6 year old boy presents at GP with a 3 day history of agitation and reduced feeding. His parents report that he has been tearful and is eating about half of what would be normal for him. He is drinking normally and talking. His mother hasn’t noticed a cough. On examination he is slightly febrile with a temperature of 38.2. Some cervical swelling is noted on the right side. The tonsils appear enlarged, inflamed and a purulent exudate is noted. His mother states she is very worried because the last time this happened he was given penicillin by the doctor, but had to stop taking it because he developed a rash.
Given the most likely diagnosis what is the most appropriate treatment?
A. Cefalexin for 7 days
B. Erythromycin for 3 days
C. Cefalexin for 3 days
D. Offer reassurance that things should resolve quickly as he has already been unwell for 3 days
E. Erythromycin for 5 days
E. Erythromycin for 5 days
-normally Phenoxymethylpenicillin (penicillin V, 500mg PO, 10 days, QDS.
4/4 on CENTOR criteria: Research has shown that patients with a score of 3 or more would benefit from taking antibiotics leading to a 1 day reduction in overall recovery time. Current guidance is to offer treatment for 5-10 days to ensure complete eradication of Streptococcus pyogenes (group A streptococcus) (most likely cause) and prevent further complications
Cefalexin is a 1st generation cephalosporin and so works in the same way as other beta-lactam antibiotics such as penicillin. Avoid cephalosporins in penicillin allergic people (cross-reactivity)
What is classified as recurrent tonsilitis (x a year, for how long)?
- > 7 episodes per year for one year
- > 5 per year for 2 years
- > 3 per year for 3 years)
when should antibiotics be prescribed in otitis media:
- if the symptoms last >4 days
- they are systemically unwell,
- immunocompromised
4, have evidence of tympanic perforation (eg discharge):
-Oral amoxicillin (or macrolides if penicillin allergic), 5 days
-Review in 6 weeks to ensure healing
clinical features of acute otitis media:
rapid onset of:
pain
fever
irritability
anorexia
vomiting
often after a viral upper respiratory tract infection
management of otitis media:
- Admit any children under 3 months with a temperature of 38 or more, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy.
- Consider admitting any children who are very systemically unwell.
- Otherwise, treat pain and fever with paracetamol or ibuprofen.
- Most children will not require antibiotics. A delayed antibiotic prescribing strategy can also be appropriate. This involves asking patients/parents to start taking antibiotics if symptoms don’t improve within four days.
- Offer immediate antibiotic prescription to children who are systemically unwell (but don’t require admission) or those at high risk of complications (e.g. immunocompromised patients).
Complications of otitis media (extracranial vs intracranial):
Extra-cranial Complications of Otitis Media
1. Facial nerve palsy:
Acute otitis media can lead to a lower motor neuron lesion of the VII cranial nerve.
Patients usually recover well with treatment of the otitis media.
- Mastoiditis:
Infection can spread from the middle ear to form an abcess in the mastoid air spaces of the temporal bone.
This leads to postauricular swelling pushing the auricle outwards and forwards.
Mastoid tenderness will be present.. - Petrositis:
Infection spreading to the apex of the petrous temporal bone.
There is a triad of symptoms which leads to Gradenigo syndrome: otorrhoea, pain deep inside the ear and the eye and ipsilateral VI nerve palsy. - Labrynthtitis:
Inflammation of the middle ear can lead to inflammation of the semicircular canals leading to the symptoms of vertigo, nausea, vomiting and imbalance.
Intra-cranial Complications of Otitis Media
- Meningitis:
-An important and life threatening complication and can present with sepsis, headache, vomiting, photophobia and phonophobia. - Sigmoid sinus thrombosis:
Patients present with sepsis, swinging pyrexia and meningitis. - Brain abscess:
-A patient will present with sepsis and neurological signs due to compression of cranial nerves.
