Paediatric ENT | Flashcards
1
Q
How do patients with foreign bodies in their ears usually present? (5)
A
- Deafness
- Discharge
- Bleeding
- Pain
- Intense irritation if insect
2
Q
How can foreign bodies be removed from the ears? (6)
A
- Wax hook
- Croc forceps (not for beads)
- Suction
- Oil/alcohol to kill buzzing insects
- Syringing best avoided
- ?GA if uncooperative
3
Q
What foreign body in particular need immediate removal?
A
Batteries
4
Q
How can a child with a foreign body in their nose present? (3)
A
- Foul smelling unilateral nasal discharge
- Unilateral nasal obstruction
- Vestibulitis or epistaxis a few weeks later
5
Q
What is a foul smelling unilateral nasal discharge diagnosed as until proven otherwise?
A
Foreign body in nose
6
Q
What should be ascertained in the history of a child with suspected foreign body in his nose? (4)
A
- Which side
- Number of objects
- Time
- Symptoms
7
Q
What is the management of foreign bodies in the nose? (3)
A
- “Parental kiss”: parent blows fast into child’s mouth while occluding good nostril
- Wax hook/ Jobson probe/suction as tolerated
- May need GA - to check further back in nose
-check for 2nd foreign body
8
Q
What are the 5 symptoms suggestive of a swallowed foreign body?
A
- Sudden discomfort on eating
- Inability to finish the meal
- Severe pain at rest and/or swallowing
- Referred earache
- Coins stuck at cricopharyngeus = complete dysphagia, drooling and distressed
9
Q
What are 2 useful signs of a swallowed foreign body?
A
- Flinching on swallowing
2. Pooling of saliva in the hypopharynx on indirect laryngoscopy
10
Q
What 3 investigations can be done for a swallowed foreign body?
A
- History and examination of the tonsillar fossae with a tongue depressor and light
- Indirect laryngoscopy
- X-ray - can be misleading because calcification of the laryngeal cartilages and other structures can be misinterpreted
11
Q
At what structures/level do foreign bodies often lodge at? 5
A
- Tonsils - esp fish bones
- Oesophagus - esp meat bones
Level:
- Cricopharyngeus -esp coins
- Arch of aorta
- Oesophageal cardia
12
Q
What investigation should not be done for the investigation of a swallowed foreign body?
A
Barium swallow
13
Q
What is the management of a swallowed foreign body where there are minor symptoms after eating?
A
Can be managed conservatively i.e. If in the tonsil e.g. fish bone, can be removed with forceps
14
Q
What are the 3 presenting features of an inhaled foreign body in a child?
A
- An acute dyspnoeic attack followed by coughing bouts
- May be wheezing
- Occasionally, bloody sputum
15
Q
Which area of the airways are objects most likely to fall into?
A
Right main bronchus - more vertical and wider
16
Q
What 3 investigations would be done for an inhaled foreign body? What would it show?
A
- Hx and examination
- X-ray
-may show a collapse
or
-hyperinflation due to ball-valve effect (air goes in and gets trapped) - Bronchoscopy - urgent
- need to make sure a lung abscess does not develop
17
Q
On what grounds would you use to decide whether a patient needs rigid bronchoscopy for a suspected inhaled body? (3)
A
If 2/3 of the following are positive:
- Hx
- Exam
- CXR
18
Q
What 3 types of stridor come from pathology of which parts of the larynx?
A
- Supraglottic and above = inspiratory stridor
- Glottic = inspiratory or biphasic
- Subglottic = biphasic or expiratory
19
Q
What are the most common differentials for stridor in the following age groups?
- Newborn
- Weeks old
- Months old
- Intubated NNU/PICU
- Years old
A
- Newborn: Vocal cord motion impairment
- Weeks old: laryngomalacia (haemangioma)
- Months old: recurrent respiratory papillomatosis
- Intubated NNU / PICU child: subglottic stenosis
- Years old: croup, epiglottitis, foreign body
20
Q
How common is vocal cord motion impairment in paediatrics?
In what position are the vocal cords?
A
2nd most common cause of stridor in neonates
In the middle
21
Q
What does a bilateral/unilateral vocal cord motion impairment indicate about the pathology and investigations?
A
Bilateral = probably CNS/idiopathic
-Need scan
Unilateral = probably iatrogenic/(PNS)
22
Q
What fraction of neonates with vocal cord motion impairment will recover in movement at least partially?
A
2/3
23
Q
What % of neonates with vocal cord motion impairment will need a trachy?
A
50%
24
Q
What is laryngomalacia?
How common is it?
