First Aid for the Pediatrics Clerkship, 3 Ed.

Special Organs - Eye, Ear, Nose

 

EYE

Amblyopia

DEFINITION

A → in visual acuity in one or both eyes caused by blurred retinal images, which → failure of the visual cortex to develop properly.


Image

Amblyopia has been called “lazy eye.”


ETIOLOGY

Image Strabismus.

Image Refractive errors.

Image Opacity in the visual path (eg, cataract, ptosis, eyelid hemangioma).


Image

Strabismus is the most common cause of amblyopia.


DIAGNOSIS

Diagnosis is made by visual acuity testing.

TREATMENT

Image Removal of the pathology such as a cataract.

Image Prescription glasses to correct refractive errors.

Image Patching the good eye until the ambylopic eye has improved its vision.


Image

Amblyopia is usually asymptomatic and can be detected only by screening examination.


Strabismus

DEFINITION

Image Deviation or misalignment of the eye (see Figure 18-1).

Image “To squint or to look obliquely.”

Image Strabismus can lead to vision loss (amblyopia).


Image

Younger children are more susceptible to the development of amblyopia.


DIAGNOSIS

Image Corneal light reflex: The child looks directly into a light source and the doctor observes where the reflex lies in both eyes; if the light is off center in one pupil or asymmetric, then strabismus exists.

Image Alternative cover test: The child stares at an object in the distance and the doctor covers one of the child’s eyes; if there is movement of the uncovered eye once the other eye is covered, then strabismus exists.


Image

For the best results, amblyopia should be treated by age 4.


TREATMENT

Image Prescription glasses may help if the strabismus is secondary to refraction.

Image Eye muscle surgery may be necessary.


Image

Amblyopia can be reversed more rapidly in younger children.


Optic Neuritis

DEFINITION

Image Inflammation of the optic nerve.

Image Retrobulbar optic neuritis: Without ophthalmoscopically visible signs of disc inflammation.

Image Papillitis or intraocular optic neuritis: Ophthalmoscopically visible evidence of inflammation of the nerve head.

Image Neuroretinitis: Inflammation of both the retina and papilla.


Image

A deviated eye is described as being turned “eso” (inward), “exo” (outward), “hypo” (downward), or “hyper” (upward).


Image

FIGURE 18-1. Child with strabismus.

ETIOLOGY

Image Idiopathic.

Image Recent immunization or viral infection (measles, chickenpox, influenza).

Image Extension from an infection involving the teeth, sinuses, or meninges.

Image Side effect of treatment with vincristine or chloramphenicol.

Image Secondary to a toxin such as lead.

SIGNS AND SYMPTOMS

Image Loss of vision.

Image Pain with extraocular motion.

Image Pain to palpation of the globe.

Image Afferent papillary defect.

Image Bilateral in children (unilateral in adults).

COMPLICATIONS

Image Color deficits.

Image Motion perception deficits.

Image Brightness sense deficits.

TREATMENT

A trial of intravenous (IV) steroids may ↓ the length of time for symptoms but has no effect on the outcome.


Image

In children, optic neuritis is rarely associated with multiple sclerosis.


Conjunctivitis

DEFINITION

Inflammation of the conjunctiva.

TYPES

Allergic

Image Immunoglobulin E (IgE)-mediated reaction caused by triggers such as pollen or dust.

Image Signs and symptoms: Include watery, itchy, red eyes with edema to the conjunctiva and lids.

Image Pruritus and chemosis are common.

Image Treatment: Includes removal of the trigger, cold compresses, and anti-histamines.


Image

Adenovirus is the most common viral cause of conjunctivitis.


Viral

Image Adenovirus and coxsackievirus are typical causes.

Image Adenovirus: Pharyngoconjunctival fever—triad: pharyngitis, fever, and conjunctivitis.

Image Epidemic keratoconjunctivitis: Fulminant vision threatening condition with the involvement of cornea.

Image Signs and symptoms: Include watery, red eyes with preauricular lymph nodes.

