Paediatric ENT Flashcards
Why is ET dysfunction and its complications (AOM, Glue ear…) more common in the paediatric population?
1) ET in children is shorter and straighter => tighter
2) Recurrent URTIs => Increased secretions and congestion
3) Adenoid Hypertrophy => Less space => exacerbation. Dissolves in adults => resolved
You are asked to see a paediatric patient with some otological problem. Give 6 Ddx for Otological problems in paediatric population
1) Glue Ear
2) Acute Otitis Media
3) Acute Mastoiditis
4) Foreign Body
5) Hearing Loss
6) Congenital (absent antihelix, prominent ears)
7) Neoplastic (V. unlikely)
A 7 year old boy presents to the OPD for a checkup. You note his ears are prominent. What is the most common reason for his prominent ears?
What is general workup and treatment for this patient?
Most common: Antihelix > Deep Concha, protruding lobule
Workup: Check hearing in examination and Pure tone audiometry
Tx: Pinnaplasty/Otoplasty
Adenoids are lymphoid tissue located at the superior posterior wall of the nasopharynx. It typically increases in size until 7 years old before starting to shrink.
What paediatric conditions may arise from adenoid hypertrophy?
If adenoids are found to be the cause or an exacerbating factor to any of these conditions, what is the tx?
As it is a lymphoid tissue, any infection may lead to its hypertrophy => obstruction
OSA (snoring, sweaty sleeps..)
ET dysfunction => Retracted TM, Glue Ear, Recurrent OM
Tx: Adenoidectomy may be escalated to adenotonsillectomy
You are asked to see a paediatric patient with some rhinological problem. Give 7 Ddx for Rhinological problems in paediatric population
1) Epistaxis
2) Allergic Rhinitis (seasonal or perennial)
3) Adenoid hypertrophy
4) Sinusitis (w/orbital complications)
5) Choanal Atresia
6) Foreign Body
7) Neoplastic
A mother in the post-natal ward complains that their neonate is unable to feed. She says that they latch on well but then it is just a constant crying then blue.
What is the most likely diagnosis? Why?
How will you confirm your diagnosis and manage the patient?
What syndrome is this associated with?
Inability to feed + Cyclical crying + cyanosis. Infants are obligate nose breathers for the first 3 months of life and hence with this presentation, most likely diagnosis = Choanal atresia
Diagnosis and tx:
1) Observe mucus/fogging of fogging-metal spatula
2) Pass NG tube -> secure with nasopharyngeal tube
If still unable then
3) Fiberoptic scope
4) CT head
CHARGE syndrome
When passing an NG tube for choanal atresia, you do not seem to be able to pass it far enough. What are your next steps?
If still unable then
3) Fiberoptic scope
4) CT head
What Oropharyngeal pathologies may the paediatric population present with?
Acute Tonsillitis
Glandular fever
Quinsy/Peritonsillar abscess, paratonsilar abscess, retropharyngeal abscess
Obstructive sleep apnea
Congenital: Cleft Palate
Blood supply to the tonsils are branches of which artery?
Venous drainage is via the lingual and pharyngeal veins. These veins anastomose with what major vein?
External Carotid Artery
Internal Jugular vein
What is the general workup of acute tonsillitis?
It is the same workup regardless if bacterial or viral.
Throat culture + FBC w differentials showing leukocytosis with neutrophils vs lymphocytes
Must rule out EBV via Monospot test
LFTs (raised in infectious mononucleosis)
How could you differentiate the presentation of bacterial vs viral tonsillitis?
go through the score and include how to analyze results
Centor Score FACT
Fever
Absence of Cough
Cervical lymphadenopathy (Tender)
Tonsillar Exudate
0-2 Do not treat with antibiotics
3-4 Treat with antibiotics
Viral: Mild pyrexia, sore throat, adenoid hypertrophy - typically resolves <48hrs
Bacterial: High-grade pyrexia, severe sore throat, adenoid hypertrophy !Lasting >48 hours
Similar to Sinusitis, A viral infection typically precedes a bacterial superinfection in Acute Tonsillitis.