A
Congenital abnormality of the laryngeal cartilage resulting in collapse of the supraglottic structures (ariepiglottic folds) leading to airway obstruction during inspiration
Most common congenital cause of stridor in children
25
What are the clinical features of laryngomalacia?
Inspiratory stridor:
- worse with feed
- worse with prone position
- agitation
26
How is laryngomalacia diagnosed?
Flexiscope diagnosis: folded epiglottis and short aryepiglottic folds
27
What is the course/management of laryngomalacia?
Self-resolving for some, if child is well, do nothing as they will grow out of it in 1-2 years
Some may need a supraglottoplasty
28
What is an hemangioma?
A benign tumor formed by a collection of excess blood vessels. Can occur on skin or extra-cutaneously e.g. on subglottis
29
What is the course of a hemangioma (4)?
1. Rapid growth during first few months of life
2. Involution over next 2-3 years
3. 50% also have cutaneous haemangioma (beard distribution)
4. Can lead to airway compromise -> tracheostomy
30
What type of stridor usually occurs with an haemangioma?
Biphasic
31
What is the treatment of haemangiomas?
Propranolol
32
What is laryngeal papillomata or recurrent respiratory papillomatosis (RRP)?
HPV infections of the throat, in which benign tumors or papillomas form on the larynx or other areas of the respiratory tract that leads to audible changes in voice quality and narrowing of the airway
33
What is RRP caused by?
How is it often transmitted?
Infection with HPV 6 and 11
Often by vertical transmission (even with C-section)
34
What are the clinical features of RRP?
Husky voice
| Airway obstruction
35
What is the treatment of RRP?
Repeated debulking until they grow out of it
36
What is a rare complication of RRP?
Malignant transformation
37
What is subglottic stenosis?
Congenital or acquired narrowing of the subglottic airway
38
What % of subglottic stenosis (SGS) are acquired?
95%
39
What is the main cause of acquired SGS?
Post-intubation
| -The cricoid/subglottic area is the narrowest point of the airway, it is the only complete ring with delicate epithelium
40
What could indicate an subglottic oedema?
Failed extubation with stridor
41
Why would ENT need to be called for SGS?
Needed for endoscopic airway optimisation or tracheostomy
42
What age does croup usually affect?
6 months - 3 years
43
What age does epiglottitis usually affect in children?
2-7 years
44
What age does tracheitis usually affect?
Any
45
What age does foreign body obstruction usually affect?
1-3 years
46
Is the onset of croup gradual or sudden?
Gradual
47
Is the onset of epiglottitis gradual or sudden?
Sudden
48
Is the onset of tracheitis gradual or sudden?
Gradual
49
Is the onset of foreign body causing airway obstruction gradual or sudden?
Sudden
50
How is swallowing affected in croup?
Not affected
51
How is swallowing affected in epiglottitis?
Drooling
52
How is swallowing affected in tracheitis?
Difficult
53
How is swallowing affected in foreign bodies causing airway obstruction?
Affected
54
What type of fever is present in a child with croup?
Mild
55
What type of fever is present in a child with epiglottitis?
Toxic
56
What type of fever is present in a child with tracheitis?
Toxic
57
What type of fever is present in a child with foreign body causing airway obstruction?
None/mild
58
What noises are heard with croup?
Barking
| Stridor
59
What noises are heard with epiglottits?
Muffled voice
| Soft tridor
60
What noises are heard with tracheitis?
Barking
| Stridor/wheeze
61
What noises are heard with foreign bodies causing airway obstruction?
?wheeze
62
What is laryngotracheobronchitis (croup)?
What is the main causative organism of croup?
Infective conditions affecting larynx in children
Parainfluenza virus
63
What is the pathophysiology of airway obstruction associated with croup?
Oedema and vascular engorgement of airways, particularly of subglottis
64
What are the clinical features of croup (3)?
1. Begins with a low-grade RTI
2. Then insipratory stridor with general deterioration and toxicity
3. Then brassy cough like a bark of a dog
65
When is croup life threatening?
Inspiratory stridor with recession - signals significant subglottic oedema
66
What is the presentation of acute epiglottitis (4)?
1. Septic/pyrexial (>38oC)
2. Drooling
3. Leaning forward
4. Stridor
67
What is the life threatening aspect of acute epiglottitis?
From airway obstruction and respiratory arrest
68
What is the most common causative agent of acute epiglottitis?
Bacteria - Haemophilis influenzae type b (Hib)
69
What is the pathophysiology of the airway obstruction in acute epiglottitis?
Hib causes marked erythema and oedema of the epiglottis and often extends onto the larynx
70
What are the cardinal features of acute epiglottitis in children (5)?