Image Treatment: Includes supportive treatment with constant hand washing to prevent transmission.


Image

Conjunctivitis with lymph nodes. Think: Viral etiology.


Bacterial

Image Three organisms: Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus.

Image Highly contagious, outbreaks can occur.

Image Signs and symptoms: Include a mucopurulent discharge, red eyes, and edema of the conjunctiva.

Image Treatment: Topical antibiotics (drops or ointment).

Episcleritis/Scleritis

DEFINITION

Inflammation of the episclera or sclera.

ETIOLOGY

High association with autoimmune diseases.

SIGNS AND SYMPTOMS

Image Eye pain.

Image Photophobia.

Image Erythema.

Image ↓ visual acuity.

Image Perforation is associated only with scleritis.


Image

Episcleritis/scleritis is usually unilateral.


TREATMENT

Image Topical steroids.

Image Nonsteroidal anti-inflammatory drugs (NSAIDs).

Image Immunosuppressive drugs in case of failure of steroids.

Image Surgery for thinning or perforated sclera

Blepharitis

DEFINITION

Inflammation of the eyelid margins.

ETIOLOGY

Image Staphylococcus aureus.

Image Staphylococcus epidermidis.

Image Seborrheic.

Image A combination of the above.

SIGNS AND SYMPTOMS

Image Burning.

Image Itching.

Image Erythema.

Image Scaling.

Image Ulceration of the lid margin.

TREATMENT

Image Daily eyelid cleansing to remove scales.

Image Topical antibiotics.

Dacryostenosis


Image

A 4-month-old child presents with an exudative eye discharge and a painful, red lacrimal sac. Think: Dacrocystitis.

Dacrocystitis is the most common infection of the lacrimal system. It is often a complication of dacryocystocele. Excessive tearing, purulent eye discharge, and fever are the common symptoms. S aureus and streptococci are the common organisms. Most patients require admission for intravenous antibiotics. An incision and drainage may be needed in the presence of a lacrimal sac abscess.


DEFINITION

A congenital nasolacrimal duct obstruction.


Image

Dacryostenosis is the most common disorder of the lacrimal system.


EPIDEMIOLOGY

Occurs in 5% of infants; appears a few weeks after birth.

ETIOLOGY

Failure of the epithelial cells of tear duct to come apart.

SIGNS AND SYMPTOMS

Image Chronic tearing.

Image Erythema occurs secondary to rubbing the tears.

COMPLICATIONS

Dacrocystitis—inflammation of the nasolacrimal sac; this must be treated with topical or systemic antibiotic and warm compresses.

TREATMENT

Image Digital massage of the lacrimal sac.

Image Eyelid cleansing.

Image Probing if still present after 1 year of age to rupture the membrane.


Image

Most dacryostenosis will resolve by 8 months of age.


Chalazion

DEFINITION

Inflammation of a meibomian (tarsal) gland leading to the formation of a granuloma.

SIGNS AND SYMPTOMS

Image Firm nodule on the eyelid.

Image Nontender.

TREATMENT

Image Warm compresses.

Image Excision if necessary.

Image Most subside spontaneously over months.

Hordeolum

TYPES

Image External hordeolum, or stye, is an infection of the glands of Zeis or Moll.

Image Internal hordeolum is infection of the meibomian gland.

ETIOLOGY

S aureus.

SIGNS AND SYMPTOMS

Image Localized swelling

Image Tenderness

Image Erythema

TREATMENT

Image Warm compresses.

Image Topical antibiotics (eg, erythromycin).

Image Incision and drainage if there is no spontaneous rupture.

Orbital Cellulitis

DEFINITION

Inflammation of the orbital tissues behind the septum.


Image

Orbital cellulitis is postseptal.


ETIOLOGY

Image Extension of a local infection including paranasal sinusitis, facial cellulitis, or dental abscess.

Image Trauma.

Image The most common organisms are H influenza, S aureus, and S pneumoniae.

Image Most common site: Medial orbital wall.

