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Paediatric ENT | Flashcards

1
Q

How do patients with foreign bodies in their ears usually present? (5)

A
  1. Deafness
  2. Discharge
  3. Bleeding
  4. Pain
  5. Intense irritation if insect
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2
Q

How can foreign bodies be removed from the ears? (6)

A
  1. Wax hook
  2. Croc forceps (not for beads)
  3. Suction
  4. Oil/alcohol to kill buzzing insects
  5. Syringing best avoided
  6. ?GA if uncooperative
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3
Q

What foreign body in particular need immediate removal?

A

Batteries

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4
Q

How can a child with a foreign body in their nose present? (3)

A
  1. Foul smelling unilateral nasal discharge
  2. Unilateral nasal obstruction
  3. Vestibulitis or epistaxis a few weeks later
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5
Q

What is a foul smelling unilateral nasal discharge diagnosed as until proven otherwise?

A

Foreign body in nose

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6
Q

What should be ascertained in the history of a child with suspected foreign body in his nose? (4)

A
  1. Which side
  2. Number of objects
  3. Time
  4. Symptoms
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7
Q

What is the management of foreign bodies in the nose? (3)

A
  1. “Parental kiss”: parent blows fast into child’s mouth while occluding good nostril
  2. Wax hook/ Jobson probe/suction as tolerated
  3. May need GA - to check further back in nose

-check for 2nd foreign body

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8
Q

What are the 5 symptoms suggestive of a swallowed foreign body?

A
  1. Sudden discomfort on eating
  2. Inability to finish the meal
  3. Severe pain at rest and/or swallowing
  4. Referred earache
  5. Coins stuck at cricopharyngeus = complete dysphagia, drooling and distressed
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9
Q

What are 2 useful signs of a swallowed foreign body?

A
  1. Flinching on swallowing

2. Pooling of saliva in the hypopharynx on indirect laryngoscopy

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10
Q

What 3 investigations can be done for a swallowed foreign body?

A
  1. History and examination of the tonsillar fossae with a tongue depressor and light
  2. Indirect laryngoscopy
  3. X-ray - can be misleading because calcification of the laryngeal cartilages and other structures can be misinterpreted
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11
Q

At what structures/level do foreign bodies often lodge at? 5

A
  1. Tonsils - esp fish bones
  2. Oesophagus - esp meat bones

Level:

  1. Cricopharyngeus -esp coins
  2. Arch of aorta
  3. Oesophageal cardia
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12
Q

What investigation should not be done for the investigation of a swallowed foreign body?

A

Barium swallow

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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

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14
Q

What are the 3 presenting features of an inhaled foreign body in a child?

A
  1. An acute dyspnoeic attack followed by coughing bouts
  2. May be wheezing
  3. Occasionally, bloody sputum
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15
Q

Which area of the airways are objects most likely to fall into?

A

Right main bronchus - more vertical and wider

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16
Q

What 3 investigations would be done for an inhaled foreign body? What would it show?

A
  1. Hx and examination
  2. X-ray
    -may show a collapse
    or
    -hyperinflation due to ball-valve effect (air goes in and gets trapped)
  3. Bronchoscopy - urgent
    - need to make sure a lung abscess does not develop
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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:

  1. Hx
  2. Exam
  3. CXR
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18
Q

What 3 types of stridor come from pathology of which parts of the larynx?

A
  1. Supraglottic and above = inspiratory stridor
  2. Glottic = inspiratory or biphasic
  3. Subglottic = biphasic or expiratory
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19
Q

What are the most common differentials for stridor in the following age groups?

  1. Newborn
  2. Weeks old
  3. Months old
  4. Intubated NNU/PICU
  5. Years old
A
  1. Newborn: Vocal cord motion impairment
  2. Weeks old: laryngomalacia (haemangioma)
  3. Months old: recurrent respiratory papillomatosis
  4. Intubated NNU / PICU child: subglottic stenosis
  5. Years old: croup, epiglottitis, foreign body
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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

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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)

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22
Q

What fraction of neonates with vocal cord motion impairment will recover in movement at least partially?

A

2/3

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23
Q

What % of neonates with vocal cord motion impairment will need a trachy?

A

50%

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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

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25
Q

What are the clinical features of laryngomalacia?

A

Inspiratory stridor:

  • worse with feed
  • worse with prone position
  • agitation
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26
Q

How is laryngomalacia diagnosed?

A

Flexiscope diagnosis: folded epiglottis and short aryepiglottic folds

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27
Q

What is the course/management of laryngomalacia?

