PEDS- HEENT

Terms in this set (76)

Nasolacrimal duct obstruction
Patho: Blocked tear duct so the tears have no where to dran.
S&S:
They eye always looks wet.
The tears may spill over onto the cheek even when the baby is not crying.
Often there is mucoid material as well on the edge of the eyelid.
Treatment Nasolacrimal duct obstruction
Treatment: usually, there is only a small membrane blocking the opening and that opens within the first year
Keep eye clean
Antibiotic eye ointment to help reduce the discharge from the eye
Massage the lacrimal sac
If it doesn't work, surgery to open it up
Dacrocystitis
Patho: When there is a blocked tear duct (not necessarily from birth), bacteria creep in and become trapped in the ducts and cause an infection.

S&S:
tearing,
redness,
swelling,
drainage.
Eye may be tender and look irritated.
Pain may be felt in the mouth, cheeks, and other areas of the face.
Some children have a fever.
Tx: Dacrocystitis
Treatment:
antibiotics,
fever reducing medication,
massage the tear ducts,
warm moist compresses 10-20 min few times a day,
hand washing

Infection can spread so make sure it is caught early
Opthalmia Neonaturm - patho and causes
Patho: AKA Neonatal conjunctivitis, conjunctivitis of the newborn
swelling (inflammation) or infection of the tissue lining the eyelids

Causes:
Blocked tear duct, infection by bacteria or viruses, or irritation from abx eyedrops with silver nitrate (not used anymore)
Bacteria: Gonorrhea and chlamydia passed during childbirth
Virus: geniral or oral herpes during childbirth. These can be really serious and lead to severe eye damage
Opthalmia Neonaturm
S&S
Diagnosis
S&S: drainage from the eyes within 1day to 2 weeks after birth
Eyelids become puffy, red, tender
There may be watery, bloody, or thick pus-like drainage from the infant's eyes.

Diagnosis: Culture of the drainage
Slit lamp examination to look for damage to the surface of the eyeball.
Treatment: Opthalmia Neonaturm
Treatment: If it is from the drops given at birth, the irritation will just go away.
For a blocked tear duct,
--- gentle warm massage between the eye and nasal area
-- If a blocked tear duct has not cleared up by the time the baby is a year old, surgery

Antibiotics, Eye drops and ointments

Salt water eye drops may be used to remove sticky yellow drainage.

Special antiviral eye drops or ointments are used for herpes infections of the eye
Opthalmia Neonatorm - Complications and prevention
Complications: (most from herpes)
Blindness,
inflammation of the iris,
scar or hole in the cornea

Prevention:
screening everyone for herpes,
eye drops in all infants to prevent Gc/CT
Congenital Cataracts
- patho and causes
Patho: clouding of the lens of the eye

Causes: most of the time - who knows
Chondrodysplasia syndrome
Congenital rubella
Conradi syndrome
Down syndrome (trisomy 21)
Ectodermal dysplasia syndrome
Familial congenital cataracts
Galactosemia
Hallerman-Streiff syndrome
Lowe syndrome
Marinesco-Sjogren syndrome
Pierre-Robin syndrome
Trisomy 13
Congenital Cataracts - S&S
Diagnosis
S&S:
Gray or white cloudiness of the pupil (which is normally black)
Infant doesn't seem to be able to see (if cataracts are in both eyes)
"Red eye" glow of the pupil is missing in photos, or is different between the two eyes
Unusual rapid eye movements (nystagmus)

Diagnosis - refer to optho
Congenital Cataracts- Tx and Complications
Tx: If mild, you don't have to treat
- If moderate to severe, cataract removal surgery - In most (noncongenital) cataract surgeries, an artificial intraocular lens (IOL) is inserted into the eye. The use of IOLs in infants is controversial. Without an IOL, the infant will need to wear a contact lens.
- See if it is an inherited disorder


Complication: amblyopia - patch will help prevent that
periorbital and orbital cellultitis
- epidemiology
Increased incidence during the winter due to the increased incidence of sinusitis
No ethnic preferences
Blindness occurs in up to 11% of cases
In children, twice as common in males
More common in children than adults: mean
age 7-12 years old.
Periorbital and orbital cellulitis - signs
Proptosis
Ptosis
Chemosis
Lid erythema/edema
Motility restriction
Ocular/periorbital pain
Decreased vision - Diplopia
Nasal discharge
Worsening pain on eye movement
Nasal tenderness
periorbital and orbital cellultitis -
treatment
In children

Inpatient - broad spectrum IV antibiotics - Consider covering for MRSA. If the patient is afebrile and improving x 48hrs, may switch to oral antibiotics.

