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PAEDIATRIC ENT FOR YEAR3 CURRICULUM Year 5 MBBS Student p.lee2@ncl.ac.uk EAR 2. Hearing Loss 3. Otitis media 4. Glue EarWhat is Otoscopy? - Otoscope is a tool used to look at the ear canal and eardrum. - The otoscope has: - a light - a magnifying lens - a speculum = a funnel- shaped viewing piece with a narrow, pointed end. 4 QUESTION 1 A 4-year-old boy has a 3-month history of decreased hearing on his right ear,since he recovered from an episode of ear infection. Staff at the child’s nursery say he doesn’t always respond immediately,and his mother is concerned that he is not talking as much as other children. Which is the SINGLE MOST likely result of the tuning fork tests? Rinne’s – conduction results Weber’s – ear localisation A Air > Bone LEFT B Air > Bone RIGHT C Bone > Air LEFT D Bone > Air RIGHT E Air same as bone EQUAL 5 QUESTION 1 A 4-year-old boy has a 3-month history of decreased hearing on his right ear,since he recovered from an episode of ear infection. Staff at the child’s nursery say he doesn’t always respond immediately,and his mother is concerned that he is not talking as much as other children. Which is the SINGLE MOST likely result of the tuning fork tests? Rinne’s – conduction results Weber’s – ear localisation A Air > Bone LEFT B Air > Bone RIGHT C Bone > Air LEFT D Bone > Air RIGHT E Air same as bone EQUAL 6 QUESTION 2 Which of the following statement is true? a) 20% of bacterial meningitis cases resulted in hearing loss b) Meningitis causes conductive hearing loss c) Post-meningitis, clinician should assess hearing loss in 6 months d) Meningitis causes fibrosis of cochlear,which can cause implantation of hearing air nearly impossible 7 QUESTION 2 Which of the following statement is true? a) 20% of bacterial meningitis cases resulted in hearing loss b) Meningitis causes conductive hearing loss c) Post-meningitis, clinician should assess hearing loss in 6 months d) Meningitis causes fibrosis of cochlear,which can cause implantation of hearing air nearly impossibleHearing Loss in Children • Conductive hearing loss (CHL) makes • Sensorineural Hearing Loss (SNHL) up the majority of hearing loss in • Meningitis – 10% will develop SNHL as children! complication – Cochlear fibrosis within 1 month • #1 cause = Otitis media with Effusion • Genetic – 30% syndromic (OME) • Hypoxia during birth • Acute Otitis Media (AOM) • Hyperbilirubinaemia • Tympanic perforation • Drug, Toxins (eg aminoglycosides) • Earwax impaction, Foreign body • Congenital infections (CMV, Rubella, Syphilis, • Cholesteatoma Toxoplasmosis) 9 FYI - WEBER & PINNE TEST Tuning fork – What frequency? 512 Hertz (Short & Stubby) • Step 1: Look at Rinne test: [Rinne to the Pinna!] • Positive (AC > BC) – air conduction likely fine-- > suspect sensorineural hearing loss (SNHL) • Negative (AC < BC) – air conduction NOT good → suspect conductive hearing loss • Step 2: Weber test • If SNHL,sound lateralises (heard louder) on the less affected ear • If conductive, sound lateralises (heard louder) on the more affected ear [because more soundwaves are trapped within that ear] 10 Normal ear drum Acute otitis media (AOM) Grommet in situ Otitis media with effusion (OEM) Cholesteatoma Ladybug in the Ear canal! 