Review – Kaplan Pediatrics: ENT Disorders

Otitis externa (swimmer’s ear)

Normal flora of external canal includes Pseudomonas aeruginosa (most common cause), S. aureus (second most common cause), coagulase-negative Staphylococcus, diphtheroids, Micrococcus spp., and viridans streptococci

Causes—excessive wetness, dryness, skin pathology, or trauma

Symptoms—significant pain (especially with manipulation of outer ear), conductive hearing loss

Findings—edema, erythema, and thick otorrhea, preauricular nodes

Malignant external otitis is invasive to temporal bone and skull base—with facial paralysis, vertigo, other cranial nerve abnormalities

Requires immediate culture, intravenous antibiotics, and imaging (CT scan)

→ may need surgery

Treatment—topical otic preparations ± corticosteroids

Prevention—ear plugs, thorough drying of canal, and 2% acetic acid after getting wet

 

Middle Ear

Otitis media (OM)

A 4-year-old child is seen in the office with a 3-day history of fever and cold symptoms, and now complains of right ear pain. Physical examination is remarkable for a bulging tympanic membrane with loss of light reflex and landmarks.

 

Acute, suppurative otitis media; accompanied by a variable degree of hearing loss (20–30 dB)

Etiology

Bacterial in up to 75%

1. pneumoniae (40%)

Nontypeable H. influenzae (25–30%)

Moraxella catarrhalis (10–15%)

– Other 5%—Group A strep, S. aureus, gram negatives (neonates and hospitalized very young infants), respiratory viruses (rhinovirus, RSV most often)

Pathogenesis

Interruption of normal eustachian tube function (ventilation) by obstruction →

inflammatory response → middle ear effusion → infection; most with URI

Shorter and more horizontal orientation of tube in infants and young children allows for reflux from pharynx (and in certain ethnic groups and syndromes)

Clinical findings—highly variable

Symptoms—ear pain, fever, purulent otorrhea (ruptured tympanic membrane), irritability, or no symptoms

Pneumatic otoscopy—fullness/bulging or extreme retraction, intense erythema (otherwise erythema may be from crying, fever, sneezing; erythema alone is insufficient unless intense), some degree of opacity (underlying effusion)

Mobility is the most sensitive and specific factor to determine presence of a middle ear effusion (pneumatic otoscopy)

Diagnosis—must have:

Acute onset

Tympanic membrane inflammation

Middle ear effusion

Treatment—It is advisable to use routine antimicrobial treatment especially for age <2 years or those systemically ill, with severe infection, or with a history of recurrent acute otitis media.

First-line drug of choice = amoxicillin (high dose)

Alternate first-line drug or history of penicillin allergy = azithromycin

Duration—10 days; shorter if mild, older child

Follow up—within days for young infants, continued pain or severe; otherwise 2 weeks (sustained improvement seen in TM)

Second-line drugs—if continued pain after 2–3 days

Amoxicillin — clavulinic acid (effective against b-lactamase producing strains)

Cefuroxime axetil (unpalatable, low acceptance)

IM ceftriaxone (may need repeat 1–2´; for severe infection if oral not possible), if patient is not taking/tolerating oral medications

Also maybe cefdinir (very palatable, shorter duration)

If clinical response to good second-line drug is unsatisfactory, perform myringotomy or tympanoscentesis

 

Otitis media with effusion (OME)

Generally after repeated infections with insufficient time for effusion to resolve

Fullness is absent or slight or TM retracted; no or very little erythema

Treatment

Monthly evaluation

Assess hearing if effusion >3 months; most resolve without problems

Recent studies suggest that in otherwise healthy children an effusion up to 9 months in both ears during first 3 years of life poses no developmental risks at 3–4 years of life.

Routine antibiotic prophylaxis is not recommended.

Tympanostomy tubes

Suggested at 6–12 months of continued bilateral OME or 4 months with bilateral hearing loss

Likelihood that middle ear ventilation will be sustained for at least as long as tubes remain in (average 12 months)

Complications

Acute mastoiditis—displacement of pinna inferiorly and anteriorly and inflammation of posterior auricular area; pain on percussion of mastoid process

Diagnosis—When suspected or diagnosed clinically, perform CT scan of temporal bone.