Outpatient - oral antibiotics for 2-3 weeks

Consider surgical management if worsening on IV antibiotics or have the special conditions listed
Retinopathy and Prematurity
Definition - abnormal blood vessel development in the retina of the eye in a premature infant.

Patho - If an infant is born very prematurely, eye development can be disrupted. The vessels may stop growing or grow abnormally from the retina into the normally clear gel that fills the back of the eye. The vessels are fragile and can leak, causing bleeding in the eye.
Retinopathy and prematurity - complications and risks
Complications: May cause vision loss or severe nearsightedness

Risks:
babies younger than 30 weeks, weighing fewer than 3 pounds at birth
Apnea
Heart disease
CO2 in the blood
Infection
Low pH
Low O2
Respiratory distress
Bradycardia
Transfusions
Retinopathy stages
Stage I: There is mildly abnormal blood vessel growth.
Stage II: Blood vessel growth is moderately abnormal.
Stage III: Blood vessel growth is severely abnormal.
Stage IV: Blood vessel growth is severely abnormal and there is a partially detached retina.
Stage V: There is a total retinal detachment.
Retinopathy S&S
Abnormal Eye movements
Crossed eyes
Severe nearsightedness
White looking pupils (leukocoria)
Retinopathy Treatment
Oxygen will help vessel growth.
Treatment must start within 72 hours of the eye exam
Cryotherapy to prevent the spread of abnormal blood vessels.
Laser therapy to prevent complications
Surgery if it detaches
Retinoblastoma S&S
Rare cancerous tumor of the retina
Mainly under the age of 6 (mostly 1-2 y/o)

S&S: Pupil have a white spot
White glow in the eye from a flash instead of the red eye
Also have
Crossed eyes*
Double vision
Eyes that do not align
Eye pain and redness
Poor vision
Differing iris colors in each eye
Retinoblastoma - Diagnosis and treatment
Diagnosis: CT scan, MRI, US of the eye, Bone marrow biopsy

Treatment: Small - laser surgery or cryosurgery, small and large - radiation, and large - chemo
Possible eye removal
ENT development
>> Maxillary and ethmoid sinuses - present at birth, though very small
>> Sphenoid sinus
-- tiny cavity at birth
-- not fully developed until puberty

Frontal sinus - develops by 7-8 years
ENT infant info
External auditory canal is shorter and has an upward curve
Eustachian tube is relatively wider, shorter and more horizontal
Reflux of nasopharyngeal secretions

Salivation increases by 3 months
Drools until swallowing is learned
Teeth
20 deciduous teeth
appear between 6 and 24 months
Eruption of permanent teeth begins about 6 years of age
Completed ~14-15 years old
3rd molar ("wisdom tooth") 18 years old
Ear Exam
>> Frequent site of congenital malformation therefore thorough examination is important."
Inspection
- Auricle - Well formed, all landmarks present
- Very flexible - Should have instant recoil after bending
= CLINCAL NOTE: Premature infant
May appear flattened with limited incurving of the upper auricle
= Slower ear recoil
- The tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)
- Low or poorly shaped auricles
= Associated with renal disorders and congenital abnormalities
- NO skin tags should be present
Ear Exam - Internal Ear Exam
* Lay the infant supine/prone
* Turn head to the side
* Hold otoscope so that the ulnar surface of your hand rests against the infant's head
* Prevent trauma to auditory canal
* Other hand stabilizes infant's head
* Pull auricle down to straighten the canal

Newborns
>> Auditory canal is often obstructed with vernix (newborn)
>> Tympanic membrane may be in an extremely oblique position until 1 month old
>> Should be examined within the first few weeks of life
Ear Exam
In neonates, you may note...
Limited mobility
Dullness and opacity of a pink or red tympanic membrane
Light reflex may appear diffuse
Tympanic membrane is not conical for several months
"As the middle ear matures in the first few months, the tympanic membrane takes on the expected appearance."
Infant Mouth Exam
Crying provides an opportunity to examine the mouth
Avoid depressing the tongue
Stimulates a strong reflex protrusion
Makes visualization of the mouth difficult
Well formed with no cleft
Buccal Exam - Pink and moist & No lesions

