Paediatrics - ENT and Ophthalmology Flashcards
What causes otitis media?
Common cause?
Presentation?
Examination findings?
Management?
Bacteria enter from the back of the throat through the eustation tube. It is often preceeded by a viral upper respiratory tract infection
The most common bacterial causes of otitis media, as well as other ENT infections such as rhino-sinusitis and tonsillitis (also GA stept for tonsilitis) is streptococcus pneumoniae.
Other common causes include:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Presentation:
- ear pain
- reduced hearing
- upper respiratory tract infection symptoms - cough, fever, sore throat, malaise
- balance issye if it affects the vestibular system
- can be non-specific - vomiting, lethargy, poor feeding in infants and young children
Examination findings:
Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane. (healthy = pearly-grey)
Management:
- most cases resolve without antibiotics! NICE guidance stresses this
- simple analgesia for pain and fever (unless high)
- Antibiotics for systemically unwell, immunocompromised or aged under two with bilateral otitis media- amoxicillin or erythromycin. Can give if not self-improving within 3 days
Rare complication is mastoiditis - life threatening
What is glue ear? What causes it.
Examination findings?
Mangement?
The middle ear become full of fluid causing a loss of hearing in that ear. When the eustation tube becomes blocked, secretions from the middle cannot drain and build up.
The main symptom of glue ear is a reduction in hearing in that ear. The main complication of glue ear is infection (otitis media). It is also called otitis media with effusion
Otoscopy can show a dull tympanic membrain with air bubbles or a visible fluid level, or be normal
Management:
- conservative managment- most resolve without treatment within 3 months
- grommets - for persistant glue ear, or structural syndromes (cleft palet, down’s syndrome) tiny tubes inserted into the tympanic mebrane to allow drainage of the fluid, usually fall out within a year and only 1/3 need replacing
What is a strabismus?
Two types of strabismus?
What is amblyopia? Why does it occour?
Esotropia vs Exotropia?
Hypertropia vs hypotropia?
Definitions
Strabismus: misalignment of the eyes
Concomitant squints (most squints) are due to differences in the control of the extra ocular muscles. The severity of the squint can vary.
With incomitant strabismus, the deviation varies in size with the direction of gaze. They are due to paralysis in one or more of the extra ocular muscles rather than a difference in their control. These are rare.
Amblyopia: the affected eye becomes passive and has reduced vision over time …Explaination: When the eyes are misaligned double vision occours. If this occurs in childhood, before the eyes have fully established their connections with the brain, the brain will cope with this misalignment by reducing the signal from the less dominant eye. This results in one eye they use to see (the dominant eye) and one eye they ignore (the “lazy eye”). If this is not treated, this “lazy eye” becomes progressively more disconnected from the brain and over time the problem becomes worse. This is called amblyopia.
Esotropia: inward positioned squint (affected eye towards the nose)
Exotropia: outward positioned squint (affected eye towards the ear)
Hypertropia: upward moving affected eye
Hypotropia: downward moving affected eye
Strabismus:
- causes?
- 2 tests on examination?
- management?
Causes:
- usually idiopathic
others:
- Hydrocephalus
- Cerebral palsy
- Space occupying lesions, for example retinoblastoma
- Trauma
Examination will include all the usually things - eye movements, fundoscopy, visual acuity
Hirschberg’s test: shine a pen-torch at the patient from 1 meter away. When they look at it, observe the reflection of the light source on their cornea. The reflection should be central and symmetrical. Deviation from the centre will indicate a squint. Make a note of the affected eye and the direction the eye deviates.
Cover test: cover one eye and ask the patient to focus on an object in front of them. Move the cover across to the opposite eye and watch the movement of the previously covered eye. If this eye moves inwards, it had drifted outwards when covered (exotropia) and if it moves outwards it means it had drifted inwards when covered (esotropia).
Management
- visual fields are developing until 8, so treatment should start before then
- occlusive patch over the good eye forces the weaker eye to develop, atropine drops to the good eye is an alternative (causes blurred vision)
- corrective lenses for refractive errors
Causes of hearing loss in children?
How do children present?
Ix?
Managemnet?
Hearing loss can be congenital, occurring prior to birth, or acquired, as the result of an illness during childhood.