11 QUESTION 3 Pure tone audiometry was done for Tommy ,a 5-year-old boy,and the result is as shown to the right.What is the most likely cause of his decreased hearing? a) Cholesteatoma b) Otosclerosis c) Meningitis d) Tympanic membrane perforation e) Eustachian tube dysfunction 12 QUESTION 3 Pure tone audiometry was done for Tommy ,a 5-year-old boy,and the result is as shown to the right.What is the most likely cause of his decreased hearing? a) Cholesteatoma b) Otosclerosis c) Meningitis d) Tympanic membrane perforation e) Eustachian tube dysfunction 13 AUDIOGRAM • Threshold for NORMAL hearing = < 20 dB Conductive Hearing Loss (CHL) Sensorineural Hearing Loss (SNHL) Gap between Gap > 10 dB NONE bone & air conduction Quantity of loss CHL alone RARELY < 60dB Can exceed 60 dB (consider mixed hearing loss) Right Conductive Hearing Loss Right Sensorineural Hearing Loss (SNHL) 14 ACUTE OTITIS MEDIA (AOM) • Y oung children at HIGHER risk: • Immature immune system • Shorter,wider,more horizontal and floppier Eustachian tube than adults • Usually preceded by Upper Respiratory Tract Infection • Causative Agents: • #1= Streptococcus pneumoniae • #2 = Haemophilus influenzae • #3 = Moraxella catarrhalis ACUTE OTITIS MEDIA 15 CLINICAL PRESENTA TION 1. Ear pain 2. Ear drum inflammation – intense erythema 3. Otorrhoea (ear discharge) 4. Middle Ear Effusion – key indicators include: 1. Bulging of eardrum (pathognomonic!) 2. Impaired mobility of eardrum 16 INVESTIGATION • Otoscopy • Tympanometry / Pneumatic Otoscopy DIFFERENTIAL DIAGNOSES • Otitis media with effusion • Chronic Suppurative Otitis Media • Otitis Externa QUESTION 4 17 An 18-month-old child was brought in by their parents to see you at the GP surgery .The child was previously well until 2 days ago when they started tugging both ears. This morning,there was discharge oozing from the child’s ears.When you put your otoscope,you saw the picture on the right.What should you do? a) Advise“watchful waiting” b) Offer delayed antibiotic description c) Prescribe PO amoxicillin x 5 days d) Prescribe topical ciprofloxacin drops QUESTION 4 18 An 18-month-old child was brought in by their parents to see you at the GP surgery .The child was previously well until 2 days ago when they started tugging both ears. This morning,there was discharge oozing from the child’s ears.When you put your otoscope,you saw the picture on the right.What should you do? a) Advise“watchful waiting” b) Offer delayed antibiotic description c) Prescribe PO amoxicillin x 5 days d) Prescribe topical ciprofloxacin drops QUESTION 5 19 A 5-year-old boy came into your GP surgery for ear pain and discharge leaking out of his ear.The symptoms started about 4 days ago,since he recently suffered a cold. You look inside his affected with your otoscope and saw the picture on the right. What should you do? a) W atchful waiting b) Prescribe delay antibiotic prescription c) Prescribe PO amoxicillin d) Prescribe topical ciprofloxacin drops e) Prescribe topical gentamicin drops QUESTION 5 20 A 5-year-old boy came into your GP surgery for ear pain and discharge leaking out of his ear.The symptoms started about 4 days ago,since he recently suffered a cold. You look inside his affected with your otoscope and saw the picture on the right. What should you do? a) W atchful waiting b) Prescribe delay antibiotic prescription c) Prescribe PO amoxicillin d) Prescribe topical ciprofloxacin drops e) Prescribe topical gentamicin drops MANAGEMENT 21 • 1 line = watchful waiting,safety-netting and analgesics • 2nd line – PO antibiotics if symptoms do NOT improve within 3 days or worsen When to start antibiotics immediately? 1. Systemically unwell (observations!) 