62 terms

ENT- Peds Exam 1

STUDY
PLAY

Terms in this set (...)

What is acute otitis media?
Pathogens in middle ear due to eustachian dysfunction and bacterial reflux.
What are the most common causes of acute otitis media?
Bacteria (75-80%): Steptococcus pneumonia, H. influenzae, Moraxella catarrhalis

Viruses (20-25%): rhinoviruses, RSV

overuse/inappropriate use of ABX due to overdiagnosis
RF for Acute Otitis Media:
Lower socioeconomic status
Native Americans or Alaskans
Tobacco exposure
Daycare attendance
Bottle-feeding/Pacifiers
Bed-time bottle
Parental history of AOM
Trisomy 21, cleft palate
Immune deficiency
Male gender
Presentation of Acute Otitis Media in infants vs. older children:
Infants: poor feeding, fever, irritability, pulling at ears

Older children: ear pain and fever

otorrhea
How to we diagnose Acute otitis media?
Pneumatic otoscopy: assess TM mobility
Tympanogram: measures TM compliance and volume of ear canal
First line treatment for acute otitis media:

Second line:

Third line:

What do you do if their TM is perforated?
High dose amoxicillin

Augmentin or cephalosporins

Azithromycin

use oral antibiotics with topical antibiotics
What can you modify risk factors to prevent acute otitis media?
limit pacifier use, avoid passive smoking, consider alternatives for daycare

prescribe ABX sparingly

be cautious with treatment because 80% resolve spontaneously
What are some complications of acute otitis media?
Chronic effusion
Hearing loss
Cholesteatoma
Intracranial extension
Mastoiditis
When should you consider pressure-equalizing tubes?
Recurrent AOM (3 episodes in 6mos/4 in a year)
Children at risk of developmental delays
3 mos of effusion with hearing loss
What is otitis media with effusion?
Build up of fluid in middle ear without symptoms of acute infections
what can cause otitis media with effusion?

How can we treat?
viruses, allergies, or exposure to irritants

usually no benefit from ABX, can treat with antihistamines and nasal steroids
What is Otitis externa?

What can cause it? Host factors vs. microbial factors?
inflammation and exudation in external canal

Host: swimming, diving, cleaning ear, water in ear during showering or bathing

Microbial: P. aeruginosa (MC), S. aureus, Candida, and aspergillus

**MOST COMMON IN SUMMER (swimmer's ear)
Presentation of otitis externa?

Diagnosis?
Pain, aural discharge, some hearing loss, pruritus and tenderness in/around ear canal, tenderness with otoscope insertion

cultures to ID pathogen if resistance to initial management occurs
How do we treat otitis externa?
Topical quinolones, neomycin/polymyxin B/ hydrocortisone otic, quinolone + steroid

NO SWIMMING FOR 7-10 DAYS

advise patient to keep moisture out for 4-6 weeks
How can you dry out ears in otitis externa?
use a 1/1/1 solution of vinegar, isopropyl alcohol, water--> burrow solution
What is mastoiditis? What is it a complication of?
complication of unresolved AOM

Bacterial infection of mastoid bone
Symptoms of mastoiditis?
fever, irritable, lethargy
Swelling of earlobe
Drainage from ear
Erythema and tenderness of posterior auricular
How do we diagnose mastoiditis?

How do we treat mastoiditis? Acute vs. Chronic
X-rays or CT, blood test, ear culture

Acute: IV ABX
Chronic: oral ABX, ear drops, regular ear cleanings, surgical drainage
What is acute sinusitis?
Obstruction of osteomeatal complex
- Mucosal inflammation obstructs mucous movement to ostia and nasopharynx
What causes the inflammation of acute sinusitis?
URI
Allergic rhinitis
Environmental pollutants(smoke)
Anatomic abnormalities
what sinuses are affected at what age:
- ethmoid and maxillary sinuses at _____
- sphenoid by age _____
- Frontal by age _____
- <7yrs: ________ sinuses
- >7yrs: ________ sinuses
birth

5 yrs
7 yrs
ethmoid and maxillary
sphenoid and frontal
Symptoms of acute sinusitis?

