paeds ENT and ophthalmology Flashcards
Who is most commonly affected by acute otitis media
young children- commonly between the ages of 6-12 months
why are young children at increased risk of otitis media
they have short, horizontal, poorly functioning eustachian tubes
what is otitis media
inflammation of the middle ear from infection
how does otitis media usually present
rapid onset ear pain
fever
irritability
poor feeding
vomiting
sleep disturbance
What are the most common causes of otitis media?
bacterial infection most common in children - strep pneumonia, haemophilus influenzae, moraxella catarrhalis
Viral infection- RSV, adenovirus, enterovirus
RF for otitis media
male
parental smokng
immunodeficiency
formula feeding
attendance of daycare
structural abnormalities associated with Down’s syndrome
Dummies
How does otitis media present on otoscopy
erythema of the tympanic membrane
presence of effusion in the middle ear - air fluid level, bulging tympanic membrane
Perforation of tympanic membrane
How is otitis media diagnosed?
physical examination
Usually no further investigations- may culture, may CT if concern for mastoiditis, audiometry
How is otitis media treated ?
If systemically unwell or immunocompromised antibiotics - amoxicillin 5-7 days
If generally well can use delayed antibiotics- give analgesia for 2-3 days and if still symptomatic give Abx
Other treatment:
- warm compress
- paracetamol or ibuprofen
- eardrops with anaesthetic and analgesia - not decongestant drops
Complications of otitis media
facial nerve palsy
mastoiditis
labyrinthitis
meningitis
brain abscess
hearing loss
otitis media with effusions
What is classified as recurrent otitis media
more than 3 episodes in 6 months or more than 4 episodes in one year
what is glue ear
otitis media with effusion
epidemiology of glue ear
peaks at age 2
more than 50% of children have an episode in the first year of life
RF for glue ear
winter
male
sibling with glue ear
bottle feeding
daycare attendance
parental smoking
Downs syndrome and GORD
presentation of glue ear
hearing loss
communcation difficulties
impaired language and speech development
lack of concentration,
balance problems
how does glue ear present on examination?
opacification of the ear drum due to scarring
no current signs of inflammation
loss of the light reflex
presence of bubbles or a fluid level
Treatment of glue ear
active observation for the first 3 months
gromet insertion- allows air to pass into the middle ear
apeniodectomy
What investigation needs to be done urgently in children presenting with eyelid swelling, redness and tenderness with no improvement after initial treatment
contrast enhanced CT scan of the orbit to assess for orbital cellulitis
What is periorbital cellulitis?
inflammation of the superficial eyelid (anterior to the orbital septum) usually from a superficial source such as an insect bite.
It includes inflammation of the eyelids, skin and subcutaneous tissues of the face but not the soft tissues behind the orbital septum
Who is most commonly affected by periorbital cellulitis
children much more than adults
more common in boys
more common in winter.
Causes of periorbital cellulitis
in adults it is usually from a superficial site such as an insect bite
In children it might be secondary to a bacterial cellulitis
What bacteria are commonly associated with periorbital cellulitis
staph aureus,
staph epidermis
strep species
How might sinusitis spread to cause periorbital cellulitis
from the ethmoid sinus across the thin lamina papracea
from the floor of the frontal sinus
from the roof of the maxillary sinus
How does periorbital cellulitis present ?
red swollen eye
painful
acute onset
fever
NO OCULAR SYMPTOMS
investigations of periorbital cellulitis
CT sinus and orbits with contrast to rule out orbital cellulitis
swabs
blood cultures
management of periorbital cellulitis
antibiotics- IV for 2-5 days or oral if can have daily follow up.
May include co-amoxiclav or cefotaxime
RF for orbital cellulitis
childhood
previous sinus infection
lack of the Hib vaccine
recent periorbital cellulitis
ear or facial infetion
most common causes of orbital cellulitis
staph. aureus
streptoccus
HiB
How does orbital cellulitis present ?
redness and swelling around the eye
severe ocular pain
visual disturbance
proptosis
ophthalmoplegia
eyelid oedema
how can you differentiate orbital and periorbital cellulitis
orbital cellulitis has ocular symptoms:
- reduced visual acuity
- ophthalmoplegia
- pain of moving eyes
- proptosis
investigations of orbital cellulitis
CT contrast
swabs
What is another name for squint
strabismus
what is strabismus
any form of misalignment of the eyes where the images projected on the retina do not match and the patient experiences double vision
What is a concomitant squit?
one which occurs due to differences in the control of the extraocular muscles
what is a paralytic squint
one that occurs due to paralysis of one or more of the extraocular muscles (rare)
Causes of strabismus
-idiopathic
-reduced vision in one eye- refractive errors, retinoblastomas, cataracts, ocular malformation
-neurodevelopmental abnormalities (cerebral palsy, downs sydrome)
-abnormal extra-ocular muscles- congenital abnormalities, head injury, hydrocephalus
Rf for strabismums
low birth weight
prematurity
maternal smoking in pregnancy
hypermetropia
family history
pseudosquint
what are the 4 types of squints
esotropia
exotropia
hypertropia
hypotropia
describe an esotropia squint
there is an inward position of the affected eye (it moves towards the nose)
describe an exotropia squint
there is outward movement of the affected eye- it deviates towards the ear
How does a hypertropia squint present?
upwards movement of the affected eye
how does a hypotropia squint present?
downwards movement of the affected eye
How can strabismus be diagnosed?
- inspection of eye movements
- fundoscopy to rule out differentials
- Hirschberg’s test
- cover test
How does hirschberg’s test work?
corneal light reflex test
- a light is shone into the patients eyes from one metre away
- the reflection of the light on their cornea should be symmetrical but in strabismus will be asymmetrical
How does the cover test work in the diagnosis of strabismus?
The child is asked to look forward and fix on an object in from of the them
One eye is covered - this is then moved to the other eye and the movement of the eye is observed
- if it moves inwards it means it was looking out when covered (exotropia)
- if it moves outwards it means it had drifted in when covered (esotropia)
How can strabismus be treated?
occlusive patch - covers the good eye to make the weaker eye develop
atoprine drops - cause blurry vision in the good eye
What is a complication of untreated stabismus and why does it occur?
amblyopia (lazy eye)
- occurs as the visual cortex suppresses the image from the misaligned eye to prevent double vision
- this reduces the development of the visual pathways of that eye and reduces its visual acuity
what lesions cause sensorineural hearing loss
caused by a lesion in the cochlear or auditory nerve
what causes conductive hearing loss
problems with the ear canal or middle ear- e.g. otitis media with effusion
What can cause congenital hearing loss?
maternal rubella or CMV infection
genetic deafness
associated syndromes such as downs syndrome
What can cause hearing loss after birth?
jaundice
meningitis and encephalitis
otitis media and glue ear
chemotherapy
What is used to test hearing in newborns as part of the newborn hearing screening programme?
otoacoustic emission test
what hearing test might be done if the otoacoustic emission test is abnormal in a newborn?
the auditory brainstem response test
what hearing test is done on school entry?
pure tone audiometry
