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Paediatrics > Paediatrics ENT > Flashcards

Paediatrics ENT Flashcards

1
Q

What is the most common cause of tonsillitis?

A

Viral infection - do not require abx

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2
Q

What is the most common cause of bacterial tonsillitis?

A

Group A streptococcus (streptococcus pyogenes)

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3
Q

How can bacterial tonsillitis be treated?

A

Penicillin V (phenoxymethylpenicillin)

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4
Q

What is the most common cause of otitis media, rhinosinusitis and alternative bacterial cause of tonsillitis?

A

Streptococcus pneumoniae

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5
Q

What are some other causes of bacterial tonsillitis?

A

Haemophilus influenzae

Morazella catarrhalis

Staphylococcus aureus

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6
Q

What is Waldeyer’s tonsillar ring?

A

A ring of lymphoid tissue in the pharynx

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7
Q

Label the following:

A
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8
Q

Which tonsils are typically infected in tonsillitis?

A

Palatine tonsils

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9
Q

What are the peak ages of tonsillitis?

A

5 to 10

15 to 20

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10
Q

How does tonsillitis present?

A

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)

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11
Q

What to examine in suspected tonsillitis?

A

Ears (otoscopy)

Palpate for cervical lymphadenopathy

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12
Q

What is the centro criteria?

A

Used to estimate probability that tonsillitis is due to bacterial infection and will benefit from antibiotics (3 or more and use abx)

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13
Q

What is given a point in the centor criteria?

A

Fever over 38C

Tonsillar exudates

Absence of cough

Tender anterio cervical lymph nodes

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14
Q

What does the FeverPAIN score tell you?

A

2-3 = 34-40% probability of bacterial tonsillitis

4-5 = 62-65% probability of bacterial tonsillitis

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15
Q

What are the components of the feverPAIN score?

A

Fever during previous 24 hours

Purulence (pus on tonsils)

Attended within 3 days of onset of symptoms

Inflammed tonsils

No cough or coryza

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16
Q

What must be ruled out before diagnosis of tonsillitis made?

A

Meningitis

Epiglottitis

Peritonsillar abscess

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17
Q

What is the management if viral tonsillitis is suspected?

A

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

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18
Q

What does the FeverPain score have to be to prescribe abx?

A

4 or more

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19
Q

In what other situations should abx be given for tonsillitis?

A

Immunocompromised

Significant co-morbidity

History of rheumatic fever

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20
Q

When should a patient be admitted for tonsillitis?

A

Immunocompromised

Systemically unwell

Dehydrated

Stridor

Respiratory distress

Evidence of peritonsillar abscess

Cellulitis

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21
Q

What abx to give in tonsillitis?

A

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

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22
Q

What are some complications of tonsillitis?

A

Chronic tonsillitis

Peritonsillar abscess (quinsy)

Otitis media (infection spreads to inner ear)

Scarlet fever

Rheumatic fever

Post-strep glomerulonephritis

Post-strep reactive arthritis

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23
Q

What is quinsy also known as?

A

Peritonsillar abscess

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24
Q

When does a peritonsillar abscess occur?

A

Bacterial infection with trapped pus forming and abscess in the region of the tonsils

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25
Q

What is peritonsillar abscess the result of?

A

Untreated / partially treated tonsillitis (can arise without)

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26
Q

How does a peritonsillar abscess present?

A

Sore throat

Painful swallowing

Fever

Nekc pain

Referred ear pain

Swollen tender lymph nodes

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27
Q

Which symptoms can indicate a peritonsillar abscess?

A

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

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28
Q

Which bacteria commonly causes quinsy?

A

Streptococcus pyogenes (group A strep)

Staphylococcus aureus

Haemophilus influenzae

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29
Q

What is the management of quinsy?

A

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

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30
Q

How many episodes of tonsillitis require a tonsillectomy?

A

7 or more in 1 year

5 per year for 2 years

3 per year for 3 years

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31
Q

What are some other indications for tonsillectomy?

A

Recurrent tonsillar abscesses (2 episodes)

Enlarged tonsils causing difficulty breathing, swallowing or snoring

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32
Q

What are some complications of tonsillectomy?

A

Pain - sore throat when tonsillar tissue has been removed (2 weeks)

Damage to teeth

Infection

Post-tonsillectomy bleeding

Risks of a general anaesthetic

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33
Q

Why is post tonsillectomy bleeding worrying?

A

Main significant complication (occurs in 5% of patients)

Urgent management (up to 2 weeks after)

Patients can aspirate blood

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34
Q

What is the management of post tonsillectomy bleeding?

A

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

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35
Q

How to stop less severe bleeds in tonsillectomy?

A

Hydrogen peroxide gargle

Adrenalin soaked swab applied topically

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36
Q

What is otitis media?

