Common Paediatric ENT

problems

BSME School Nursing Course

June 2 2016

Dr David Cremonesini

Aims

Management of:

Sore throats

Sleep apnoea

Earache

Neck lumps

Case 1

Fareed is 10yr old boy with lumps in his

neck

He had fever/sore throat 2 weeks ago now

ok

Mother worried about the lumps

He’s a bit tired

No weightloss/bruising/night sweats

Cervical Lymph Nodes

Common problem in children

Thin necks so easily felt

Get lots of upper respirtaory infections

Studies show around 50% of healthy children

will have palpable lymph nodes at some point

Vast majority a benign response to self-

limiting infection but parents worry about

malignancy

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

Immunisation status

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

Actual lump:

Size, location, consistency, mobility, pain

Worrying features

Case 2

Leo is 5year old boy with sore throat

2 days, no fever

Throat looks red, what do you advise?

Assessment

Clinical assessment – is he unwell/septic?

Check breathing ok, no stridor

Does he need antibiotics? Center score gives 1 point for each:

Tonsillar exudate

Tender anterior cervical lymph nodes

History of fever

Absence of cough

Likelihood of strep infection is 25-86% if scores 4, 2-23% with score of 1 (Not validated < 3yrs)

Management

No antibiotics for symptomatic relief

Pain relief, paracetamol first line

Little evidence for lozenges, gargles and

sprays

Eat cool, soft food, drink plenty of fluids

Avoid smoking/smoky environments

Antibiotics

Should not be given routinely

In cases that warrant them first line is

Penicillin V / Amoxicillin for 10 days

2nd line is azithromycin for 5 days

Recurrent sore throats

When should we take the tonsils out?

Benefit of tonsillectomy increases with the

severity and frequency of sore throats.

If not sure, watch and wait for 6 months

with parents reporting number and severity

of attacks

Antibiotic prophylaxis not recommended

Contraindications to

tonsillectomy

Caution if known bleeding disorder

Postpone surgery if episode of tonsilitis

within 2 weeks of date of surgery

Adenoidectomy contraindicated in presence

of cleft palate repair

Main risk is post-op bleeding, 2-5% chance

needing to go back to theatre

Case 2

Johnny is 3 years old

Mouth breathing all the time

At nursery is sleepy, not hungry in the

morning

Mother says he snores at night and is

worried his behavior is changing

What do you advise?

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

Why is it a problem

Prevalence estimated 2-3% in children <10yrs

Recurrent obstruction leads to repeated desaturation each of which may cause arousal = sleep fragmentation

Sleep important esp growth hormone secretion and consolidation of memory

Associated with negative effect on cognition and behaviour with clear improvement post op

Can persist to adult life

Treatment

Adenotonsillectomy first line, though v

young children may only need adenoids

Small number problem may persist, then

consider CPAP/medicines

KEY MESSAGE is detection and

intervention

Case 3

Jessica has earache

Crying and in pain

No fever

You have a look in the ear…...

Diagnosing Acute Otitis Media

Look at position of the tympanic membrane

Moderate to severe bulging of TM or new

onset earache not due to otitis externa

May hve it if present with mild bulging,

<48hrs of pain and/or intense redness of TM

Severe AOM – AOM with moderate to

severe pain or fever > 39ºC

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

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)

Treatment

Simple analgesia – ibuprofen and/or paracetamol

Antibiotics wont help pain in first 24 hours

Antibiotics prescribed if:

Severe AOM in children > 6mths

Non-severe bilateral AOM 6-23mths

First choice is amoxicillin

Abx or observation for those with non-severe unilateral AOM (6-23mths) or non-severe uni or bi in > 2years. Give Abx if worsens after 2-3 days

Give for 5 days and longer if symptoms don’t improve

Key points

Routine Abx not warranted in non-severe

Ensure imms and adequate pain relief

Offer to observe/review in 2-3 days, maybe

seek advice if gets worse

Glue ear

Otitis Media with Effusion (OME)

commonest caus of childhood hearing loss

85% of children will experience episode of

OME during childhood, 50% resolve

spontaneously by 3 mths

Increase risk if not breastfed ot attend

daycare

Important to advise against smoking

Presentation

Hearing loss not main feature

Poor speech

Inattentiveness in class

Behavioural concerns

Reduced social interaction

Poor balance in younger children

OME - exam

Growth

Development

ENT

LRTI

Tympanometry

Hearing tests

Management

Once confirmed, active monitoring over 3 months recommended

Usual first line is grommets

Medications rarely effective – little evidence for

Surgeyr if doesn’t resolve or gets worse during watching periodwith adverse affect on speech/education performance

Difficulty is knowing when to intervene or when ok to watch and wait, as after 12 mths likely to resolve

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

Otitis Externa

Inflammation of skin of ear canal

Swimming common association

External canal maybe:

Red/narrow/swollen

Pain on moving pinna/tragal tenderness

Discharge maybe from burst TM, then pain

better

Treatment

Topical antibiotic/steroid drops eg

Gentisone HC

Give for 2 weeks and review

If very swollen need ENT sooner

Redness spreading beyond ear needs urgent

review

Managing at home

Regular analgesia

Lie head on pillow, problem ear facing up,

give drops, massage the tragus and keep

still for 5-10mins

Keep ear dry

Continue for 1 week after symptom

resolution