Common Paediatric ENT problems - PowerPoint Presentation

1. Common Paediatric ENT problemsDr Shane LingEar Nose and Throat Surgery20 August 2022

2. OtologyOtitis MediaOtitis ExternaRhinologyNasal obstructionTonsils and adenoidsOSATonsillitis

3. The EarEustachian tube is shorter, horizontal and floppierEarly colonization of nasopharynx with biofilm

4. AssessmentEar symptoms - Recent onset ear pain (irritability in pre-verbal children), pulling on earsPrevious or recurrent episodes of acute otitis media (AOM).HearingResult of newborn hearing screen if performedHistory or signs of hearing loss, delayed speech and language developmentSystemic – Fever, loss of appetite, vomiting, lethargy PMH – Immunocompromise, syndromes, cleft palateAny pre-existing disability or high risk of speech, language, or learning disabilityRisk factors – Day care, parents smoking, overcrowdingHigh‑risk population groups or region – esp. ATSI, the Kimberleys

5. Outer EarInspect pinna and conchaOtoscopic examinationPull upwards, outwards and backwards for adultsDown and out for kids

6. Normal tympanic membraneTM is translucentThe handle of the malleus is verticalNo erythema

7. Injected Tympanic MembranePink/red TMOften seen with fever, eustachian tube dysfunction or viral URTITM is transparent (there is no middle ear effusion)The handle of the malleus is well seen

8. Acute Otitis MediaBulging and red tympanic membraneLoss of the TM landmarks, especially the handle of the malleusTM is opaque, may be red from inflammation or white from pus in the middle ear80% of children will have experienced it by age 3 yo

9. Most cases of AOM in children resolve spontaneously and antibiotics are not recommendedTreat pain with adequate and regular simple analgesiaDecongestants, antihistamines and corticosteroids are not effective in AOMIf symptoms do not improve within 48 hours, start Amoxicillin 50mg/kg/day in 2 to 3 divided doses for 5 days If associated with otorrhea, consider AOM with perforation – add Ciprofloxacin drops 3 drops BD for 5 daysConsider antibiotics initially if:Child <2 yoHas signs of systemic illness – high fever, severe painManagement may also differ for children from higher risk groups, such as those living in Aboriginal or Torres Strait Islander communities The Kimberley Protocol

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11. ComplicationsTympanic membrane perforationAOM with TM perforation is common and results in otorrhoea and frequently, relief of painOtorrhoea due to TM perforation should be distinguished from Otitis ExternaAcute Subperiosteal Mastoiditis Rare, but is the most common suppurative complication of AOM and may be associated with intracranial complicationsThe diagnosis is based on post auricular inflammatory signs (erythema, oedema, tenderness or fluctuance), a protruding auricle (“Down and Out”) often with external auditory canal oedema and signs of AOM Requires prompt treatment with appropriate IV antibioticsUrgent referral to PCH ED

12. Otitis Media with Effusion (OME) “glue ear”TM is retracted with prominence of the handle of the malleus, which is also drawn in/more horizontalTM may be bulging or have an air-fluid level behind the TMYellow/amber appearance is consistent with fluid

13. Otitis Media with EffusionOME is fluid in the middle ear without signs and symptoms of infection, other than transient hearing impairmentThe presence of a middle ear effusion is not a diagnostic sign of AOM (an effusion may not resolve for up to 12 weeks following AOM)Antibiotics and ENT referral are not routinely required for initial presentation OME, as the majority of cases occur after an episode of AOM and resolve spontaneously with no long-term effects on language, literacy or cognitive developmentPersistent bilateral effusion beyond 3 months, or unilateral for more than 6 months should refer for hearing assessment and ENT review

14. Glue ear (OME)If subsequent sets of grommets are needed, adenoidectomy is performed if it has not been performed previously Related to colonisation of adenoids – independent of size

15. Request PCH Emergency Assessmentsuspected mastoiditisfacial nerve palsybacterial labyrinthitispatient appears unwell e.g., high temperature, severe pain, or evidence of dehydrationpatient is aged < 1 monthRequest ENT review in children and arrange an audiogram if possible before referral if:≥ 3 episodes of acute otitis media within 6 months, or > 4 to 5 episodes in 12 monthsfailure to respond to antibiotic treatmentpersisting otitis media with effusion (OME) for > 3 months (bilateral case) or > 6 months (unilateral case)hearing loss at 2 hearing assessments > 3 months apartdevelopmental speech delaychild has Down syndrome, cleft palate or any craniofacial syndromes (Refer to PCH)child aged > 6 years, with perforation not healed in 3 months and a hearing loss > 20 dB

