Clinical Reasoning: Pediatric ear, nose, and throat conditions

Questions

USMLE® Step 1 style questions USMLE

1 questions

USMLE® Step 2 style questions USMLE

3 questions
Preview

 A 13-year-old male comes to the ambulatory care center for right ear pain and muffled hearing. He dove from the high dive yesterday and turned his head before hitting the water causing a loud crashing sound and a sharp pain in his ear. Since then he has had mild ringing in the ear, decreased hearing and pain. He woke up with some blood on his pillow prompting his mother to bring him to the office. Otoscopic examination confirms a tympanic membrane perforation. Which of the following would be expected on physical examination assuming he has hearing loss due to the observed perforation?  

Transcript

The most common ear, nose, and throat issues that occur in children can be divided into four categories.

First, ear pathologies associated with ear pain and hearing loss include otitis externa, otitis media, mastoiditis, aural atresia, and ear foreign bodies.

Second, nose-related conditions associated with rhinorrhea include viral and bacterial sinusitis, foreign bodies, and nose bleeding - mostly anterior posterior epistaxis.

Third, breathing difficulties usually include nasal polyps, adenoids, and choanal atresia.

And fourth, throat pathologies that cause a sore throat include viral and bacterial pharyngitis.

Let’s begin with ear pathologies. First, otitis externa or external otitis refers to inflammation of the external auditory canal usually caused by Pseudomonas aeruginosa or Staphylococcus aureus. Diagnosis is clinical.

On presentation, individuals show signs of external ear canal inflammation like ear pain, pruritus, discharge, and hearing loss due to ear canal edema. The auricle and tragus might also show signs of erythema and might be painful when touched. Individuals might have a history of tympanic membrane perforation, ear infection, recent ear instrumentation, or hearing devices use.

Pneumatic otoscopy is needed to see if the tympanic membrane is affected.

In otitis externa, otoscopy detects a swollen and erythematous ear canal and an erythematous tympanic membrane, which might be only partially visible due to canal edema.

The tympanic membrane is typically mobile with pneumatic insufflation, moving inwards and outwards, respectively.

Now, there should be no evidence of middle ear fluid or a perforated tympanic membrane as this is rare in otitis externa but common in otitis media.

If there are signs of external ear inflammation that appear over 48 hours within three weeks and the tympanic membrane has preserved its mobility and integrity, a diagnosis can be established.

Treatment begins with removing any infected debris with suction or dry cotton swabs under adequate lighting.

Mild external otitis can be treated by altering the ear canal’s pH with 2% acetic acid and by relieving inflammation with topical hydrocortisone drops for 7 days.

In moderate to severe cases, a topical preparation of ciprofloxacin and hydrocortisone is preferred.

Therapy in severe cases includes topical antibiotic therapy, wick placement in case the canal is swollen and doesn’t allow the medication to reach the tympanic membrane, and, if there is evidence of deep tissue infection, oral antibiotics.

A quinolone like ciprofloxacin or ofloxacin is recommended for coverage of Pseudomonas aeruginosa and Staphylococcus aureus. Ciprofloxacin can be given at a dose of 10 milligrams per kilogram twice daily for 7 to 10 days. Additionally, an analgesic like acetaminophen or ibuprofen can be given in all cases if the pain is significant.

Fungal external otitis requires thorough cleaning of the ear canal and application of an antimycotic solution like gentian violet or clotrimazole. These solutions should not be used if the tympanic membrane is perforated because they can cause severe pain or damage to the inner ear.

Next, otitis media is a bacterial or viral infection of the middle ear. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates.

There are two forms of otitis media. Acute otitis media is when the individual shows signs of inflammation secondary to purulent middle ear fluid.

Otitis media with effusion is when there are no signs of inflammation since the middle ear fluid is serous.

On presentation, acute otitis media presents with ear pain, hearing loss, ear discharge, and pruritus. Other symptoms individuals might present include fever; nausea and vomiting; and sometimes signs of upper respiratory infection like cough and shortness of breath. Otitis media with effusion is usually asymptomatic but it might be associated with hearing loss.

