Paediatrics- respiratory and ENT Flashcards
Mild croup
- Occasional barking cough
- No audible stridor at rest
*No or mild suprasternal and/or intercostal recession - The child is happy and is prepared to eat, drink, and play
Moderate croup
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
Severe croup
- Frequent barking cough
- Prominent inspiratory (and occasionally, expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
Croup- when to admit to hospital
- Moderate or severe croup
- <6 months of age
- Known upper airway abnormalities i.e. Laryngomalacia, Down’s syndrome
- Uncertainty about diagnosis
Croup- investigations
- the vast majority of children are diagnosed clinically
- however, if a chest x-ray is done: a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’. In contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Tonsilitis- causes and symptoms
Inflammation of palatine tonsils (often due to infection)
* Causes: Viruses (rhinovirus, coronavirus, RSV, EBV); bacteria (mainly group A beta-haemolytic streptococci = ‘strep throat’)
*Symptoms: Throat pain; odynophagia; referred ear pain; hoarse voice(esp. if associated laryngitis); headache; small children may have abdominal pain
* Signs: Red, swollen tonsils +/- exudate; fever; cervical lymphadenopathy
Tonsillitis- investigations and when to refer
- Investigations: Usually not needed; sepsis 6 if septic; consider throat swab (esp. for streptococci)
- Refer: Difficulty breathing; dehydration; systemic illness/possible sepsis; peritonsillar/retropharyngeal abscess
Tonsilitis- centor criteria
- Exudate on tonsils (1 point)
- Tender anterior cervical lymph nodes (1 point)
- Absence of cough (1 point)
- Fever >38 degrees (1 point)
Tonsilitis- management
- Conservative: Explanation and reassurance, ‘delayed prescription’
- Medical: Analgesia/antipyretics (paracetamol/ibuprofen); topical analgesia (benzydamine spray); consider antibiotics if Centor score >3 (10 days penicillin V/clarithromycin)
Interpreting centor score
- A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus.
- A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.
A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression
Antibiotics prescribed in tonsilitis
- 1st line: Penicillin V 500mg PO QDS for 5-10 days
- Alternative in penicillin allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
Surgical management of tonsillitis
- Tonsillectomy if recurrent episodes (3 yearly for 3 years; 5 for 2 years or 7 in 1 year)
- Also indicated for obstructive sleep apnoea from enlarged tonsils/adenoids
- Admit for drainage if peritonsillar abscess forms
Otitis media- symptoms
Bacteria transfer more easily in children from the nasopharynx due to a shallower Eustachian tube angle
Signs and symptoms
* Symptoms: ear pain (young children may pull at affected ear), fever, coryza, vomiting
* Signs: fever, red eardrum, if discharging (suppurative) suggests perforation, sometimes red pinna
Types of otitis media
- Benign chronic otitis media: dry tympanic membrane perforation without chronic infection
- Chronic secretory otitis media (glue ear): presents as persistent pain, lasting a couple of weeks after the initial episode. The drum looks abnormal and shows reduced mobility of the membrane
- Chronic Suppurative Otitis Media: diagnosed when there is persistent purulent drainage through the perforated tympanic membrane
Management of otitis media
- Investigations: usually none (swab if recurrent/grommets in situ)
- Conservative: reassurance, ‘delayed prescription’, safety net advice
- Medical: simple analgesia/antipyretics. 5 days amoxicillin/erythromycin IF systemically unwell/AOM for > 4 days/ comorbidities (e.g/ congenital heart disease/chronic lung disease/immunocompromise)
- Surgical: refer to ENT surgeon if recurrent episodes or complications
Otitis media- when to admit
- Admit any children under 3 months with a temperature of 38 or more, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy.
- Consider admitting any children who are very systemically unwell.
- Otherwise, treat pain and fever with paracetamol or ibuprofen
Otitis media: complications
- Extra-cranial: Facial nerve palsy, Mastoiditis, Petrositis, Labrynthitis
- Intra-cranial: Meningitis, Sigmoid sinus thrombosis, Brain abscess
Glue ear
Build up of middle ear fluid causing hearing loss in affected ear (often self limiting). No acute inflammation, often follows AOM.
Glue ear- presentation
- Presentation: ear fullness/popping/pain; hearing loss (loud TV, poor communication, speech/language delay, difficulty at school)
- Signs: yellow, retracted tympanic membrane, fluid level/bubbles behind it, loss of light reflex
Glue ear- investigation
- Hearing test: audiometry/McCormick toy test if preschool repeat in 3 months
- McCormick toy test: the child is shown 7 pairs of toys whose names sound similar (e.g. tree and key, plane and plate) and asked at different volumes to indicate a particular toy