Overview

• Otitis Externa ⇒
  • Inflammation of outer ear.
  • Causes → typically bacterial. Recent swimming is a common trigger.
  • Sx → ear pain, itch and discharge. Red, swollen or eczematous canal on otoscopy.
  • Mx → topical aceitic acid (only effective for one week) and topical antibiotics.
    • If patient doesn’t respond to topical antibiotics then refer to ENT.
    • If cellulitis or cervical lymphadenopathy → oral antibiotics.
• Acute Otitis Media ⇒
  • Very common in young children. Typically preceeded by URTI.
  • Sx → otalgia, fever, hearing loss (Otitis Media with Effusion - Glue Ear, occurs after acute otitis media, most common cause of hearing loss in children), ear discharge (if tympanic membrane perforates).
  • Ix → otoscopy: red and bulging tympanic membrane with loss of the cone of light.
  • Mx → self-limiting (should resolve within 3 days), no antibiotics needed. Seek help if doesn’t improve in 3 days.
    • If with perforation or lasting >3 days → 5 day course of oral amoxicillin and review after 6 weeks to ensure perforation is healing.
      • Antibiotics → if systemically unwell or age <2 years old with bilateral infection.
    • Admission → <3 months + temp ≥38, severely systemically unwell, complications (mastoiditis, meningitis, facial nerve palsy).
  • Complications → mastoiditis (discharge and swelling behind ear), meningitis, brain abscess, facial nerve paralysis.
  • Otitis Media with Effusion (Glue Ear) → collection of fluid within the middle ear space without signs of acute inflammation. Hearing loss is usually the presenting symptom (may be bilateral). Can cause delay in speech and language development (= LD). Features of effusion on otoscopy include loss of the light reflex, opacification of the drum, and an air-fluid level behind the drum. There should not be any signs of inflammation or discharge. Children with OME should be actively observed for 6-12 weeks as spontaneous resolution is common. Should have two hearing tests using pure tone audiometry and tympanometry during this period. If features persist, refer child to an ENT specialist.
    • If also have Down Syndrome or Cleft Palate → refer to ENT for specialist assessment.
• Tonsillitis ⇒
  • CENTOR Criteria (max 4) → tonsillar exudate, tendor anterior cervical lymphadenopathy, fever >38, absence of a cough.
  • FeverPAIN (max 5) → fever, purulence (tonsillar exudate), attend rapidly (within 3 day of sx), inflamed tonsils, no cough or coryza.
    • 3 or 4 on Centor or 4 or 5 on FeverPAIN → Phenoxymethylpenicillin for 5-10 days, clarithromycin if penicillin allergic (avoid amoxicillin as can cause widespread maculopapular rash if due to EBV).
    • Admit if → difficulty breathing, clinical dehydration, peri-tonsillar abscess (severe unilateral throat pain - hospital admission and urgent ENT review) or cellulitis, signs of marked systemic illness or sepsis, suspected rare cause (kawasaki or diptheria), if taking DMARDs/carbimazole (do urgent FBC).
  • Ix → throat culture or rapid streptococcal antigen test (if centor 3 or 4).
• Acute Epiglottitis ⇒
  • Serious infection caused by haemophilus influenzae type B. Incidence now decreased due to introduction of Hib immunisation (8w, 12w, 16w, 1yr).
  • Sx → rapid onset, high temperature (’toxic looking child’), soft inspiratory stridor, drooling of saliva. ABSENCE OF COUGH (unlike croup with barking cough).
    • ‘Tripod Position’ → patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position.
  • Dx → via direct visualisation (flexible laryngoscopy) - only by senior/airway trained staff who are able to intubate if necessary, DO NOT EXAMINE THE THROAT. CXR = ‘thumbprint sign’ (swelling of epiglottis).
  • Mx → immediate referral to ENT/Paeds/Anaesthetics and ITU admission. Endotracheal intubation (SECURING AIRWAY = PRIORITY) to protect the airway. IV antibiotics (cefuroxime).
  • Most children recover within 2-3 days. Rifampicin prophylaxis to close contacts.

Making Diagnosis

Clinical Features

Investigations

Management Plan

Complications →

Prognosis →