E2 Special populatons
Nose and Sinuses
Infants are obligate nasal breathers and have difficulty breathing through their mouths.
Key exam component in the infant is testing nasal patency:
Occlude each nostril alternately while holding the infant’s mouth closed.
Do not occlude both nares simultaneously (causes distress).
Choanal atresia is a consideration for nasal obstruction in newborns.
In severe cases, obstruction can be assessed by attempting to pass a #8 feeding tube through each nostril into the posterior pharynx (often in the delivery room).
Inspect the nose for a midline nasal septum.
Sinuses:
At birth, maxillary and ethmoid sinuses are present but small; pneumatization occurs over time.
Palpation of the sinuses in newborns is not helpful.
Mouth and Pharynx
Inspection and palpation with a tongue depressor and flashlight; parental assistance helps stabilize the infant’s head and arms.
Mouth in newborns is edentulous; alveolar mucosa is smooth with finely serrated borders.
Pearl-like retention cysts along the alveolar ridges may be mistaken for teeth but disappear within 1–2 months.
Petechiae commonly found on the soft palate after birth.
Supernumerary teeth are rare, usually dysmorphic, and are shed within days but may be removed to prevent aspiration.
Palpate the upper hard palate to ensure it is intact.
Epstein pearls: tiny white or yellow mucous retention cysts along the posterior midline of the hard palate; they disappear within months.
A congenital fissure of the median palate is a cleft palate.
Saliva production is low in the first 3 months; older infants produce more saliva and drool frequently.
Tongue
Inspect the tongue; frenulum varies in tightness:
Can be very tight (ankyloglossia or tongue-tie) causing limited protrusion.
Macroglossia (prominent protruding tongue) may signal:
Congenital hypothyroidism, Down syndrome, or Beckwith–Wiedemann syndrome.
Beckwith–Wiedemann: macroglossia + hypoglycemia + omphalocele = likely diagnosis.
Tongue surface often has a whitish coating; if milk-derived, it can be wiped away with a tongue depressor or gloved finger (careful not to insert depressor too deep to avoid gag reflex).
Oral candidiasis (thrush) is common in infants: white plaques with erythematous raw base; difficult to wipe away.
Tongue or mouth cysts may be noted.
Thyroglossal duct cysts may open at the posterior tongue or more commonly in the neck.
Teeth
There is a predictable eruption pattern but wide variation in age of appearance.
Rule of thumb for primary teeth: a child will have about
Natal teeth are teeth present at birth; usually early eruptions of normal teeth but can be part of syndromes and may need removal to prevent aspiration.
The pharynx is best seen when the baby is crying.
Do not insert the tongue depressor more than two-thirds of the way over the tongue to avoid a strong gag reflex.
Dysmorphic Features and Cysts in the Head/Neck
Teeth eruption abnormalities may reflect local or systemic disease.
Boxed topics include:
Cysts of the neck (congenital) and branches (e.g., branchial cleft cysts).
Preauricular cysts and sinuses: small pinhole pits anterior to the helix; often bilateral; may be associated with hearing deficits and renal disorders.
Thyroglossal duct cysts: midline neck mass just above the thyroid cartilage; mobile and move upward with tongue protrusion or swallowing; detected after ~2 years.
Congenital torticollis (wry neck): from intrapartum or in utero positioning; a firm fibrous mass within the sternocleidomastoid appears 2–3 weeks after birth and gradually resolves.
Clavicle examination: newborn clavicle palpation for fracture signs (contour break, tenderness, crepitus, limited arm movement); birth-related fracture possible during difficult delivery.
Neck and Lymph Nodes
Lymph nodes of the neck are not usually enlarged in infancy but become common in childhood; most enlargements are infectious (viral or bacterial); see Table 25-9 for abnormalities.
Branchial cleft cysts present as small dimples or openings anterior to the midportion of the sternocleidomastoid; may be associated with a sinus tract.
Preauricular cysts/sinuses: pinhole pits anterior to the ear helix; often bilateral; possible association with hearing and renal issues.
Thyroglossal duct cysts: midline neck mass; mobile; moves with tongue protrusion or swallowing; typically noticed after age 2.
Assess neck mobility; important when central nervous system disease such as meningitis is suspected.
Avoid confusing low posterior cervical nodes with supraclavicular nodes in young children; supraclavicular nodes are always abnormal and raise suspicion for abdominal malignancy.
Nuchal rigidity is a more reliable sign of meningeal irritation than Brudzinski or Kernig signs in children.
To test nuchal rigidity in older children: have them sit upright and touch chins to chests; younger children can be helped to flex the neck by following a toy or light; the child may lie and be tested as shown in Figure 25-75 if needed.
Sinuses—Age of Pneumatization and Examination
Sinuses develop at varying ages:
Ethmoid: Birth
Maxillary: Birth to several years
Sphenoid:
Frontal: (continues until adolescence)
Transillumination of paranasal sinuses in younger children has poor sensitivity and specificity for diagnosing sinusitis or fluid in sinuses.
Purulent, foul-smelling unilateral nasal discharge in young preschoolers may indicate a foreign body; consider the possibility when object insertion is suspected.
Nasal polyps: gray/yellow growths inside the nares.
Sinusitis criteria in children: if there is purulent rhinorrhea for more than , or a worsening course, or severe symptoms with purulent rhinorrhea > and fever, consider sinusitis; may be associated with headache and sore throat; sinus tenderness may be elicited on percussion or palpation.
