POM III - Pediatric Ear, Nose, and Throat

otitis externa

infxn of outer ear canal resulting in skin breakdown

pseudomonas aeruginosa

What is the m/c causative bug of otitis externa?

ABX otic drops (ciprofloxacin or polymyxin-neomycin)

What is the best way to medically manage otitis externa?

- strep pneumo

- h flu type B

- moraxella catarrhalis

What are common agents involved in acute otitis media (AOM)?

- strep pneumo

- mycoplasma

If bullae are present with AOM, what are the m/c causative bugs?

poor TM mobility

What does pneumatic otoscopy of AOM reveal?

immediately if < 6 months

if sxs continue to worsen over 2-3d in a 6mo-2yr old

if severe in >2yr old

When should you treat AOM?

high-dose amoxicillin (90 mg/kg/d)

What is the 1st line tx for AOM?

serous otitis media (aka otitis media w/ effusion)

presence of middle ear effusion w/o signs of acute infxn

myringotomy tubes

What is a good prophylaxis measure taken for patients with serous otitis media (OME)?

bullous myringitis

inflammation of the TM in association w/ AOM – bullae present on tympanic membrane

perennial

What type of allergic rhinitis is caused by indoor allergens?

- intranasal CCS

- oral antihistamines

- montelukast (less helpful)

What are the best txs for allergic rhinitis?

rhinovirus and enterovirus

What are the mcc of acute viral rhinitis?

acute viral rhinitis

sudden onset of clear or mucoid rhinorrhea, nasal congestion, +/- fever, +/- sore throat

Sxs usually last 7-14 days, sxs peak @ 4-5 days

acute sinusitis

viral URI that does not improve after 10d or worsens after 5-7d

- nasal saline irrigation

- ABX

*1st line - augmentin or high-dose amoxil

*2nd line - 2nd/3rd gen cephalosporin

*bactrim or macrolides

*clinda if known to be strep

- decongestants

- intranasal steroid or cromolyn

How do you treat acute sinusitis?

- do NOT irritate if TM is not intact, organic material is in canal, or alkaline battery present

- Scooping out object, suction (if available), consult ENT

How do you manage a FB in the ear?

- lidocaine

- phenylephrine

- irrigation

- alligator forceps

- R-angle hook

How do you manage a FB in the nose?

audiometry - sound

tympanometry - pressure buildup in middle ear

Audiometry assesses __________, while tympanometry assesses __________.

audiometry

What type of hearing test?:

- sounds are played at various dB levels & plotted to determine whether hearing deficit occur above or below a certain range

- Checking behavioral response to tones

- subjectively evaluates hearing

tympanometry

What type of hearing test?:

- results are plotted on a graph and categorized as either type A (NL), B (little/no eardrum movement), or C (negative pressure in the ear)

- measures the movement, or compliance, of the eardrum as air pressure is increased or decreased in the ear canal... it is NOT a test of hearing sensitivity

fluid in the middle ear

What is the mcc of conductive hearing loss?

False - discontinue them

True or false:

- Patients with severe epistaxis should begin taking nasal steroids to stop the bleeding.

- anterior or posterior nasal pack

- foley catheter

What do you do if your patient is having severe epistaxis?

candida albicans

M/c infective agent for oral candidiasis?

coxsackie A viruses, enterovirus

M/c infective agent for herpangina?