16. Perforated Tympanic MembraneCiprofloxacin drops +/- hydrocortisone are safe to use in perforations/grommets

17. CholesteatomaChronic otorrheaHearing lossReferral to (Tertiary) ENT – Tympanomastoidectomy, may need second stage hearing related surgery and ongoing surveillance

18. Otitis ExternaEar is tender to examineCrusting around meatus, erythema of pinnaSkin of the external ear canal is swollen and there can be thin pusFungal OE - Off-white, grey, or black fungal hyphae; PruritisCommonly associated with water exposure/moisture traumaSwimmingTropical climatesCotton budsFingers

19. TreatmentStrict dry ear precautionsSwabs of EACTopical antibiotic drops – Sofradex, Ciproxin HCTopical antifungal drops - 1% Clioquinol/1% Hydrocortisone drops (compounded) – Locacorten Vioform no longer made commerciallyAnalgesia – Paracetamol, ibuprofenOtowicks if canal very oedematousDry ear toileting – no ear syrningingNo role for oral antibiotics

20. 5yo girlMother reports loud snoring for many years, can be heard outside her rooms sometimesWakes tired, grumpy, and seems to have more behavioral issues at the end of the dayOccasional enuresisFussy when eating meat – “chews forever”No significant history of pharyngitis/tonsillitis

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22. Snoring & Obstructive Sleep Apnoea10% children primary snoring; up to 5.7% have OSAThe QoL of children with OSA is comparable to that of children with other chronic conditions, such as asthma and juvenile rheumatoid arthritisUp to 40% of children with oSDB exhibit behavioral problems that include enuresis, hyperactivity, aggression, anxiety, depression, and somatization.OSA is also associated with poor school performance and a decrease in QoL.SnoringObstructive Sleep Disordered BreathingOSA

23. HistoryAgeWeight and height – failure to thrive, obesitySnoring – frequency, severity, witnessed apnoeaSleep quality – restless, neck extension, neck extended, enuresisOral cavity – dental issues, oral dysphagia, teeth grinding (bruxism)Pharyngitis/tonsillitis, rhinitis or nasal symptomsBehavioural issues - aggression, hyperactivitySchool performance – memory and attentionMedical history – Syndromes, neurological disorders, cardiac history, other

24. ExaminationHeight and weight – under and overweightOral/oropharynx cavity – tonsil size gradeSize alone does not correlate with severity – may correlate with total volume when adenoids are consideredNasal cavity – inferior turbinate size, septal deviationIf possible, flexible nasendoscopy for adenoid size

25. InvestigationsCan be useful for non compliant children for an endoscopic examinationIf tonsils are small, but has a convincing historyLateral X-ray of the post-nasal space/neckLooking for the degree of indentation of adenoidal tissue into the nasopharyngeal airway

26. When to consider sleep study in children?ObesityDown syndromeCraniofacial abnormalitiesSignificant PMH – cardiac, neuromuscular disorders, sickle cell disease, mucopolysaccharidosesPersistence of symptoms after surgeryDiagnosis uncertain, or discordance between parents/guardians

27. ReferralRequest ENT for surgical management ifHas features of obstructive sleep disordered breathing/OSAReferral to PCH if <2yrs of age, excessive underweight or overweight, syndromic children, other significant medical issuesInclude any other significant symptoms – otitis media, hearing loss

28. Same 5 yo snoring girlHas been a “mouth-breather” for a year or so nowConstant sniffing of nose, always seems to be blowing their nose or complaining of crustsEczemaParents have allergic rhinitis and asthma

29. Nasal obstructionCommon in children due to smaller anatomyEasier for mucous to cause obstructive symptomsInferior turbinate hypertrophy is frequently the causeNasal obstruction can be aggravated by adenotonsillar hypertrophyCan contribute to OSAChronic rhinitis and/or adenoiditis can lead to middle ear pathologies

30. AssessmentAirway – noisy breathing, mouth breathing, nasal obstructionDischarge – crusting, rhinorrhoea, post nasal drip (cough)Nose picking, wiping, sniffing, constant blowingAllergic symptoms – pruritis, sneezing, urticaria, exposure historyEpistaxisCoexistent otitis media, OSARED FLAG – unilateral symptoms, foul rhinorrhoea

31. ExaminationOcclude each nostril in turn and assess air entryAnterior rhinoscopyLook at vestibules by lifting tip and look for size of inferior turbinates and any septal deviationRare – polyps, massesOtoscopy – middle ear pathologies, e.g. middle ear effusion

32. Nasal obstructionRhinitis is common, especially up to 18 months – “neonatal rhinitis”Likely multifactorial etiologyGeneralized mucosal oedemaVarying severitySaline nasal drops/spraysIf not causing distress, self limitingRare causes – choanal atresia, nasolacrimal duct cyst, nasal meningocele, neoplasmsManaged at PCH