A

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

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28
Q

What is an hemangioma?

A

A benign tumor formed by a collection of excess blood vessels. Can occur on skin or extra-cutaneously e.g. on subglottis

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29
Q

What is the course of a hemangioma (4)?

A
  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
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30
Q

What type of stridor usually occurs with an haemangioma?

A

Biphasic

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31
Q

What is the treatment of haemangiomas?

A

Propranolol

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32
Q

What is laryngeal papillomata or recurrent respiratory papillomatosis (RRP)?

A

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

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33
Q

What is RRP caused by?

How is it often transmitted?

A

Infection with HPV 6 and 11

Often by vertical transmission (even with C-section)

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34
Q

What are the clinical features of RRP?

A

Husky voice

Airway obstruction

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35
Q

What is the treatment of RRP?

A

Repeated debulking until they grow out of it

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36
Q

What is a rare complication of RRP?

A

Malignant transformation

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37
Q

What is subglottic stenosis?

A

Congenital or acquired narrowing of the subglottic airway

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38
Q

What % of subglottic stenosis (SGS) are acquired?

A

95%

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39
Q

What is the main cause of acquired SGS?

A

Post-intubation

-The cricoid/subglottic area is the narrowest point of the airway, it is the only complete ring with delicate epithelium

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40
Q

What could indicate an subglottic oedema?

A

Failed extubation with stridor

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41
Q

Why would ENT need to be called for SGS?

A

Needed for endoscopic airway optimisation or tracheostomy

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42
Q

What age does croup usually affect?

A

6 months - 3 years

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43
Q

What age does epiglottitis usually affect in children?

A

2-7 years

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44
Q

What age does tracheitis usually affect?

A

Any

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45
Q

What age does foreign body obstruction usually affect?

A

1-3 years

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46
Q

Is the onset of croup gradual or sudden?

A

Gradual

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47
Q

Is the onset of epiglottitis gradual or sudden?

A

Sudden

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48
Q

Is the onset of tracheitis gradual or sudden?

A

Gradual

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49
Q

Is the onset of foreign body causing airway obstruction gradual or sudden?

A

Sudden

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50
Q

How is swallowing affected in croup?

A

Not affected

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51
Q

How is swallowing affected in epiglottitis?

A

Drooling

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52
Q

How is swallowing affected in tracheitis?

A

Difficult

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53
Q

How is swallowing affected in foreign bodies causing airway obstruction?

A

Affected

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54
Q

What type of fever is present in a child with croup?

A

Mild

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55
Q

What type of fever is present in a child with epiglottitis?

A

Toxic

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56
Q

What type of fever is present in a child with tracheitis?

A

Toxic

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57
Q

What type of fever is present in a child with foreign body causing airway obstruction?

A

None/mild

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58
Q

What noises are heard with croup?

A

Barking

Stridor

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59
Q

What noises are heard with epiglottits?

A

Muffled voice

Soft tridor

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60
Q

What noises are heard with tracheitis?

A

Barking

Stridor/wheeze

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61
Q

What noises are heard with foreign bodies causing airway obstruction?

A

?wheeze

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62
Q

What is laryngotracheobronchitis (croup)?

What is the main causative organism of croup?

A

Infective conditions affecting larynx in children

Parainfluenza virus

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63
Q

What is the pathophysiology of airway obstruction associated with croup?

A

Oedema and vascular engorgement of airways, particularly of subglottis

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64
Q

What are the clinical features of croup (3)?

A
  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
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65
Q

When is croup life threatening?

A

Inspiratory stridor with recession - signals significant subglottic oedema

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66
Q

What is the presentation of acute epiglottitis (4)?

A
  1. Septic/pyrexial (>38oC)
  2. Drooling
  3. Leaning forward
  4. Stridor
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67
Q

What is the life threatening aspect of acute epiglottitis?

A

From airway obstruction and respiratory arrest

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68
Q

What is the most common causative agent of acute epiglottitis?

A

Bacteria - Haemophilis influenzae type b (Hib)

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69
Q

What is the pathophysiology of the airway obstruction in acute epiglottitis?

A

Hib causes marked erythema and oedema of the epiglottis and often extends onto the larynx

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70
Q

What are the cardinal features of acute epiglottitis in children (5)?

A
  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
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71
Q

What must be considered in the immediate management of acute epiglottitis? What must you NOT do? (5)

A
  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
Q

What investigations/management would be done for acute epiglottitis after the airway has been secured? (6)

A
  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
Q

What choanal atresia?

What are the dangers of it?

A

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
Q

What are signs and symptoms of upper airway obstruction (8)?

A
  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
Q

What are the criteria to assess severity of stridor? (8)

A
  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
Q

What are the clinical features of follicular tonsillitis? (4)

A
  1. Sore throat
  2. Pain on swallowing
  3. Enlarged erythematous tonsils with ‘white spots’
  4. Systemic illness:
    - Fever
    - Malaise
    - Cervical lymphadenopathy
    - Halitosis
77
Q

What is the usual course of tonsillitis?

A

Usually self-limiting with resolution within 5 days

78
Q

What is the criteria for tonsillectomy?

A

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
Q

What should you advise a patient when undergoing a tonsillectomy? (3)

A
  1. Painful for 1-2 weeks
  2. Need regular analgesia and normal diet
  3. Post-tonsillectomy bleed common (3-10 days)
80
Q

What are the 2 types of post-tonsillectomy bleeds? Where do they need to be treated?

A

Primary bleed - to do with the op so may need theatre

Secondary bleed - to do with infection, usually settle conservatively on admission

81
Q

When is a child referred to ENT with tonsillitis?

A

Recurrent and severe - to consider tonsillectomy

82
Q

What are the features of a tonsillectomy? (3)

A
  1. The surgical removal of the tonsils
  2. Usually done as a day case
  3. Is done under GA
83
Q

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?

A
  1. FBC
  2. Coag
  3. G+S

Give iv abx, rarely need to go to theatre

84
Q

What are complications of obstructive sleep apnoea in children (7)?

A

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
Q

What presenting features would you look for in the history of a child presenting with possible OSA? (3)

A
  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
Q

What 3 risk factors would you ask about for OSA in children?

A
  1. Adenotonsillar hypertrophy
  2. Obesity
  3. Congenital conditions (such as Down’s syndrome, neuromuscular disease, craniofacial abnormalities, achondroplasia, and Prader–Willi syndrome)
87
Q

What would you examine for in a child with possible OSA? (3)

A
  1. Enlarged tonsils
  2. Small jaw
  3. Nasal blockage (for example due to polyps or a deviated nasal septum)
88
Q

What investigations could you do for a child presenting with OSA?

A

Sleep studies

89
Q

When would you refer a child with OSA to ENT? (3)

A

Presence of:

  1. Adenotonsillar hypertrophy
  2. Symptoms of persistent snoring
  3. Features of OSAS
90
Q

What is the treatment of OSA in children? (4)

A
  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
Q

How would you explain what OSA was to a parent/child?

A

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
Q

What are the definitions of low and high grade pyrexia?

A

Low grade: 37.5-38 degrees

High grade: >38

93
Q

What causes nasal symptoms in children?

A

URTI

-5-10% are complicated by sinusitis

94
Q

What is rhinosinusitis?

A

An inflammatory process involving the mucosa of the nose and sinuses

95
Q

What are the main causative organisms of rhinosinusitis? (2)

A
  1. Streptococcus pneumoniae

2. Haemophilus influenza

96
Q

What are the symptoms of rhinosinusitis? (7)

A
  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
Q

What is the course of rhinosinusitis?

A

Usually self-resolves but for some it can be chronic

98
Q

What factors can contribute to nasal discharge in children? (5)

A
  1. Frequency of URTI
  2. Immature immune system
  3. Prevelance of allergic rhinitis
  4. Adenoid hypertrophy
  5. Factors influencing persistent mucosal oedema
99
Q

What are the 5 treatments for children with nasal symptoms?

A
  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
Q

Why are children so prone to having URTI and nasal symptoms?

A

Immature immune system - usually grow out of it by 7 years old

101
Q

What must you check for/ask about if you suspect a genuine recurrent rhinosinusitis? (3)

A
  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
Q

What are the intracranial complications of rhinosinusitis? (2)

A
  1. Meningitis

2. Extra/subdural cerebral abscesses

103
Q

What are the symptoms that may lead you to consider a diagnosis of intracranial complications of rhinosinusitis and immediate referral? (4)

A
  1. Effortless vomiting
  2. Progressive headache
  3. 5th/6th cranial nerve palsy
  4. Peri-orbital swelling (can lead to intracranial complication)
104
Q

On average, how many times a year do children suffer from viral URTIs?
What makes it worse?

A

7-10

  • Day-care
  • Autumn/winter
105
Q

How long do mucosal changes persist after a URTI?

A

8 weeks

106
Q

What does purulent rhinorrhoea and obstruction usually indicate?

A

Sinus involvement

107
Q

How long does a common cold usually last?

When does a common cold become acute rhinosinusitis?

How long does an acute rhinosinusitis last?

A

Common cold duration <10 days

ARS when symptoms of cold last >10 days or get worse after 5 days

ARS = <12 weeks

108
Q

When does rhinosinusitis become chronic?

A

> 12 weeks

109
Q

What is the treatment of chronic rhinosinusitis? (2)

A
  1. Medical: douching, steroid nose spray

2. Surgical: adenoidectomy (+/- sinus washout)

110
Q

What are the 4 presenting features of peri-orbital cellulitis?

A
  1. Unilateral eyelid swelling, pain, redness
  2. Blurred vision
  3. Nasal obstruction/discharge/URTI
  4. Fever, headaches, meningism, septicaemia
111
Q

What are the predisposing factors for peri-orbital cellulitis? (3)

A
  1. Eye lid trauma
  2. Skin infection
  3. URTI/sinusitis
112
Q

What examinations would you do to investigate peri-orbital cellulitis (2)?
What would you find?

A
  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
Q

What is the Chandler periorbital cellulitis classification? (5)

A

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
Q

What are the indications for CT with rhinosinusitis? (7)

A
  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
Q

What is the management of periorbital cellulitis? (8)

A
  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
Q

What are the different types of otitis media?
Acute (2)
Chronic (3)

A

Acute:

  1. Acute otitis media (AOM)
  2. Recurrent acute otitis media (AOM): >/=3 in 6 months, >/=4 in 12 months

Chronic:

  1. Otitis media effusion (OME): no symptoms/signs of acute inflammation
  2. Chronic suppurative otitis media (CSOM): inflammation, TM perforation
  3. Cholesteatoma: squamous epithelium in middle ear
117
Q

What is acute otitis media?

A

Inflammation of the middle ear, can be viral (50%) or bacterial in origin

118
Q

What are the 5 symptoms of acute otitis media?

A
  1. Preceding URTI
  2. Fever
  3. Ear ache / tugging
  4. Irritability
  5. Poor feeding
119
Q

What are the signs of AOM (4)?

A
  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
Q

What are predisposing factors to AOM and OME (9)?

A
  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
Q

What are the causes of AOM? (3)

A

Bacteria cause 75%

  1. Streptococcus pneumoniae 25-50%
  2. Haemophilus influenzae (non typeable) 15-30%
  3. Moraxella catarrhalis 3-20%
122
Q

What is the management of AOM in primary care (2)?

A
  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
Q

When would a child with AOM need an ENT referral (3)?

A
  1. Failure of resolution
  2. Persistent discharge
  3. Complications (facial palsy, mastoiditis, intracranial sepsis)
124
Q

What is the management of recurrent AOM (6)?

A
  1. Mostly get better after 2 yrs old
  2. Avoid pacifiers

Options

  1. Treat each episode individually
  2. Long term abx: 1.5 fewer episodes (azithro weekly)
  3. Grommets: 1.5 fewer episodes of AOM
  4. (grommets and abx only effective whilst treated)
125
Q

What are causes of TM perforations? (3)

A
  1. Direct trauma
  2. Blow
  3. AOM
126
Q

What is the course of TM perforations?

A

Most heal within 6 weeks

127
Q

What is the management of TM perforations in primary care? (3)

A
  1. Most heal within 6 weeks
  2. Keep dry
  3. GP follow up in 6 weeks
128
Q

When would you refer a child with TM perforations to ENT? (2)

A
  1. Severe bleeding

2. Significant symptoms (deafness, tinnitus, vertigo, facial palsy)

129
Q

What is otitis media with effusion (glue ear)?

A

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
Q

What is the course of OME?

A

Majority (90%) resolve within 3 months

131
Q

How can OME present in children? (4)

A
  1. Hearing impairment: usually mild
  2. Failed hearing screening
  3. Speech delay
    4 .School problems
132
Q

What examinations and investigations are done for OME? (3)

A
  1. Otoscopy
  2. Pure tone audiometry
  3. Tympanometry
133
Q

What signs would be seen on otoscopy for OME? (3)

A
  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
Q

What is the management of OME? (5)

A

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
Q

What are some hearing tactic you can recommend to help a child with OME? (4)

A
  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
Q

When should a child with OME be referred to ENT? (6)

A
  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
Q

What are the complications of middle ear infections? (4)

A
  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
Q

What are 5 symptoms of mastoiditis?

A
  1. Otalgia
  2. Hearing Loss
  3. Swelling behind ear
  4. Malaise
  5. Fever
139
Q

What are the 4 signs of mastoiditis on examination?

A
  1. Pyrexia
  2. Post auricular swelling
  3. Pinna-down & forwards
    4 .Loss of post aural sulcus
140
Q

What is the treatment of mastoiditis?

A

IV abx +/- surgery

141
Q

How can intracranial sepsis present? (6)

A

Neurological signs:

  1. Confusion
  2. Meningism
  3. Papilloedema
  4. Fits
  5. Focal CNS deficit
  6. Coma
142
Q

What symptoms indicating complications of middle ear infection would prompt a referral and to who? (3)

A
  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
Q

What is a thyroglossal duct cyst? (2)

A
  1. Congenital cyst - although more commonly presents in childhood or early adulthood
  2. Result from defects in the development of the thyroid gland
144
Q

How do thyroglossal duct cysts develop and where? (3)

A

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

  1. As a result of this descent, a tract is left that runs from the foramen caecum of the tongue to the thyroid gland
  2. The tract usually resorbs, if it remains, a cyst or fistula formation of the tract can result
145
Q

How does a thyroglossal duct cyst present? (2)

A
  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
Q

How and where to branchial cysts present? (4)

A
  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
Q

How are branchial cysts thought to develop?

A

May result from epithelial inclusions within a lymph node that later undergoes a process of cystic degeneration

148
Q

How do branchial fistulae/sinuses occur?

A

Occur as a result of defects in fusion of the branchial clefts

149
Q

Where does a branchial fistulae/sinus run from?

A

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
Q

In what age group are pre-auricular sinuses common in?

A

Children

151
Q

How do pre-auricular sinuses occur?

A

They arise due to inadequate fusion of the six hillocks

152
Q

When do pre-auricular sinuses need treatment? What is the treatment?

A

When they cause symptoms due to infection, they can be excised

153
Q

How serious are pre-auricular skin tags?

A

Mild cosmetic deformity

154
Q

What are nasal dermoids?

A

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
Q

What is a possible complication of a nasal dermoid?

A

A fistula to the brain, leading to meningitis

156
Q

What are 2 types of lymphatic malformations?

A
  1. Lymphangioma (benign tumour of lymph vessels)
  2. Lymph node enlargement
    - Infective lymphadenopathy
    - Neoplastic lymphadenopathy
157
Q

How does infective lymphadenopathy usually present? (3)

A
  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
Q

What signs in the lymph node prompt a need to investigate for malignancies?

What is the most likely neoplasm in children and early adulthood?

A

Malignancies must be excluded when an enlarging or persistently palpable lymph node is present

In early adulthood, the most likely neoplasm is lymphoma

159
Q

What are the differentials for a child presenting with lymphadenopathy? (7)

A
  1. Tonsillitis
  2. Glandular fever
  3. Quinsy
  4. Supra/epiglottitis
  5. DNSI
  6. Leukaemia
  7. Lymphoma
160
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is tonsillitis? (4)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is glandular fever? (6)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is quinsy? (9)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is epiglottitis? (6)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is DNSI?
Symptoms (7)
Signs (7)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is a leukaemia? (9)

A

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
Q

In a child with lymphadenopathy, what questions would you ask to ascertain whether the cause is a lymphoma? (9)

A

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
Q

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)
A

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)
  2. Drooling
  3. Leaning forward
  4. Stridor
  5. Muffled voice

DNSI:

  1. Odynophagia
  2. Dysphagia
  3. Trismus
  4. Drooling
  5. Fever
  6. Muffled voice
  7. . Septic
  8. Poor head movement
  9. Neck mass
  10. Airway compromise
  11. Displaced pharynx
  12. 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
  7. Weight loss
168
Q

What is the neonatal hearing screening (3)?

A
  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
Q

What are the different methods of testing hearing in a neonate (3)?

A
  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
Q

How is Automated otoacoustic emission (AOAE) performed?

A

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
Q

How is automated auditory brainstem response (AABR) performed?

A

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
Q

How is hearing assessed in infants and children (6)?

A
  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
Q

What are risk factors for congenital hearing loss? (10)

A
  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
Q

What is the normal RR in:

  1. Neonates
  2. Infants
  3. Young children
  4. Older children
A
  1. 30-50
  2. 25-40
  3. 25-35
  4. 20-25
175
Q

What is the normal resting pulse rate in ages:

  1. <1 year
  2. 2-5 years
  3. 5-12 years
  4. > 12 years
A
  1. 110-160
  2. 95-150
  3. 80-120
  4. 60-100
176
Q

What are the common causes of deafness in children? (6)

A
  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

ENT (4 decks)

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