Paediatrics ENT Flashcards
What is the most common cause of tonsillitis?
Viral infection - do not require abx
What is the most common cause of bacterial tonsillitis?
Group A streptococcus (streptococcus pyogenes)
How can bacterial tonsillitis be treated?
Penicillin V (phenoxymethylpenicillin)
What is the most common cause of otitis media, rhinosinusitis and alternative bacterial cause of tonsillitis?
Streptococcus pneumoniae
What are some other causes of bacterial tonsillitis?
Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus
What is Waldeyer’s tonsillar ring?
A ring of lymphoid tissue in the pharynx
Label the following:
Which tonsils are typically infected in tonsillitis?
Palatine tonsils
What are the peak ages of tonsillitis?
5 to 10
15 to 20
How does tonsillitis present?
Non-specific (particularly in younger children)
Fever
Poor oral intake
Headache
Vomiting
Abdo pain
Red, inflamed and enlarged tonsils with/without exudates (small white patches of pus on the tonsils)
What to examine in suspected tonsillitis?
Ears (otoscopy)
Palpate for cervical lymphadenopathy
What is the centro criteria?
Used to estimate probability that tonsillitis is due to bacterial infection and will benefit from antibiotics (3 or more and use abx)
What is given a point in the centor criteria?
Fever over 38C
Tonsillar exudates
Absence of cough
Tender anterio cervical lymph nodes
What does the FeverPAIN score tell you?
2-3 = 34-40% probability of bacterial tonsillitis
4-5 = 62-65% probability of bacterial tonsillitis
What are the components of the feverPAIN score?
Fever during previous 24 hours
Purulence (pus on tonsils)
Attended within 3 days of onset of symptoms
Inflammed tonsils
No cough or coryza
What must be ruled out before diagnosis of tonsillitis made?
Meningitis
Epiglottitis
Peritonsillar abscess
What is the management if viral tonsillitis is suspected?
Educate patients
Give safety net advice about when to return
Simple analgesia with paracetamol and ibuprofen
Return if pain has not settled after 3 days or fever rises above 38.3
Consider delayed prescription
What does the FeverPain score have to be to prescribe abx?
4 or more
In what other situations should abx be given for tonsillitis?
Immunocompromised
Significant co-morbidity
History of rheumatic fever
When should a patient be admitted for tonsillitis?
Immunocompromised
Systemically unwell
Dehydrated
Stridor
Respiratory distress
Evidence of peritonsillar abscess
Cellulitis
What abx to give in tonsillitis?
Penicillin V (phenoxymethylpenicillin) 10 day course
- this tastes bad so young children requiring syrups often reluctant to take it
Amoxicillin has a better taste but not part of guidelines
Clarithromycin is first choice in true penicillin allergy
What are some complications of tonsillitis?
Chronic tonsillitis
Peritonsillar abscess (quinsy)
Otitis media (infection spreads to inner ear)
Scarlet fever
Rheumatic fever
Post-strep glomerulonephritis
Post-strep reactive arthritis
What is quinsy also known as?
Peritonsillar abscess
When does a peritonsillar abscess occur?
Bacterial infection with trapped pus forming and abscess in the region of the tonsils
What is peritonsillar abscess the result of?
Untreated / partially treated tonsillitis (can arise without)
How does a peritonsillar abscess present?
Sore throat
Painful swallowing
Fever
Nekc pain
Referred ear pain
Swollen tender lymph nodes
Which symptoms can indicate a peritonsillar abscess?
Trismus, patient is unable to open their mouth
Change in voice due to pharyngeal swelling (hot potato voice)
Swelling and erythema in area beside tonsil on examination
Which bacteria commonly causes quinsy?
Streptococcus pyogenes (group A strep)
Staphylococcus aureus
Haemophilus influenzae
What is the management of quinsy?