1. May start as an URTI
2. Child is unwell, toxic, lethargic and febrile (38oC)
3. Young children DROOL as it is too painful to swallow
4. Leaning forward
5. Stridor can develop rapidly and can be rapidly followed by respiratory arrest
71
What must be considered in the immediate management of acute epiglottitis? What must you NOT do? (5)
1. Do not make child cry
2. Do not examine throat
3. Do not send xrays
4. Do not insert cannulas
5. Take them to theatre where there is an experienced anesthetist and ENT surgeon to secure the airway
72
What investigations/management would be done for acute epiglottitis after the airway has been secured? (6)
1. Fibreoptic or direct laryngoscopy
2. Endotracheal intubation for 3-4 days
3. FBC, Blood cultures, throat swab
4. Heliox
5. IV abx and steroids (for inflammation and oedema)
6. Do sepsis 6
73
What choanal atresia?
What are the dangers of it?
A rare congenital condition that is present from birth, in which the nasal passages are blocked by bone or tissue, causing breathing difficulties. It can occur uni or bilaterally
Newborns are obligate nose-breathers so need emergency airway management if can't breathe through nose
74
What are signs and symptoms of upper airway obstruction (8)?
1. stridor
2. Use of accessory muscles
3. Tracheal tug and intercostal/subcostal recession
4. Cyanosis
5. Tachycardia and tachypnoea
6. Reduced consiousness
7. Unable to complete full sentences
8. Absence of breath sounds
75
What are the criteria to assess severity of stridor? (8)
1. Only present on exertion
2. Only present on deep inspiration
3. Audible at all times but unable to hold a normal conversation
4. Has to talk in short phrases
5. Only able to get odd words out as concentrating on breathing
6. Unable to talk, using accessory muscles of respiration (intercostal recession or tracheal tug)
7. Cyanosed
8. Respiratory arrest
76
What are the clinical features of follicular tonsillitis? (4)
1. Sore throat
2. Pain on swallowing
3. Enlarged erythematous tonsils with 'white spots'
4. Systemic illness:
- Fever
- Malaise
- Cervical lymphadenopathy
- Halitosis
77
What is the usual course of tonsillitis?
Usually self-limiting with resolution within 5 days
78
What is the criteria for tonsillectomy?
If >7 episodes per year in 1 year
If >5 episodes per year in 2 years
If>3 episodes per year in 3 years or more
79
What should you advise a patient when undergoing a tonsillectomy? (3)
1. Painful for 1-2 weeks
2. Need regular analgesia and normal diet
3. Post-tonsillectomy bleed common (3-10 days)
80
What are the 2 types of post-tonsillectomy bleeds? Where do they need to be treated?
Primary bleed - to do with the op so may need theatre
Secondary bleed - to do with infection, usually settle conservatively on admission
81
When is a child referred to ENT with tonsillitis?
Recurrent and severe - to consider tonsillectomy
82
What are the features of a tonsillectomy? (3)
1. The surgical removal of the tonsils
2. Usually done as a day case
3. Is done under GA
83
If the post-op bleed occurring after a tonsillectomy is preceded by the child being unwell, fevers and decrease in oral intake, what investigations and management should be done?
1. FBC
2. Coag
3. G+S
Give iv abx, rarely need to go to theatre
84
What are complications of obstructive sleep apnoea in children (7)?
Can lead to:
1. Cognitive deficits
2. Behavioural abnormalities
3. Lower QOL
4. Impulsivity
5. Hyperactivity
6. Poor growth: children are usually thin
7. May affect long term cardiovascular health
85
What presenting features would you look for in the history of a child presenting with possible OSA? (3)
1. Snoring and pauses in breathing, which may be followed by a gasp or snort.
2. Restlessness and sudden arousals from sleep, laboured breathing, unusual sleep posture (for example head bent backwards), and bedwetting.
3. Daytime symptoms such as changes in behaviour (for example irritability), poor concentration, decreased performance at school, tiredness and sleepiness, failure to gain weight or grow, and mouth breathing.
86
What 3 risk factors would you ask about for OSA in children?
1. Adenotonsillar hypertrophy
2. Obesity
3. Congenital conditions (such as Down's syndrome, neuromuscular disease, craniofacial abnormalities, achondroplasia, and Prader–Willi syndrome)
87
What would you examine for in a child with possible OSA? (3)
1. Enlarged tonsils
2. Small jaw
3. Nasal blockage (for example due to polyps or a deviated nasal septum)
88
What investigations could you do for a child presenting with OSA?