A

Infection in the middle ear

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37
Q

What sits in the inner ear?

A

Cochlea

Vestibular apparatus

Nerves

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38
Q

What is the most common bacteria causing otitis media? What else does it cause?

A

Streptococcus pneumoniae

(also commonly cause rhino-sinusitis and tonsillitis)

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39
Q

Which other bacteria also commonly cause otitis media?

A

Haemophilus influenzae

Moraxella catarrhalis

Staphylococcus aureus

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40
Q

How does otitis media present?

A

Ear pain

Reduced hearing in affected ear

Symptoms of an URTI (fever, cough, coryzal symptoms, sore throat)

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41
Q

What symptoms may indicate vestibular problems?

A

Balance issues

Vertigo

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42
Q

When can discharge come from the ear?

A

Tympanic membrane perforation

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43
Q

What should be examined in unwell children?

A

Both ears and throat

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44
Q

What instrument is used to examine the ear?

A

Otoscope (pull pinna up and backwards)

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45
Q

How should the tympanic membrane appear in a normal child?

A

Pearly grey

Translucent

Slightly shiny

(cone of light reflects light of otoscope)

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46
Q

How does tympanic membrane appear in otitis media?

A

Bulging

Red

Inflamed

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47
Q

What is the management of otitis media?

A

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

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48
Q

What is a complication of otitis media?

A

Mastoiditis

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49
Q

What are the 3 options for abx in otitis media?

A

Immediate abx

Delayed prescription

No abx

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50
Q

When to consider prescribing abx in otitis media?

A

Significant co-morbidities

Immunocompromised

Children less than 2 years with bilateral otitis media

Children with otorrhoea (discharge)

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51
Q

When to consider a delayed prescription for otitis media?

A

Collected and used after 3 days if symptoms have not improved

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52
Q

What abx to use for otitis media?

A

Amoxicillin

Erythromycin / clarithromycin

Always safety net

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53
Q

What are some complications of otitis media?

A

Otitis media with effusion

Hearing loss (usually temporary)

Perforated eardrum

Recurrent infection

Mastoiditis (rare)

Abscess (rare)

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54
Q

What is glue ear also known as?

A

Otitis media with effusion (middle ear is full of fluid causing hearing loss)

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55
Q

What is the main symptom of glue ear?

A

Reduction in hearing in that ear

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56
Q

What does otoscopy show on glue ear?

A

Dull tympanic membrane

Air bubbles

Visible fluid level

Can look normal

57
Q

What is the management of glue ear?

A

Audiometry - diagnosis and extent of hearing loss

Treated conservatively and resolves without treatment in 3 months

58
Q

Which co-morbities can affect the structure of the ear?

A

Down’s syndrome

Cleft palate

59
Q

What are grommets?

How are they inserted?

How are they removed?

A

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

60
Q

What are some congenital causes of hearing loss?

A

Maternal rubella / cytomegalovirus infection during pregnancy

Genetic deafness (recessive / dominant)

Associated symptoms e.g. Down’s syndrome

61
Q

What are some perinatal causes of deafness?

A

Prematurity

Hypoxis during or after birth

62
Q

What can cause deafness after birth?

A

Jaundice

Meningitis and encephalitis

Otitis media or glue ear

Chemotherapy

63
Q

What programme tests hearing in all neonates?

A

UK newborn hearing screening programme (NHSP)

64
Q

How may children with hearing difficulties present?

A

Parental concerns about hearing

Behavioural changes (ignoring calls, frustration / bad behaviour, poor speech, poor school performance)

65
Q

How are childrens hearing tested?

A

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)

66
Q

What is plotted on the x and y axis of an audiogram?

A

X axis = Frequency in hertz (HZ)

Y axis = Volume in decibels (dB) - loud at bottom and quiet at top

67
Q

What symbols are used to plot left and right sided air and bone conduction?

A

X – Left sided air conduction

] – Left sided bone conduction

O – Right sided air conduction

[ – Right sided bone conduction

68
Q

What decible hearing is normal?

A

Between 0 and 20 dB

69
Q

What is the management of hearing loss in children?

A

Establish diagnosis

Speech and language therapy

Educational psychology

ENT specialist

Hearing aids for children who retain some hearing

Sign language

70
Q

Where does epistaxis originate from?

A

Kiesselbach’s plexus also known as Little’s area

71
Q

What can cause epistaxis?

A

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)

72
Q

What may cause recurrent nosebleeds?

A

Thrombocytopenia

Clotting disorders

73
Q

How to manage a nosebleed at home?

A

Sit up - tilt head forwards

Squeeze soft part of nostrils together for 10-15 minutes

Spit any blood rather than swallowing

74
Q

When may patients require admission to hospital for nosebleed?