Referred to hospital under ENT for incision and drainage under general anaesthetic
Abx after surgery (broad spectrum = co-amoxiclav)
Maybe steroids (i.e. dexamethasone) to settle inflammation
How many episodes of tonsillitis require a tonsillectomy?
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
What are some other indications for tonsillectomy?
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
What are some complications of tonsillectomy?
Pain - sore throat when tonsillar tissue has been removed (2 weeks)
Damage to teeth
Infection
Post-tonsillectomy bleeding
Risks of a general anaesthetic
Why is post tonsillectomy bleeding worrying?
Main significant complication (occurs in 5% of patients)
Urgent management (up to 2 weeks after)
Patients can aspirate blood
What is the management of post tonsillectomy bleeding?
Call ENT registrar
IV access send bloods for FBC, clotting screen, G&S + crossmatch
Keep child calm and adequate analgesia
Sit upright and encourage to spit blood
NBM (incase anaesthetic)
IV fluids
If bleeding severe then call anaesthetist as intubation may be required
How to stop less severe bleeds in tonsillectomy?
Hydrogen peroxide gargle
Adrenalin soaked swab applied topically
What is otitis media?
Infection in the middle ear
What sits in the inner ear?
Cochlea
Vestibular apparatus
Nerves
What is the most common bacteria causing otitis media? What else does it cause?
Streptococcus pneumoniae
(also commonly cause rhino-sinusitis and tonsillitis)
Which other bacteria also commonly cause otitis media?
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
How does otitis media present?
Ear pain
Reduced hearing in affected ear
Symptoms of an URTI (fever, cough, coryzal symptoms, sore throat)
What symptoms may indicate vestibular problems?
Balance issues
Vertigo
When can discharge come from the ear?
Tympanic membrane perforation
What should be examined in unwell children?
Both ears and throat
What instrument is used to examine the ear?
Otoscope (pull pinna up and backwards)
How should the tympanic membrane appear in a normal child?
Pearly grey
Translucent
Slightly shiny
(cone of light reflects light of otoscope)
How does tympanic membrane appear in otitis media?
Bulging
Red
Inflamed
What is the management of otitis media?
If severe then referral to paediatrics for assessment
Admission in infants younger than 3 months (temp above 38) or 3-6 months (temp above 39)
Simple analgesia (for pain and fever)
Most cases resolve in 3 days (up to a week) without abx
What is a complication of otitis media?
Mastoiditis
What are the 3 options for abx in otitis media?
Immediate abx
Delayed prescription
No abx
When to consider prescribing abx in otitis media?
Significant co-morbidities
Immunocompromised
Children less than 2 years with bilateral otitis media
Children with otorrhoea (discharge)
When to consider a delayed prescription for otitis media?
Collected and used after 3 days if symptoms have not improved
What abx to use for otitis media?
Amoxicillin
Erythromycin / clarithromycin
Always safety net
What are some complications of otitis media?
Otitis media with effusion
Hearing loss (usually temporary)
Perforated eardrum
Recurrent infection
Mastoiditis (rare)
Abscess (rare)
What is glue ear also known as?
Otitis media with effusion (middle ear is full of fluid causing hearing loss)
What is the main symptom of glue ear?
Reduction in hearing in that ear
What does otoscopy show on glue ear?
Dull tympanic membrane
Air bubbles
Visible fluid level
Can look normal
What is the management of glue ear?
Audiometry - diagnosis and extent of hearing loss
Treated conservatively and resolves without treatment in 3 months
Which co-morbities can affect the structure of the ear?
Down’s syndrome
Cleft palate
What are grommets?
How are they inserted?
How are they removed?
Tubes inserted into the tympanic membrane by ENT surgeon
Inserted under general anaesthetic as a day case procedure
Grommets fall out within a year
1 in 3 patients require further grommets
What are some congenital causes of hearing loss?
Maternal rubella / cytomegalovirus infection during pregnancy
Genetic deafness (recessive / dominant)
Associated symptoms e.g. Down’s syndrome
What are some perinatal causes of deafness?