3mm ulcers surrounded by halo (located on anterior pillars, soft palate, uvula)

What does herpangina look like?

anterior of mouth

Where will you NOT find herpangina?

viruses

90% of cases of sore throat are d/t...?

mycoplasma pneumoniae

M/c infective agent for bacterial pharyngitis?

usually amoxil or augmentin

if GAS -> Pen VK (K+), cephalexin, erythromycin

others -> erythromycin, azithromycin

How do you treat bacterial pharyngitis?

peritonsillar cellulitis/abscess

tonsillar infxn penetrates tonsillar capsule → spreads to surrounding tissues = cellulitis → necrosis and abscess

beta-hemolytic strep

What is the mcc of peritonsillar cellulitis/abscess?

zosyn, ceftriaxone

admit for 12-24 hrs of IV PCN or clinda to prevent progression

How do you treat peritonsillar cellulitis/abscess?

retropharyngeal abscess

infxn of retropharyngeal nodes that drain adenoids, nasopharynx, and paranasal sinuses → abscess

retropharyngeal abscess

The following is the clinical presentation of...?:

- Fever, respiratory sxs and neck hyperextension in child < 2 y/o

- Dysphagia, sore throat, drooling, dyspnea, and gurgling respirations

- Prominent swelling on posterior pharyngeal wall

- Neck stiffness, deviation of wall or pharynx

- Lateral neck film – retropharyngeal space wider than C4

h flu type B

What is the mcc of epiglottitis?

epiglottitis

sudden onset fever, dysphagia, drooling, muffled voice, inspiratory retraction, cyanosis, soft stridor, sniffing position

tx:

- Immediate endotracheal intubation by airway expert

- Cultures of blood and epiglottis

- Vancomycin, ceftriaxone IV x 3 days

- Oral ABX x 10 days

laryngotracheobronchitis

Viral croup is aka...?

epiglottitis - supraglottic

viral croup - subglottic

Epiglottitis is inflammation of the __________ region.

Viral croup is inflammation of the __________ region.

parainfluenza

What is the mcc of viral croup?

laryngotracheobronchitis

sxs usually last 2-3 days → barking cough, stridor (edema in subglottic space), fever absent or low-grade but may be high, increased work of breathing, stridor when agitated → stridor at rest, severe (retractions, air hunger, cyanosis), (+) steeple sign on plain film

- O2

- racemic epinephrine

- dexamethasone

How is severe viral croup treated?

throat culture

What is the gold standard for diagnosing strep pharyngitis?

rapid strep test - minutes

throat culture - 1-2 days

How long does it take to obtain a rapid strep test result compared to a throat culture result?

airway foreign body

upper

lower

______________________

_________ airway: acute onset of choking along w/ inability to vocalize or cough, may have cyanosis with marked distress, may have drooling stridor and ability to vocalize if partially obstructed

_________ airway: sudden onset of coughing/wheezing/resp distress, asymmetrical findings of decreased breath sounds or localized wheezing, asymmetrical radiographs

laryngomalacia

congenital softening of the tissues of the larynx above the vocal cords

Persistent stridor in infants usually seen in first 6wks of life (Stridor worse in supine position, with increased activity, URIs, & during feeding)

laryngomalacia

What is the mcc of noisy breathing in infancy?

laryngeal papillomas

- rare, benign warty growths (d/t HPV 6/11/16) that are difficult to treat

- Usually onsets at age 2-4 yrs

- Pts develop hoarseness, voice changes, croupy cough, or stridor

- Can cause life-threatening airway obstruction

3+

What grade of airway obstruction d/t tonsillar enlargement?:

- extended 3/4 of way to midline (50-75% of oropharynx)

1+

What grade of airway obstruction d/t tonsillar enlargement?:

- in tonsillar fossa (<25% of oropharynx)

4+

What grade of airway obstruction d/t tonsillar enlargement?:

- completely obstructing airway; "kissing tonsils" (>75% of oropharynx)

0

What grade of airway obstruction d/t tonsillar enlargement?:

- no tonsils seen (either small or removed)

2+

What grade of airway obstruction d/t tonsillar enlargement?:

- visible beyond anterior pillars (25-50% of oropharynx)

obstructive sleep apnea

What is the m/c indication for a tonsillectomy?

7

5

3

Indications for a tonsillectomy

* ___(+) documented strep pyogenes infxns in 1 yr

* ___ infxns per yr for 2 yrs

* ___ infxns per yr for 3 yrs