Image ↑ incidence secondary to ↑ in methicillin-resistant S aureus (MRSA).

Image Orbital cellulitis is caused most commonly by ethmoid sinusitis.


Image

Periorbital cellulitis is much more common than orbital cellulitis.


SIGNS AND SYMPTOMS

Image Proptosis, ophthalmoplegia, and ↓ vision differentiate it from preseptal cellulitis.

Image Painful extraocular motion.

Image Proptosis.

Image ↓ vision.

Image Erythema.

Image Edema.

COMPLICATIONS

Image Loss of vision.

Image Meningitis.

Image Central nervous system (CNS) abscess.

TREATMENT

Image Orbital computed tomography (CT) scan.

Image Ophthalmology consultation.

Image Intravenous antibiotics, possible surgical drainage.

Periorbital Cellulitis

DEFINITION

Inflammation of the eyelids and periorbital tissue anterior to the septum.


Image

Periorbital cellulitis is preseptal.


ETIOLOGY

Image Extension of local infections including upper respiratory infection (URI), sinusitis, facial cellulitis, or eyelid infection.

Image Trauma: Skin trauma is the most likely etiology.

SIGNS AND SYMPTOMS

Image Erythema.

Image Edema.

Image No pain with extraocular movements.


Image

The most common organisms causing both preorbital and orbital cellulitis

SHIP

S aureus

H influenzae

Pneumoniae


COMPLICATIONS

Development of an orbital cellulitis.

TREATMENT

Image Oral or IV antibiotics (eg, ceftriaxone).

Image The most common cause of leukocoria is a cataract.

Corneal Ulcer

ETIOLOGY

Image Trauma (sand, contact lens, etc.) with secondary infection. Often preceded by a traumatic corneal abrasion.

Image Bacterial: Pseudomonas aeruginosa, Neisseria gonorrhoeae.

Image Fungal: Especially in contact lens users.

SIGNS AND SYMPTOMS

Image Corneal haze

Image Painful

Image Photophobia

Image Tearing

COMPLICATIONS

Image Perforation

Image Scarring

Image Blindness

DIAGNOSIS

Image Slit-lamp exam: Fluorescein staining reveals an epithelial defect.

Image Scraping of the cornea to identify infectious etiology.


Image

Retinoblastoma gene: Mutation in the long arm of chromosome 13.


TREATMENT

Image Local antibiotics.

Image In some cases, systemic treatment may be required.

Retinoblastoma

Image The most common primary ocular malignancy in children.

Image Average age: 18 months (90% < 5 years).


Image

Must evaluate for the presence of retinoblastoma in a child presenting with strabismus.


SIGNS AND SYMPTOMS

Image Leukocoria: White pupillary reflex is the most common presentation.

Image Strabismus is the second most common presentation.

Image Orbital inflammation.

Image Hyphema: Blood layering anterior to the iris.

Image May be bilateral (40%).

DIAGNOSIS

Image Direct visualization during eye exam.

Image Computed tomography (CT) or ultrasound (US) can help confirm and evaluate spread.


Image

Retinoblastoma is the most common primary malignant intraocular tumor in children.


TREATMENT

Image Chemotherapy.

Image Laser photocoagulation.

Image Cryotherapy.

Image Enucleation for unresponsive tumors.

Image Referral for genetic counseling in parents with a family history of retinoblastoma.


Image

Family members of a patient with retinoblastoma should be checked because it may be hereditary.


EAR

Otitis Media

DEFINITION

Inflammation of the middle ear.

EPIDEMIOLOGY

Image The incidence of otitis media is higher in:

Image Boys.

Image Children in day care.

Image Children exposed to secondhand smoke.

Image Non-breast-fed infants.

Image Immunocompromised children.

Image Children with craniofacial defects like cleft palate.

Image Children with a strong family history for otitis media.

Image The incidence of infection is higher in children because of their eustachian tube anatomy:

Image Horizontal

Image Short in length

Image ↓ tone

ETIOLOGY

Image S pneumoniae

Image H influenzae

Image Moraxella catarrhalis


Image

The most common overall complication of otitis media is hearing loss.