Sleep studies
89
When would you refer a child with OSA to ENT? (3)
Presence of:
1. Adenotonsillar hypertrophy
2. Symptoms of persistent snoring
3. Features of OSAS
90
What is the treatment of OSA in children? (4)
1. Nasal steroid spray (mild OSA)
2. Adenotonsillectomy
- most improve but may persist if obese
3. CPAP
4. Airway/craniofacial surgery depending on pathology
91
How would you explain what OSA was to a parent/child?
Irregular breathing at night due upper airway collapsing during sleep, with excessive daytime sleepiness.
This leads to a transient arousal from deep sleep to wakefulness or a lighter sleep phase, reducing sleep quality.
Risk factors can include having large tonsils, being obese, having a small jaw and some congenital conditions
92
What are the definitions of low and high grade pyrexia?
Low grade: 37.5-38 degrees
| High grade: >38
93
What causes nasal symptoms in children?
URTI
| -5-10% are complicated by sinusitis
94
What is rhinosinusitis?
An inflammatory process involving the mucosa of the nose and sinuses
95
What are the main causative organisms of rhinosinusitis? (2)
1. Streptococcus pneumoniae
| 2. Haemophilus influenza
96
What are the symptoms of rhinosinusitis? (7)
1. Follows an acute viral URTI
2. Nasal obstruction
3. Mucopurulent rhinorrhoea
4. Poor smell
5. Severe unilateral pain over the infected sinus
6. Malaise
7. Pyrexia
It is neither a single clinical or pathological entity
97
What is the course of rhinosinusitis?
Usually self-resolves but for some it can be chronic
98
What factors can contribute to nasal discharge in children? (5)
1. Frequency of URTI
2. Immature immune system
3. Prevelance of allergic rhinitis
4. Adenoid hypertrophy
5. Factors influencing persistent mucosal oedema
99
What are the 5 treatments for children with nasal symptoms?
1. Explanation of natural history and incidence of URTI
2. Nose blowing to prevent stagnation
3. Saline/steroid sprays
4. Treat allergic element
5. Ephedrine nose drops <0.5% for up to 5 days (use sparingly) i.e decongestants
100
Why are children so prone to having URTI and nasal symptoms?
Immature immune system - usually grow out of it by 7 years old
101
What must you check for/ask about if you suspect a genuine recurrent rhinosinusitis? (3)
*****
1. Immunity: ask about presence of
- Recurrent pneumonia
- cellulitis
- candidiasis
- chronic diarrhoea
- failure to thrive
2. Cystic fibrosis: secretions causing sinus blockage and polyps leading to expansion and bony erosion
3. Primary ciliary dyskinesia
102
What are the intracranial complications of rhinosinusitis? (2)
1. Meningitis
| 2. Extra/subdural cerebral abscesses
103
What are the symptoms that may lead you to consider a diagnosis of intracranial complications of rhinosinusitis and immediate referral? (4)
***
1. Effortless vomiting
2. Progressive headache
3. 5th/6th cranial nerve palsy
4. Peri-orbital swelling (can lead to intracranial complication)
104
On average, how many times a year do children suffer from viral URTIs?
What makes it worse?
7-10
- Day-care
- Autumn/winter
105
How long do mucosal changes persist after a URTI?
8 weeks
106
What does purulent rhinorrhoea and obstruction usually indicate?
Sinus involvement
107
How long does a common cold usually last?
When does a common cold become acute rhinosinusitis?
How long does an acute rhinosinusitis last?
Common cold duration <10 days
ARS when symptoms of cold last >10 days or get worse after 5 days
ARS = <12 weeks
108
When does rhinosinusitis become chronic?
>12 weeks
109
What is the treatment of chronic rhinosinusitis? (2)
1. Medical: douching, steroid nose spray
| 2. Surgical: adenoidectomy (+/- sinus washout)
110
What are the 4 presenting features of peri-orbital cellulitis?
1. Unilateral eyelid swelling, pain, redness
2. Blurred vision
3. Nasal obstruction/discharge/URTI
4. Fever, headaches, meningism, septicaemia
111
What are the predisposing factors for peri-orbital cellulitis? (3)
1. Eye lid trauma
2. Skin infection
3. URTI/sinusitis
112
What examinations would you do to investigate peri-orbital cellulitis (2)?
What would you find?
1. Opthalmology:
- red eye, swollen lid, reduced opening
- bad signs: reduced eye movements, proptosis, vision loss, loss of red colour vision an early sign
2. Rhinoscopy:
- pus
113
What is the Chandler periorbital cellulitis classification? (5)
1: Pre-septal inflammation. Lid erythema/oedema only, probably with open eye.
