title: "Week 1: ENT & General Paediatrics"
Week 1: ENT & General Paediatrics
1. Ear Conditions
Otoscopy Technique
When performing otoscopy, pull the pinna up and back to visualise the tympanic membrane.
Foreign Body in Ear
- Remove via direct visualisation or microscopy
- Only batteries and organic matter (may expand with moisture) require urgent removal
- Live insects: kill first with oil (sesame or olive oil)
- Irrigation can be used but ensure tympanic membrane is intact first
Otitis Externa
Otitis externa is a skin infection of the external auditory canal. Key sign: pain when pulling the pinna on examination.
| Type | Pathogen | Treatment |
|---|---|---|
| Diffuse | Pseudomonas (commonest), Staph spp. | Antibiotic drops with steroid (Sofradex/Ciproxin HC) |
| Focal (boil) | Staph aureus | Oral anti-staph antibiotics |
| Fungal | Aspergillus niger, Candida | Locacorten-vioform drops |
Prevention of otitis externa: dry ears after swimming with acidified alcohol drops (e.g., Aquaear, Ear Clear).
Do NOT syringe the ear canal to clean out debris in otitis externa. May carefully suction instead.
Acute Otitis Media (AOM)
AOM bacterial causes (in order): Streptococcus pneumoniae (most common, causes acute complications), Haemophilus influenzae, Moraxella catarrhalis.
- Peak age: 6-18 months
- 75% have at least one episode by school age
- Particularly significant in Aboriginal and Torres Strait Islander children (prevalence up to 90%)
Diagnosis requires:
- Acute onset of signs/symptoms (otalgia, fever)
- Bulging, opaque tympanic membrane with reduced mobility
Infants may only show ear pulling as a sign of otalgia. Always consider AOM in irritable infants.
When to Give Antibiotics for AOM
- Age under 6 months
- Age under 2 years with bilateral AOM
- Ear discharge present
- Craniofacial anomalies (e.g., Down syndrome)
- Reduced immune function
- Cochlear implant
- Aboriginal or Torres Strait Islander
Watchful waiting for 48 hours is appropriate for most AOM. If not improving or higher-risk: treat with amoxicillin (dose per eTG/local antimicrobial guideline) for 5 days.
Source: Therapeutic Guidelines (eTG) / local antimicrobial guideline.
Decongestants, antihistamines, and corticosteroids are useless for AOM.
Acute Mastoiditis
- Most common suppurative complication of AOM
- Presents in children under 3 years
- Usually Strep pneumoniae
Mastoiditis sign: Swelling is postero-superior to the pinna, pushing it down and forward.
Management: IV (Intravenous) antibiotics (3rd gen cephalosporin), grommet insertion, cortical mastoidectomy if abscess.
Otitis Media with Effusion (OME / Glue Ear)
- Fluid in middle ear without inflammation
- Causes conductive hearing loss
- Most cases resolve spontaneously after AOM
Grommets "break the suction" of negative middle ear pressure. In selected children (especially older children with adenoidal hypertrophy/recurrent OME), adenoidectomy can reduce the need for repeat grommets.
Source: local ENT guideline.
| Grommet Type | Duration |
|---|---|
| Shepard (small) | 6 months |
| Reuter-Bobbin | 12 months |
| Sheehy/T-type | 18-24 months |
Kids with grommets must avoid dirty water. Pools need high chlorine and low pH (Pseudomonas is acid-sensitive). Beach and showers are okay.
2. Hearing Assessment
| Classification | Threshold |
|---|---|
| Normal | Under 20 dB |
| Mild loss | 20-40 dB |
| Moderate loss | 40-60 dB |
| Severe loss | 60-80 dB |
| Profound loss | Over 80 dB |
Audiogram symbols: Round = Right ear. Bone conduction greater than air conduction = conductive hearing loss.
Tympanometry Types
| Type | Meaning |
|---|---|
| Type A | Normal |
| Type B (flat) | Middle ear effusion (glue ear) |
| Type C | Negative middle ear pressure |
3. Nose Conditions
Epistaxis
- L - Local trauma (nose picking!)
- I - Infection/inflammation
- F - Foreign body
- T - Tumour (rare in children)
Management:
- Lean forward, pinch soft part of nose for 10-15 minutes
- If recurrent: consider cautery, nasal packing
- Check for bleeding disorders if severe/recurrent
Septal Haematoma
Septal haematoma requires urgent drainage to prevent septal perforation or abscess. Fractures must be reduced within 7-10 days.
4. Throat Conditions
Viral Pharyngitis
Most common cause of sore throat in children.
| Virus | Features |
|---|---|
| Adenovirus | Exquisitely painful, high fevers, conjunctivitis |
| EBV (Glandular Fever) | Prolonged malaise, hepatosplenomegaly, grey tonsillar exudate |
| Coxsackie | Herpangina; vesicles on palate. A16 causes hand, foot, and mouth |
| HSV | Cold sores, gingivostomatitis in young children |
Infectious Mononucleosis (EBV)
Monospot test: Rapid and specific but lacks sensitivity. Children under 4 may not develop antibodies.
Avoid amoxicillin in EBV - causes severe rash!
Bacterial Tonsillitis
Most common bacterial cause: Group A β-haemolytic streptococcus (GABHS). Peak age 5-6 years, rare under 3.
Always check the throat in a child with nausea and abdominal pain - may be referred pain from tonsillitis!
Tonsillectomy indications:
- 7+ episodes in 1 year
- 5+ episodes/year for 2 years
- 3+ episodes/year for 3 years
Scarlet Fever vs Kawasaki Disease
| Feature | Scarlet Fever | Kawasaki Disease |
|---|---|---|
| Cause | Group A Strep toxin | Unknown (immune-mediated) |
| Age | 5-15 years | Under 5 years |
| Fever | Responds to antipyretics | Persistent over 5 days |
| Rash | Fine sandpaper texture, Pastia's lines | Polymorphous, trunk/groin |
| Tongue | Strawberry tongue | Red tongue, cracked lips |
| Eyes | No conjunctivitis | Bilateral non-exudative conjunctivitis |
| Extremities | Diffuse desquamation | Red/swollen hands, periungual peeling |
| Lymph nodes | Tender, cervical | Painless, unilateral cervical |
| Complications | Rheumatic fever, PSGN | Coronary artery aneurysm |
| Treatment | Penicillin | IVIG + aspirin |
Kawasaki Disease requires treatment with IVIG and aspirin to prevent coronary artery aneurysm.
5. Growth and Development
Determinants of Growth
- G - Genetics (mid-parental height)
- N - Nutrition
- E - Environment
- H - Health status
- E - Ethnicity
Practice Questions
What is the most appropriate management?
What is the most likely diagnosis?
What is the most appropriate treatment?