COMPLICATIONS

Image Hearing loss.

Image Perforation.

Image Mastoiditis.

Image Cholesteatoma: Saclike epithelial structures.

Image Facial nerve paralysis: The facial nerve may not be completely covered with bone in the middle ear; therefore, infection can spread to the nerve.

Image Labyrinthitis.

Image Abscess formation.

Image Tympanosclerosis: Scarring of the tympanic membrane.

Image Meningitis.


Image

The most common intracranial complication of otitis media is meningitis.


Acute Otitis Media

Eustachian tube dysfunction is the most important factor.

SIGNS AND SYMPTOMS

Image Ear tugging

Image Ear pain

Image Fever

Image Malaise

Image Irritability

Image Hearing loss

Image Nausea and vomiting


Image

Remember that younger children who are unable to communicate may have only nonspecific signs like nausea and vomiting with an acute illness such as acute otitis media.


DIAGNOSIS

Image Diagnosis is made with a pneumatic otoscope—the tympanic membrane will have ↓ mobility and will appear hyperemic and bulging with loss of landmarks.

Image Tympanocentesis should be used as an adjunct in patients who are < 8 weeks old, are immunocompromised, have a complication, or were treated with multiple courses of antibiotics without improvement; the fluid is sent for culture and sensitivity.


Image

A red eardrum in a crying child is normal; the most specific sign of acute otitis media is ↓ mobility of the tympanic membrane.


TREATMENT

Image Typically, the first-line antibiotic is amoxicillin. High dose can be used for cases most likely to be resistant.

Image Antipyretics: Ibuprofen and/or acetaminophen.

Image Topical anesthetic eardrops (eg, benzocaine).

Image For healthy children > 2 yr old with milder case, watchful waiting for 24–48 hr is an option.

Image Pneumococcal vaccine has reduced the incidence of acute otitis media.

Recurrent Acute Otitis Media

DEFINITION

Three to four episodes of acute otitis media in 6 months or six episodes in a year.

TREATMENT

Image Prophylactic antibiotics.

Image Myringotomy and ventilating tubes should be considered.

Otitis Media with Effusion

SIGNS AND SYMPTOMS

Image Hearing loss

Image Dizziness

Image No fever

Image No ear pain

DIAGNOSIS

Pneumatic otoscope shows a retracted eardrum with loss of landmarks and air-fluid levels or bubbles.

TREATMENT

Image If asymptomatic, a child is observed for 3 months to see if effusion resolves.

Image If symptomatic after 3 months of observation, treatment includes antibiotics and possibly myringotomy and insertion of tympanostomy tubes.

Otitis Externa


Image

A 4-year-old boy presents with what looks like herpetic vesicles in the ear canal and tympanic membrane. Think: Ramsay Hunt syndrome (facial paralysis + herpes zoster oticus). CN VIII involved = sensorineural hearing loss or vertigo.

It is due to herpetic involvement of the facial (geniculate), vestibulocochlear, or trigeminal ganglia which results in pain and vesicular eruptions about the auricle and external ear canal.


DEFINITION

Image Inflammation of the external auditory canal.

Image Occurs when trauma introduces bacteria into an area that is excessively wet or dry.


Image

Otitis externa is known as “swimmer’s ear.”


ETIOLOGY

Image Bacterial: P aeruginosa, S aureus, Proteus mirabilis, Klebsiella pneumoniae.

Image Viral: Herpes.

Image Fungal: Candida.

SIGNS AND SYMPTOMS

Image Ear pain with movement of the pinna.

Image Pruritus of the ear canal.

Image Edema of the ear canal.

Image Otorrhea: Usually white in color.

Image Palpable lymph nodes: Peri- and preauricular.

Image Normal tympanic membrane.

COMPLICATIONS

Image Malignant otitis externa leads to hearing loss, vertigo, and facial nerve paralysis.