2: Orbital cellulitis. More severe symptoms, closed eye.
3: Subperiosteal abscess. Severe symptoms, proptosis, ophthalmoplegia, visual impairment.
4: Orbital abscess.
5: Cavernous sinus thrombosis. Bilateral symptoms, CNS signs.
114
What are the indications for CT with rhinosinusitis? (7)
***
1. CNS symptoms/signs, drowsiness, seizure, cranial nerves
2. Diplopia/ophthalmoplegia/proptosis/abnormal pupil reflex
3. Deteriorating acuity or colour vision
4. Unable to evaluate vision / Unable to open eye
5. Bilateral periorbital oedema
6. No improvement or deterioration at 24-36h
7. Swinging pyrexia not resolving within 36h
115
What is the management of periorbital cellulitis? (8)
1. Majority need admission
2. Analgesia
3. IV antibiotics
4. Close observation of eye (red colour desaturation is an early sign of optic compression)
5. Topical nasal decongestants
6. Combined ENT /Ophthalmology / Paeds
7. May need abscess drainage and sinus washout
8. Watch for intracranial complications
116
What are the different types of otitis media?
Acute (2)
Chronic (3)
Acute:
1. Acute otitis media (AOM)
2. Recurrent acute otitis media (AOM): >/=3 in 6 months, >/=4 in 12 months
Chronic:
3. Otitis media effusion (OME): no symptoms/signs of acute inflammation
4. Chronic suppurative otitis media (CSOM): inflammation, TM perforation
5. Cholesteatoma: squamous epithelium in middle ear
117
What is acute otitis media?
Inflammation of the middle ear, can be viral (50%) or bacterial in origin
118
What are the 5 symptoms of acute otitis media?
1. Preceding URTI
2. Fever
3. Ear ache / tugging
4. Irritability
5. Poor feeding
119
What are the signs of AOM (4)?
1. Bulging/ fullness TM
- most important single clinical finding in AOM
- TM may be retracted in early stages
2. TM colour
- less reliable than bulging
- most feverish crying children have a reddish TM with increased vascularity (usually bilateral)
3. Reduced TM mobility
4. Symptoms / signs of complications, incl. perf TM
120
What are predisposing factors to AOM and OME (9)?
1. Environmental: crowding, day care, nutrition, smoking
2. Bottle (vs breast) feeding; pacifier use
3. Race: White & American Indians
4. Sex: male
5. Age: 6 month to 3 years (AOM); 2.5-5 (OME)
6. Prior / early AOM
7. Comorbidity: cleft, craniofacial abnormality, prematurity, immunodeficiency, ciliary dyskinesia, Down’s syndrome
8. FHx of middle ear disease
9. Winter
121
What are the causes of AOM? (3)
Bacteria cause 75%
1. Streptococcus pneumoniae 25-50%
2. Haemophilus influenzae (non typeable) 15-30%
3. Moraxella catarrhalis 3-20%
122
What is the management of AOM in primary care (2)?
1. Supportive. Most don’t need abx
2. Abx if: <6/12 old, or at risk of infectious complications, or symptoms >4 days, or systemically unwell. (consider if bilateral, perf/discharge, <2 yo)
123
When would a child with AOM need an ENT referral (3)?
***
1. Failure of resolution
2. Persistent discharge
3. Complications (facial palsy, mastoiditis, intracranial sepsis)
124
What is the management of recurrent AOM (6)?
1. Mostly get better after 2 yrs old
2. Avoid pacifiers
Options
3. Treat each episode individually
4. Long term abx: 1.5 fewer episodes (azithro weekly)
5. Grommets: 1.5 fewer episodes of AOM
6. (grommets and abx only effective whilst treated)
125
What are causes of TM perforations? (3)
1. Direct trauma
2. Blow
3. AOM
126
What is the course of TM perforations?
Most heal within 6 weeks
127
What is the management of TM perforations in primary care? (3)
1. Most heal within 6 weeks
2. Keep dry
3. GP follow up in 6 weeks
128
When would you refer a child with TM perforations to ENT? (2)
1. Severe bleeding
| 2. Significant symptoms (deafness, tinnitus, vertigo, facial palsy)
129
What is otitis media with effusion (glue ear)?
A sterile collection of fluid in the middle ear cleft resulting in conductive deafness. The viscous properties are due to mucus glycoproteins, mucins. No symptoms or signs of acute infection
130
What is the course of OME?