Prematurity
Hypoxis during or after birth
What can cause deafness after birth?
Jaundice
Meningitis and encephalitis
Otitis media or glue ear
Chemotherapy
What programme tests hearing in all neonates?
UK newborn hearing screening programme (NHSP)
How may children with hearing difficulties present?
Parental concerns about hearing
Behavioural changes (ignoring calls, frustration / bad behaviour, poor speech, poor school performance)
How are childrens hearing tested?
Under 3 = basic response i.e. turning towards a sound
Over 3 = headphone testing with specific tones and volumes
Results recorded on audiogram (identifies and differentiates between conductive and sensorineural hearing loss)
What is plotted on the x and y axis of an audiogram?
X axis = Frequency in hertz (HZ)
Y axis = Volume in decibels (dB) - loud at bottom and quiet at top
What symbols are used to plot left and right sided air and bone conduction?
X – Left sided air conduction
] – Left sided bone conduction
O – Right sided air conduction
[ – Right sided bone conduction
What decible hearing is normal?
Between 0 and 20 dB
What is the management of hearing loss in children?
Establish diagnosis
Speech and language therapy
Educational psychology
ENT specialist
Hearing aids for children who retain some hearing
Sign language
Where does epistaxis originate from?
Kiesselbach’s plexus also known as Little’s area
What can cause epistaxis?
Nose picking
Colds
Vigorous nose blowing
Trauma
Changes in the weather
Vomiting blood (if children swallow the blood)
Unilateral bleeding (if bilateral then indicated bleeding posteriorly in the nose)
What may cause recurrent nosebleeds?
Thrombocytopenia
Clotting disorders
How to manage a nosebleed at home?
Sit up - tilt head forwards
Squeeze soft part of nostrils together for 10-15 minutes
Spit any blood rather than swallowing
When may patients require admission to hospital for nosebleed?
Not stopping after 10-15 mins
Both nostrils
Unstable
What are the treatment options for epistaxis
Nasal packing using nasal tamptoms or inflatable packs
Nasal cautery using silver nitrate stick
What is prescribed to prevent crusting, inflammation or infection after a nosebleed?
Naseptin (clorhexidine and neomycin)
What is cleft lip?
What is cleft palate?
Cleft lip = Congenital condition, split in upper lip
Cleft palate = opening between mouth and nasal cavity
Can occur together or on their own
What causes a cleft lip / palate?
Random (if FH then slightly more likely)
No traditional inheritance pattern
What are the complications of cleft lip?
Problems with feeding, swallowing and speech
Psycho-social implications (bonding between mother and child)
More prone to hearing problems, ear infections and glue ear
Who forms part of the MDT for cleft lips?
Specialist nurses
Plastic, maxillofacial and ENT surgeons
Dentists
Speech and language therapists
Psychologists
GPs
What is the management of cleft lip or cleft palate?
Specially shaped bottles and teats
Cleft lip surgery at 3 months
Cleft palate surgery at 6-12 months
What is tongue tie also known as?
Ankyloglossia (short and tight lingual frenulum) - presents as poor feeding
What is the management of tongue tie?
If mild = no treatment
For treatment = frenotomy (trained person cutting the tongue tie in ward / clinic without anaesthetic)
What are the complications of a frenotomy?
Excessive bleeding
Scar formation
Infection
What is a cystic hygroma?
Malformation of the lymphatic system resulting in a cyst filled with lymphatic fluid - most commonly a congenital abnormality typically located in the posterior triangle of the neck on the left side
When is a cystic hygroma found?
Antenatal scans
Routine baby checks
Discovered later when noticed incidentally
What are the features of a cystic hygroma?
Can be very large
Soft
Non-tender
Transilluminate
What are the complications of a cystic hygroma?
Inferfere with feeding, swallowing or breathing
How does an infected cystic hygroma present?
Red, hot and tender (also possible haemorrhage into the cyst)
What is the management of cystic hygroma?
