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
different congenital neck lump causes
periorbital cellulitis algorithm
Preseptal vs orbital cellulitis
orbital cellulitis emergency management
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.
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.
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.
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
