Transcript Paediatric ENT

Paediatric ENT
Gill Robinson
Aims

Management of:
 Cervical Lymphadenopathy
 Chronic stridor
 Sleep apnoea
 Earache
 Intermittent childhood deafness
Cervical Lymphadenopathy
-causes





Infectious
 viral
 bacterial typical and atypical
 Infected eczema
Oncology
 leukaemia / lymphoma
 Secondary
Kawasaki
Connective tissue disorders
Is it a node?
Cervical lymphadenopathy history
Age
 Onset and persistence of symptoms
 Recent health
 URTI / LRTI
 Bruising
 Weight loss, fever etc
 PMH – immunodeficiency, CT disorders

Cervical Lymphadenopathy Exam
Growth and nutritional status
 Skin – rashes, bruising / purpura, eczema
 Is it a node?
 Other nodes – axilla/ groin
 ENT – esp tonsils
 Chest
 Abdomen - spleen

What sort of neck mass is this?
Management
Airway safety
septic work up
IV benz pen
No tests, reassure
Treat underlying cause
Small + fluctate
in size
lymphadenitis
Rapid increase
Acute
Chronic
(With fever)
Progressive enlargement
With rash
Atypical TB, malignancy
Consider kawasaki
CT disorders
FBC, ESR, Mantoux test, CXR,
biopsy
Chronic stridor- causes



Above larynx
 Tonsillar hypertrophy
 Tongue – Pierre Robin sequence, facial
abnormalities
Larynx
 Laryngomalacia
 Sublgottic stenosis
 Haemangioma, cysts, web, cleft
 Vocal cord paralysis – recurrent laryngeal nerve
 Papilloma
Compression – vascular ring, tumour, goitre
History
Age onset
 Voice / cry
 Progression +/- neck mass
 Feeding, URTI, LRTI
 BH / PMH – intubation, neck surgery,
 FH – maternal gential warts

Examination








Health and growth
Dysmorphic features and scaring
Posture, support – sats monitoring, NG fed
Is this stridor?
Metal condensation test
Respiratory distress
Neck mass- inc transillumination and ascultation
ENT – oral cavity- cleft, tumour, Tonsils
Investigation

If respiratory distress / or > 6/52
 Ba Swallow
 Larynogoscopy
 Bronchoscopy
Laryngomalacia
Small infantile larynx – omega shaped that
narrows to slit on inspiration
 Appears 1-4 weeks
 Worse with feeding / crying
 Rarely obstructs, improves by 1 year, gone
by 3 years

Sleep apnoea
Causes



Airway –
 Within - Obstruction
 adenoids / tonsils
 Structure airway
 Trachomalacia, Pierre Robin
 Muscle weakness Vocal cord paralysis
 Without airway
 Compression – vascular ring, fat
GI – reflux
Central – odines curse, seizure, arrythmia
Sleep apnoea
Presentation
Snoring / apnoea
 Mouth breathing when awake
 Day time tiredness
 Poor school performance
 Headache
 Enuresis
 Pulmonary hypertension / cor pulmonale

Sleep apnoea
Exam
Dysmorphic – facial abnormalities
 Signs muscle disease
 ENT – palate, tonsils
 Nasal obstruction
 Chest – deformity / distress

Sleep apnoea
Investigation
Oximetry
 ENT opinion
 plesmography
 Early morning gas
 ECG / echocardiography

Earache
Ear
 Otitis media
 Otitis externa
 Rare
 Dental

AOME – history and exam
Earache, screaming
 Fever, vomiting
 Usually with hearing deficit
 Altered color: red to yellow, buldging
 Decreased mobility on + and – pressure by
pneumatic otoscopy, tympanometry

Otitis Media



Inflammatory reaction to foreign antigens in the middle
ear that cannot adequately drain via the eustachian
tube.
Three major divisions
 Acute otitis media with effusion (AOME)
 Otitis media with effusion (OME)
 Chronic draining otitis media (CDOM)
AOME or OME may be intermittent, persistent, or
recurrent
Why does it happen
Altered ear “toilet”: secretions and refluxing
bacteria inadequately cleared
 Stagnation of middle ear contents
 Bacteria multiply in middle ear
 Inflammatory/immune response (as much as 1
cc/hr)