Varies depends on size, location and complications
Benign condition so watch and wait (can show regression)
Aspiration (temporary improvement)
Surgical removal
Sclerotherapy
How does the thyroglossal duct form?
In fetal development the thyroid gladn starts at base of tongue and migrates down to final position in front of trachea (leaving a track called thyroglossal duct)
When does a thyroglossal cyst form?
Thyroglossal duct persists and leaves a thyroglossal cyst
What is a differential for a thyroglossal cyst?
Ecoptic thyroid tissue
What is the main complication of a thyroglossal cyst?
Infection in the cyst causing hot, tender and painful lump
What are the features of thyroglossal cysts?
Mobile
Non-tender
Soft
Fluctuant (moves up and down - due to connection between thyroglossal duct and base of tongue)
What is the management of thyroglossal cysts?
Ultrasound or CT scan to confirm diagnosis
Surgical removal of thyroglossal cysts to confirm diagnosis on histology and prevent infection
Removal of full thyroglossal duct to prevent reoccurence
What is a branchial cyst?
Congenital abnormality where the second branchial cleft fails to properly form during fetal development
Leaving space surrounded by epithelial tissue in lateral aspect of the neck (can fill with fluid causing a branchial cyst)
Can branchial cyst arise from first, third and fourth branchial clefts?
Possible although much more rare
Where are branchial cysts found?
Round, soft, cystic swelling
Between angle of the jaw and sternocleidomastoid muscle in the anterior triangle of the neck
Transilluminates
When do branchial cysts present?
After age of 10
Most commonly in young adulthood (noticable / infected)
What causes an increased risk of infection in branchial cysts?
Sinuses and fistulas
What is a sinus?
What is a fistula?
Sinus = blind ending pouch
Fistula = abnormal connection between two epithelial surfaces
What is a branchial cleft sinus?
Connection between branchial cyst and outer skin surface via a tract (small hole visible in skin beside cyst - may be noticable discharge)
What is a branchial pouch sinus?
Branchial cyst connected to oropharynx via a tract
What is a branchial fistula?
Tract connecting oropharynx to outer skin surface via the branchial cyst
What is the management of a branchial cleft?
Conservative management if branchial cleft is not causing functional / cosmetic issues
Recurrent infection requires surgical excision
What is the difference in acute and chronic otitis externa?
Acute = less than 3 weeks
Chronic = more than 3 weeks
What is otitis externa?
Infection in the skin in the external auditory canal?
What are the causes of otitis externa?
Bacterial = pseudomonas aeruginosa or staphylococcus aureus (caused by blockage, absence of cerumen due to cleaning, trauma, pH change)
Fungal infection
What are some risk factors for otitis externa?
Hot / humid climates
Swimming
Diabetes mellitus
Eczema
Over cleaning
What are the features of otitis externa?
Pain
Itching
Discharge
Hearing loss
What may be seen on otoscopy of otitis externa?
Oedema
Erythema
Exudate
Pain on moving tragus
What are some differentials for otitis externa?
- Acute otitis media with perforation of TM
- Furunculosis (infection of hair follicle in cartilaginous part of ear)
- Viral infections
- Cholesteatoma
- Foreign body
- Impacted wax
What are the investigations for otitis externa?
Generally not needed
If thought to be atypical - swabs for microscopy and culture
What is the management of otitis externa?
Advice = cap for swimming / showering, remove hearing aids / earrings, painkillers
Specific = antibiotic / antifungal ear drop, if cellulitis / lymphadenopathy then oral abx
What are the complications of otitis externa?
Abscesses
Stenosis of ear canal
Perforated ear drum
Cellulitis
What is acute mastoiditis?
Intratemporal complication of otitis media - infection spreads to mastoid air cells
How do mastoid air cells communicate with middle ear?
Aditus to mastoid antrum
What does mastoiditis lead to?
Breakdown of fine trabeculae of mastoid air cells - pus collects under pressure causing bone necrosis - causing sub-periosteal abscess
Where can a sub-periosteal abscess be found?
