Ear, Nose, & Throat (c FW06) ppt child

Ear, Nose, and Throat

Adapted from Mosby’s Guide to Physical Examination, 6th

Ed.Ch. 12

Development

• Maxillary and ethmoid sinuses– present at birth, though very small

• Sphenoid sinus– tiny cavity at birth– not fully developed

until puberty

• Frontal sinus– develops by 7-8 years

Infant

• External auditory canal is shorter and has an upward curve

• Eustachian tube is relatively wider, shorter and more horizontal

– Reflux of nasopharyngeal secretions

Child

• As the child grows, the eustachian tube lengthens and its pharyngeal orifice moves inferiorly

• Growth of adenoids may occlude the eustachian tube– Interferes with aeration of the middle

ear

• Salivation increases by 3 months– Drools until swallowing

is learned

Teeth

20 deciduous teeth • appear between 6

and 24 months

Teeth

• Eruption of permanent teeth begins about 6 years of age

• Completed ~14-15 years old

• 3rd molar (“wisdom tooth”)– 18 years old

Ear, Nose, Mouth Exam

“Frequent site of congenital malformation therefore thorough

examination is important.”

Inspection

• Auricle– Well formed, all landmarks present– Very flexible

• Should have instant recoil after bending

CLINCAL NOTE: Premature infant– May appear flattened with limited incurving

of the upper auricle– Slower ear recoil

• The tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)

• Low or poorly shaped auricles– Associated with renal disorders and

congenital abnormalities

• NO skin tags should be present

• Preauricular skin tagor preauricular pit– anterior to the tragus– remnant of 1st branchial cleft

Internal Ear Exam

1. Lay the infant supine/prone2. Turn head to the side3. Hold otoscope so that the ulnar surface

of your hand rests against the infant’s head

*Prevent trauma to auditory canal

4. Other hand stabilizes infant’s head5. Pull auricle down to straighten the

canal

Newborns

• Auditory canal is often obstructed with vernix (newborn)

• Tympanic membrane may be in an extremely oblique position until 1 month old

*Should be examined within the first few weeks of life

In neonates, you may note…

• Limited mobility• Dullness and opacity of a pink or

red tympanic membrane• Light reflex may appear diffuse

– Tympanic membrane is not conical for several months

“As the middle ear matures in the first

few months, the tympanic

membrane takes on the expected appearance.”

Hearing

Use a bell, toy, voice, or clap your hands

• Make sure the infant is not responding to air movement or visual stimulus

• Remember, responses to repeated sound stimuli will diminish as the infant tunes it out

Expected Hearing Response

Birth to 3 months

Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice

4 to 6 months Turns head toward source of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound producing toys

Expected Hearing Response

6 to 10 months Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound

10 to 12 months Recognizes and localizes source of sound; imitates simple words and sounds

Infant Nose Exam

External Nose• Symmetric appearance• Positioned in the vertical midline on the

face– Deviation of the nose may be related to

fetal position

• Only minimal movement of the nares with breathing should be apparent

Consider a possible congenital abnormality if…

• Saddle-shaped nose with a low bridge and broad base

• Short small nose• Large nose

Internal nose• Inspect by shining a light inside

– Gently tilt the nose tip up with your thumb

• In infants, you may see a small amount of clear fluid discharged; crying

• Nasal patency must be determined at the time of birth

– Obligatory nose breathers

Mouth closed, occlude one naris and then the other

Observe the respiratory pattern

With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris

Consider:• Septal deviation

– Delivery trauma

• Choanal atresia

Infant Sinuses

• Maxillary and ethmod sinuses are small during infancy

• Few problems arise in these areas

• Examination is generally unnecessary

Infant Mouth Exam

• Crying provides an opportunity to examine the mouth

• Avoid depressing the tongue– Stimulates a strong reflex protrusion– Makes visualization of the mouth

difficult

• Well formed with no cleft

• Buccal mucosa– Pink and moist – No lesions

• NOTE: Secretions that accumulate in the newborn’s mouth may indicate esophageal atresia

• Scrape any white patches with a tongue blade

– Nonadherent• milk deposits

– Adherent• candidiasis (thrush)