2. High risk of complications (age < 6 months,co-morbidities) 3. Children aged < 2 and bilateral AOM 4. Acute onset ear discharge from spontaneous ear drum rupture Patient with discharge coming out of ventilation tube should get topical antibiotic (quinolone preferred over ototoxic aminoglycosides!) COMPLICA TIONS 22 Extracranial Intracranial • Mastoiditis • Meningitis • Petrositis • Brain abscess,epidural abscess, subdural empyema • Permanent sensorineural • Sigmoid / Lateral sinus hearing loss thrombosis • Labyrinthitis • Facial nerve palsy • Neck abscess 23 QUESTION 6 A 4-year-old girl was brought into your clinic because her mom noticed she has difficulty following instructions both at the nursery and at home. She has been socially withdrawn.She listens to her iPad at really loud volume.Upon inspection,you saw air-fluid level in her eardrums.The tympanometry result is as shown on the right.What would you recommend to her mother? a) Active surveillance,follow up in 3 months b) Refer for hearing aid insertion c) Myringotomy & grommet insertion d) Schedule for adenoidectomy 24 QUESTION 6 A 4-year-old girl was brought into your clinic because her mom noticed she has difficulty following instructions both at the nursery and at home. She has been socially withdrawn.She listens to her iPad at really loud volume.Upon inspection,you saw air-fluid level in her eardrums.The tympanometry result is as shown on the right.What would you recommend to her mother? a) Active surveillance,follow up in 3 months b) Refer for hearing aid insertion c) Myringotomy & grommet insertion d) Schedule for adenoidectomy 25 OTITIS MEDIA WITH EFFUSION (OME) • Aka:“Glue Ear” • MOST COMMON cause of hearing loss in children. • Build-up of viscous inflammatory fluid within the middle ear without signs of acute infection • Eustachian tube dysfunction + Chronic Inflammatory changes Age 6 months – 4 years 50% follow an AOM episode Winter months! 26 • Normal Eardrum • Retracted Eardrum • Otitis Media with Effusion (Dull,tympanic membrane, lost light reflex)  Air-Fluid level in OME! • OME – filled to the brim 27 OME – PRESENTA TION • Hearing loss – often missed OME = Flat as a pancake! • Speech & Language development • Social withdrawal (development) • Behavioural problem • Balance problems,clumsiness • Sensation of pressure Investigation – 1. Otoscope 2. Tympanometry 3. Pure tone audiogram 28 OME – MANAGEMENT • 1 line = Active Surveillance (50% resolution within 3 months) After 3 months: • 2nd line = Hearing aid insertion • 2nd line = Myringotomy & Grommet insertion • Adenoidectomy – if persistent symptom despite multiple grommet insertionNOSE Allergic RhinitisQuestion 7 It is spring season, and the flowers are in full bloom. Your patient is a 13- year-old male with a history of eczema. Both of his parents suffer from asthma. He is presenting with clear nasal discharge, watery eyes and and walks outdoor. What medications would you NOT recommend forirst wakes up long-term use? a) Cetirizine tablets b) Beclomethasone nasal spray c) Fluticasone nasal spray d) Xylometazoline nasal spray e) Fexofenadine tabletsQuestion 7 It is spring season, and the flowers are in full bloom. Your patient is a 13- year-old male with a history of eczema. Both of his parents suffer from asthma. He is presenting with clear nasal discharge, watery eyes and and walks outdoor. What medications would you NOT recommend forirst wakes up long-term use? a) Cetirizine tablets b) Beclomethasone nasal spray c) Fluticasone nasal spray d) Xylometazoline nasal spray e) Fexofenadine tabletsAllergic Rhinitis • IgE-mediated type 1 hypersensitivity • Environmental allergens cause inflammation of nasal mucosa • Pollen, grass (seasonal) • Dust mites, moulds, pets (perennial) • Wood / Grain dust (occupational) • Atopy Triad: (i) asthma (ii) eczema (iii) allergic rhinitisPresentationsInvestigations • Clinical Diagnosis! • Physical exam – “allergic shiners” • turbinate mucosahypertrophy, Bluish