Treatment—myringotomy and IV antibiotics (S. pneumoniae, nontypable

1. influenzae, P. aeroginosa); if bone destruction, intravenous antibiotics and

mastoidectomy

Acquired cholesteatoma = cyst-like growth within middle ear or temporal bone; lined by keratinized, stratified squamous epithelium

Most with long-standing chronic otitis media

Progressively expands—bony resorption and intracranially; life-threatening

Discrete, white opacity of eardrum through a defect in TM or persistent malodorous ear discharge

CT scan to define presence and extent

Treatment—tympanomastoid surgery

Choanal atresia

A newborn is noted to be cyanotic in the wellborn nursery. On stimulation, he cries and becomes pink again. The nurse has difficulty passing a catheter through the nose.

 

Unilateral or bilateral bony (most) or membranous septum between nose and pharynx

Half have other anomalies (CHARGE association)

Unilateral—asymptomatic for long time until first URI, then persistent nasal discharge with obstruction

Bilateral—typical pattern of cyanosis while trying to breathe through nose, then becoming pink with crying; if can breathe through mouth, will have problems while feeding

Diagnosis

Inability to pass catheter 3−4 cm into nasopharynx

Fiberoptic rhinoscopy

Best way to delineate anatomy is CT scan

Treatment

Establish oral airway, possible intubation

Transnasal repair with stent(s)

 

Foreign body

Any small object

Clinical—unilateral purulent, malodorous bloody discharge

Diagnosis—may be seen with nasal speculum or otoscope; lateral skull film if radiopaque (may have been pushed back, embedded in granulation tissue)

Treatment—if cannot easily remove with needle-nose forceps, refer to ENT

 

Epistaxis

An 8-year-old child has repeated episodes of nosebleeds. Past history, family history, and physical examination are unremarkable.

 

Common in childhood; decreases with puberty

Most common area—anterior septum (Kiesselbach plexus), prone to exposure

Etiology

Digital trauma (nose picking; most common)

Dry air (especially winter)

Allergy

Inflammation (especially with URI)

Nasal steroid sprays

Severe GERD in young infants

Congenital  vascular anomalies

Clotting disorders, hypertension

Treatment—most stop spontaneously

Compress nares, upright, head forward; cold compress

If this does not work, then local oxymetazolone or phenylephrine

If this does not work, then anterior nasal packing; if appears to be coming posteriorly, need posterior nasal packing

If bleeding site identified, cautery

Use humidifier, saline drops, petrolatum for prevention

 

Polyps

Benign pedunculated tumors from chronically inflamed nasal mucosa

Usually from ethmoid sinus external to middle meatus

Most common cause is cystic fibrosis—suspect in any child <12 years old with polyp; EVEN in absence of other typical symptoms

May also be associated with the Samter triad (polyps, aspirin sensitivity, asthma)

Presents with obstruction → hyponasal speech and mouth breathing; may have profuse mucopurulent rhinorrea

Examination—generally glistening, gray, grape-like masses

Treatment—intranasal steroids/systemic steroids may provide some shrinkage (helpful in CF); remove surgically if complete obstruction, uncontrolled rhinorrhea, or nose deformity.

 

 

Sinusitis

Acute—viral versus bacterial

Most with URI—most viral, self-limited; up to 2% complicated by bacterial sinusitis

Sinus development

Ethmoid and maxillary present at birth, but only ethmoid is pneumatized

Sphenoid present by 5 years

Frontal begins at 7–8 years and not completely developed until adolescence

Etiology—S. pneumonia, nontypeable H. influenzae, M. catarrhalis; S. aureus in chronic cases

May occur at any age

Predisposed with URI, allergy, cigarette smoke exposure

Chronic—immune deficiency, CF, ciliary dysfunction, abnormality of phagocytic function, GERD, cleft palate, nasal polyps, nasal foreign body

Pathophysiology—fluid in sinuses during most URIs from nose blowing. Inflammation and edema may block sinus drainage and impair clearance of bacteria.