Acute Otitis Media









1.5 episodes of AOME/year in average child
Daycare, passive smoke, or wood burning heat – X 3-7
Age variable attack rate, most <2yo, big drop at 5yo
Males > females, 1.8:1
Otitis prone children average 3 episodes/6 months
Seasonal (less in summer)
Association with conjunctivitis or sinusitis
Viral prodromes frequently noted
Immunodeficiency predisposes: Ig deficiency, HIV
Genetic predisposition: Down syndrome, cleft palate,
family history
Causative organisms






Organisms isolated from middle ear aspirates in AOME
differ geographically.
No growth =10-15%: viral or innate defenses killed
bacteria
S. pneumoniae =30-50: ~1/5 PCN resistant
NT. H.influenzae =25-30%: ~1/3 produce -lactamase
Branhamella (Moraxella) catarrhalis =8-45%: >95%
produce -lactamase
Group A streptococcus =5-8%: almost never in
persistent or recurrent
Treatment AOM - Cochrane
Analgesics
 Antibiotics not alter pain within 1st day and
only minor decrease on days 2 and 3
 Not alter deafness
 No info on serious SE
 SE antibiotics – rashes, diarrhoea
 May have some role in very young / severe

Suspected OME - history








Intermittent hearing difficulty
Indistinct speech / delayed language
Repeated ear infection
Poor educational progress
Recurrent URTI
Attention problems
Behaviour problems
Rarely balance / tinitus
OME - exam
Growth
 Development
 ENT
 LRTI
 Tympanometry
 Hearing tests

Normal hearing
Hearing tests
Neonatal hearing screen – OAE
Otoacoustic emssions 



Sleeping child
Click from ear piece if
intact cochlea then the
ear piece will pick up
the cochlear
response.
Simple and quick to
Relatively high false
positive rate
ABR - Auditory Brainstem
Response




recording brain activity in
response to sounds.
Sleeping infant.
Earphones are placed in the
baby's ear canals.
Usually, click-type sounds
are introduced through the
earphones, and electrodes
measure the auditory
pathway’s response to the
sounds.
Visual response audiometry



6/12 to 21/2 years
Sounds of different
frequencies and
loudness are played
through speakers.
When the child hears
the sound, they will
turn their head when a
visual ‘reward’
Pure tone audiogram





3 Years +
Younger children are
shown how to move a
toy.
Older children say yes
or pressing a button.
Sounds come through
headphones, or
speaker
Bone conduction,
vibration behind ear
Tympanogram
OME Treatment





Wait 3 months
Risks and benefits
Advise on educational / behavioural strategies
Auto inflation – if will and can use
Avoid decongestants, antihistamines,
antibiotics, steriods, homeopathy, dietary
modification, acupuncture
Useful advice - preschool
Maximize hearing
 ‘Together time’ with parent
 Reading picture books together
 Visual cause and effect toys
 Use of gestures
 Encourage Peer group play
 Encourage Imaginative play

Advice – school aged child
Classroom organization
 Sitting at the front of the class
 Better ear towards the teacher
 Reduce ambient noise e.g. carpets,
blinds, double glazed windows, material
on walls, e.g. pin boards. Soft
furnishings absorb noise.
 Cue Using child’s name

OME treatment





If >25dB hearing loss for > 3/12 the grommets
50% of children who require one set of tubes will need
second set within 1 year, and 15% will require a 3rd set
Some evidence that prolonged or repeated tube
placement leads to excessive scarring of TM and
permanent damage to TM
No evidence of long-term improvement in hearing due
to tube placement
If refused / inappropriate then use hearing aids
Chronic discharging otitis media
a) Lack of integrity of TM
 b) Chronic drainage
 c) Usually with hearing deficit

CDOM




Requires ENT specialty consultation
Need to rule out cholesteatoma
Rare that surgery will help until post puberty
Interim care:
 Keep ear dry
 Selective use of topical agents
 External drainage cultures always yield
Pseudomonas or Enterics
Children will present to
paediatricians with:
Cervical Lymphadenopathy
 Chronic stridor
 Sleep apnoea
 Earache
 Intermittent childhood deafness