Ok so, pneumatic otoscopy is used to confirm otitis media by showing tympanic involvement and middle ear effusion, which is when there’s fluid behind the tympanic membrane. This is confirmed by bubbles or an air-fluid level behind the tympanic membrane or two of the following: abnormal color, opacity, and impaired mobility of the tympanic membrane.

In acute otitis media, pneumatic otoscopy also reveals a bulging and inflamed tympanic membrane, and sometimes purulent discharge and tympanic perforation.

Now tympanic bulging alongside acute symptoms of inflammation and middle ear effusion is usually enough for diagnosing acute otitis media. Alternatively, diagnosis can also be established if the individual presents signs of acute inflammation and middle ear effusion but no tympanic bulging.

On the other hand, in otitis media with effusion, otoscopy usually shows middle ear effusion but no sign of tympanic inflammation, which is enough for diagnosis. Other findings might include greyness, opacification or retractions of the tympanic membrane.

Tympanometry and acoustic reflectometry can be used in conjunction or instead of pneumatic otoscopy.

Tympanometry detects middle ear fluid by creating variations of air pressure in the ear canal. Usually, a flattened tracing with a low static admittance indicates middle ear effusion.

Acoustic reflectometry measures the level of sound transmitted and reflected from the middle ear to a microphone located in a probe tip placed against the ear canal. When there is fluid in the middle ear, the tympanic membrane is immobilized and the reflected sound is louder with a narrower spectrum.

If both tympanometry and acoustic reflectometry are normal, otitis media is unlikely.

And finally, tympanocentesis or aspiration of the middle ear fluid for culture is required for an etiologic diagnosis.

An etiologic diagnosis is not always necessary since the antimicrobial agent can be chosen empirically. However, tympanocentesis is warranted if the individual appears toxic, has immune deficits, or when antibiotic therapy has failed.

Regarding treatment, acute otitis media usually spontaneously resolves within one to two weeks. Antibiotics are recommended for those younger than six months, for those six months to two years of age when the diagnosis is certain, and for all individuals older than two years with severe infection, which is defined as moderate to severe otalgia or temperature greater than 102° F. Amoxicillin, 90 milligrams per kilogram per day, divided in two doses, is the preferred antibiotic. Children under two years should be treated for 10 days and those older than two for 5 to 7 days.

Otitis media with effusion is managed by "watchful waiting" and myringotomy with tympanostomy tube placement to clear the middle ear fluid.

Additionally, surgery is needed for those with structural changes of the tympanic membrane or middle ear, like retraction, tympanic membrane perforation, or cholesteatoma which is abnormal skin growth.

In both, pain management with acetaminophen, ibuprofen or, alternatively, antipyrine or benzocaine otic suspension is needed when pain is significant.

Moving on, mastoiditis is a bacterial infection of the mastoid air cells, typically secondary to acute otitis media. On presentation, individuals might be completely asymptomatic or severely affected.

It usually presents signs of mastoid inflammation, including tenderness, erythema, and swelling behind the ear; fluctuation over the mastoid process due to abscess formation; and protrusion of the auricle; symptoms of ear inflammation like ear discharge, pain, and hearing loss; and systemic symptoms like lethargy, fever, and nausea.

Next, pneumatic otoscopy might show signs of acute otitis media, like bulging, middle ear effusion, and perforation.

Sometimes the tympanic membrane cannot be seen due to swelling of the external auditory canal.

If signs of mastoid inflammation and otitis media were found, a clinical diagnosis could be established. Conversely, a normal-appearing tympanic membrane usually excludes mastoiditis.

Next, in those with inconclusive symptoms and signs, CT of the temporal bone is necessary to confirm the diagnosis.

A diagnostic finding is erosion of the mastoid air cell bony septae.

Other signs on CT include clouding of mastoid, which by itself does not indicate mastoiditis; destruction or irregularity of the mastoid cortex; and periosteal thickening or subperiosteal abscess.

Next, if an etiological diagnosis is necessary, any middle ear drainage can be sent for culture and sensitivity.