33. Older children ( >18 months) the most frequent cause is acute rhinitis/sinusitis, frequently viralInferior turbinate congestion and associated adenoiditisSupportive management – purulence does not indicate the need for antibioticsRisk factors – Smoking by parents, day careReferral ENT – persistent inferior turbinate hypertrophy, adenoid hypertrophy/adenoiditisAdenoidectomy can reduce persistent rhinitis/sinusitis by 50%

34. Allergic rhinitisIdentify possible allergens – history, RAST, skin prick testingIntranasal steroids –2nd generation such as mometasone, safe >2yoAntihistamines – oral non-sedatingReferrals:Allergist – skin prick testing and immunotherapyENT – persistent obstructive symptoms are amenable to conservative turbinate reduction surgery and adenoidectomy

35. Adenoidal hypertrophyMultifactorial cause, but commonly secondary to chronic inflammation/infectionReflux has been implicatedReferral to ENT – As per OSAForeign bodiesAcutely – Referral to PCH ED +/- ENT, if impacted then in theatre under GARED FLAG – EMERGENT referral if button cell battery a possibilityLong standing – persistent unilateral purulent (foul) rhinorrheaReferral to ENT - assessment and removal in theatre with washout

36. Septal deviationSimilar as in adultsFunctional issues – esp sleep and OSA, school performanceAssociated with inferior turbinate hypertrophyReferral to ENT - Surgical reduction of IT can be done early to help alleviate symptoms, while waiting for child to be older to consider septoplastyNasal polypsRare in childrenOnly seen in cystic fibrosis, primary ciliary dyskinesiaReferral to ENT - generally already arranged via Respiratory teams

37. 4 yo boyNo significant peri-natal history, past medical historyAttending part time day care, both parents work3 day history of sore throat, not eating well and needing paracetamol to help with mealsMother says he is “warm”, but is not systemically unwellSnoring now, but doesn’t usually – sleeping in the same room of parents while sick3rd episode in 6 months

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39. TonsillitisMost cases of sore throat are viral.Sore throat due to group A streptococcus (GAS) infection is:Uncommon in children aged < 4 years, and older adults.relatively common in children aged 3 to 15 years.most significant for those at risk of rheumatic fever, so identification and correct treatment in this group is important.With the exception of scarlet-fever type rash, there are no clinical features alone that reliably discriminate between Group A streptococcal (GAS) and viral pharyngitis

40. AssessmentAge and ethnicityOral intakeAssociated viral features (cough, coryza, conjunctivitis, hoarseness, ulcers, diarrhoea, characteristic viral exanthem)High-risk groups:Rheumatic feverAboriginal and/or Torres Strait Islander (ATSI) people in rural or remote areasATSI, Maori and Pacific Islander people in overcrowded household or socioeconomic disadvantagePersonal history of rheumatic fever or rheumatic heart diseaseFamily history of rheumatic fever or rheumatic heart diseaseImmunosuppressed children are at increased risk of suppurative complications

41. TreatmentSupportive managementSimple analgesia Corticosteroids can be considered in patients with severe pain unresponsive to simple analgesia:dexamethasone 0.15 mg/kg (max 10 mg) oral/IV/IM as a single dose ORprednisolone 1 mg/kg (max 50 mg) oral as a single doseMaintain hydrationAntibiotics for groups at high risk of acute rheumatic fever

42. ReferralRequest ENT for consideration of tonsillectomy if:Recurrent tonsillitis – ≥7x/yr, ≥ 5x/yr for 2 yrs, ≥3x for 3yrsExtraordinary circumstances – e.g. excess time off school (or work for adults)Swallowing difficulties causing pathological weight loss

43. Question 1What are the signs and symptoms of a suppurative complication of tonsillitis?

44. Red flagsEmergency referral into PCHUnwell/toxic appearanceRespiratory distressStridor           TrismusDrooling        “Hot potato” voice (muffled voice associated with pharyngeal/peritonsillar pathology)TorticollisNeck stiffness/fullnessDehydration

45. Question 2Which situation requires a referral to an ENT?5yo in daycare who has had 3 episodes of self limiting AOM in the last 12 months, but has been well5yo who had AOM a month ago, and has a dull TM on examination on follow-up5yo who failed their first school hearing screen last month, but without any development concerns5yo who had an URTI at the start of the year, and now has confirmed OME >3 months

46. Health Pathways WA - https://wa.communityhealthpathways.org/The Royal Children’s Hospital Melbourne - https://www.rch.org.au/Therapeutic Guidelines - Antibiotics46