A

Not stopping after 10-15 mins

Both nostrils

Unstable

75
Q

What are the treatment options for epistaxis

A

Nasal packing using nasal tamptoms or inflatable packs

Nasal cautery using silver nitrate stick

76
Q

What is prescribed to prevent crusting, inflammation or infection after a nosebleed?

A

Naseptin (clorhexidine and neomycin)

77
Q

What is cleft lip?

What is cleft palate?

A

Cleft lip = Congenital condition, split in upper lip

Cleft palate = opening between mouth and nasal cavity

Can occur together or on their own

78
Q

What causes a cleft lip / palate?

A

Random (if FH then slightly more likely)

No traditional inheritance pattern

79
Q

What are the complications of cleft lip?

A

Problems with feeding, swallowing and speech

Psycho-social implications (bonding between mother and child)

More prone to hearing problems, ear infections and glue ear

80
Q

Who forms part of the MDT for cleft lips?

A

Specialist nurses

Plastic, maxillofacial and ENT surgeons

Dentists

Speech and language therapists

Psychologists

GPs

81
Q

What is the management of cleft lip or cleft palate?

A

Specially shaped bottles and teats

Cleft lip surgery at 3 months

Cleft palate surgery at 6-12 months

82
Q

What is tongue tie also known as?

A

Ankyloglossia (short and tight lingual frenulum) - presents as poor feeding

83
Q

What is the management of tongue tie?

A

If mild = no treatment

For treatment = frenotomy (trained person cutting the tongue tie in ward / clinic without anaesthetic)

84
Q

What are the complications of a frenotomy?

A

Excessive bleeding

Scar formation

Infection

85
Q

What is a cystic hygroma?

A

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

86
Q

When is a cystic hygroma found?

A

Antenatal scans

Routine baby checks

Discovered later when noticed incidentally

87
Q

What are the features of a cystic hygroma?

A

Can be very large

Soft

Non-tender

Transilluminate

88
Q

What are the complications of a cystic hygroma?

A

Inferfere with feeding, swallowing or breathing

89
Q

How does an infected cystic hygroma present?

A

Red, hot and tender (also possible haemorrhage into the cyst)

90
Q

What is the management of cystic hygroma?

A

Varies depends on size, location and complications

Benign condition so watch and wait (can show regression)

Aspiration (temporary improvement)

Surgical removal

Sclerotherapy

91
Q

How does the thyroglossal duct form?

A

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)

92
Q

When does a thyroglossal cyst form?

A

Thyroglossal duct persists and leaves a thyroglossal cyst

93
Q

What is a differential for a thyroglossal cyst?

A

Ecoptic thyroid tissue

94
Q

What is the main complication of a thyroglossal cyst?

A

Infection in the cyst causing hot, tender and painful lump

95
Q

What are the features of thyroglossal cysts?

A

Mobile

Non-tender

Soft

Fluctuant (moves up and down - due to connection between thyroglossal duct and base of tongue)

96
Q

What is the management of thyroglossal cysts?

A

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

97
Q

What is a branchial cyst?

A

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)

98
Q

Can branchial cyst arise from first, third and fourth branchial clefts?

A

Possible although much more rare

99
Q

Where are branchial cysts found?

A

Round, soft, cystic swelling

Between angle of the jaw and sternocleidomastoid muscle in the anterior triangle of the neck

Transilluminates

100
Q

When do branchial cysts present?

A

After age of 10

Most commonly in young adulthood (noticable / infected)

101
Q

What causes an increased risk of infection in branchial cysts?

A

Sinuses and fistulas

102
Q

What is a sinus?

What is a fistula?

A

Sinus = blind ending pouch

Fistula = abnormal connection between two epithelial surfaces

103
Q

What is a branchial cleft sinus?

A

Connection between branchial cyst and outer skin surface via a tract (small hole visible in skin beside cyst - may be noticable discharge)

104
Q

What is a branchial pouch sinus?

A

Branchial cyst connected to oropharynx via a tract

105
Q

What is a branchial fistula?

A

Tract connecting oropharynx to outer skin surface via the branchial cyst

106
Q

What is the management of a branchial cleft?

A

Conservative management if branchial cleft is not causing functional / cosmetic issues

Recurrent infection requires surgical excision

107
Q

What is the difference in acute and chronic otitis externa?

A

Acute = less than 3 weeks

Chronic = more than 3 weeks

108
Q

What is otitis externa?

A

Infection in the skin in the external auditory canal?

109
Q

What are the causes of otitis externa?

A

Bacterial = pseudomonas aeruginosa or staphylococcus aureus (caused by blockage, absence of cerumen due to cleaning, trauma, pH change)

Fungal infection

110
Q

What are some risk factors for otitis externa?

