E2: Peds - pediatric ENT

what is the severity hearing loss:

difficulty w whisper, misses up to 50% speech

3-5 y/o at diagnosis

mild (25-40 dB)

what is the severity of hearing loss:

misses 50-100% speech

poor voice and speech quality

moderate (41-55 dB)

what is the severity of hearing loss:

loud shout heard as whisper

needs education interventions

moderate to severe (56-70 dB)

what is the severity hearing loss:

difficulty w hearing aids

can only hear as low as a garbage disposal

severe (71-90 dB)

what is the severity of hearing loss:

feels vibrations only, relies on vision for communication

can hear as low as a motorcycle @ 25 ft

profound (>90 dB)

what are physical features of hearing loss?

all development delayed → speech & language deficits

infants with profound deafness will be able to do what actions??

"startle", laugh and babble

hearing loss beginning after 5 years has _____ language impact

less

what is the cause of conductive hearing loss?

interference with mechanical transmission of sound through external and middle ear

what type of hearing loss:

usually 20-60 dB of hearing loss

often treatable

BC > AC

conductive

what are the causes of acquired conductive hearing loss?

**middle ear effusion**

foreign body/cerumen impaction

TM perforation

cholesteatoma

ossicular disruption

what are causes of congenital/inherited conductive hearing loss?

microtia/atresia

abnormal ossicles/TMs

syndromes w ear/craniofacial abnormalities (Treacher-Collins, Down)

what are causes of acquired sensorineural hearing loss?

meningitis

acoustic trauma

aminoglycosides, vanco

what are causes of congenital sensorineural hearing loss?

infection (TORCH)

hereditary

inner ear dysplasia → enlarged vestibular aqueduct

perilymph fistula → leak of inner ear fluid

what type of hearing loss:

abnormal bone and air conduction

bone is > 10 dB better than air conduction

mixed hearing loss (SNHL and CHL)

what type of hearing loss:

auditory processing abnormality beyond the level of cochlear nucleus

signal is degraded when stimulus reaches level of brainstem

central hearing loss

most common type of hearing loss?

conductive hearing loss

most common acquired hearing loss?

middle ear effusion

most common non-syndromic genetic sensorineural hearing loss?

connexion 26 gene defect

most common congenital infection causing sensorineural hearing loss?

CMV

most common acquired infection causing sensorineural hearing loss?

meningitis

what type of hearing loss can be identified in the newborn hearing screening?

mod-sev hearing loss

not mild!

when is AAP/NIH recommendation for hearing loss screening?

by 1 month

which hearing loss screening test assesses cochlea function and can't tell the degree of hearing loss, just pass/fail?

otoacoustic emission (OAE)

which type of hearing loss screening test assesses neurologic function and can estimate ear specific threshold?

brainstem auditory evoked response (BAER)

what audiometry behavioral test supplies stimuli with external speakers and looks for a change in the child's reflexive behavior?

behavioral observation audiometry

what audiometry behavioral test supplies sounds that are played through headphones and instructs the child to perform a simple task?

conditioned play audiometry

what audiometry behavioral test supplies the child with specific info through headphones and asks the child to do a task in response to su=ound?

conventional audiometry

what hearing test can distinguish CHL from SNHL?

visual reinforcement audiometry

what is the treatment for conductive hearing loss?

treat underlying cause

what is the treatment for sensorineural hearing loss?

hearing aids

cochlear implants

what are the 4 Ds of the ear examination?

discharge, displacement, discoloration, deformity

MC organisms causing otitis externa?

pseudomonas, strep, staph

exposure to excessive moisture allows for bacterial/fungal overgrowth causing symptoms of pain w pulling on the pinna/pressing on tragus, canal erythema, and thick white discharge

acute otitis externa

what is the treatment for acute otitis externa?

1st line → ciprodex (> 6 mos) or cortisporin (> 2 yrs)

systemic ABX on if evidence of AOM

condition that typically follows a viral URI, caused by Eustachian tube dysfunction and fluid collection in the middle ear

AOM

what are the MC bacteria that causes AOM?

S. pneumo

H. flu

M. cat

risk factors for AOM?

exposure to cigarette smoke

drinking from bottle while laying flat

craniofacial anomalies

daycare attendance

what are prevention measures for AOM?

breast feeding at least 6 mos

avoid bottle propping

reduce pacifier use after 6 mos

vaccines

what condition has an erythematous bulging TM, air-fluid level behind TM, diminished TM mobility and possible decreased hearing?

AOM

what is the treatment for AOM?

symptomatic → Tylenol or ibuprofen

1st line → amox

2nd line → augmentin

PCN allgx → macrolide or cephalosporin

when do you refer a pt w AOM?

> 3 AOM episodes in less than 6 months

> 4 episodes in 12 months

what are complications of AOM?

