PEDS ENT Flashcards
Opto vs Opthomology
Optometrist is an eye doctor that can examine, diagnose, and treat eye problems
An ophthalmologist is a medical doctor who can perform medical and surgical interventions for eye conditions
What is the visual acuity of newborns
Visual acuity in newborns ~ 20/400
How do you assess vision in children
Infants: regard for the parent’s face, feeding most evident
2 wks old: more sustained interest in large objects
8-10 wks old: can follow an object 180 degrees
Term: Fix and Follow
When is the onset of proper eye coordination
About 3-4 months
Refer to Ophthalmology at 4 months if dysconjugate gaze persists
Refer at 6 months if strabismus persists
When should you refer a child for persisting strabismus
6 months
When should you refer for persistent dysconjugate gaze
4 months
What reflex in the eye should be checked in all peds pts
Red eye reflex
How do you assess visual acuity in peds
Electronic vision screeners: 6 months and above
Age 3-5 years: shape chart
> 5 years: try Snellen chart
At what age should visual acuity reach 20/20
6yo
What is the most common cause of visual impairment in peds
retinopathy of prematurity
Legal blindness: visual acuity 20/200 or worse
What is the critical line for NML visual acuity in peds
Age (years)/Rule of 8s /”Critical line” for normal visual acuity
Example:
2 2 + 6 = 8 20/60
3 3 + 5 = 8 20/50
“If it equals eight, vision is great! Nine or more, vision is poor.”
Hyperopia vs Myopia
Hyperopia—farsightedness
(cannot see things close)
Infants: hyperopic at birth
Myopia-nearsightedness
(cannot see things far away)
Blurred vision for distant objects
Infrequent in infants and pre-school children, unless preemies (ROP)
Eso, eso and hyper strabismus
Nasal = “eso” Temporal = “exo” (exiting out) Superior = “hyper” (much less common)
Define tropia
Constant strabismus
What is latent strabismus or phobia
Strabismus Only when visual fixation of the affected (non-dominant) eye is interrupted = latent strabismus = “phoria”
Define amblyopia
Amblyopia
Unilateral or bilateral central vision loss due to inappropriate visual development
3 types of amblyopia:
Strabismic
Refractive
Deprivation
What are the types of deprivation amblyopia
Retinopathy of prematurity (ROP)
Congenital cataracts/glaucoma
Retinoblastoma
-Usually presents w/ leukocoria
How do you determine pseudostabismus
(looks like eyes are not aligned straight but they really are)
will have normal corneal light reflex
What is the normal and late onset of esotropia
Can be congenital
Needs surgical correction
Onset between 2-5 yo
- Often due to refractive error
- Requires patching/glasses
Late onset (after 5 yo) may signify CNS disease (tumors, etc.)
What is the onset and tx fro exo tropia
Onset around 2 yo
Treatment options:
Observation
(for mild cases & self correcting)
Patching/glasses
(for persistent cases)
Surgical correction (for extreme cases)
How to do the cover and cover/uncover test
Cover test (strabismus)
(confirms which eye is affected):
-Misalignment that is present on simple observation
Cover affected eye, normal eye does NOT move
Cover normal eye, affected eye moves
Moves opposite direction of deviation*
Cover/uncover test:
-May reveal a slight or latent muscle imbalance not otherwise seen
Cover “bad” eye & it deviates from fixation; it swings back to midline when uncovered
Absence of a red reflex what is the DDX
Leukocoria (white reflex): can be indicative of the following-
- Cataracts
- Ocular tumors (e.g., retinoblastoma)
- Severe chorioretinitis
- Retinopathy of prematurity
A child with poor school performance should get what w/u
rule out/in vision problems
Also ears
Any child w/ a visual acuity worse than 20/40 in either eye after 4 yo or 2 line difference on eye chart between eyes
….