Image Temporary hearing loss secondary to swelling.

Image Necrotizing otitis externa:

Image Pseudomonas osteomyelitis in the temporal bone.

Image Risk factor: Diabetes, immunocompromised (Aspergillus fumigatus).

DIAGNOSIS

Diagnosis is made by otoscopic examination.

TREATMENT

Topical antibiotics and steroids to reduce edema (eg, Cortisporin suspension [hydrocortisone-polymyxin-neomycin-bacitracin]).


Image

Malignant otitis externa is caused by P aeruginosa.


Mastoiditis

DEFINITION

Image Inflammation of the mastoid air cells in the temporal bone.

Image Most common pathogen: S pneumoniae.

ACUTE MASTOIDITIS

Image Mostly seen in children after/with an acute otitis media.

Image If resolution does not occur, may → acute mastoiditis with periosteitis, acute mastoid osteitis, or chronic mastoiditis.

Image Fever.

Image Pain behind the ear.

Image Erythema and tenderness over the mastoid area.

ACUTE MASTOIDITIS WITH PERIOSTEITIS

Image Includes the involvement of the periosteum.

Image Treatment: Includes myringotomy with ventilation tube placement and IV antibiotics.

ACUTE MASTOID OSTEITIS

Image Occurs when there is destruction of the mastoid cells and empyema is present.

Image The child will have a tender, swollen, red mastoid process with the ear displaced down and out.

Image Treatment: Includes IV antibiotics, and mastoidectomy may be necessary.

CHRONIC MASTOIDITIS

Involves treatment with antibiotics and possibly a mastoidectomy if osteitis is present.

COMPLICATIONS

Image Hearing loss.

Image Facial nerve palsy.

Image Subperiosteal abscess.

Image Cranial osteomyelitis.

Image Labyrinthitis.

Image Intracranial spread (meningitis, epidural or cerebellar abscess, subdural empyema).

Image Dural sinus thrombosis.

Tinnitus

DEFINITION

Image Ringing heard in the ear.

Image Commonly found in children who have middle ear disease or hearing loss.

Vertigo

DEFINITION

Dizziness with the feeling that one’s body is in motion.


Image

Benign positional vertigo (BPV) will present with ataxia and horizontal nystagmus.


SIGNS AND SYMPTOMS

Image Difficulty walking straight or stumbling.

Image Spinning sensation.

ETIOLOGY

May occur secondary to the following conditions:

Image Otitis media

Image Labyrinthitis

Image Trauma

Image Cholesteatoma

Image BPV

Image Ménière disease

Image CNS disease


Image

Ménière’s triad includes vertigo, tinnitus, and hearing loss.


TREATMENT

Address the underlying cause.

Ototoxic Drugs

See Table 18-1.

TABLE 18-1. Ototoxic Drugs

Image

NOSE

Sinusitis

DEFINITION

Inflammation of the membranes covering the sinuses.

SINUS DEVELOPMENT

Image Ethmoid sinus at birth.

Image Maxillary sinus at birth.

Image Sphenoid sinus 5 yr.

Image Frontal sinus 7 yr.

ETIOLOGY

Image A child may be at ↑ risk for sinusitis if there is an obstruction or cilia impairment.

Image S pneumoniae.

Image H influenzae.

Image M catarrhalis.

Image Rhinovirus is the most common viral pathogen.

Image Bacterial sinusitis is usually preceded by a viral upper respiratory infection.

PREDISPOSITIONS

Image Occlusion of the sinus ostium.

Image Cystic fibrosis.

Image Allergy/asthma.

Image Cyanotic congenital heart disease.

Image Dental infections.

SIGNS AND SYMPTOMS

Image Headache.

Image Sinus tenderness to palpation.

Image Persistent nasal discharge (purulent) > 10 days’ duration.

Image Halitosis.

Image Cough secondary to postnasal drip.


Image

At birth, only the maxillary and ethmoid sinuses are present.


COMPLICATIONS

Image Cellulitis.