TM perforation

conductive hearing loss

mastoiditis

cholesteatoma

what should you consider if pt has recurrent or chronic OM?

tympanostomy tubes

which condition is caused by URI and has clinical features of clear gray/yellow fluid (effusion) behind TM, poor mobility of TM, and hearing loss?

serous otitis media (OME)

what should you do if pt has persistent effusions for > 3-4 months w hearing loss?

refer for myringotomy and insertion of tubes

AOM or OME:

bulging TM +/- opacification or air-fluid level

can be tx w ABX

AOM

AOM or OME:

opacification of TM or air-fluid level

can't be tx w ABX

OME

who is chronic recurrent OM seen in?

young children and those w facial hypoplasia (cleft palate, Down syndrome)

which condition has clinical features of hearing impairment, intermittent discomfort and permanent myringosclerotic changes (TM white, thickened and scarred)?

chronic recurrent OM

what is the treatment for chronic recurrent OM?

tympanostomy tubes

trapped epithelial tissue that grows beneath the surface of the membrane, can be congenital or acquired and considered one of the most serious lesions of the ear drum

cholesteatoma

what are complications of a cholesteatoma?

progressive hearing loss

lateral sinus thrombosis

sepsis

brain abscess

treatment for cholesteatoma?

surgical removal

what is MCC of aural polyps?

old, retained tympanostomy tube

who do granulomas/polyp develop in?

children w chronic middle ear infections

treatment for granuloma/polyps?

topical & oral ABX

surgical removal

infection of the mastoid air cells MCC is s. pneumo, s. pyogenes or s. aureus (pseudomonas if recurrent OM)

mastoiditis

what condition has clinical features of pain, swelling, tenderness and redness behind the ear in the area of the mastoid bone; pinna may be displaced?

mastoiditis

what are the diagnostic tests for mastoiditis?

CT → most reliable

tympanocentesis → send fluid for culture

treatment for mastoiditis w/o recurrent AOM and recent ABX?

unasyn

treatment for mastoiditis with recurrent AOM or recent ABX?

zosyn

treatment for mastoiditis w PCN allergy?

vanco + metro

causes for nasal congestion?

URI → tx w saline drops

nasopharyngitis secondary to GERD

congenital → choanal atresia or stenosis, tumors/cyst/polyps

blockage of the nasal opening causing noisy breathing and cyanosis that worsens w feed and improves w crying

choanal atresia

what is the definitive study for choanal atresia?

CT

treatment for choanal atresia?

if bilateral → med emergency = placement of oral airway

definitive → surgery

what condition has a leftward deviation of the cartilaginous portion of the nasal septum and if often a result of being punch in the nose?

deviated septum

any child presenting w nasal polyp should be evaluated for _____

CF and asthma

what condition has features of:

- submucosal bleeding along the nasal septum

- saddle nose deformity

septal hematoma

(MOI = facial trauma)

when do the sinuses present/mature?

ethmoid & maxillary present at birth

sphenoid matures at 5 y/o

frontal matures > 7 y/o

what are the causes of sinusitis?

MC → viral URI/allergic rhinitis

bacterial → S. pneumo, H. flu, M. cat

obstructions

what condition has features of:

- prolonged URI for 7-10 days w halitosis

- purulent rhinorrhea

- facial pain

- HA

sinusitis

what is the diagnostic test for complicated sinusitis?

CT

treatment for sinusitis?

augmentin

frontal bone osteomyelitis associated w subperiosteal abscess (complication of osteomyelitis)

Pott Puffy tumor

what condition has features of;

- erythematous forehead swelling that is exquisitely tender

- HA

- fever

Pott Puffy tumor

how is Pott Puffy tumor diagnosed?

head CT

treatment for Pott Puffy tumor?

surgical drainage + broad spec IV ABX

erosion through the posterior wall of the frontal bone that causes S&S of high fever, severe HA, altered mental status and signs of toxicity

epidural abscess

what is the preferred imaging for an epidural abscess?

MRI WITH contrast

treatment for epidural abscess?

IV ABX

consult neurosurgery

what are complications of sinusitis?

periorbital & orbital cellulitis

intracranial extension (abscess, meningitis)

which condition has features of:

- unilateral bright erythema, tender and indurated

- ethmoid & maxillary sinuses affected

- lid & periorbital swelling

periorbital cellulitis (pre septal)

diagnostic test for periorbital cellulitis?

CT without contrast

treatment for periorbital cellulitis?

augmentin

no improvement in 24 hrs → add linezolid

infection from ethmoid sinus that spreads into the orbit commonly caused by strep and staph

orbital cellulitis (septal)

what condition has features:

- appears ill, toxic and lethargic

- intense retro-orbital pain aggravated by ocular mvmt

- proptosis (eyelid edema)

- decreased EOMs & vision

orbital cellulitis (septal)

diagnostic test for orbital cellulitis?

CT with contrast or MRI

treatment for orbital cellulitis?

vanco + ceftriaxone

surgical drainage w ethmoidectomy

what are complications of orbital cellulitis?

abscess formation

option neuritis

retinal vein thrombosis

pan ophthalmitis

meningitis

cavernous sinus thrombosis

what are the causes of acute tonsillopharyngitis?

GAS

EBV

adenovirus

coxsackie

what condition has features:

- fever, HA, red/hypertrophic tonsils +/- exudate

- palatal petechia

- sore throat

acute tonsillopharyngitis caused by GAS

what condition has features:

- posterior LAD

- fatigue

- splenomegaly

acute tonsillopharyngitis caused by EBV

diagnostic tests for GAS tonsillopharyngitis?

rapid strep

throat culture

treatment for GAS tonsillopharyngitis?

Pen V

amox

PCN allgx → azithro

diagnostic test for EBV tonsillopharyngitis?

EBV titer

monospot test

treatment for EBV tonsillopharyngitis?

no contact sports

what is the criteria for recurrent tonsillitis?

> 6 episodes in 1 calendar yr

> 5 episodes/yr for 2 consecutive yrs

> 3 episodes/yr for 3 consecutive yrs

abscess that form btw the capsule of the palatine tonsil and pharyngeal muscles and causes S&S of a hot potato voice, drooling, dysphagia, pain radiating to ipsilateral ear and unilateral sore throat

peritonsillar abscess