Drooling• Normal from 6 weeks

to 6 months

• Consider a neurologic disorder if it persists >12 months

Gums • Should be endentulous

– smooth with a serrated edge of tissue along the buccal margins

Teeth• Count deciduous teeth• Note any unusual sequence of eruption

Tongue• fits well in the floor of the mouth• protrudes beyond the alveolar ridge

– If not, possible feeding difficulties

• Frenulum– Usually attaches midway between the

ventral surface of the tongue and its tip

• Insert your finger into the infant’s mouth– Fingerpad to the

roof of the mouth

Evaluate the infant’s suckPalpate the hard and soft palatesStimulate a gag reflex by touching

the tonsillar pillars

Normally…

• Should have a strong suck– Tongue pushing vigorously upward against

the finger

• Palatal arch should be dome shaped• Neither hard nor soft palate should have

palpable clefts• Soft palate should rise symmetrically

when the infant cries

Note in records if…

• Narrow, flat palate roof OR• High, arched palate

– affect the tongue’s placement– feeding and speech problems

*Associated with congenital anomolies

Child ENT Exam

Modifying Your Instruments

• Oto/ophthalmoscope– Decorative covers

http://quickmedical.com/pediapals/products

• Postpone until the end– often resist otoscopic and oral exams

• Be prepared to use restraint if encouraging the child fails– Ask parent to restrain

the child

Restraining a Child – Oral Exam

• Seated in the parent’s lap, back to the parent and legs between the adult’s legs

• Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other

• Can usually be accomplished without forcing– Force only makes them more angry…

Restraining a Child - Otoscope

• Face the child sideways with one arm placed around parent’s waist

• Parent holds the child firmly against his/her trunk– One arm restrains the head– One arm restrains the body

• Doctor further stabilizes the child’s head while inserting the otoscope

Restraining a Child - Supine

If the child actively resists…• Place child supine on the exam table• Parent holds arms extended above the

head and assists in restraining the head• Doctor lies across the child’s trunk and

stabilizes the child’s head • Third person may need to hold the

child’s legs

Remember

“Children of any age who are not too big to sit on a parent’s lap are better examined there than in a prone or supine position on the

examining table.”

Child Ear Exam

Otoscopic exam• Pull auricle either down and back OR up

and back – gain best view of the tympanic membrane

As the child grows, the shape of the auditory canal changes to the S-shaped curve of the adult.

• If the child is crying or has recently cried vigorously…– Dilation of blood vessels in the

tympanic membrane can cause redness “red reflex”

• Cannot assume that redness of the membrane alone is a middle ear infection

Pneumatic Otoscope• needed to differentiate

Crying Red Moveable

Infection RedNo mobility *see common

conditions at the end of this ENT section

Tympanometry

• Accurate way to identify middle ear effusion– Ear piece must be sealed in the canal

to provide accurate reading– Wax, ruptured membrane, tubes

Toddler’s Hearing

• Observe response to a whispered voice and various noise makers– Rattle, bell, tissue paper– Outside of the child’s vision

• As they get older, ask child to perform tasks in a soft voice– May want to have a parent do it…– Avoid visual cues

• Use words that have meaning for them– Big Bird, Mickey Mouse, Barney

Child’s Hearing

Weber, Rinne, and Schwabach tests• Used only when a child

understands directions and can cooperate with the examiner– Usually 3-4 years of age

• Refer for audiometric screenings

Nose Exam

Inspect internal nose• Usually adequate to tilt the nose

tip upward– Largest otoscopic speculum may be

used• Visualization of larger area

“Adenoidal” or “Allergic Salute”

• Children often wipe their noses with an upward sweep of the palm of the hand– If repeated often enough, causes a

crease

• Transverse crease at the juncture between the cartilage and the bone of the nose

Sinuses – Child

• Maxilary sinuses should be palpated

• Few sinus problems occur since the sinuses are still developing– Wide variation however– Do not rule out sinusitis simply on the

basis of age

Child Mouth Exam

Getting cooperation• Let the child hold and manipulate

the tongue blade and light– Reduce fear of the procedure

• Start by asking to see their teeth– Usually not threatening

• Ask child to protrude the tongue and say “ ah”– Tongue blade is often

unnecessary

• Ask the child to pant “like a puppy”– Raises the palate

If child refuses to open mouth…

• Insert a tongue blade through the lips to the back molars

• Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue

• This should stimulate the gag reflex– Gives you a brief view of the mouth

and oropharynx

Inspection

• Highly arched palate– Children who are chronic mouth

breathers

Why are they breathing through their mouth?

• Flattened edges on the teeth– Bruxism

• Unconscious grinding of the teeth

Why are they grinding?

• Baby bottle syndrome– Multiple brown areas (caries) on

upper and lower incisors– d/t bedtime bottle of juice/milk

• Black or grey colored teeth– Pulp decay– Oral iron therapy

• Mottled or pitted teeth– Tetracycline treatment during tooth

development– Enamel dysplasia

Tonsils• Should blend with the color of the

pharynx• Gradually enlarge to their peak size

between 2 - 6 years– should retain an unobstructed passage

• Graded to describe their size

Grading Tonsils

1+ -visible2+ -halfway

between tonsillar pillars and the uvula

3+ -nearly touching the uvula

4+ -touching each other

Common Abnormalities

Choanal Atresia

• Congenital nasal obstruction of the posterior nares– Junction between nasal

cavity and nasopharynx

• Newborns may experience respiratory distress– Obligatory nose breathers

*Will breathe when crying

Copyright © 2006 University of Washington.