Complete blood count, erythrocyte sedimentation rate, and C-reactive protein can be abnormal but are neither sensitive nor specific and add little to the diagnosis.

Empiric treatment consists of intravenous antibiotic that provides central nervous system penetration, like ceftriaxone 50 to 75 milligrams per kilogram once a day for at least two weeks, and middle ear drainage. Subsequent antibiotic choice is guided by culture and sensitivity test results.

Any subperiosteal abscess will also require a simple mastoidectomy, in which the abscess is drained and the infected mastoid cells are removed.

Fourth, aural atresia is characterized by ear canal stenosis and improper formation in utero of the middle ear structures like the three ossicles. The condition can be either unilateral or bilateral and diagnosis is mostly clinical.

On presentation, individuals might have different degrees of severity, varying from complete atresia when there’s no ear canal, ossicles or auricle to partial atresia when the ear canal is narrow with a pinhole aperture but not completely obstructed and the auricle is present but small and misshapen. Additionally, hearing loss might also be present. Diagnosis can be established based on these findings.

Next, otoscopy might provide extra information, like the presence of an underdeveloped detached tympanic membrane.

Next, the child’s usable residual hearing and the need for amplification should be determined as soon as possible after birth to ensure speech and language development. This is done with the help of auditory brainstem response audiometry which assesses the brain’s response to auditory stimuli. In most cases, the sensorineural function is normal and atresia of the external ear canal causes a 45-60 decibels conductive hearing loss.

Ok so next CT of the temporal bone can be performed at the age of 5 to 6 years to assess the middle ear morphology and any other defect individuals might have like congenital cholesteatoma, which may need early intervention.

Regarding treatment, it is not necessary for those with unilateral atresia if the pinna is well formed and the contralateral ear has normal hearing.

By contrast, because bilateral atresia is associated with a maximal conductive hearing loss, it requires early intervention usually consisting of a bone-conduction hearing aid within weeks of birth to assist with early language acquisition. It might also require corrective surgery, which is usually performed toward the end of the first decade of life, when substantial mastoid development has occurred.

Surgery entails the creation of a new ear canal and eardrum, providing a skin lining for the canal and drum, and mobilizing or repositioning the ossicles to allow transmission of sound.

Additionally, empiric antibiotic therapy is needed if acute otitis media is suspected clinically, because the diagnosis cannot be confirmed through otoscopy.

And finally, foreign bodies in the ear canal are very common among children. These range from cerumen and insects to small toys and twigs. Diagnosis is usually clinical, based on the direct observation of the foreign body.

Now, on presentation, individuals might be asymptomatic or might present with pain, redness, discharge, or pruritus over the ear lobe or ear canal. Sometimes hearing can be affected if the object completely obstructs the ear canal.

Next, if the object can’t be seen directly, otoscopy might be able to detect its position and any other lesion that might need further management.

When it comes to treatment, foreign bodies that are easy to grasp can be removed with alligator forceps. Smooth objects that cannot be grasped are best removed with a small, blunt hook under operating microscope guidance. In other cases, suction can be successful.

For insects, killing them by filling the canal with viscous lidocaine and removing them with forceps is the best approach.

A general anesthetic or deep sedation may be needed in agitated individuals or when removal is difficult or if there's a risk of injury to the tympanic membrane or ossicles. Antibiotic drops should be prescribed to treat any possible infections.

Ok. Let’s now switch gears to nose-related problems. The most common issues associated with rhinorrhea are rhinitis and nose foreign objects.

First, rhinitis refers to inflammation of the mucosal lining of the nasal cavity, and rhinosinusitis, also known as sinusitis, refers to inflammation of both the nasal cavity and paranasal sinuses. It can be allergic due to exposure to a specific trigger, such as animals, dust, or seasonal; or it can be infectious, which is mostly caused by viruses like rhinovirus, influenza, and parainfluenza, and sometimes by bacteria, and it can be either acute or chronic.

Acute rhinosinusitis diagnosis is clinical.