discoloration to • Trial of antihistamine +/- intranasal corticosteroids • Skin-prick test (SPT) • Serum Radio-AllergoSorbent Test (RAST)Management Non-drug measures (conservative): 1) Trigger avoidance 2) Nasal irrigation with saline Medications: 1) 1 line = PO antihistamine (non-sedating) 2) 2 ndline = Intranasal corticosteroids for a minimum of 4-6 weeks 3) Intranasal antihistamine + corticosteroid combination (Dymista) 4) Intramuscular injection (triamcinolone) 5) Leukotriene receptor antagonist (if concurrent asthma) 6) Allergen immunotherapy – SL or SC (desensitization) Note: Do NOT use intranasal decongestant (xylometazoline) for > 5 days – Risk of rhinitis medicamentosa (rebound hypertrophy of nasal mucosa)!THROAT Epiglottitis Foreign BodysQuestion 8 A 5-year-old girl developed severe sore increasing difficulty breathing over the last 8 hours. A picture of her at the clinic was shown on the left. After her airway was secured, what would you expect to see on her X-ray? a)Steeple sign b)Thumbprint sign c)Double ring sign d)Egg-on-stringQuestion 8 A 5-year-old girl developed severe sore throat, drooling of saliva, high fever and increasing difficulty breathing over the last 8 hours. A picture of her at the clinic was shown on the left. After her airway was her X-ray?hat would you expect to see on a)Steeple sign – Croup b)Thumbprint sign c)Double ring sign – Battery ingested d)Egg-on-string – Transposition of Great ArteriesRed Flags in Sore Throat 1. DYSPHAGIA • Can they eat and drink? Any problem with swallowing? • Absolute aphagia – saliva drooling! 2. DYSPHONIA • Do they have any change in voice? • Weak / croaky • “Hot potato voice” 3. SEPTIC • Are they systemically well? The famous “Impending airway disaster Triad”!Epiglottitis – Background • RARE • Croup = #1 most common cause of Acute Stridor in children! • Causative agent = • Haemophilus influenzae type b (Hib) (before vaccine) • Streptococcal species (post- vaccine) • Children more at risk of airway obstruction due to anatomy but can affect any age!Epiglottitis – Clinical Presentation 1. NOT preceded by coryza → NO cough 2. Acute onset within HOURS, Symptom duration < 12 hours o 3. Septic, High fever (>38.5 C) 4. Sore throat 5. Dysphagia - dehydration, saliva drooling 6. Hoarseness – Quiet voice 7. Stridor (quiet) – LATE sign 8. Tripod position – tongue out Epiglottitis – Differential Diagnoses Croup Epiglottitis 1 Onset over DAYS Over HOURS 2 Preceding coryza? YES NOPE 3 Cough Barking Cough (severe) Absent, slight 4 Able to drink? YES NO 5 Drooling saliva NO YES 6 Appearance Simply unwell SEPTIC, very ill, tripod position to breathe 7 Fever < 38.5oC >38.5oC (HIGH) 8 Stridor Harsh, rasping Soft, whispering [Remember: Quiet is Worse] 9 Voice, cry HOARSE Muffled, reluctant to speakEpiglottitis – Management • Stay calm & organised → ↓ anxiety • Do NOT examine throat to trigger complete obstruction! • Early escalation to seniors! • Secure the airway (intubation) • Oxygen + Nebulised adrenaline rd • IV antibiotics (3 generation cephalosporin) • IV Steroids (delayed effect) • Investigations – throat swabs, FBC, cultures, CRP, lateral neck X-rayTonsilitis – Pathogenesis • Tonsils at their largest ~4-8 years of age • Large tonsils ≠ infection • Mainly VIRAL • Bacteria ~15-30% cases Group A beta- haemolytic Streptococcus [GABHS] Question 9 A 6-year-old girl comes into your GP surgery after developing sore throat and a body inspecting her mouth, you saw the picture onen the right. She has no cough. How will you manage this patient? a) Watchful waiting b) Prescribe amoxicillin x 7 days c) Prescribe phenoxymethylpenicillin PO x 10 days d) Refer