NOTE: Secretions that accumulate in the newborn's mouth may indicate esophageal atresia


Insert your finger into the infant's mouth
Fingerpad roof of the mouth
Evaluate the infant's suck
Scrape any white patches with a tongue blade
Nonadherent - milk deposits
Adherent - candidiasis (thrush)
Drooling
Normal from 6 weeks to 6 months
Consider a neurologic disorder if it persists >12 months
Gums
Should be endentulous
smooth with a serrated edge of tissue along the buccal margins
Teeth
Count deciduous teeth
Note any unusual sequence of eruption
Tonsils
Should blend with the color of the pharynx
Gradually enlarge to their peak size between 2 - 6 years
should retain an unobstructed passage
Graded to describe their size

Grading Tonsils
1+ -visible
2+ -halfway between tonsillar pillars and the uvula
3+ -nearly touching the uvula
4+ -touching each other
Otitis Externa - patho and Epid
Patho: Swimmers ear
Painful condition of the pinna
Ear canal is slightly acidit and moisture changes the pH

Epid: More common in children and teenagers
More in the summer but can occur in winter (bath)
The patient is more at risk if there is broken skin from excessive moisture, ear plugs, hearing aids, headphones, chemicals from dye, hair bleach, shampoos
Often from trauma such as wax impaction, Qtip trauma
Otitis Externa S&S
S&S: Ear pain, unilateral. Worse when the ear is touched or pulled, may itch
The outer ear may be red, and in severe cases the ear canal may be swollen shut.
The ear may drain. This drainage may be clear, white, yellow, or sometimes bloody and foul smelling. Some fluid may crust at the opening of the ear canal.
With severe swelling or drainage, the person may have trouble hearing.
Ringing in the ear (tinnitus) and dizziness or vertigo may also be present.
Fever is generally not present. If there is a fever, it is not usually high
Otitis Externa - Treatment
Treatment - otic abx drops - neomycin/polymyxin/hydrocortisone (Cortisporin Otic Suspension)
Heat to the ear
Tylenol, ibuprofen
Clean the ear thoroughly
Possible anti-inflammatory agent drop as well
Debridement
Ear wick
Otitis Media - Epid
Most common ear infection in young children
- Likelihood much higher in first 3 years of life
Childhood differences
Eustachian Tube - Childhood
17-18mm in length & Horizontal
- Adult: 31-38mm in length & 45 degree angle
Immune Naïve
Environmental exposure
Exploration through touch and taste
Pacifier use
Daycare attendance
Environmental tobacco smoke
Factors associated with decrease - Breast Feeding
Otitis Media - patho
Patho: Eustachian tube inflammation: Anatomy, Viral infection, Allergy

Ear Drum
Air is needed behind ear drum
Negative pressure, fluid can build up in ear
Hearing can be effected
Otitis media - symptoms and treatment
Symptoms
Pain
Fever
Decreased hearing

Medical treatment
Antibiotics
Decongestants
Nasal irrigation
Nasal Steroid
Otitis Media - Managment surgically
Surgical Management: Ear Tubes
One of the most common surgeries for Children
Provide alternative route for pressure changes and fluid
Allow Child to outgrow anatomic

Ear Tube limitations
Average tube stays 9-12 months
- Can extrude early
- Can retain tube
Usually tubes come out on own
Ear drum perforation
Otitis Media - Complications and Enlarged Adenoids
Complication: Ear Drum Perforation
Most heal spontaneously
Location and size dictate effect on hearing
Surgery for Ear Drum Perforation