Majority (90%) resolve within 3 months
131
How can OME present in children? (4)
1. Hearing impairment: usually mild
2. Failed hearing screening
3. Speech delay
4 .School problems
132
What examinations and investigations are done for OME? (3)
1. Otoscopy
2. Pure tone audiometry
3. Tympanometry
133
What signs would be seen on otoscopy for OME? (3)
1. Varied appearance
2. Negative ME pressure
- horizontal handle malleus
- cone-shaped PT
- neo-annular fold
3. Colour change
- grey to blue
- opaque PT
134
What is the management of OME? (5)
At least 3 months observation: often resolves
Options:
1. Further observation
2. Hearing aid
3. Grommets
4 .Autoinflation (Valsalva or otovent balloon)
5. Advise parents to stop smoking around children
135
What are some hearing tactic you can recommend to help a child with OME? (4)
1. Attract child’s attention before talking e.g. tap on shoulder
2. Sit at front of class
3. If hearing better in one ear – sit with that ear facing teacher
4. Listening in background noise or rooms with lots of echoing will be especially difficult
136
When should a child with OME be referred to ENT? (6)
1. Any hearing loss with significant impact on the child's developmental, social, or educational status
2. Hearing loss is severe (61 dB or greater) and requires urgent referral within 2 weeks to exclude additional sensorineural deafness
3. Significant hearing loss persists on two documented occasions (usually following repeat testing after 6–12 weeks)
4. The tympanic membrane is structurally abnormal
5. There is a persistent, foul-smelling discharge suggestive of a possible cholesteatoma. Referral should be urgent (within 2 weeks).
6. The child has Down's syndrome or has a cleft palate
137
What are the complications of middle ear infections? (4)
*****
1. Recurrence of infection.
2. Hearing loss (usually conductive and temporary).
3. Tympanic membrane perforation.
4. Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis, intracranial sepsis
138
What are 5 symptoms of mastoiditis?
1. Otalgia
2. Hearing Loss
3. Swelling behind ear
4. Malaise
5. Fever
139
What are the 4 signs of mastoiditis on examination?
1. Pyrexia
2. Post auricular swelling
3. Pinna-down & forwards
4 .Loss of post aural sulcus
140
What is the treatment of mastoiditis?
IV abx +/- surgery
141
How can intracranial sepsis present? (6)
Neurological signs:
1. Confusion
2. Meningism
3. Papilloedema
4. Fits
5. Focal CNS deficit
6. Coma
142
What symptoms indicating complications of middle ear infection would prompt a referral and to who? (3)
1. Neurological signs: to Neuro, paeds
- confusion
- meningism
- fits
- focal CNS deficit etc
- Facial nerve palsy
2. Mastoiditis: to ENT
3. Tympanic membrane perforation without discharge, persisting for 6 weeks: to ENT
143
What is a thyroglossal duct cyst? (2)
1. Congenital cyst - although more commonly presents in childhood or early adulthood
2. Result from defects in the development of the thyroid gland
144
How do thyroglossal duct cysts develop and where? (3)
1 .The thyroid develops at the tongue base and in the embryo descends downwards, around or through the hyoid bone and through the tissues of the neck, to eventually overlie the trachea and thyroid cartilage
2. As a result of this descent, a tract is left that runs from the foramen caecum of the tongue to the thyroid gland
3. The tract usually resorbs, if it remains, a cyst or fistula formation of the tract can result
145
How does a thyroglossal duct cyst present? (2)
1. Usually a cyst in the midline
| 2. Cyst moves upwards when patient sticks out their tongue, due to attachment of the tract to the hyoid and tongue base
146
How and where to branchial cysts present? (4)
1. Usually present before age of 30
2. Present with a lump in the neck in the middle third of the SCM
3. Can be painful if it is infected
4. FNAC will result in a pus-like aspirate that is rich in cholesterol crystals
147
How are branchial cysts thought to develop?
May result from epithelial inclusions within a lymph node that later undergoes a process of cystic degeneration
148
How do branchial fistulae/sinuses occur?
Occur as a result of defects in fusion of the branchial clefts
149
Where does a branchial fistulae/sinus run from?
A fistula tract runs from the skin, usually close to the anterior border of the SCM, to the tonsillar or pyriform fossae.
It passes between the great arteries and veins of the neck, in close proximity to the lower cranial nerves, making surgical excision difficult
150
In what age group are pre-auricular sinuses common in?
Children
151
How do pre-auricular sinuses occur?
They arise due to inadequate fusion of the six hillocks
152
When do pre-auricular sinuses need treatment? What is the treatment?
When they cause symptoms due to infection, they can be excised
153
How serious are pre-auricular skin tags?