Exam of the Mouth/Pharynx in Children (Practical Tips)
For anxious or young children, delay mouth examination until near the end; try to examine ears first, then mouth.
A cooperative child may sit on a parent’s lap.
The “ahhh” technique: a child who can say “ahhh” often affords a sufficient view of the posterior pharynx without a tongue depressor (Box 25-39).
Techniques to obtain a view of the posterior pharynx when using a tongue depressor:
If needed, push down and slightly forward toward yourself while the child says “ahhh,” avoiding deep insertion that triggers gag reflex.
In anxious children, gently slip the depressor between teeth/cheek in the vertical plane to the back of the gums, then rotate horizontally toward the tongue.
Requires careful planning and parental help.
Teeth examination includes timing, sequence, number, condition, and position; observe for enamel abnormalities that may reflect local or systemic disease.
Dental caries are the most common health problem in children; disproportionately high in impoverished populations; highly preventable with dental visits; nursing-bottle caries are common in young children.
Use the “lift the lip” technique to visualize early caries on upper teeth; see Figure 25-73 and Table 25-9 for abnormalities of the teeth, pharynx, and neck.
Staining of teeth:
Intrinsic stains (e.g., tetracycline exposure before age 8) appear yellow/gray/brown.
Green stain associated with liver disease; fluorosis (white stain) from excess fluoride in early childhood.
Extrinsic stains (iron, fluoride) can be polished off; intrinsic stains cannot.
Box 25-40 lists tooth types and age of eruption (approximate), including primary and permanent teeth; note variations and delayed eruption can occur due to genetic or systemic diseases.
Malocclusion and misalignment of teeth can result from thumb sucking, pacifier use, heredity, or premature loss of primary teeth; normal occlusion is when the lower teeth are contained within the upper arch.
Tongue examination:
Inspect all parts of the tongue and the underside.
Geographic tongue is a benign chronic condition with map-like rough areas that vary over time; may co-occur with fissured tongue.
A tight frenulum can cause tongue-tie; severe tongue-tie may affect eating or speech.
A coated tongue and a red “strawberry tongue” can accompany viral infections or streptococcal infections (scarlet fever).
Tonsils and Pharynx in Children
Tonsils vary in size; peak growth between ; size often assessed as a percentage of the posterior wall opening (<25%, ~50%, etc.).
Tonsils in children often have deep crypts with white concretions or food particles; this is usually not disease.
Streptococcal pharyngitis signs: white/yellow exudates on tonsils or posterior pharynx, beefy-red uvula, and palatal petechiae; see Table 25-9 for abnormalities.
Peritonsillar abscess signs: erythema, asymmetric protrusion of one tonsil, trismus, and lateral displacement of the uvula.
Submucosal cleft palate signs: notching of the posterior margin of the hard palate or a bifid uvula; referral to otolaryngology is advised if suspected.
Rarely, a child with sore throat and difficulty swallowing may sit upright in a “tripod” position due to throat obstruction; do not aggressively examine the throat in suspected acute epiglottitis (now rare due to Hib vaccination) to avoid laryngospasm.
Bacterial tracheitis and epiglottitis are possible causes of airway obstruction in the pediatric population; epiglottitis is now rare due to vaccination; be vigilant for acute airway symptoms.
Voice changes can indicate underlying abnormalities (Box 25-41):
Hypernasal speech, nasal voice with snoring, hoarseness with cough, or hot potato voice suggest adenoidal hypertrophy, viral infection (croup), tonsillitis, or related conditions.
Neck, Voice, and Systemic Considerations
Normal-adolescent notes: neck examination follows adult technique; lymphadenopathy is common in childhood and mostly due to infections; malignancy suspicion if a node is >, hard, fixed to skin or underlying tissues, and accompanied by systemic signs such as weight loss.
When examining the neck, check for mobility and symmetry; ensure head and neck mobility in all directions, especially if CNS disease is suspected.
In older children, nuchal rigidity more reliably indicates meningeal irritation than Brudzinski or Kernig signs.
The overall ENT exam in older patients includes refractive evaluation and hearing testing similar to adults; visual acuity testing should be monocularly performed at regular visits.
In older adults (note): common thyroid disorders include hyperthyroidism (Graves disease, toxic multinodular goiter) and hypothyroidism (autoimmune thyroiditis, drugs, radiotherapy, thyroidectomy, or radioiodine ablation).
Practical and Thematic Takeaways
Many pediatric ENT findings are age-dependent and require technique adapted to cooperation and patience.
Normal variants (e.g., Epstein pearls, geographic tongue, deep tonsillar crypts) are common and usually benign.
Many symptoms overlap across common pediatric ENT conditions; careful history, gradual examination order, and parental involvement improve safety and accuracy.
When in doubt, refer to otolaryngology for congenital deformities, suspected submucosal clefts, persistent dysphonia, severe airway symptoms, or atypical neck masses.
Key References and Conceptual Links
Classic pediatric ENT exam steps mirror adult methods but emphasize cooperation, safety, and age-appropriate techniques (e.g., play-based approaches to “open wide”).
Understanding of sinus development informs interpretation of pediatric sinus tenderness and transillumination findings.
The nasal patency test and risk of choanal obstruction are critical in neonates due to obligate nasal breathing.
Early dental health is a strong predictor of overall health; nursing-bottle caries and early eruption patterns have long-term implications for pediatric care.
Immunization status influences the likelihood of severe airway infections (epiglottitis) and informs diagnostic caution during throat examination.