Enlarged Adenoids
(Normally - Impair Eustachian tube function, Harbor infective Agents)
Adenoidectomy
Proven to decrease incidence of Otitis Media
Theorized to improve eustachian tube function
Theorized to decrease pathogens near middle ear
Indications with otitis media for surgery***
>>Indications for Tonsillectomy and adenoidectomy
-- seven episodes of tonsillitis in the past year
-- five episodes of tonsillitis each year for the past two years
-- three episodes of tonsillitis each year for the past three years
Indications for myringotomy
(tubes)
Severe acute otitis media (middle ear infection)
Hearing loss greater than 30 dB in patients with otitis media with effusion present for greater than three months.
Poor response to antibiotics for otitis media.
Impending mastoiditis or intracranial complications due to otitis media.
Recurrent episodes of acute otitis media (more than 3 episodes in 6 months or more than 4 episodes in 12 months).
Chronic retraction of tympanic membrane or pars flaccida . This may form a retraction pocket of the eardrum which may eventually form a cholesteatoma. Barotrauma .
Autophony (hear body sounds such as breathing) due to patulous (wide open) eustachian tube.
Craniofacial anomalies that predispose to middle ear dysfunction (e.g. cleft Palate ).
Middle ear dysfunction due to head and neck radiation and skull base surgery. {Note some feel that radiation therapy is a relative contraindication, because of a possible higher incidence of chronic infection which can lead to osteoradionecrosis (death of bony tissue due to radiation) . }
Epistaxis
Patho - Acute hemorrhage from the nostril, nasal cavity, or nasopharynx.
>> Vasculature supply originates from the ethmoid branches of the internal carotid arteries and the facial and internal maxillary divisions of the external carotid arteries.
>> Nose bleeds are very common

Etiology includes: infection, trauma, allergic rhinitis, renal failure, nasal defects, hypertension, tumors, use of blood thinners, aspirin. Sticking your finger up there going digging for gold
>> Two types - Anterior and Posterior location
Anterior Epistaxis
Cause: Kiesselbach's plexus most common.

S&S Clinical Manifestations:
- History
- Unilateral bleeding
- No sensation of post nasal drip
- Blood is bright red

Diagnostics
- Hemoglobin/Hematocrit
- CBC
- Bleeding time
Anterior Epistaxis
Management:
> ABC
>Direct pressure. Pinch nostrils sit forward.
> Cautery- chemical, electric, thermal. Silver nitrate sticks
> Use of vasoconstrictors sprays. / anesthetic agents.
> Anterior packing Merocel: compressed sponge.
> Remove any clots visualized
> Anterior epistaxis balloons.

Complications of nasal packing:
- Septal hematomas/abscess
- Sinusitis
- Pressure necrosis
Posterior Epistaxis - Cause and S&S
Cause: Usual source is the branches of the sphenopalatine artery. Bleeding occurs behind the posterior portion of the middle turbinate or posterior superior roof of the nasal cavity.

S&S: Clinical Manifestations:
Nausea, hematemesis, anemia, hemoptysis or melena.
No visualized anterior source of bleeding
Post nasal drip of blood
Blood is dark red
Brisk arterial bleed
Posterior Epistaxis - Diagnostics
Diagnostics:
Hemoglobin/ Hematocrit
History of bleeding disorder
Posterior Epistaxis - Management
Attempt to locate the source
Vasoconstrictive/ anesthetic agents
Posterior nasal packing
Immediate otolaryngologist referral
Prophylactic antibiotics
Hospitalization and monitoring
Indications for surgery/ embolization
> Continued bleeding with packing
> Required transfusion
> Nasal anomaly precluding packing
> Patient intolerance to packing
Osler-Weber-Rendu syndrome
Disorder of blood vessels
Etiology: Genetic:
Clinical manifestations: telangiectases on the lips, tongue and nasal mucosa
Complications include hemorrhage
Pediatric Airway
Almost all of pediatric codes are due to respiratory origin
80% of pediatric cardiopulmonary arrest are primarily due to respiratory distress
Majority of cardiopulmonary arrest occur at <1 year old
URIs include
colds
tonsilitis/pharyngitis/laryngitis
otitis media
conjunctivitis
rhinosinusitis
Who should be seen by PCP?
Symptoms last longer than 10 days.
Severe sore throat, earache, or headache not relieved by Tylenol or ibuprofen.
History of tuberculosis, rheumatic fever, kidney disease, or heart disease.
Severe chest pain or shortness of breath.
You are coughing up thick, green or bloody sputum.
You have swollen glands on the sides or back of your neck
How long will cold & flu symptoms last
Fever and sore throat generally improve within 4 days
Cough and nasal discharge may last 2 weeks or more
Disadvantages of antibiotics
Disadvantages of antibiotics
Adverse effects
Higher treatment costs
Increased bacterial drug resistance
What organism is MOST likely to cause AOM with conjunctivitis?
H. influenzae
The MOST likely cause of exudative tonsillopharyngitis
1. Adenovirus
What organism is the MOST likely etiology of pharyngitis-conjunctivitis?
Adenovirus
croup
Cause: parainfluenzae
Steeple Sign