REFER To optho
What are the 4 types of conjunctivitis
Neonatal
Infectious
Allergic
Chemical
Conjunctivitis on day 2-7
Think what agent
N. gonorrhoeae, Staphylococcus, Streptococcus, Pseudomonas, E. coli
Conjunctivitis on day 4-19 post birth
Think what agent
Chlamydia
Dendritic lesions on the cornea
Think
HSV
What is the Rx for gonococal infection prevention in the eyes
erythromycin 0.5% ointment after birth
Tx for Conjunctivitis Gonorrhea
Ceftriaxone single dose (25-50 mg/kg) IV or IM
Hospitalize (irrigation intense!)
Tx for Chlamydia Conjunctivitis
Erythromycin PO x 14 days
Tx for pseudomonas conjunctivitis
Systemic abx (gentamycin IV), local saline irrigation, gentamycin ointment
Tx for S. Aureus Conjunctivitis
erythromycin or polysporin
What is the main virus causing conjunctivitis
Adenovirus
Conjunctivitis with a pre auricular lymphnode
Think
Adenovirus (viral )
MGMT for Viral Conj
Supportive treatment & infection control (hand washing)
Cool compresses recommended over warm (increases swelling)
Overtreatment (treatment w/ antibiotic drops/ointment) is common & often excusable due to diagnostic challenges
Tx options for bacterial conjunctivitis
H. influenzae, S. pneumoniae, M. Catarrhalis are the most common agents
Treat wtih:
Topical antibiotics work well: erythromycin, polytrim
ABX to use in the eyes for children over 1
Polytrim drops
ABX to use in the eyes in peds under 1
Erythromycin ophthalmic ointment
Conjunctivitis that is pruritic and bilateral
Think
Allergic
Tx for allergic conj
Topical vasoconstrictors, NSAIDs & antihistamines
Topical cromolyn
Nasal steroids can help concurrent eye symptoms
Systemic antihistamines less effective for eye
If a pt presents with ciliary flush
(Injections around the limbus)
What is the next step
SAME DAY referral
A child presents with photophobia, burning/ irritation of the eyes, that causes rubbing of the eyes
Agent is staph
Think
Blepharitis of the eye lid margin
staphylococcal infection + seborrhea + meibomian gland dysfunction
TX:
Initial: eyelid hygiene w/ eyelid scrub
(i.e., gentle cleansing w/ baby shampoo—tear free!)
Warm compresses & topical antibiotics
1st line tx for Dacryostenosis
Duct massage
What is the treatment for severe dacrocystitis
Oral ABX -> if no improvement x 24-48hours -> refer to optho
What is the tx for dacryocysitis
If uncomplicated is nasolacrimal massage 2-3 x/day
Cleanse lids with warm water
Topical abx if mucopurulent drainage
Bland ophthalmic ointment on eyelids
If severe dacroystitis: oral abx
DDX for Hordeolum vs chalazion
Hordeolum: Tender and erythematous
Chalazion : non tender
Tx for Hordeolum
Warm compresses
-15 min 4-6x a day
NSAIDS
If no improvement/resolution in 1-2 wks: Ophthalmology for I&D
Tx for Chalazion
If small → spontaneous resolution in weeks to months
Warm compress
No resolution/symptomatic → Ophthalmology for steroid injection or surgical removal
DDX for periorbital vs orbital cellulitis
No proptosis or ophthalmoplegia (pain with eye movement)
Agent causes of periorbital cellulitis
S. aureus!!, pneumococcus or group A streptococcus
MGMT for periorbital cellulitis
Management: Outpatient treatment (CT scan not needed)
-As long as child non-toxic appearing
Treatment: Oral cephalexin, clindamycin or amoxicillin/clavulanate
MRSA concern: trimethoprim-sulfamethoxazole (Bactrim) or clindamycin
Follow daily!
What are the main agents of Orbital Cellullitis
Causes: S. aureus!, S. pneumoniae!, other streptococci, H. influenza
MGMT for orbital cellulitis
Hospitalization!!