Image Abscess formation.

Image Osteomyelitis.

Image Meningitis may occur through spread of the ethmoid, sphenoid, or frontal sinuses.

DIAGNOSIS

Image Diagnosis is made clinically.

Image If a test is required, a CT scan is preferred over plain films, which are not as sensitive.


Image

The most common location for epistaxis in children is from the anterior nasal septum because Kiesselbach’s plexus is located there.


TREATMENT

Image Antibiotics (eg, amoxicllin) for 14–21 days.

Image If no improvement, a macrolide or amoxicillin-clavulanate may be used.

Image Decongestants.

Image Nasal saline drops/mist.

Epistaxis

DEFINITION

Image Nosebleed.

Image Common age: 2–10 yr.

Image Unusual during infancy. Must consider coagulopathy or nasal organic causes (eg, choanal atresia).


Image

Blood in vomit may be present if a child has swallowed blood from an epistaxis; always ask about epistaxis if a patient presents with hematemesis.


ETIOLOGY

Image The most common location for a nosebleed in children is the anterior septum.

Image The most common cause is trauma secondary to a fingernail.

Image Other causes may include foreign bodies, inflammation, or dry air.

Image If a child has recurrent, severe epistaxis, other, more serious causes should be looked into such as thrombocytopenia, clotting deficiencies, and angiofibromas.


Image

Allergic rhinitis is the most common atopic disease.


SIGNS AND SYMPTOMS

Bleeding may occur from one or both nostrils.

TREATMENT

Image Compression for 10 min with head tilted forward.

Image Cold compresses to the nose.

Image Topical vasoconstrictors may allow visualization of the bleeding site.

Image Cauterization using silver nitrite.

Image Packing the nose.


Image

The “allergic salute,” seen in allergic rhinitis—horizontal crease on the nose that occurs from constant rubbing.


Allergic Rhinitis

DEFINITION

An IgE-mediated response to an allergen causing an inflammation of the nasal mucous membranes.

SIGNS AND SYMPTOMS

Image Generally don’t develop until 2–3 yr of age.

Image Sneezing.

Image Watery nasal discharge.

Image Red, watery eyes.

Image Itchy ears, eyes, nose, and throat.

Image Nasal obstruction secondary to edema.


Image

Children with allergic rhinitis may exhibit rabbit-like nose wrinkling because of pruritus.


DIAGNOSIS

Characteristic findings on physical exam, including:

Image Boggy, bluish mucous membranes of the nose.

Image Dark circles under the lower eyelids (“allergic shiners”).

Image Allergic salute.

Image Rabbit nose.

Image A smear of nasal secretions will show a high number of eosinophils.


Image

Allergic rhinitis in children may be a precursor for the development of asthma.


TREATMENT

Image Avoid triggers

Image Antihistamines

Image Decongestants

Image Cromolyn nasal solution

Image Topical steroids

Choanal Atresia

DEFINITION

Image A separation of the nose and pharynx by a membrane or bone (90%); may be unilateral or bilateral.

Image The most common congenital anomaly of the nose.


Image

Fifty percent of children with choanal atresia have other associated congenital anomalies—

CHARGE syndrome

Coloboma

Heart disease

Atresia choanae

Retarded growth

Genital anomalies

Ear involvement


SIGNS AND SYMPTOMS

Image Each child’s presentation will differ depending on his or her ability to mouth breathe.

Image Respiratory distress that improves as the child cries because the mouth is open.

Image Cyanosis, especially when the child is feeding or sucking. Crying relieves the cyanosis.

DIAGNOSIS

Image Inability to pass a catheter through one or both nostrils.

Image CT will show the extent of the atresia.

TREATMENT

Image Prompt placement of an oral airway, maintaining the mouth in an open position or intubation.

Image The ultimate treatment is surgical correction.

Image Maintaining an open airway by an orogastric tube or large nipple.

Image Tracheostomy or intubation may be required depending on the severity.


Image

Restenosis of corrected choanal atresia is common.



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