Worry if
Drooling
Dyphagia
Toxic appearance
Stridor without cough or without fever
Incomplete immunizations
Mimics Croup
Epiglottis
Bacterial Tracheitis
Bacterial superinfection of croup
Retropharyngeal peritonsilar abscess
Neoplasm
Foreign Body
Angioneurotic edema
Spasmotic croup (not really badness)
Bacterial Tracheitis - cuase
Epid: 6 mo - 8 years old
Patho: Bacterial infection complicating viral LTB
Cause: Staph Aureus
S&S: URI symptoms
Acute onset high fever and respiratory distress
No odynophagia
Bacterial Tracheitis - diagnosis and complications
Diagnosis
Steeple sign on AP neck
Intraluminal soft tissue irregularities
Endoscopy best diagnostic method

Complications
Subglottic edema
Ulceration
pseudomembrane formation
Bacterial Tracheitis - treatment
suction and debride
nasotracheal intubation
IV antibiotics
extubate after 3-7 days
Tough to tell the difference, but the treatment is the same
Bacterial superinfection of croup
Symptoms 5-7 days
Worsening quickly over hours
Increasingly high fevers
Toxic appearance
Retropharyngeal peritonsilar abscess
Fever
Odynophagia
Prodrome of sore throat
Often swollen, tender ant. cerv. Nodes.
Resistence to neck movement
angioneurcrotic edema
recurrent lip swelling
spasmotic croup
recurrent
afebrile
nightime
Supraglottitis / Epiglottitis - cause
Patho:
"angina epiglottidea anterior"
bacterial cellulitis of supraglottis
Epid: 2 to 7 years old
incidence greatly decreased since vaccine
Cause: Haemophilus influenzae type B most common
Suprglottitis / epiglottitis
- S&S and diagnosis
S&S
- odynophagia
- fever
- irritability
- stridor
- rapidly progressive

Diagnosis
- if suspected, diagnose by direct laryngoscopy in OR
- lateral neck film - "thumb sign"
Supraglottitis / epiglottitis
- S&S and diagnosis
1nasotracheal intubation
IV antibiotics
extubate when air leak noted - usually within 48 hours
Complications of foreign body aspiration
Mortality after bronchoscopy < 1%
Bronchiectasis
Pneumonia / bronchitis
Subcutaneous Emphysema
Pneumothorax / pneumomediastinum
Granulation tissue and hemorrhage
Cartilage destruction
Airway compromise
Death
Symptoms and Physical findings
Of foreign body aspiration
Cough
Dyspnea
Wheezing
Stridor
Cyanosis
Decreased breath sounds
Tachypnea
Rhonchi
Somnolence
Decreased unilateral breath sound
Unilateral Wheezing
Stridor
Dx of foreign body aspiration
Radiography
> Normal in 20- 40 % of cases
> Most are radiolucent (food origin)
> Inspiratory/ expiratory film
---- Air-trapping on expiration
---- Atelectasis
---- Infiltration
---- Consolidation
---- Hyperinflation of Right lung
---- Double lumen sign
Battery
True emergency
Double lumen sign
Leakage of battery contents
Toxic effect
Pressure necrosis
Electrolytic reaction and mucosal burn
tests for peds foregin body aspiration
Fluoroscopy
Normal in 53 % of FB patients (Even L 2005)
Mediastinal shift
Paradoxical movement of the diaphragm

CT scan
Can visualize radiolucent FBs
treatment of foreign body
Medical management
The role of beta-2 agonist remains unclear
Alleviation of discomfort
Expelling foreign body could be life threatening
Not a replacement for bronchoscopy
Perform bronchoscopy if another one of the following is positive:
History - Bronchoscopic evaluation is warranted on the basis of a positive history alone
PE
Radiography
cystic fibrosis - dx
sweat test
Bronchioloitis
RSV - most comomn cause
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