Obtain blood cultures to guide therapy
Broad spectrum IV antibiotics:
MRSA + S. pneumonia + gram negative bacilli coverage
-vancomycin + cefotaxime or ceftriaxone
Ophthalmology referral
CT scan (determines need for surgical intervention)
->Surgical drainage if indicated
What is otalgia and otorrhea
Otalgia = acute ear pain
Otorrhea = ear drainage
What is otitis media with effusion
Collection of non-infected fluid in middle ear space
Other names: serous OM or secretory OM
Most often seen with concurrent URI or pharyngitis
What is middle ear effusion
presence of fluid in middle ear space
Often residual from recent AOM
Can take 3 months to clear
Can result in conductive hearing loss (CHL)
What is the age most at risk for OM
Under age 2
MC causes of AOM
Bacterial (most common):
S. pneumoniae, H. influenzae,
M. catarrhalis, group A streptococcus
Viral (<20%): rhinovirus, influenza, RSV
(VIRAL MORE RARE)
Criteria to Dx AOM
Presence of following 3 things:
- Acute onset of signs/symptoms
- Middle ear effusion
- Middle ear inflammation
Tx/ MGMT for AOM
1st Treat Pain!
All are treated with ABX
(Amoxicillin Po)
(Ceftriaxone IV or IM)
Unless
Older than 2 years with bilateral AOM without otorrhea can observe
Or Any age that is unilateral without otorrhea
When should peds get ear tubes places for AOM
Children w/ developmental risks OR recurrent AOM + 3 mos persistent effusion w/ bilateral hearing loss
Refer to ENT for pressure equalization tubes (PET) insertion*
What is the typical resolution of persistent middle ear effusions
May last weeks to months
Usually resolves in 3 months
Regular evaluation for persistent effusion at every well-child exam
-Associated w/ conductive hearing loss
(mild to moderate & transient or fluctuating)
Leads to speech delay
What is the MGMT approach to Reccurent Otitits media
If recurrent <1 month since tx, ->change antibiotic
-Suspect resistant bacteria
If recurrent >1 month, may use ->same antibiotic
-Suspect separate infections
If >3 episodes in 6 months OR if >4 episodes in 12 months OR persistent OME for >3 months: ->ENT referral: eval for PE tubes
Step I-4 ABX for AOM
Amoxicillin
- > amoxicillin/ clav
- > Cefuroxime
- > IM ceftriaxone
What is swimmers ear
otitis externa
A peds presents with ear pain, tenderness, and discharge with a tender pinna on manipulation
Suspect
Otitis externa
See:
Tenderness at tragus & w/ chewing
Auditory canal: erythema & edema
Discharge (scant to copious)
TM typically unaffected
Tx for Otitis externa
Pain meds: NSAIDS and ASA
Topical ABX:
Ofloxacin or ciprofloxacin w/ hydrocortisone or dexamethasone
Fluoroquinolones safe for tympanostomy tubes (not ototoxic)
Polymyxin B-neosporin-hydrocortisone
Most common site for epistaxis
90% from anterior nose (Kiesselbach’s plexus) due to dry, friable mucosa
If a nose bleed persists beyond 10 minutes of pressure
What are the next steps
Afrin -> Referal to ENT if still unresolved
If the bleeding is posterior
-> ENT referal (Avoid sepal necrosis)
What bacterial agent is common in epistaxis recurrence
S. Aureus
Tx with Mupirocin
Most common cause of the common cold
Rhinovirus
What is the most common complication of the common cold in peds
Otitis media
What is the age limit in peds to use Anithistamines and decongestants
Antihistamines & decongestants → not in children <6yo (due to adverse effects & lack of benefits)
Should cough suppressants or expectorants be used in peds for the common cold
NO!
