Paediatrics ENT Flashcards
1
Q
What is the most common cause of tonsillitis?
A
Viral infection - do not require abx
2
Q
What is the most common cause of bacterial tonsillitis?
A
Group A streptococcus (streptococcus pyogenes)
3
Q
How can bacterial tonsillitis be treated?
A
Penicillin V (phenoxymethylpenicillin)
4
Q
What is the most common cause of otitis media, rhinosinusitis and alternative bacterial cause of tonsillitis?
A
Streptococcus pneumoniae
5
Q
What are some other causes of bacterial tonsillitis?
A
Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus
6
Q
What is Waldeyer’s tonsillar ring?
A
A ring of lymphoid tissue in the pharynx
7
Q
Label the following:
A
8
Q
Which tonsils are typically infected in tonsillitis?
A
Palatine tonsils
9
Q
What are the peak ages of tonsillitis?
A
5 to 10
15 to 20
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)
11
Q
What to examine in suspected tonsillitis?
A
Ears (otoscopy)
Palpate for cervical lymphadenopathy
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)
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
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
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
16
Q
What must be ruled out before diagnosis of tonsillitis made?
A
Meningitis
Epiglottitis
Peritonsillar abscess
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
18
Q
What does the FeverPain score have to be to prescribe abx?
A
4 or more
19
Q
In what other situations should abx be given for tonsillitis?
A
Immunocompromised
Significant co-morbidity
History of rheumatic fever
20
Q
When should a patient be admitted for tonsillitis?
A
Immunocompromised
Systemically unwell
Dehydrated
Stridor
Respiratory distress
Evidence of peritonsillar abscess
Cellulitis
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
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
23
Q
What is quinsy also known as?
A
Peritonsillar abscess
24
Q
When does a peritonsillar abscess occur?
A
Bacterial infection with trapped pus forming and abscess in the region of the tonsils
25
What is **peritonsillar abscess** the result of?
**Untreated / partially treated** tonsillitis (can arise without)
26
How does a **peritonsillar abscess** present?
Sore throat
Painful swallowing
Fever
Nekc pain
Referred ear pain
Swollen tender lymph nodes
27
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
28
Which **bacteria** commonly causes quinsy?
**Streptococcus pyogenes** (group A strep)
Staphylococcus aureus
Haemophilus influenzae
29
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
30
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**
31
What are some **other indications** for tonsillectomy?
Recurrent tonsillar **abscesses (2 episodes)**
Enlarged tonsils causing **difficulty breathing, swallowing or snoring**
32
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**
33
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
34
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
35
How to **stop less severe bleeds** in **tonsillectomy**?
**Hydrogen peroxide** gargle
**Adrenalin** soaked swab applied topically
36
What is **otitis media**?
**Infection** in the **middle ear**
37
What sits in the **inner ear**?
Cochlea
Vestibular apparatus
Nerves
38
What is the **most common bacteria** causing **otitis media**? What else does it cause?
**Streptococcus pneumoniae**
(also commonly cause **rhino-sinusitis** and **tonsillitis**)
39
Which other bacteria also **commonly** cause **otitis media**?
**Haemophilus influenzae**
**Moraxella catarrhalis**
**Staphylococcus aureus**
40
How does **otitis media** present?
**Ear pain**
**Reduced hearing** in affected ear
Symptoms of an **URTI** (**fever**, **cough**, **coryzal** symptoms, **sore throat**)
41
What **symptoms** may indicate **vestibular** problems?
**Balance issues**
**Vertigo**
42
When can **discharge** come from the ear?
**Tympanic membrane perforation**
43
What should be **examined** in **unwell children**?
Both **ears** and **throat**
44
What instrument is used to **examine the ear**?
**Otoscope** (pull pinna up and backwards)
45
How should the **tympanic membrane** appear in a normal child?
**Pearly grey**
**Translucent**
**Slightly shiny**
(cone of light reflects light of otoscope)
46
How does **tympanic membrane** appear in **otitis media**?
**Bulging**
**Red**
**Inflamed**
47
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
48
What is a **complication** of **otitis media**?
**Mastoiditis**
49
What are the **3 options** for abx in **otitis media**?