On examination, individuals usually present symptoms and signs compatible with sinus inflammation, like rhinorrhea, daytime cough, conjunctivitis, facial pain, nasal congestion, hyposmia or decreased sense of smell, and halitosis or bad breath. Malaise can develop as well. Fever and chills suggest an extension of the infection beyond the sinuses. The area over the affected sinus can be tender, swollen, and erythematous.

Now, the type of rhinorrhea may suggest the underlying cause.

Thin serous or watery nasal discharge can be caused by allergic rhinitis or viral rhinitis.

If an individual presents with thin nasal discharge and there’s a history of exposure to a specific allergen, then the diagnosis is probably allergic rhinitis.

To be sure, some individuals may get allergen-specific testing through in vivo skin prick tests, which is where small drops of up to 40 allergens, like pollens, fungi, animal dander, house dust mites, and various foods, are pricked into the skin on the forearm or upper back. After that, if there are signs of urticaria within about 20 minutes, that implies that the substance is a trigger. Another way is with in vitro blood tests that look for IgE antibodies against specific allergens, such as foods, insect venoms, pollen, mold, latex, or antibiotics.

Once the trigger is confirmed, treatment involves a combination of allergen avoidance and medical therapy.

Individuals are generally treated with intranasal glucocorticoid sprays, and if glucocorticoid nasal sprays alone are not sufficient to control symptoms, then individuals may get additional treatment with antihistamines, which can be intranasal, oral, or eye drops depending on the most prominent symptoms. Finally, for individuals with rhinitis symptoms that are refractory to glucocorticoid nasal sprays and concomitant asthma or nasal polyposis, the addition of montelukast may be helpful.

Now, thick purulent nasal discharge can be caused by viral and bacterial rhinitis.

The most important factors in differentiating viral from bacterial rhinosinusitis are the overall symptom duration and the symptom trajectory.

Symptoms of viral infection usually peak early and resolve gradually in around 10 days.

In bacterial rhinosinusitis symptoms last for more than 10 days and don't improve easily.

Symptoms that worsen after an initial improvement, a thing so-called 'double sickening', is suggestive of secondary bacterial infection.

Another thing that points toward bacterial infection is a clinical picture consisting of severe symptoms like ill appearance, temperature over 102.2°F, and purulent nasal discharge for more than three consecutive days.

To diagnose acute rhinosinusitis, the symptoms must last less than four weeks, and there shouldn’t be any complications like ophthalmoplegia, sepsis or abscesses.

To diagnose chronic rhinosinusitis, symptoms must last 12 weeks or longer.

Next, if the individual presents any complication, if the diagnosis is uncertain, or if empiric treatment fails, further testing is recommended. Sinus aspiration with sinus fluid culture could be a great first step.

Diagnosis is confirmed if the culture yields at least 104 colony-forming units per milliliter of a significant bacteria. Next, CT is usually performed in those suspected to have orbital and intracranial complications. Findings consistent with, but not diagnostic of, acute rhinosinusitis include sinus opacification, air-fluid level, or marked or severe mucosal thickening.

For treatment, uncomplicated viral rhinosinusitis usually resolves with just symptomatic therapy in 7 to 10 days. This consists of steam inhalation, adequate rest and hydration, warm facial packs, as well as use of over-the-counter medications like ibuprofen for pain management. Intranasal corticosteroids are recommended for those with congestion.

Conversely, management in with mild acute bacterial rhinosinusitis consists of watchful waiting and symptomatic therapy for up to 10 days before instituting subsequent antibiotic therapy. Those with severe or worsening symptoms require antibiotics are usually to prevent complications. Amoxicillin with or without clavulanic acid, 25 milligrams per kilogram, taken by mouth every 12 hours is the first-line choice.

Next, intranasal foreign bodies consist of a variety of inorganic and organic objects like beans, toys, insects, and food. Diagnosis is clinical.

On examination, individuals are usually asymptomatic. When symptoms do occur, these can include unilateral mucopurulent nasal discharge, foul odor, epistaxis, nasal obstruction, and mouth breathing.