What sinuses are present at birth
Maxillary & Ethmoid sinuses
When do the sphenoid sinuses develop
Age 5
When dot eh frontal sinuses develop age 7
What are the ostia of the sinuses
Openings that drain sinuses
Narrow : 1-3mm
Drain into the middle meatus (ostiomeatal complex)
What is the criteria to Dx sinusitis
Physical findings lasting >10-14 days w/out improvement or increased severity compared to common cold
Most common: mucopurulent rhinorrhea, nasal stuffiness, cough (esp., at night)
Other si/sx: Nasal quality to voice, halitosis, facial swelling, facial tenderness/pain, headache
Lab/Rad—usually not needed
WHat ist he 1st line Tx for Sinusitis
amoxicillin-clavulanate x10-14 days
-High-dose therapy (80-90 mg/kg): -high risk for resistant bacteria:
Penicillin allergy: -Levofloxacin (type 1 hypersensitivity) -Clindamycin + 3rd generation cephalosporin (cefixime, cefpodoxime) (non-type 1 hypersensitivity)
> 50% recover w/out any antimicrobial therapy
What are the risk factors for resisting bacteria in sinusitis
Antibiotics in preceding 1-3 months
Age <2yrs
High rates of local antimicrobial resistance
What is hay fever
Allergic rhinitis (seasonal or perineal)
Sneezing, itching, rhinorrhea, & congestion
NO FEVER!!
(If fever think infectious etiology)
What are the early and late phase allergic rhinitis
IgE-mediated allergic response
Early phase
->Mast cells degranulate
→ release histamine & tryptase, leukotrienes, prostaglandins, & platelet-activating factor
Late phase (4-8 hrs later)
- Eosinophils, basophils, CD4 T cells, monocytes, & neutrophils release chemical mediators
- > chronic nasal inflammation & platelet-activating factor
What is the atopic triad
Eczema + asthma + allergic rhinitis
What is rhinitis medicamentosa
overuse of topical nasal decongestants (oxymetazoline, phenylephrine, or cocaine)
seen more in adolescent
Suspect ______w/ hx of unilateral, purulent nasal discharge or foul odor
Foreign bodies
What is the 1st line Tx for Allerigic Rhinitis
Intranasal corticosteroids
2nd line: oral antihistamines
Cetirizine
When is Montelukast best to use in sinusitis pts
best in concomitant asthma
What is the most common cause of pharyngitis
Viral viral viral and viral
What is the only bacteria that is tested for in pharyngitis
Strep
What is the most important clinical finding in Group A strep pharyngitis
Sore throat+ fever+ NO COUGH!
What is the modified CENTOR criteria
- Absence of cough
- Tender/swollen anterior cervical adenopathy
- Fever of >100.4F
- Tonsillar swelling or exudates
- Age 3-14 yo (however, if ≥45 yo then -1 point)
Interpretation:
0: strep unlikely, treat as viral (i.e., no antibiotics)
1-3: culture or rapid strep test & antibiotics if positive
4-5: probable strep, rapid test or culture
Can consider empiric antibiotics but frowned upon if rapid available
What is the clinical manifestations of Group A strep pharyngitis
- Sudden onset of sore throat
- Age 5-15 yr
- Fever
- Headache
- Nausea, vomiting, abdominal pain
- Tonsillopharyngeal inflammation
- Patchy tonsillopharyngeal exudates
- Palatal petechiae
- Anterior cervical adenitis (tender nodes)
- Winter and early spring presentation
- History of exposure to strep pharyngitis
- Scarlatiniform rash
What are the clinical manifestations of Viral Pharyngitis
- Conjunctivitis
- Coryza
- Cough
- Diarrhea
- Hoarseness
- Discrete ulcerative stomatitis
- Viral exanthema
What is the gold standard testing for pharyngitis and tonsillitis
Strep culture (swab) if suspected
Gold standard
Takes 24-48 hours to get result
CAn you throat swab for mono
If mononucleosis is in differential diagnosis → monospot (highly specific & sensitive) & CBC w/ differential—blood test, not a swab
What is the tx for GAS pharyngitis
Amoxicillin 50mg/kg QD x 10 days (low dose)
2*: Oral Penicillin V 10mg/kg/dose bid-tid x10 days
3* Benzathine penicillin G IM
(single dose) (compliance issues)
Does prevention of rheumatic fever in pharyngitis prevent post strep Glomerulonephritis?
NO
What does PANDAS stand for in Pharyngitis
Pediatric autoimmune neuropsychiatric disorders associated w/ streptococcal (PANDAS) infection
→ basal ganglia inflammation
S/s :OCD, tics (motor and/or vocal)