**Immediate** abx
**Delayed** prescription
**No abx**
50
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)
51
When to consider a **delayed prescription** for **otitis media**?
Collected and used **after 3 days** if **symptoms** have **not improved**
52
What **abx** to use for **otitis media**?
**Amoxicillin**
Erythromycin / clarithromycin
**Always safety net**
53
What are some **complications** of **otitis media**?
Otitis media with effusion
Hearing loss (usually temporary)
Perforated eardrum
Recurrent infection
Mastoiditis (rare)
Abscess (rare)
54
What is **glue ear** also known as?
**Otitis media** with **effusion** (middle ear is full of fluid causing hearing loss)
55
What is the **main symptom** of **glue ear**?
**Reduction** in **hearing** in that ear
56
What does **otoscopy** show on **glue ear**?
**Dull tympanic membrane**
**Air bubbles**
**Visible fluid level**
Can look normal
57
What is the **management** of **glue ear**?
**Audiometry** - diagnosis and extent of hearing loss
Treated conservatively and **resolves without treatment** in **3 months**
58
Which **co-morbities** can affect the **structure** of the ear?
**Down's syndrome**
**Cleft palate**
59
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
60
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**
61
What are some **perinatal causes** of deafness?
**Prematurity**
**Hypoxis** during or **after birth**
62
What can cause **deafness** after birth?
**Jaundice**
**Meningitis** and **encephalitis**
**Otitis media** or glue ear
**Chemotherapy**
63
What programme tests hearing in all neonates?
UK **newborn hearing screening programme** (NHSP)
64
How may children with **hearing difficulties** present?
**Parental concerns** about hearing
**Behavioural changes** (ignoring calls, frustration / bad behaviour, poor **speech**, poor **school performance**)
65
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**)
66
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
67
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
68
What decible hearing is normal?
Between **0** and **20 dB**
69
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**
70
Where does **epistaxis** originate from?
**Kiesselbach's plexus** also known as **Little's area**
71
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)
72
What may cause **recurrent nosebleeds**?
**Thrombocytopenia**
**Clotting** disorders
73
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**
74
When may patients require **admission** to hospital for nosebleed?
Not stopping after 10-15 mins
**Both nostrils**
**Unstable**
75
What are the **treatment** **options** for epistaxis
**Nasal packing** using **nasal tamptoms** or **inflatable packs**
**Nasal cautery** using **silver nitrate stick**
76
What is **prescribed** to prevent **crusting**, **inflammation** or **infection** after a nosebleed?
**Naseptin** (clorhexidine and neomycin)
77
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**
78
What causes a cleft lip / palate?
**Random** (if FH then slightly more likely)
No traditional inheritance pattern
79
What are the **complications** of **cleft lip**?
Problems with **feeding**, **swallowing** and **speech**
**Psycho-social implication****s** (bonding between mother and child)
More prone to **hearing problems, ear infections** and glue ear
80
Who forms part of the **MDT** for **cleft lips**?
**Specialist nurses**
Plastic, maxillofacial and ENT surgeons
Dentists
Speech and language therapists
Psychologists
GPs
81
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
82
What is **tongue tie** also known as?
**Ankyloglossia** (short and tight **lingual frenulum**) - presents as poor feeding
83
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)
84
What are the **complications** of a **frenotomy**?
Excessive **bleeding**
## Footnote
**Scar formation**
**Infection**
85
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**
86
When is a **cystic hygroma** found?
**Antenatal scans**
Routine **baby checks**
Discovered later when **noticed incidentally**
87
What are the **features** of a cystic hygroma?
Can be very **large**
**Soft**
Non-tender
**Transilluminate**
88
What are the **complications** of a **cystic hygroma**?
Inferfere with **feeding**, **swallowing** or **breathing**
89
How does an **infected cystic hygroma** present?
Red, hot and tender (also possible **haemorrhage into the cyst**)
90
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
91
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**)
92
When does a **thyroglossal cyst** form?
Thyroglossal duct persists and leaves a **thyroglossal cyst**
93
What is a **differential** for a **thyroglossal cyst**?
**Ecoptic thyroid tissue**
94
What is the main **complication** of a **thyroglossal cyst**?