A

Hot / humid climates

Swimming

Diabetes mellitus

Eczema

Over cleaning

111
Q

What are the features of otitis externa?

A

Pain

Itching

Discharge

Hearing loss

112
Q

What may be seen on otoscopy of otitis externa?

A

Oedema

Erythema

Exudate

Pain on moving tragus

113
Q

What are some differentials for otitis externa?

A
  • Acute otitis media with perforation of TM
  • Furunculosis (infection of hair follicle in cartilaginous part of ear)
  • Viral infections
  • Cholesteatoma
  • Foreign body
  • Impacted wax
114
Q

What are the investigations for otitis externa?

A

Generally not needed

If thought to be atypical - swabs for microscopy and culture

115
Q

What is the management of otitis externa?

A

Advice = cap for swimming / showering, remove hearing aids / earrings, painkillers

Specific = antibiotic / antifungal ear drop, if cellulitis / lymphadenopathy then oral abx

116
Q

What are the complications of otitis externa?

A

Abscesses

Stenosis of ear canal

Perforated ear drum

Cellulitis

117
Q

What is acute mastoiditis?

A

Intratemporal complication of otitis media - infection spreads to mastoid air cells

118
Q

How do mastoid air cells communicate with middle ear?

A

Aditus to mastoid antrum

119
Q

What does mastoiditis lead to?

A

Breakdown of fine trabeculae of mastoid air cells - pus collects under pressure causing bone necrosis - causing sub-periosteal abscess

120
Q

Where can a sub-periosteal abscess be found?

A
  • Behind pinna in Macewen’s triangle
  • Superior to pinna towards zygomatic process
  • Over squamous temporal bone
121
Q

What are the risk factors for mastoiditis?

A

Younger children

Immunocompromised patients

Cholesteatoma

122
Q

What are the features of mastoiditis?

A
  • Hx of recurrent otitis media
  • Otalgia
  • Blocked ear
  • Pyrexia
123
Q

What can be seen on examination for otitis media?

A
  • 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)
124
Q

What is the differential diagnosis of acute mastoiditis?

A
  • Infected pre-auricular sinus (near front of ear)
  • Infected post-aural lymph node
  • Langerhans cell histiocytosis
125
Q

What are the investigations for mastoiditis?

A
  • 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
126
Q

What is the management of mastoiditis?

A

IV abx (following local guidelines - co-amoxiclav / ceftriaxone) - oral switch when recovering

127
Q

What are some indications for surgery for mastoiditis?

A
  • Uncomplicated mastoiditis: fails to improve clinically after 48 hours
  • Continuing pyrexia
  • Persistent erythema behing ear
128
Q

What are the surgical treatment options for mastoiditis?

A

Needle aspiration of pus

Incision and drainage

Cortical mastoidectomy to formally open mastoid antrum and drain infection

129
Q

What are the complications of mastoiditis?

A

Extracranial = facial nerve palsy, hearing loss (conductive and sensorineural), labyrinthitis, subperiosteal abscess, cranial osteomyelitis

Intracranial = meningitis, subdural empyema, dural sinus thrombosis

130
Q

What is peri-orbital cellulitis?

A

Infection of periorbital soft tissue (causing erythema and oedema)

131
Q

What separates pre-septal and post-septal cellulitis?

A

Orbital septum (prevents spread of infection)

132
Q

What causes peri-prbital cellulitis?

A

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

133
Q

Which organisms cause peri-orbital cellulitis?

A

Those causing rhinosinusitis e.g. strep pneumoniae, haemophilus influenzae, moracella catarrhalis, staph aureus

134
Q

What are the features of periorbital cellulitis?

A

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

135
Q

How is peri-orbital cellulitis diagnosed?

A

History + examination:

  • Dentition
  • Appearance of nasal mucosa (rhinoscopy)
  • Ophthalmic examination (movement, acuity, pupillary response, tonometry, anterior segment)
  • Neuro examination
136
Q

What investigation can be used for peri-orbital cellulitis?

A

CRP and WCC

Assessment of degree of sepsis: FBC, U+E, CRP, ABG and lactate

CT scan - confirmation of extension of disease

137
Q

What are some differentials for peri-orbital cellulitis?

A

Vesicles of herpes zoster ophthalmicus

Erythmatous irritation of contact dermatitis

Stye

Chalazion

Blepharitis

138
Q

What is the treatment of peri-orbital cellulitis?

A

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

139
Q

What are some complications of pre-orbital cellulitis?

A

Vision loss (papulloedema / neuritis causing atropy of optic nerve)

Asymmetrical eyelid opening, impaired ocular motility, eyelid inflammation

Encephalomeningitis

Cavernous sinus thrombosis

Sepsis

Paediatrics (18 decks)

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