- Behind pinna in Macewen’s triangle
- Superior to pinna towards zygomatic process
- Over squamous temporal bone
What are the risk factors for mastoiditis?
Younger children
Immunocompromised patients
Cholesteatoma
What are the features of mastoiditis?
- Hx of recurrent otitis media
- Otalgia
- Blocked ear
- Pyrexia
What can be seen on examination for otitis media?
- Red bulging eardrum
- Ear discharge with perforated ear drum
- Tenderness behind pinna
- In advanced disease may be CN 6, 7, 5a involvement (causes facial pain)
What is the differential diagnosis of acute mastoiditis?
- Infected pre-auricular sinus (near front of ear)
- Infected post-aural lymph node
- Langerhans cell histiocytosis
What are the investigations for mastoiditis?
- Ear swab = MC + S
- Blood tests = raised WCC and CRP
- CT head and mastoid with contrast (show coalescence of mastoid air cells)
- MRI head (under anaesthesia) better at highlighting soft tissue collections
What is the management of mastoiditis?
IV abx (following local guidelines - co-amoxiclav / ceftriaxone) - oral switch when recovering
What are some indications for surgery for mastoiditis?
- Uncomplicated mastoiditis: fails to improve clinically after 48 hours
- Continuing pyrexia
- Persistent erythema behing ear
What are the surgical treatment options for mastoiditis?
Needle aspiration of pus
Incision and drainage
Cortical mastoidectomy to formally open mastoid antrum and drain infection
What are the complications of mastoiditis?
Extracranial = facial nerve palsy, hearing loss (conductive and sensorineural), labyrinthitis, subperiosteal abscess, cranial osteomyelitis
Intracranial = meningitis, subdural empyema, dural sinus thrombosis
What is peri-orbital cellulitis?
Infection of periorbital soft tissue (causing erythema and oedema)
What separates pre-septal and post-septal cellulitis?
Orbital septum (prevents spread of infection)
What causes peri-prbital cellulitis?
Spread of infection from surrounding periorbital structures e.g. paranasal sinuses (ethmoidal sinusitis is the most common - frontal doesnt develop until 7 y/o), dental infection, endophthalmitis, trauma, foreign bodies
Which organisms cause peri-orbital cellulitis?
Those causing rhinosinusitis e.g. strep pneumoniae, haemophilus influenzae, moracella catarrhalis, staph aureus
What are the features of periorbital cellulitis?
Pre-septal = eyelid oedema (impedance ro drainage through ethmoid vessels), erythema (normal vision, absence of proptosis, full ocular motility - no pain on movement)
Post-septal = proptosis, ophthalmoplegia, decreased visual acuity, painful diplopia
How is peri-orbital cellulitis diagnosed?
History + examination:
- Dentition
- Appearance of nasal mucosa (rhinoscopy)
- Ophthalmic examination (movement, acuity, pupillary response, tonometry, anterior segment)
- Neuro examination
What investigation can be used for peri-orbital cellulitis?
CRP and WCC
Assessment of degree of sepsis: FBC, U+E, CRP, ABG and lactate
CT scan - confirmation of extension of disease
What are some differentials for peri-orbital cellulitis?
Vesicles of herpes zoster ophthalmicus
Erythmatous irritation of contact dermatitis
Stye
Chalazion
Blepharitis
What is the treatment of peri-orbital cellulitis?
Mild / older than 1 = outpatient broad spectum oral abx
Orbital cellulitis = hospital, IV abx (local guidelines), IV fluids, analgesia, optic nerve monitoring, urgent drainage for nerve compromise
What are some complications of pre-orbital cellulitis?
Vision loss (papulloedema / neuritis causing atropy of optic nerve)
Asymmetrical eyelid opening, impaired ocular motility, eyelid inflammation
Encephalomeningitis
Cavernous sinus thrombosis
Sepsis
