Paediatric ENT problems
Ears Otitis media Otitis media with effusion FBs Otitis externa Ruptured TM Nose FBs Allergic rhinitis Septal perforation expistaxis Throat FB Croup Stidor Tonsillitis Paediatric ENT
Normal anatomy revision
4 year old, febrile and sad
Otitis media with effusion is the presence of fluid in the middle ear without signs or symptoms of acute ear infection.
16 year old with painful ear, keen swimmer, no discharge.
Chronic "dry" anterior tympanic membrane perforation, pain is due to water entering the middle ear. Perforation probably due to recurrent otitis media. Acute perforation would show a smaller perforation, fresh edges and there would be discharge
A 14 year old girl presents with a five day history of pain in her right ear, reduced hearing, and yellow coloured ear discharge.
Acute otitis externa An infection of the external auditory canal. It is usually unilateral, gradual onset pruritis, pain, hearing loss, and ear discharge. The patient is usually well. It can be precipitated by cotton bud or other trauma or getting water in the ear. Immunosuppression (eg diabetes ) or eczema are also risk factors. On Examination: discharge and debris in a swollen, erythematous canal Granulation tissue or polyps more serious pathology = specialist review. The tympanic membrane is intact but may not be visible as a result of oedema or discharge. It can be complicated by pinna cellulitis which causes a red, hot, swollen, and tender pinna. "Malignant" otitis externa = severe infection causing osteomyelitis of the skull base, severe pain, If untreated, it can involve the cranial nerves and brain. It is not a neoplastic process.
A 4 year old boy presents with right sided ear pain for 24 hours. He also has a fever and a poor appetite. He has just started at school and his older sister has recently had a cold. Clinically he looks well.
Acute otitis media Infection of the middle ear, usually in children < 6 years old. Rapid onset pain with malaise and fever. The child will have a hearing loss but this symptom may not be volunteered. In those younger than 2 years it often presents non-specifically with irritability, pulling at the ear, poor feeding, and can cause gastrointestinal upset. Frequently preceded by an URTI. It does not cause ear discharge unless the tympanic membrane has become perforated. Otoscopy reveals a bulging, immobile, red tympanic membrane, discharge may be present if there is a perforation. AOM frequently viral resolves spontaneously within 7 days in the majority of patients. Coryzal symptoms are suggestive of a viral aetiology. Adequate analgesia alone should be appropriate for most patients as long as the child is not seriously unwell and there is diagnostic certainty. If there is no improvement within 72 hours they should be given oral antibiotics. Amoxicillin recommended in all unwell patients or those not improving after 72 hours since they shorten the duration of the symptoms.
Acute mastoiditis Extra cranial complication of aggressive or untreated AOM Infection passes to mastoid air cells causing infection & bone necrosis Infection can track further leading to brain abscess, meningitis, subdural abscess
Epstein Barr Virus (aka glandular fever) Causative agent for infectious mononucleosis. Symptoms : malaise, headache, tiredness, tender lymphadenopathy, and a sore throat. Slow recovery characterised by lethargy lasting 6-8 wks. Teenagers and young adults are typically affected, with about half the population being immune following a childhood illness. Transmission is by saliva droplets, "kissing disease Hepatosplenomegaly is a rare complication, but should be looked for, and patients should be warned about this, particularly those who play contact sports. Patients with infectious mononucleosis often develop a rash with ampicillin and, for this reason, you should avoid co-amoxiclav. The appropriate blood test is the monospot, which tests for Epstein-Barr virus..
Peritonsillar abscess AKA: quinsy This is demonstrated by the full, erythematous appearance of the right peritonsillar area, Abscess, usually of mixed flora including both anaerobic and aerobic bacteria, develops in the peritonsillar space
Modified Westley Croup Score is use to indicate the severity of the disease Interpretation: Total Score 0-17 Score > 8 indicate respiratory failure Clinical indicator Inspiratory stridor None At rest, with stethoscope At rest, no stethoscope required to hear score 0 1 2 Level of consciousness Normal Altered Air entry Normal Decreased Severe decreased Cyanosis None Agitated Resting Retractions None Mild Moderate Severe 0 5 0 1 2 0 4 5 0 1 2 3
Alberta Clinical Practice Guideline working group; (2008) Mild: Occasional barking cough and 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: Frequent barking cough and 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: Frequent barking cough with 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.
4 year old child suffering prolonged febrile convulsion, you become aware of a loud stridor: Temp 39.5 HR 160 RR 65
Ideas? Foreign Bodies
Removal of Foreign bodies Parental kiss http://www.racgp.org.au/afp/2013/may/mothers-kiss/ Crocodile forceps Wound glue Fine bore suction Embedded earrings: good anaesthesia http://lifeinthefastlane.com/nasal-foreignbodies/
Summary Assess using an ABC approach Maybe the primary PC or an underlying cause Use guidelines and ENT advice Always be mindful of potential airway compromise