what is the most common neck lump in children (presentation):
lymphadenitis
-transiently enlarged, tender lymph nodes
* There may often be multiple small tender bumps
advice for otitis media without effusion
- Acute otitis media lasts about 3 days (up to 1 week) – most recover without ABx
- simple analgesia: Use regular ibuprofen/paracetamol
- No evidence to support the use of decongestants or antihistamines
what is glue ear? signs & symptoms/associations/investigations
- Otitis media with effusion (OME) / “Glue Ear”:
- Signs & symptoms = asymptomatic except for possible reduced hearing (conductive hearing loss)
* Can interfere with normal speech development learning difficulties
* Otoscopy = eardrum is dull and retracted, often with a fluid level visible - Investigations:
* Tympanometry
* Audiometry - Management:
* Co-existent cleft palate or Down’s syndrome or other* refer to ENT
* * hearing loss, structurally abnormal tympanic membrane, cholesteatoma discharge
* No co-morbidities active observation for 6-12 weeks:
* 1) Two hearing tests (pure tone audiometry), 3 months apart
- 2) If persistent past 6-12 weeks, refer to ENT
Non-surgical – hearing aids, active monitor for 3m, auto-inflation
-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.
Surgical – myringotomy and grommets
* Benefits do NOT last longer than 12 months
* Problems after extrusion of grommet reinsertion of grommets
- SEs: otorrhoea > cholesteatoma, bleeding, tympanosclerosis
- Complications…
1. Perforation
2. Mastoiditis (chronic OM honeycomb structure behind ear inflamed discharge + swelling behind ear)
3. Meningitis
4. Facial nerve palsies
5. Febrile convulsions
medical management of otitis media without effusion:
- Antibiotic regimen:
- No antibiotic prescription – most cases will resolve spontaneously seek help if symptoms haven’t improved after 3 days or if the child deteriorates clinically
- Delayed antibiotic prescription –antibiotics NOT needed immediately but should be used if symptoms not improved after 3 days or if worsened greatly at any time
- Immediate antibiotic prescription – systemically unwell, age <2yo
- Antibiotics of choice:
- 1st line = amoxicillin, 5 days penicillin allergy: clarithromycin, erythromycin
Common causes of hearing loss:
Congenital
- Maternal rubella or cytomegalovirus (CMV) or measles infection (most common complication of measles) during pregnancy
- Genetic deafness can be autosomal recessive or autosomal dominant
- Associated syndromes, for example Down’s syndrome/cleft palate especially for Glue Ear
Perinatal
- Prematurity
- Hypoxia during or after birth
After birth
- Jaundice
- Meningitis and encephalitis
- Otitis media or glue ear
- Chemotherapy
what tumour can cause hearing loss?
acoustic neuroma (aka vestibular schwannomas)
What can bilateral acoustic neuromas indicate?
almost certainly indicate neurofibromatosis type II.
how do children with hearing loss typically present?
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
Investigations for children with hearing loss:
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.
management of hearing loss:
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 (SALT)
- Educational psychology
- ENT specialist
- Hearing aids for children who retain some hearing
- Sign language
Difference between lymphadenitis & reactive lymphadenopathy:
The key difference between lymphadenitis and reactive lymphadenopathy lies in the underlying cause. Lymphadenitis is specifically characterized by an infection of the lymph nodes, whereas reactive lymphadenopathy is a general term for lymph node enlargement in response to various stimuli, including infections, inflammation, or immune reactions.
different congenital neck lump causes
features/symptoms of thyroglossal cysts:
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.
Signs/symptoms of orbital cellulitis
It is characterised by eyelid oedema, erythema and chemosis, with orbital signs (such as gaze restriction and blurred or double vision). Painful eye movements, reduced visual acuity, proptosis and pupillary defects are red-flag features and should prompt consideration of severe post-septal disease.
periorbital cellulitis algorithm
Preseptal vs orbital cellulitis
orbital cellulitis emergency management
what is the gold standard imaging modality in orbital cellulitis?
Contrast-enhanced CT of orbit, sinuses ± brain gold-standard imaging modality
Treatment of orbital cellulitis:
Patients with orbital cellulitis require intravenous antibiotics for 7–10 days. They are usually started on co-amoxiclav; if allergic to it, clindamycin with metronidazole is suggested.
However, the antibiotic choice depends on local guidelines and results from microbiological investigations.
cystic hygroma meaning:
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.
cystic hygroma assocations:
Genetic conditions like Down syndrome, Turner syndrome or Noonan syndrome. C
cystic hygroma symptoms:
Cystic hygromas most commonly present in the neck or armpit. They:
Can be very large
Are soft
Are non-tender
Transilluminate
complications of cystic hygroma:
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.
management of cystic hygroma:
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.
branchial cyst meaning & presentation:
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.
sinuses & fistulas meaning:
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.
branchial cyst management:
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.
branchial cyst management:
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.