Mild cosmetic deformity
154
What are nasal dermoids?
Congenital saclike growths that are present at birth and usually sit over the bridge of the nose. They may be completely unconnected with the nasal structures, within the nose or both. Dermoid cysts grow slowly and are not tender unless ruptured or infected. May contain structures such as hair, fluid, teeth or skin glands
155
What is a possible complication of a nasal dermoid?
A fistula to the brain, leading to meningitis
156
What are 2 types of lymphatic malformations?
1. Lymphangioma (benign tumour of lymph vessels)
2. Lymph node enlargement
- Infective lymphadenopathy
- Neoplastic lymphadenopathy
157
How does infective lymphadenopathy usually present? (3)
1. Are usually tender
2. Enlarge as a result of infection, where often the site of infection is obvious e.g. tonsillitis.
3. If one or more nodes enlarge without any obvious primary infected site, consider: glandular fever, tuberculosis, HIV, toxoplasmosis, actinomycosis etc
158
What signs in the lymph node prompt a need to investigate for malignancies?
What is the most likely neoplasm in children and early adulthood?
Malignancies must be excluded when an enlarging or persistently palpable lymph node is present
In early adulthood, the most likely neoplasm is lymphoma
159
What are the differentials for a child presenting with lymphadenopathy? (7)
1. Tonsillitis
2. Glandular fever
3. Quinsy
4. Supra/epiglottitis
5. DNSI
6. Leukaemia
7. Lymphoma
160
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is tonsillitis? (4)
Is there any of the following:
1. Sore throat
2. Pain on swallowing
3. Enlarged erythematous tonsils with 'white spots'
4. Systemic illness:
- Fever
- Malaise
- Cervical lymphadenopathy
- Halitosis
161
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is glandular fever? (6)
Is there any of the following:
1. Sore throat and pain on swallowing
2. Enlarged erythematous tonsils covered with white/grey exudates
3. Systemic illness with:
- Fever
- Malaise
- Marked cervical and generalised lymphadenopathy
- Abdominal pain
4. Patient looks unwell with nasal congestion and sterterous breathing
5. Hepatosplenomegaly can occur
6. Long incubation and prodromal illness
162
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is quinsy? (9)
Is there any of the following:
1. Severe unilateral tonsillar pain
2. Unilateral swelling - pus made develop in soft tissues superolateral to the tonsil, displacing the tonsil and uvual inferomedially
3. Odynophagia
4. Dysphagia
5. Trismus, drooling may occur
6. Hot potato voice
7. Referred otalgia
8. Generally malaise and fever
9. Cervical lymphadenopathy
163
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is epiglottitis? (6)
Is there any of the following:
1. Previous URTI
2. Child is unwell, toxic, lethargic and febrile (38oC)
3. Young children DROOL as it is too painful to swallow
4. Leaning forward
5. Stridor can develop rapidly and can be rapidly followed by respiratory arrest
6. Muffled voice
164
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is DNSI?
Symptoms (7)
Signs (7)
Is there any of the following?
1. Sore throat
2. Odynophagia
3. Dysphagia
4. Trismus
5. Drooling
6. Fever
7. Muffled voice
Signs:
1. Septic
2. Poor head movement
3. Neck mass
4. Airway compromise
5. Displaced pharynx
6. Tongue swelling
7. Brawny induration - hardening of skin
165
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is a leukaemia? (9)
Is there any of the following:
1. Unexplained bleeding or bruising
2. Persistent or unexplained bone pain
3. Persistent fatigue
4. Unexplained fever
5. Unexplained heptaosplenomegaly
6. Unexplained and persistent infection
7. Generalised lymphadenopathy
8. Pallor
9. Unexplained petechiae
166
In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is a lymphoma? (9)
Is there any of the following:
1. Fever with unexplained lymphadenopathy
2. Fever with unexplained splenomegaly
3. Night sweats with lymphadenopathy
4. Unexplained lymphadenopathy
5. Pruritus with lymphadenopathy (unexplained)
6. Pruritus with splenomegaly(unexplained)
7. Shortness of breath with lymphadenopathy
8. Shortness of breath with splenomegaly (unexplained)
9. Weight loss with lymphadenopathy (unexplained)/splenomegaly
167
In a child with lymphadenopathy, what symptoms would be alarming and be indicative of a referral?