Symptoms of severe sinusitis?
URI sx lasting >10days
Headache/irritability
low-grade fever

Purulent rhinorrhea
High fever
Periorbital edema
Toxic appearance
Acute vs. Chronic sinusitis
- how long do symptoms last?
- when do they cough?
- how often do they get it?
Acute:
Symptoms resolve < 30 days
Daytime cough
Spontaneously resolves in 40-60 %

Chronic: Symptoms last > 90 days
Night time cough common
6 or more episodes/ year
common causes of acute sinusitis?
S. pneumo- 20-30%
Nontypeable H. flu- 15-20%
M. catarrhalis- 15-20%
How do we diagnose acute sinusitis?
Diagnosis is clinical
- allergy testing may be helpful in diagnosing allergic rhinitis
- CT scans required before surgery that show mucosal thickening or sinus opacification
When is abx indicated in acute sinusitis? What abx are used?

ancillary therapy options?
Toxic child
Severe acute sinusitis
Persistent sinusitis

4 weeks of beta lactamase resistant 2nd line antibiotic

Saline nasal irrigation
Nasal steroids for allergic rhinitis
Antihistamines for allergic symptoms
Nasal decongestants and mucolytics have variable efficacy
What is pharyngitis?

Common causes?
Inflammation of the pharynx due to viral or bacterial pathogen

Bacterial: group A strep
Viral: rhinoviruses, adenoviruses, RSV, herpangina, coxsackie, EBV
Pharyngitis- Strep
- Transmission?
- Incubation period?
- Who is most affected?
- What time of the year does it occur?
Droplet or physical transfer of respiratory secretions
2-5 days
children 5-15 yrs
winter/early spring
Clinical manifestations of Strep pharyngitis?

What is scarlet fever?
rapid onset of fever (<101F)
sore throat with dysphagia, HA, nausea, abdominal pain, vomiting
Erythema of tonsils and pharynx with white/yellow exudate
"Strawberry" tongue
Tender and enlarged anterior cervical lymph nodes

Scarlet fever: fine, diffuse erythematous macular-papular rash (sandpaper-like)
How do you diagnose Strep Pharyngitis?
Rapid Streptococcal antigen- 90-95% sensitivity

Throat culture is gold standard
How do you treat strep?

When can kids return to school?
treatment of choice is PCN
- Benzathine penicillin G IM
- Amoxicillin
- if allergic to PCN: erythromycin

24 hours after starting abx
What changes should you make at home with strep?

Follow-up for strep?
Change toothbrush after abx for 24 hrs

Recheck in office in 2-4 weeks, refer to ENT if recurrent
What are some complications of strep?
Post-streptococcal glomerulonephritis
appears 1-3 weeks after strep infection
UA will show hematuria and proteinuria.
- S/Sx: elevated BP, edema, joint pain

Post-strep rheumatic fever
takes 1-5 weeks to show up-symptoms
- S/Sx include fever, carditis, migratory polyarthritis
How do we treat viral pharyngitis?
Antipyretics
Saltwater gargle
Soft, cool foods or warm liquids
Humidifier
Mononucleosis:
- What is it?
- Triad of symptoms?
- Cause?
- Transmission?
- Who is affected?
Acute viral syndrome
Triad of fever, pharyngitis, and adenopathy
EBV
saliva
adolescents and college-age adults
How do we diagnose mononucleosis?
Common symptoms include the classic triad as well as fatigue, eyelid edema, headache, pain behind eyes, and a palatal petechial rash.
Splenic enlargement may occur
CBC with diff-lymphocytosis
Monospot test
EBV antibody test
EBV antibody test results for possible early, primary infection:
- VCA-IgM:
- VCA-IgG:
- EA-D, IgG:
- EBNA,IgG
positive
positive
negative
negative
How do we treat mono?

What should you avoid?
Uncomplicated mono requires only symptomatic therapy (Usually last 3-4 weeks), plan a realistic schedule of rest (some patients experience fatigue for 6-12 months)

Avoid contact sports and strenuous activity for at least 1 month splenic rupture
Avoid Amoxicillin/Ampicillin during course of disease as a drug-related rash may develop
What is a Peritonsillar abscess/Cellulitis?

Who is is most common in?
Localized infection of peritonsillar tissues (usually unilateral, but can be bilateral)

Males 3:1, most common in older children and adults
Physical exam findings of Peritonsillar abscess?
HOT POTATO VOICE
Unilateral ear and throat pain
Drooling
Dysphagia
Uvular deviation
Peritonsillar tissues-swollen, red, displaced downward and medially
Swelling and erythema of soft palate
Tender cervical adenopathy, ipsilateral
How do we diagnose peritonsillar abscess?

Treatment?
CBC: WBC elevation with left shift

Immediate referral to specialist.
- aspiration
- I&D
- IV abx initially, then oral
Hand foot and mouth disease
- cause?
- common population?
- symptoms?
Coxsackie virus

children

Small oral vesicles or ulcers on tonsils, pharynx, or posterior buccal mucosa
Fever
Headache and malaise
Sore throat
Papulovesicular lesions with erythematous halo on hands and feet-may have also on arms, legs, and buttocks as well(HFM)
How do we manage HFM?
antipyretics, Mary's magic mouthwash, hydration, handwashing
Aphthous stomatitis
- AKA?
- what are they?
- common cause?
- symptoms?
- management?
"canker sores"
- chronic inflammation of oral mucosal tissue with ulcers
- by immunologic response to oral mucosal antigens
- lesions in children usually singular, small (<1 cm) and painful
- Mary's magic mouthwash, avoid spicy, salty, and acidic foods
Nasal foreign body:
- who gets them?
- presentation?
- treatment?
Commonly seen in children < 5 years

Late presentation → signs of infection, Unilateral purulent discharge, foul breath

Treatment is removal
No urgency for removal unless battery
Parotitis:
- Causes?