**Infection** in the **cyst** causing hot, tender and painful lump
95
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**)
96
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
97
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)
98
Can **branchial cyst** arise from **first, third** and **fourth branchial clefts**?
Possible although **much more rare**
99
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**
100
When do **branchial cysts** present?
**After age of 10**
Most commonly in **young adulthood** (noticable / infected)
101
What causes an **increased risk of infection** in **branchial cysts**?
**Sinuses** and **fistulas**
102
What is a **sinus**?
What is a **fistula**?
**Sinus** = blind ending pouch
**Fistula** = abnormal connection between **two epithelial surfaces**
103
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)
104
What is a **branchial pouch sinus**?
**Branchial cyst** connected to **oropharynx** via a tract
105
What is a **branchial fistula**?
Tract connecting **oropharynx** to **outer skin surface** via the **branchial cyst**
106
What is the management of a **branchial cleft**?
**Conservative** management if **branchial cleft** is **not causing functional / cosmetic issues**
**Recurrent** infection requires **surgical excision**
107
What is the difference in **acute** and **chronic** otitis externa?
**Acute** = less than 3 weeks
**Chronic** = more than 3 weeks
108
What is **otitis externa**?
**Infection in the skin** in the **external auditory canal**?
109
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)
## Footnote
**Fungal infection**
110
What are some **risk factors** for **otitis externa**?
**Hot / humid** climates
**Swimming**
**Diabetes** mellitus
**Eczema**
**Over cleaning**
111
What are the **features** of **otitis externa**?
**Pain**
**Itching**
Discharge
Hearing loss
112
What may be seen on **otoscopy** of **otitis externa**?
Oedema
Erythema
Exudate
Pain on moving tragus
113
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
114
What are the **investigations** for otitis externa?
Generally **not needed**
If thought to be **atypical** - swabs for microscopy and culture
115
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
116
What are the **complications** of **otitis externa**?
**Abscesses**
**Stenosis** of ear canal
Perforated ear drum
Cellulitis
117
What is **acute mastoiditis**?
Intratemporal complication of **otitis media** - **infection** spreads to **mastoid air cells**
118
How do mastoid air cells communicate with **middle ear**?
**Aditus to mastoid antrum**
119
What does **mastoiditis** lead to?
**Breakdown** of fine trabeculae of mastoid air cells - **pus collects** under pressure causing **bone necrosis** - causing **sub-periosteal abscess**
120
Where can a **sub-periosteal abscess** be found?
- Behind pinna in **Macewen's triangle**
- **Superior** to **pinna** towards zygomatic process
- Over **squamous temporal bone**
121
What are the **risk factors** for **mastoiditis**?
**Younger children**
**Immunocompromised patients**
**Cholesteatoma**
122
What are the **features** of **mastoiditis**?
- Hx of recurrent otitis media
- **Otalgia**
- **Blocked ear**
- Pyrexia
123
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)
124
What is the **differential diagnosis** of **acute mastoiditis**?
- Infected **pre-auricular sinus** (near front of ear)
- Infected **post-aural lymph node**
- Langerhans cell histiocytosis
125
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
126
What is the **management** of **mastoiditis**?
IV abx (following local guidelines - co-amoxiclav / ceftriaxone) - oral switch when recovering
127
What are some **indications** for **surgery** for **mastoiditis**?
- Uncomplicated mastoiditis: **fails to improve clinically** after 48 hours
- **Continuing pyrexia**
- Persistent erythema behing ear
128
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**
129
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
130
What is **peri-orbital cellulitis?**
Infection of **periorbital soft tissue** (causing erythema and oedema)
131
What separates **pre-septal** and **post-septal cellulitis**?
**Orbital** septum (prevents spread of infection)
132
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
133
Which **organisms** cause **peri-orbital cellulitis**?
Those causing **rhinosinusitis** e.g. strep pneumoniae, haemophilus influenzae, moracella catarrhalis, **staph aureus**
134
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
135
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
136
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
137
What are some **differentials** for **peri-orbital cellulitis**?
**Vesicles** of **herpes zoster ophthalmicus**
**Erythmatous irritation** of **contact dermatitis**
**Stye**
**Chalazion**
**Blepharitis**
138
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
139
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**