```
Quinsy (7)
Epiglottitis (6)
DNSI (13)
Leukaemia (8)
Lymphoma (8)
```
Quinsy:
1. Severe unilateral tonsillar pain
2. Unilateral swelling
3. Drooling
4. Odynophagia
5. Dysphagia
6. Trismus
7. Hot potato voice
Epiglottitis:
1. Toxic and febrile (38oC)
3. Drooling
4. Leaning forward
5. Stridor
6. Muffled voice
DNSI:
1. Odynophagia
3. Dysphagia
4. Trismus
5. Drooling
6. Fever
7. Muffled voice
8. . Septic
9. Poor head movement
10. Neck mass
11. Airway compromise
12. Displaced pharynx
13. Tongue swelling
Leukaemia
1. Unexplained bleeding or bruising
2. Persistent or unexplained bone pain
3. Persistent fatigue
4. Unexplained fever
5. Unexplained heptaosplenomegaly
6. Unexplained and persistent infection
7. Generalised lymphadenopathy
8. Unexplained petechiae
Lymphoma
1. Fever
2. Unexplained lymphadenopathy
3. Unexplained splenomegaly
4. Night sweats
5. Pruritus
6. Shortness of breath
8. Weight loss
168
What is the neonatal hearing screening (3)?
1. A hearing test done on all newborns within the first four to five weeks to test for permanent hearing loss in one or both ears. Usually done at the bedside before mother and baby is discharged
2. Done by automated otoacoustic emission (AOAE) test.
3. If the responses aren't clear or abnormal, then a 2nd test can be done: automated auditory brainstem response (AABR) test.
169
What are the different methods of testing hearing in a neonate (3)?
1. Automated otoacoustic emission (AOAE)
2. Automated auditory brainstem response (AABR)
3. Mother has a checklist in red book assessing whether the child can make and respond to sounds.
170
How is Automated otoacoustic emission (AOAE) performed?
A small soft-tipped earpiece is placed in the baby's ear and gentle clicking sounds are played. When an ear receives sound, the cochlea responds. This can be picked up by the screening equipment.
It takes a few minutes
171
How is automated auditory brainstem response (AABR) performed?
It involves placing three small sensors on the baby's head and neck. Soft headphones are placed over your baby's ears and gentle clicking sounds are played. Computer analysis of electroencephalogram waveforms are done in response to a series of auditory stimuli.
Takes around 15 minutes
172
How is hearing assessed in infants and children (6)?
1. Tympanometry - measures movement of TM with changing pressures
2. Distraction testing - for infants 7-9 months of age who have not had newborn screening or cannot tolerate or cooperate with more complex testing. The test relies on the baby locating and turning appropriately towards sounds. Need properly trained staff incase the infants use non-auditory cues.
3. Visual reinforcement audiometry - for 10-18 months. Hearing thresholds are established using visual rewards (illumination of toys) to reinforce the child's head turn to stimuli of different frequencies
4. Performance and speech discimination testing - for children with suspected hearing loss at 18 months-4 years or older with learning disabilities. Performance testing using high and low-frequency stimuli and speech discrimination testing using miniature toys
5. Pure tone audiometry for children aged 4 and above
6. Hearing checklist for parents -see if child responds to sounds
173
What are risk factors for congenital hearing loss? (10)
1. Family history of permanent childhood hearing loss
2. NICU for over 48 hours
3. In utero infections, such as Cytomegalovirus (CMV), herpes, rubella, syphilis, and toxoplasmosis
4. Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and
temporal bone anomalies
5. Physical findings, such as white forelock, that are associated with a syndrome known to
include a sensorineural or permanent conductive hearing loss
6. Syndromes associated with hearing loss or progressive or late-onset hearing loss, such as
neurofibromatosis, osteopetrosis, and Usher syndrome
7. Neurodegenerative disorders, such as Hunter syndrome, or sensory motor neuropathies,
such as Friedreich ataxia and Charcot-Marie-Tooth syndrome
8. Culture-positive postnatal infections associated with sensorineural hearing loss, including
confirmed bacterial and viral (especially herpes viruses and varicella) meningitis
9. Head trauma, especially basal skull/temporal bone fracture that requires hospitalization.
10. Chemotherapy
174
What is the normal RR in:
1. Neonates
2. Infants
3. Young children
4. Older children
1. 30-50
2. 25-40
3. 25-35
4. 20-25
175
What is the normal resting pulse rate in ages:
1. <1 year
2. 2-5 years
3. 5-12 years
4. >12 years
1. 110-160
2. 95-150
3. 80-120
4. 60-100
176
What are the common causes of deafness in children? (6)
1. Ear wax
2. Ear infection
- otitis externa
- AOM
- OME
3. Cholesteatoma
4. Perforated ear drum
5. Otosclerosis
6. Congenital
- Perinatal infection e.g. CMV
- craniofacial abnormalitis