Suppurative Parotitis:
- who is usually affected?
- symptoms?
- Dx?
- Tx?
viral- parainfluenza, EBV, HIV possible if known to be at risk

mostly newborns

parotid gland is swollen, tender, and erythematous (usually unilateral), fever and leukocytosis

Culture of purulent material

hospitalization and IV abx (cover S. aureus- MCC)
What is ankyloglossia?
Tx?
"Tongue-Tie"- A short lingual frenulum can hinder both
protrusion and elevation of the tongue.

Puckering of the midline tongue tip is
noted with tongue movement. Can cause feeding difficulties in the neonate, speech problems, and dental problems.

Frenulectomy (early treatment is favored)
What is allergic rhinitis?

common comorbidities?
Inflammation of mucous membranes of nose, usually accompanied by edema of mucosa and nasal discharge

otitis media
strong association with sinusitis
etiology of allergic rhinitis?
Inhalation of aeroallergens
- Allergic response mediated by IgE, histamine, and other chemicals
- Biphasic allergic inflammatory response with first peak 15-30 min after exposure and second peak several hours after exposure
What are the two types of allergic rhinitis?
Seasonal allergic rhinitis- "hay fever"

Perennial allergic rhinitis
Symptoms of allergic rhinitis
Watery rhinorrhea
Sneezing
Itching (eyes, ears, and throat)
Eye discharge or tearing
Cough
Throat clearing
Allergic salute
Physical exam findings of allergic rhinitis:
Pale, blue, boggy nasal mucosa
Cobblestoning of posterior pharynx
Postnasal drainage
*Infraorbital venous congestion "allergic shriners" (can be red, blue or purple)*
Conjunctival injection
How do we diagnose allergic rhinitis?
Skin test is confirmatory test of choice
Allergen specific IgE test
How do we manage allergic rhinitis?
Step 1: Allergen Avoidance and Environmental Control

Step 2: Pharmacotherapy- nasal steroids (preferred), antihistamines, decongestants, mast cell stabilizer, singulair

Step 3: Immunotherapy
What is the common cold? AKA?
- etiology?
- transmission?
- incubation period?
Commonly classified as URI
- An acute, mild and self-limiting syndrome caused by a viral infection of the upper respiratory tract mucosa
- rhinoviruses, coronaviruses, RSV (older children)
-Direct contact with infected secretions, Hand-to-hand, Hand-to environmental surface-to hand, Spread by aerosoles
- 1 to 3 days, shedding in 2-4 days
Clinical presentation of common cold:
Usually last 5-7 days but can predispose to bacterial infections
- Dry scratchy sore throat
- Sneezing, nasal stuffiness, rhinorrhea
- Hoarseness, cough
- Low grade fever, headache, and malaise
- Conjunctivae may be watery and inflamed
Treatment of common cold:
Supportive care
Antipyretics
Saline nose drops
Steamy showers or inhalation of steam
No benefit to use antibiotics
OTC cough medications and decongestants
What is influenza?
acute viral disease of respiratory tract
What are the 3 types of influenza?
Type A
- Most virulent cause
- Potential to cause pandemics

Type B
- Cause annual winter epidemics

Type C
- Causes mild illness, not epidemics
- Flu vaccines does not cover
How is influenza transmitted?
Incubation period?
Spread person-to-person by inhalation of small particle aerosols, by direct contact, by large droplet infection, or by articles recently contaminated with nasopharyngeal secretions
- most infectious in first 24 hours before onset of symptoms

1-4 days
Symptoms of influenza
Abrupt onset of fever, malaise, diffuse myalgia, headache, rhinitis, and nonproductive cough
Sore throat, nasal congestion, and sneezing
Nausea, vomiting, and diarrhea occur in children
Symptoms usually last 3-4 days but cough and malaise may persist for 1-2 weeks
Diagnosis of Flu?
Treatment?
Flu test (nasopharyngeal rapid test)
Consider CBC and UA

Antiviral Drugs
- Oseltamivir (Tamiflu): Can give as young as 2 weeks of age. Must begin within first 2 days of symptoms. Prophylactic treatment for household members

Symptomatic treatment

Influenza vaccine