Pediatrics
[EARS NOSE THROAT]
Introduction A lot of things go on in the head. Children need to be exposed to bugs to develop an immune system. That means orifices become potential sites for problems to develop, which is why this topic is in peds. Each disease has its own un ique presentation so it’s usually not a differential - just know what to do. 1) Otitis Media Otitis media is an infection of the middle ear caused by the respiratory bugs. The child is going to be in pain. Unilateral ear pain in a child, with or without fever, leukocytosis, etc. is most likely to be otitis. Kids will pull on their ear ( no pain with pinna manipulation) to relieve the sensation. The diagnosis is confirmed by pneumatic insufflation (a little puff of air reveals a tense immobile membrane ). Things like a bulging red angry membrane with loss of light reflex are indicative of fluid behind the ear but aren’t pathognomonic. Don’t get tests but definitely treat with amoxicillin . Failure to treat can cause spread of the infection to the mastoid, inner ear, and brain. If the infection does not clear give amoxicillin and clavulanate. If the infections recur do tubes to equalize pressure and allow drainage - especially if there’s residual fluid behind the ear. 2) Otitis Externa Otitis Externa presents as unilateral ear pain (like media), but there’s pain on palpation of pinna (unlike media). Caused by frequent contact with water (“swimmer’s ear”), it’s commonly caused by pseudomonas (a bug associated with water). It can also be caused by repeated trauma or an infection by Staph Aureus. On physical exam an angry erythematous canal can be seen. It usually improves spontaneously. It becomes important to educate patients not to put anything in their ear and to dry ears after swimming and showering. 3) Sinusitis An infection of the nose and sinuses that occurs in both kids and adults. Purulent bilateral nasal discharge is a giveaway something’s wrong nearby. Adults and older kids may complain of a congested, stuffed feeling with sinus tenderness. The facial tap is a sensitive physical finding (tapping an inflamed sinus hurts). Radiographs are not necessary but will show air-fluid levels and opacification (XR + CT). They’re expensive and are usually reserved for refractory or recurrent sinusitis to make sure there’s no congenital defect. But before doing anything make sure this isn’t just a cold - a regular viral illness. If it’s been >7 days or there’s also a cough, simply presume bacterial infection. This is an URI so treat the URI bugs with amoxicillin .
URI Bugs Most Common
Otitis Externa
Strep Pneumo H. Influenza Moraxella Catarrhalis Pseudomonas
Amoxicillin + clavulanate
Spontaneous Resolution
E ar P ain
Otitis Media Otitis Externa Foreign Body
Visual Inspection Pinna Manipulation Lidocaine / Retrieval
Rhinorrhea
Viral Sinusitis Bacterial Sinusitis Foreign Body
Ø Cough and < 7 days Culture Inspection
Bacterial Viral Mono
Rapid Strep
Digital Trauma
Cold compress, lean forward, humidified air, ablation
Sore Sore Throat
B loody loody Nose
Is it viral (wait )
or is it
Short Duration Low-Grade Fever Mild Symptoms
Culture
Monospot
bacterial (amoxicillin )?
Longer Duration High Fever Worse Sxs Culture
4) Cold – Viral Nasal Typically caused by rhinovirus and transmitted between people by large droplets . It’s also gives “boogers”, rhinorrhea, congestion , and low-grade fever so it looks like sinusitis. Nasopharyngeal Nasopharyngeal washes with culture (to rule out bacterial infection) and Immunofluorescence (to rule out viral infection) could be gotten but it’s better to not do anything because this will just get better on its own. If it’s <7 days AND no cough it’s likely viral and the patients should wait it out.
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Pediatrics
[EARS NOSE THROAT]
5) Pharyngitis Much like sinusitis, viral pathogens are the most common cause occurring in kids and adults. The primary complaint will be sore throat with pain on swallowing . Like otitis, physical exam findings are nonspecific for viral versus bacterial ( erythematous pharynx, swollen tonsils, purulent exudates). Because a bacterial infection with Group A Strep can cause rheumatic heart disease and poststreptococcal glomerulonephritis, we must find out if it’s bacterial or viral. However, those physical findings are not specific. Instead, use the Centor Criteria to help direct decision making. Keep in mind the risk of mimicry (PSGN and Rheumatic Heart) are higher in kids, so we’re more likely to treat. The treatment is amoxicillin-clavulanate if there’s strep, but do nothing if it’s viral. Using the Centor Criteria (right) we can make the decision. Doing a Rapid Strep Test is specific (if start treatment) but not sensitive (if move onto culture). Cultures take 23 days to come back; treatment does not need to be started until cultures confirm bacterial infection.
Calculating the score +1 Fever +1 Exudates +1 Adenopathy +1 ABSENCE of cough +1 < 15 years old -1 >44 years old Interpreting the Score < 1 No treatment (viral) 2-3 Throat Culture (Rapid Strep acceptable) > 4 Empiric Treatment, no testing needed
6) Foreign Body Children: Kids like to stick things places. Things can go into the nose (producing foul-smelling unilateral rhinorrhea), ear (pain), and sometimes down their throat (aspiration, covered in the pulmonary videos). Essentially, the object has to be retrieved with a rigid bronchoscope and the infection treated. Adults: One particular foreign body are insects; homeless are aware of this and sometimes sleep with coins in their ears. Bugs present with a unilateral scratching or buzzing and should be treated with lidocaine and retrieval, but never light (they just burrow deeper). 7) Epistaxis Whether out of habit or because the nose itches, epistaxis is most commonly caused by digital trauma (nose-picking). Normal nosebleeds are unilateral and last <30 minutes. Applying a cold compress (vasoconstriction) and leaning forward (backwards is just drinking the blood causing a cough breaking the clot) can cause an active bleed to stop. Look inside the nose to make sure there isn’t anything anatomical or foreign inside. Treat recurrent bleeds with humidified air. Ultimately, ablation is used to prevent bleeding. Posterior epistaxis may require packing (essentially a tampon inserted into the posterior of the oropharynx with prophylactic antibiotics to prevent toxic shock syndrome).
8) Choanal Atresia Finally, something isolated to pediatrics. This is an atretic or anatomically stenosed (i.e. really big tonsils) connection between the nose and mouth. In severe cases the baby will be blue at rest (nasal breathing is insufficient) and then pink up with crying (as he/she uses his/her mouth). If it’s just partially obstructed there might be a childhood snore; kids shouldn’t snore. If there’s complete atresia a catheter will fail to pass . If it’s incomplete a fiber-optic scope will identify the lesion. Surgery is required to remove the tonsils or open the atretic passage.
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