Tracheoesophageal Fistula (TOF) & Oesophageal Atresia presentation/investigations/management
- OA = malformation of oesophagus so it does not connect to stomach
- TOF = part of oesophagus joined to trachea; often occurs alongside OA
o Type C most common (90%)
o Stomach acid can regurgitate and go into the lungs –> CLD/BPD (chronic lung disease/bronchopulmonary dysplasia)
* Associations: polyhydramnios (no swallow), other developmental issues
- Investigations:
o NG tube to aspirate stomach contents can quickly confirm/exclude
o Gold-standard Gastrograffin swallow - Management:
o 1st = Replogle tube (drain saliva from oesophagus)
o 2nd = Surgical repair (few days of birth/neonatal) NICU and ventilator support - Complications:
o Take longer to adjust to solids Respiratory complications GORD
o Tracheomalacia Feeding issues – stricture formation
what is the gold standard imaging modality in orbital cellulitis?
Contrast-enhanced CT of orbit, sinuses ± brain gold-standard imaging modality
what is the most common cause of tonsilitis?
The most common cause of tonsillitis is a viral infection.
what is the most common cause of bacterial tonsilitis?
group A streptococcus (Streptococcus pyogenes)
what is group A strep tonsilitis treated with?
penicillin V ((phenoxymethylpenicillin): 10 days
Clarithromycin is the usual first-line choice in true penicillin allergy.
what is the 2nd most common bacterial cause of tonsilitis:
Streptococcus pneumoniae.
what are other causes of bacterial tonsilitis:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
what is waldeyer’s tonsilar ring?
In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils on either side at the back of the throat.
typical presentation of tonsilitis:
A typical presentation of acute tonsillitis is with:
- Sore throat
- Fever (above 38°C)
- Pain on swallowing
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.
There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).
mnemonic for CENTOR criteria:
Cetta
-cough absent (1)
-exudate or swollen tonsils (1)
-tender lymph nodes (1)
-temperature >38 (1)
-age 3-14 (1)
score of 0-1: unlikely (eg could just be 8 yrs, nothing further needed)
-score of 2-3 (consider rapid streptococcal antigen test (RADT) or throat swab culture)
-score 4-5 (consider rapid streptococcal antigen test (via a throat swab) or throat swab culture and Antibiotics): high suspicion
school exclusion for tonsilitis:
-school exclusion until fever resolves or 24 hours after starting antibiotics
PACES counselling supportive care of tonsilitis:
-adequate fluids
paracematol/calpol
-rest
-difflam (prescribed)
-salt water gargling
-lozenges
FeverPAIN score:
FeverPAIN Score
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
management of tonsilitis:
Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score.
Educate patients 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. Starting antibiotics or an alternative diagnosis should be considered.
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 severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or 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 to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.
complications of tonsilitis:
-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
- GAS (S. pyogenes) infection can progress to Scarlet Fever (timeline):
o S/S (after 2-4 day incubation)…
Fever, coryza (fever, headache, vomiting, myalgia)
Rash (12-48 hours later) ± erythroderma:
* Neck + chest spread to trunk + legs
* Characteristic ‘sandpaper’ texture
* ‘Pastia’s lines’ (rash in prominent skin creases)
Strawberry tongue (≤2 days = white tongue ≥2 days = desquamated strawberry tongue)
May progress to Rheumatic Fever with a week latency period
o Ix: clinical (also, FBC (polymorphonuclear lymphocytosis, eosinophilia), ELISA, rapid antigen test, etc.)
presentation of Oesophagheal atresia and trachaeo-oesophageal fistulae
Antenatal:
- Polyhydraminos. As the oesophagus is blind-ending, fluid cannot pass through the baby to be absorbed. This results in an accumulation of fluid outside the baby – hence the polyhydramnios.
Postnatal:
- Respiratory distress
- . Distended abdomen
- Choking/problems with swallowing. The baby will have difficulty feeding and has overflow saliva.
- Neonatal doctors will find difficulty passing NG tubes down