Congenital
Maternal rubella or cytomegalovirus infection during pregnancy
Genetic deafness can be autosomal recessive or autosomal dominant
Associated syndromes, for example Down’s syndrome
Perinatal
Prematurity
Hypoxia during or after birth
After birth
Jaundice
Meningitis and encephalitis
Otitis media or glue ear
Chemotherapy
Presentation:
- most are identified in the newborn hearing screeening programme (on the post natal ward otocasutic emission test)
- children with hearing difficulties may present with parental concerns about hearing or with behavorial changes associated with not being able to hear
Ix - audiometry. Assuming there are test for the above underlying causes as well but there weren’t on zero to finals. Conductive hearing loss (outer and middle ear) invovles reduced air conduction but preserved bone conduction, Sensoroneural HL (conchlear and auditory nerve) affects both.
Mx:
- Speech and language therapy
- Education psychology
- ENT input
- Hearing aids for children who retain some hearing or cochlear implants if profound (me)
- Sign language
Conductive vs sensorineural hearing loss?
How is air and bone conduction affected by each?
Sensorineural = inner ear. Both bone and air conduction are affected. This inlcudesthe hair cells of the cochlear being dammaged - e.g. in age related hearing loss.
Conductive = outer or middle ear affected. So air conduction is affected (can’t tranmit though outer ear) but bone conduction works.
its literally in the name
In mixed hearing loss, both air and bone conduction will be affected but bone conduction will still be better than air conduction.
Audiograms record the amplitude at which different freuqencies of sound can be heard. The Worse the hearing loss the higher the amplitude needed (up to 20 Db) to hear the sound.
Periorbital (Preseptal) vs Orbital Cellulitis?
Ix?
Management for both?
Periorbital:
Periorbital cellulitis (also known as preseptal cellulitis) is an eyelid and skin infection in front of the orbital septum (in front of the eye). It presents with swollen, red, hot skin around the eyelid and eye.
It must be differentiated from orbital cellulitis, a sight and life-threatening emergency. Patients are referred urgently to ophthalmology for assessment. A CT scan can help distinguish them.
Treatment is with systemic antibiotics (oral or IV). Preorbital cellulitis can develop into orbital cellulitis, so vulnerable patients (e.g., children) or severe cases may require admission for monitoring.
Orbital:
Orbital cellulitis is an infection around the eyeball involving the tissues behind the orbital septum. Symptoms include pain with eye movement, reduced eye movements, vision changes, abnormal pupil reactions, and proptosis (bulging forward of the eyeball).
Orbital cellulitis requires emergency admission under ophthalmology and intravenous antibiotics. Surgical drainage may be needed if an abscess forms.
What is the most common cause of tonsilitis and what is the treatment required?
The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The most common cause of otitis media, rhinosinusitis and the most common alternative bacterial cause of tonsillitis is Streptococcus pneumoniae. Other causes: Haemophilus influenzae, Morazella catarrhalis, Staphylococcus aureus
Not on the paeds list but i think it should be…
A typical presentation is a child with a fever, sore throat and painful swallowing. Tonsillitis can present with non-specific symptoms, particularly in younger children. They may present with only a fever, poor oral intake, headache, vomiting or even abdominal pain.
What score can be used to determine whether or not to a tonsilitis is likely to have a bacterial cause? Score at which antibitoics are given?
Antibiotic choice?
What is Quinsy and how does it present?
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
Always examine the ears (otoscopy) to visualising the tympanic membranes and palpate for any cervical lymphadenopathy when assessing a child with suspected tonsillitis.
SCORES:
Centor Criteria
The Centor criteria can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present:
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
Fever PAIN is another score that is basically the same but replaced Cervical lyphadenopathy with attedence within 3 days of Sx onset.
Consider prescribing antibiotics if the Centor score is ≥ 3 or the FeverPAIN score is ≥ 4. Also consider antibiotics if they are at risk of more serious infections, for example young infants, immunocompromised patients or those with significant co-morbidity, or there is a history of rheumatic fever.
Penicillin V is first line (GA strept is most common bacterial cause, viral is most common cause), clarithromycin if allergic to penecillin
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Quinsy is a peritonsillar absess, which is a complicaiton of untreated tonsillitis. Additional symptoms that can indicate a peritonsillar abscess include:
- Trismus, which refers to when the patient is unable to open their mouth
- Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
Swelling and erythema in the area beside the tonsils on examination
Management - REQUIRES: incision and drainage