Clinical features

Nonspecific complaints—nasal congestion, discharge, fever, cough

Less commonly—bad breath, decreased sense of smell, periorbital edema headache, face pain

Sinus tenderness only in adolescents and adults; exam mostly shows mild erythema and swelling of nasal mucosa and discharge

Diagnosis—entirely historical and clinical presentation (evidence-based)

Persistent URI symptoms without improvement for at least 10 days

Severe respiratory symptoms with purulent discharge and temperature at least 38.9°C (102°F) for at least 3 consecutive days

Only accurate method to distinguish viral versus bacterial is sinus aspirate and culture, but this is NOT done routinely

Sinus films/CT scans—show mucosal thickening, opacification, air-fluid levels, but does not distinguish viral versus bacterial

Treatment

Initial—amoxicillin (adequate for majority)

Alternative—cefuroxime axetil, cefpodoxime, azithromycin

Treat 7 days past improvement

If still does not work—to ENT (maxillary sinus aspirate)

 

Throat

Acute pharyngitis

An 8-year-old girl complains of acute sore throat of 2 day’s duration, accompanied by fever and mild abdominal pain. Physical examination reveals enlarged, erythematous tonsils with exudate and enlarged, slightly tender cervical lymph nodes.

 

Viruses versus group A beta-hemolytic strep (GABHS)

Viral—typical winter and spring; close contact

GABHS—uncommon <2–3 years of age; increased incidence in childhood, then decreases in adolescence; all year long (but most in cold months)

Clinical presentation

Strep pharyngitis

Rapid onset

Severe sore throat and fever

Headache and gastrointestinal symptoms frequently

Exam—red pharynx, tonsilar enlargement with yellow, blood-tinged exudate, petechiae on palate and posterior pharynx, strawberry tongue, red swollen uvula, increased and tender anterior cervical nodes

Scarlet fever—from GABHS that produce one of three streptococcal pyogenic exotoxins (SPE A, B, C); exposure to each confers a specific immunity to that toxin, and so one can have scarlet fever up to three times

Findings of pharyngitis plus circumoral pallor

 

Red, finely papular erythematous rash diffusely that feels like sandpaper

Pastia’s lines in intertriginous areas

Viral—more gradual; with typical URI symptoms; erythematous pharynx, no pus

° Pharyngoconjunctival fever (adenovirus)

Coxsackie:

} Herpangina—small 1–2 mm vesicles and ulcers on posterior pharynx

} Acute lymphonodular pharyngitis—small 3–6 mm yellowish-white nodules on posterior pharynx with lymphadenopathy

} Hand-foot-mouth disease—inflamed oropharynx with scattered vesicles on tongue, buccal mucosa, gingiva, lips, and posterior pharynx

→ ulcerate; also on hands and feet and buttocks; tend to be painful

Diagnosis of strep

First—rapid strep test; if positive, do not need throat culture

But must confirm a negative rapid test with cultures if clinical suspicion is high

Treatment—early treatment only hastens recovery by 12–24 hours but prevents acute rheumatic fever if treated within 9 days of illness

Penicillin

Allergy—erythromycin

Complications

Retropharyngeal and lateral pharyngeal abscess—deep nodes in neck; infection from extension of localized infection of oropharynx

Clinical—nonspecific—fever, irritability, decreased oral intake, neck stiffness, torticollis, refusal to move neck, muffled voice

Examination—bulging of posterior or lateral pharyngeal wall

Soft tissue neck film with head extended may show increase width

Definitive diagnosis—incision and drainage, C and S—most polymicrobial (GABHS, anaerobes, S. aureus)

Treatment

} Intravenous antibiotics + surgical drainage

} Third-generation cephalosporin plus ampicillin/sulbactam or clindamycin

} Surgical drainage needed if respiratory distress or failure to improve

Peritonsillar abscess—bacterial invasion through capsule of tonsil

Typical presentation—adolescent with recurrent history of acute pharyngotonsillitis

Sore throat, fever, dysphagia, trismus

Examination—asymmetric tonsillar bulge with displacement of uvula away from the affected side is diagnostic

GABHS + mixed oropharyngeal anaerobes

Treatment

} Antibiotics and needle aspiration

} Incision and drainage

} Tonsillectomy if recurrence or complications (rupture with aspiration)

Indications for tonsillectomy, and adenoidectomy

Tonsillectomy

Rate of strep pharyngitis

} ≥7 documented infections within the past year

} 5/year for 2 years

} 3/year for 3 years

– Unilateral enlarged tonsil (neoplasm most likely but rare)

Adenoidectomy

Chronic nasal/sinus infection failing medical treatment

Recurrent/chronic OM in children with tympanostomy tubes and persistent otorrhea

Nasal obstruction with chronic mouth-breathing and loud snoring

Tonsillectomy and adenoidectomy

> 7 infections

Upper airway obstruction secondary to hypertrophy resulting in sleep-disordered breathing and complications