for tonsillectomy e) Offer reassurance to the parent and explain this infection is viral in nature. Question 9 A 6-year-old girl comes into your GP surgery after developing sore throat and a body inspecting her mouth, you saw the picture onen the right. She has no cough. How will you manage this patient? a) Watchful waiting b) Prescribe amoxicillin x 7 days c) Prescribe phenoxymethylpenicillin PO x 10 days d) Refer for tonsillectomy e) Offer reassurance to the parent and explain this infection is viral in nature.Tonsilitis – Clinical Presentation • Sore throat • Odynophagia, dysphagia • Ear pain (referred) • Swollen tonsils + /- exudate • “Hot potato voice” – nasal, muffled • Fever, malaise bacterial infection 4 => 40-60% risk of bacterial vs viral infection, so the scoring scale merely provides an estimation! Grade 2 tonsil Grade 3 tonsil Grade 4 tonsilTonsilitis – Differential Diagnoses 1. Pharyngitis that does not involve tonsillar inflammation 2. Glandular Fever 3. Quinsy (aka: “Peritonsillar Abscess”) 4. Epiglottitis 5. Tonsillar malignancy – lymphoma Question 10 An 18-year-old female patient presented with sore throat for the last 5 days. She has trouble swallowing, but maintains a liquid diet. She has malaise, anorexia and abdominal pain. She has a swollen neck and inflamed tonsils bilaterally. How will you manage this patient? a) Prescribe amoxicillin x 10 days b) Prescribe acyclovir x 10 days c) Prescribe dexamethasone to relieve symptom d) Advise patient to stay away from rugby practice for 4 weeks e) Advise patient that she may kiss her partnerQuestion 10 An 18-year-old female patient presented with sore throat for liquid diet. She has malaise, anorexia and abdominal pain. a She has a swollen neck and inflamed tonsils bilaterally. How will you manage this patient? a) Prescribe amoxicillin x 10 days b) Prescribe acyclovir x 10 days c) Prescribe dexamethasone to relieve symptom d) Advise patient to stay away from rugby practice for 4 weeks e) Advise patient that she may kiss her partnerGlandular Fever • Caused by Epstein-Barr Virus (EBV) • Bimodal = age 1-6 and age 18-22 • Most adults are antibody positive by age 30 (90%) • ~50% seroconvert with overt symptoms • Sore throat + Fever + malaise / fatigue + myalgia • Cervical lymphadenopathy • Abdominal pain, hepato-spleno-megaly, LFT elevation • Lymphocyte predominance on FBC • Monospot test for IgM, ELISA-based immunoassay for IgG • More prolonged symptom (1-2 weeks for odynophagia to resolve; generalised fatigue & myalgia may take several weeks)Tonsilitis – Investigation •Throat swab – limited value •Full Blood Count (FBC), CRP – look for white blood cells & neutrophil predominance •Liver Function Test (LFT)– deranged in glandular fever •Urine & Electrolytes (U&E) – possible dehydration & AKI if odynophagia prevents fluid intake •Monospot (optional) – identify non-specific IgM antibodies against EBV in glandular feverBacterial Tonsilitis – Management • Symptomatic relief – analgesic, hydration • Difflam (benzydamine) – topical spray • Fluid resuscitation st • Antibiotic – 1 line = phenoxymethylpenicillin (aka: Penicillin V) PO x 7-10 days • 2ndline = erythromycin (macrolides) • Do NOT prescribe amoxicillin (Type 4 HSR) • Refer for surgery if recurrent tonsillitis (stringent criteria) – eg ≥ 7 episodes in 1 yearBacterial Tonsilitis – Complication •Peritonsillar abscess (Quinsy) – deviated uvula, unilateral •Retropharyngeal / Parapharyngeal abscess – Septic, stiff neck •Post-streptococcal Glomerulonephritis – haematuria, oedema, hypertension •Rheumatic Fever – 2-5 weeks afterward; “JONES”FOREIGN BODY Blook like coins!)(theySign up Link: