Paediatric ENT

Question 1

Name two important congenital conditions to rule out in children

Answer 1

Moebius syndrome (bilat VI, bilat VII with uni or bilateral XII N palsies)
Hemifacial microsomia (unita VII with microtia, hemifacial hypoplasia)

Question 2

What are the causes for congenital hearing loss?

Answer 2

associated with external or middle ear abnormalities most common anomaly is is dysplasia/aplasia of membranous labyrinth intrauterine infections (rubella) can cause inner ear damageperinatal hypoxia/anoxia, Rhesus incompatibility are RFs

Question 3

How is neonatal hearing screening carried out?

Answer 3

automated otoacoustic emission (AOAE) test (A small soft-tipped earpiece is placed in your baby’s ear and gentle clicking sounds are played.
When an ear receives sound, the inner part (called the cochlea) responds. This can be picked up by the screening equipment. Automated auditory brainstem response (AABR) test (The AABR test involves placing three small sensors on your baby’s head and neck. Soft headphones are placed over your baby’s ears and gentle clicking sounds are played.

Question 4

What are the hearing methods used in children?

Answer 4

Visual reinforcement audiometry (VRA) - young babies (7months - 2.5years)
Play audiometry (2-5 years) 
Pure tone audiometry (older children, before they start school)
Bone conduction test (device passes into inner ear)
Tympanometry (tests how flexible the ear drum is) 
Speech perception test (test child's ability to recognise words)

Question 5

What are the different types of otitis media?

Answer 5

suppurative otitis media 
secretary otitis media 
otitis media with effusion (OME)
glue ear (eustachian tube dysfunction) 
chronic otitis media (inactive/active with cholesteatoma/active with no cholesteatoma) 
recurrent acute otitis media

Question 6

What should you remember to ask in children presenting with hearing loss?

Answer 6

young children may give few us any localising signs - look for pyrexia and systemic upset

Question 7

What is otitis media?

Answer 7

inflammation of the middle ear which is characterised by the formation of an effusion which can be sterile (glue ear) or infective (acute otitis media)

Question 8

How does chronic otitis media (perforation) occur?

Answer 8

repeated attacks of acute suppuration can lead to weakening of the ear drum and eventually a non-healing perforation

Question 9

What are the different types of chronic otitis media?

Answer 9

inactive - dry perforation
active - otorrhoea -> non cholesteatoma (safe)
active - otorrhoea -> cholesteatoma (unsafe)

Question 10

What are the symptoms of otitis media?

Answer 10

hearing loss 
pain 
otorrhoea 
pyrexia 
systemic upset

Question 11

How is otitis media (infection) treated?

Answer 11

antibiotics and simple analgesia
ear must be kept dry if there is a perforation
discharging ear maybe by treated with a combination of antibiotic and steroid drops

Question 12

How is OME treated?

Answer 12

If glue ear does not resolve over 3 months and if it is symptomatic treatment is required
current mainstay of treatment is insertion of grommets which provides a different route for middle ear ventilation

Question 13

Identify the different types of OM on examination

Answer 13

LOOK UP IMAGES

Question 14

Which ear perforations (CSOM) are considered to be safe and which are considered to be unsafe?

Answer 14

safe - a central pars tense perforation - tubotympanic
safe - a subtotal perforation (central) - tubotympanic unsafe - a marginal pars tensa perforation - attico-antral unsafe - a attic/pars flaccida - tubotympanic

Question 15

What are the symptoms of CSOM?

Answer 15

hearing loss

otorrhoea - intermittent; mucoid/mucopurulent

Question 16

How is CSOM treated?

Answer 16

depends on treatment
steroid and antibiotic drops and keeping ear dry will help settle active infection
surgical repair of the ear drum will help prevent reinfection no symptoms - no treatment

Question 17

What is a cholesteatoma?

Answer 17

a cyst or sac of keratinising squamous epithelium (skin) leads to foul smelling discharge from the ear (infection), conductive hearing loss, attic retraction filled with squamous debris
cholesteatoma is able to erode bone and damage important structures of the middle ear

Question 18

What is the treatment of cholesteatoma?

Answer 18

cholesteatoma usually requires surgical removal or radical mastoidectomy is it extends to mastoid bone

Question 19

when do complications of otitis media occur?

Answer 19

occur when infection spreads outside the inner ear/ involves bone and blood

Question 20

What are the extracranial complications of otitis media?

Answer 20

mastoiditis - mastoid air cells fill with pus facial nerve palsy labryinthitis - spread of infection to inner earpetrositis

Question 21

What are the intracranial complications of otitis media?

Answer 21

temporal lobe abscess 
cerebellar abscess
sigmoid sinus thrombosis 
meningitis 
jugular vein thrombosis otitis 
hydrocephalus

Question 22

Where are thyroglossal cysts found?

Answer 22

present in the midline of the neck and move upwards if the patient sticks out their tongue, due to the attachment of the tract to the hyoid and tongue base

Question 23

Where do branchial cysts present?

Answer 23

present before the age of 30 lump in the neck situated in the middle third of the SCM painful if infected

Question 24

What are dermoids?

Answer 24

These are defects of fusion in the embryo, elements of the skin become trapped subcutaneously and develop into cysts

Question 25

Where do dermoids present?

Answer 25

they present as painless midline swellings anywhere between the suprasternal notch and then chin do not move with tongue protrusion or on swallowing treatment = surgical excision

Question 26

What are lymphatic malformations?

Answer 26

Lymphatic malformations are rare, non-malignant masses consisting of fluid-filled channels or spaces thought to be caused by the abnormal development of the lymphatic system

Question 27

Where are lymphatic malformations found?

Answer 27

commonly found on head and neck, can be wide spread or localised

Question 28

What are important questions to ask in a lymphadenopathy history of a child?

Answer 28

Characteristics of node? 
Location? 
Size? 
Duration? 
Associated symptoms? 
Painful or erythematous? 
Recent infection? 
Rashes? 
Changes in bowel movements? 
Resp probs? 
Urinary Sx? 
Skin lesions? 
Trauma? 
Wounds or bites?
General Health? 
Recent travel? 
Immunisation status?
Medications?
Allergies?

Question 29

What are some of the likely causes of lymphadenopathy in children?

Answer 29

Infectious
Viral (most common): URTI, measles, varicella, rubella, hepatitis, HIV, EBV, CMV, adenovirus
Bacterial: syphilis, brucellosis, tuberculosis, typhoid fever, septicemia
Fungal: histoplasmosis, coccidioidomycosis·
Protozoal: toxoplasmosis

Non-infectious inflammatory diseases
Rheumatologic diseases: Sarcoidosis, rheumatoid arthritis, SLE
Storage diseases: Neimenn-Pick disease, Gaucher disease
Serum sickness Rosai-Dorfman disease
Malignant: leukemia, lymphoma, neuroblastoma
Drug reaction: phenytoin, allopurinolHyperthyroidism

Question 30

How should you investigate a suspected foreign body?

Answer 30

Take a history - look for symptoms of foreign body in oesophagus or stomach
Differentiate whether swallowed or aspirated
Physical exam
Chest x-ray or chest CT can help
Bronchoscopy if aspirated
REFER TO ENT IN EMERGENCY - e.g. battery
Referal to ENT can also be made when child is very distressed, in which case objects should be removed under GA

Question 31

How should you take a history from a child presenting with snoring?

Answer 31

usually from parental reports
ask about frequency - when does it occur
ask about patient symptoms
ask about apnoeas

Question 32

How should you examine a child presenting with snoring?

Answer 32

Examination of upper airway to look for adenotonsiller hypertrophy