Suckling Callus

• Newborn’s upper lips (other body parts)– First few weeks

• Plaques or crusts

Natal Teeth

• Teeth or tooth buds in a newborn

• If loose, potential for aspiration– May be removed

Retention Cystsaka Epstein Pearls

• Appear along the buccal margin

• Pearl-like retention cysts

• Disappear in 1-2 months

Macroglossia

• Abnormally large tongue

• Associated with congenital anomalies– Congenital hypothyroidism– Down Syndrome

Short Frenulum

Associated with• Feeding problems• Speech difficulties

Cleft Lip and Palate • Fissure in the upper lip and/or palate

– Congenital malformation

• Complete cleft– Extends through the lip and hard and

soft palates to the nasal cavity

• Partial Cleft– Any of the tissues

Long term issues:– feeding problems – chronic otitis media– hearing loss– speech difficulties– improper tooth development and

alignment

Otitis Externa (swimmer’s ear)

• Infection of the auditory canal

– trauma or moist environment • favor bacterial or fungal growth

• Initial Symptoms– Itching in the ear canal

• Pain– Intense with movement of pinna– Chewing

• Discharge– Watery, then purulent & thick mixed with pus and

epithelial cells– Musty, foul-smelling

• Hearing– Conductive loss caused by exudate and swelling of ear

canal• Inspection

– Canal is red, edematous; tympanic membrane obscured

Bacterial Otitis Media• Infection of the middle ear

– Often follows or accompanies an upper respiratory tract infection

Most common infection in childhood

• Initial Symptoms– Fever, feeling of blockage, tugging earlobe,

anorexia, irritability, dizziness, vomiting & diarrhea• Pain

– Deep-seated earache• Discharge

– Only if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling

• Hearing– Conductive loss as middle ear fills with pus

• Inspection– Tympanic membrane may be red, thickened,

bulging; full, limited, or no movement to +/- pressure

Otitis Media with Effusion• Inflammation of the

middle ear resulting in the collection of liquid (effusion) – Serous, mucoid, or purulent

• Causes:– Allergies– Enlarged lymph tissue

(nasopharynx)– Obstructed or dysfunctional

eustachian tube

Once the obstruction occurs…• middle ear absorbs the air,

creating a vacuum

• mucosa secretes a transudate into the middle ear

Average duration: 23 days

• Initial Symptoms– Sticking or cracking sound on yawning or swallowing;

no signs of acute infection• Pain

– Uncommon; feeling of fullness• Discharge

– uncommon• Hearing

– Conductive loss as middle ear fills with fluid• Inspection

– Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles

Sinusitis• Infection of or more paranasal sinuses

– May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose

– Blockage of the sinus meatus prevents drainage

Symptoms:– Fever, headache, local tenderness, and pain

Signs:– May be swelling of the skin overlying the

involved sinus and copious nasal discharge

• Children may alternatively suffer from:– upper respiratory symptoms– nasal discharge– low-grade fever– daytime cough– malodorous breath– cervical adenopathy– intermittent painless morning eye

swelling– NO facial pain or headache

Tonsillitis• Inflammation or infection of the

tonsils– Frequently caused by streptococci

Symptoms:– Sore throat, referred pain to the ears,

dysphagia, fever, fetid breath, and malaise

Signs:– Tonsils appear red and swollen;

purulent exudate• yellow follicles are associated

with streptococcal infection

– Anterior cervical lymph nodes enlarged

Peritonsillar Abscess• Infection of the tissue between the tonsil

and pharynx*Complication of tonsillitis

Symptoms:– Dyphagia, drooling, severe sore throat with

pain radiating to the ear, muffled voice, fever

Signs:– Tonsil, tonsillar pillar and adjacent soft palate

become red and swollen– Tonsil may appear pushed forward or

backward, possibly displacing the uvula

Epiglottitis

• Impending airway obstruction d/t acute inflammation of the epiglottis

• Though rare, it should always be considered!

Suspected with…• Sudden high fever• Croupy cough• Sore throat• Drooling• Apprehension• Focus on breathing

– Tripod position, neck extended

Caution!

• Inserting tongue blade may be deadly!– may result in complete airway

obstruction

• Treat this as a medical emergency• No one should examine the child’s

mouth until intubation equipment is available

Obstructive Sleep Apnea

• Periodic cessation of breathing during sleep d/t airflow obstruction– Can be seen in children with

excessively large tonsils

– Loud snoring, restless sleep– Daytime sleepiness– Morning headaches

Developmental delay Frequent infection