What are the viral and bacterial pathogens involved?
What is the workup of Acute Tonsillitis
What are the viral and bacterial pathogens involved?
Viral: Adenovirus, Parainfluenza virus
Bacterial: S.Pneumoniae, H.Influenzae, and M. Catarrhalis (same as AOM and Sinusitis)
What is the workup of Acute Tonsillitis:
In all cases same cuz of risk of infectious mononucleosis
=> Full hx and examination (check for splenomegaly)
=> Throat culture + FBC (increased UCC mostly neutrophils vs lymphocytes) + procalcitonin + CRP…
=> Monospot test + LFTs
How would you treat acute tonsillitis?
What are the complications of acute tonsillitis?
How would you treat acute tonsillitis?
Viral: Antipyretics, cough suppressants, !hydration
Bacterial (>48 hours): penicillin or clarithromycin (avoid amoxicillin => infectious mononucleosis) + viral tx + analgesia
Surgical: (if indications met) Tonsillectomy/Adenotonsillectomy
What are the complications of acute tonsillitis?
Suppurative: Quinsy (Peritonsilar abscess), Parapharyngeal abscess, retropharyngeal abscess,
Non-suppurative: Post-strep => rheumatic fever, scarlet fever and post-strep glomerulonephritis + OSA
IMP: What are the indications for a tonsillectomy?
1) Recurrent disabling sore throat due to acute tonsillitis
a) 7 or more in preceding year
b) 5 or more in preceding 2 years
c) 3 or more in preceding 3 years
2) Suspected neoplasm (e.g. asymmetrical tonsils)
3) 2+ peritonsillar abscess
4) Causing dysphagia/OSA
5) Part of Staged procedure
Parents always ask if removing the tonsils will have an effect on their child’s immunity. There is no evidence to prove that => it has no effect on that. With that, what are the actual complications of tonsillectomy?
Bonus (no effect on grade): What exam findings are found post-tonsillectomy?
Bleeding (Primary <24hrs post secondary >24)
Palatal dysfunction
TMJ dislocation
Teeth damage
Pulmonary: pneumonia, barotrauma…
Voice changes/hoarsness
Typical: Scarring dehydration, hemorrhage, anesthetic risk, DVT…
Post-tonsillectomy:
Eschar (dead tissue that sloughs off)
Foul smelling
palatal oedema
NOT IN BOOK: How would you differentiate glandular fever from typical acute tonsillitis when seeing a patient with enlarged palatine tonsils?
FBC increased WCC with increased leukocytes (vs neutrophils)
Monospot test +vs (vs -ve)
Abnormal LFTs (vs normal)
Rash w/Ampicillin
!!Hepatosplenomegaly on Exam
Grey Slough on grossly enlarged tonsils (picture)
Lymphadenopathy is incorrect as other viruses may cause that (correct if differentiating vs bacterial in general)
What is seen in this image. Describe it
Give 2 differentials
It is a large maculopapular throughout the back of the patient.
This may be consistent with infectious mononucleosis or Rubella infection
You are asked to examine this patient. Describe what you see and your most likely diagnosis.
What is the typical presentation and clinical features?
how would you workup this patient?
How would you manage this patient?
This is oral cavity of a patient presenting with acute tonsillitis. The tongue is depressed with a tongue depressor and there is a clear shift to of the uvula to the left (patient’s) as there is clear enlargement of the right tonsil. This finding is consistent with a peritonsillar abscess or Quinsy
Presentation: Severe !!unilateral sore throat, dysphagia, and odynophagia
Clinical features: Deviated uvula
Peritonsilar swelling
Trismus
Deviated Uvula
Hot potato voice
Workup:
=> Full hx and examination (check for splenomegaly)
=> Throat culture + FBC (increased UCC mostly neutrophils vs lymphocytes) + CRP….
=> Monospot test + LFTs (dont forget to rule out EBV)
Tx: (surgical emergency => ABCDE)
Medical: IV Antibiotics (Penicillin)
Surgical: Draingage +/- Tonsillectomy (it is an indication by itself even)
