Pediatrics (week 2): EENT

[liveonearth]

Jen Gibbons
1998 grad, practices at Nat Fam and Childbirth clinic
"very much a family practice" peds, wmns health, midwifery, men: strep throat, smattering of chronic, menopause

EYEs

red reflex
is pos if there's a diff btw the eyes: refer to opthamologist if abn
ck in newborns and all kids, detect retinoblastoma, rhabdomyosarcoma
mb harder to get reflex when iris is dark but keep checking if abn

strabismus
misalignment may not be constant, misalignment-->no binocular vision, poor depth perception
initial double vision then brain shuts off info from weaker eye: amblyopia develops
misalignment may occur in certain distance ranges
kids crosseyed at birth, haven't been using mm, by 3-6mo eyes should align
at 3mo she likes to hear that sometimes eyes deviate but usu aligned, at 6mo expect fulltime alignment
"are their eyes workin' together well?"
tx: patch strong eye, exercises, intermittent, may need corrective lens, rare EOM surgery

red eye and eye discharge
80% of peds practice
uni or BL? a cold? others sick? onset? spreading? what part of eye?
ddx:
usu no culture just tx presumptively

congenital nasal lacrimal duct stenosis aka dacrostenosis
eye doesn't wash normally, gets irritated, infx
presents at 3-12 weeks
"eye is always watery", "some goop in it"
v common, 1/4 kids, most mild, most resolve by 6-12mo, rare to last to age 3
tx: cleanliness, herbal eyewash, erythromycin eye ointment if infx
homeop: pulsatilla, silica
dacrocystitis = infx of duct

conjunctivitis
bact, viral, allergic
usu viral if kid has a cold, bilateral, clear conjunctiva
bact starts unlat and spreads, usu conjunctiva injected, parents want to know if it is pinkeye
pinkeye: kids can't go back to school until txd, is bacterial usudt staph or strep, v contagious
tx for breastfeeding mom: milk into eye is very best tx
tx: warm compresses and eyewash: mix using 1oz sterile saline,
herbs for eyewash: 2-5 drops each: ech, calendula, hydrastis, euphrasia
usu total of 10 drops alcohol tincture/1oz saline, dosing: in eyes 4x/day
test in own eyes, no sharing, don't save leftovers they spoil
may take 2 parents to get kid to stay down and open eye and get drops in
put in corner of eye with eye closed, then open eye
tx: standard of care is topical abx, erythromycin eye ointment tid, or polymixin b or gentamycin eye drops
if you give abx they usu get better, even tho we say it is usu viral
tx: cham tea bags, black tea bags?, immune system support
tx for allergic: same as for adults

periorbital and orbital cellulitis
mc in children
etio: skin disruption, bug/spider bite, sinusitis, hflu or strep flu, bacteremia
usu unlat with pain, mb fever, if orbital the eyeball may swell, be immobile
complic: retinal damage if orbit involved, risk of meningitis of brain abscess
tx: oral abx and close followup if not severe, refer for iv abx if severe
(call er, may get to bypass for admit)
abx: augmentin, azythromycin, cephalosporin
24 hour followup and give pts cell phone in case they get worse

bletharitis
infected eyelids, tends to be chronic, relapsing
crusting, scaling, ulcerations, lash loss
tx: daily cleansing with baby shampoo, hot packs
tx: boil an egg, let it cool, then hold warm egg to eye for heat source
tx: efas, zinc, b6
cure: reverse cause of inflammation
parents think they've done something wrong when it comes back so warn them

styes
hot packs, hot egg tx
do not lance unless good clear head

NOSE AND SINUSES

rhinitis
usu w URI, d/c mb any color any kind, parents worry about weird colors (green) which are more there in am
may cause postnasal drip, coughing when supine
tx: reassure parents, normal to be green, thicker in am
mb chronic, last all winter, 18months of age is mc timing
etio: teething causes inflam, environmental irritants, URI
allergies-->snoring, big adenoids, mouth breathing, eczema?
tx: remove irritants, clean windowsills, try humidifier, if chronic avoid food sensitivities (dairy, gluten)
tx: vit c and bioflavonoids, quercetin if allergies but it is bitter, maxiflav product 1/4 tsp mix with honey
tx: wisewoman children's glycerite for immune modulation and cough, give 1 dropper 4x/day for kids under 30lbs
tx: immune support liquid (pur encapsulations) zinc, beta carotene, elderberry, melissa, etc
she combines the last two
tx: adds oregon grape or horseradish for congestion
tx: mother earth cough syrup
if pet or grass allergies: modify environment, keep pet out of kids room, air purifier in bedroom
no carpet in child's room, whole house?, washable carpets, allergen covers?
frequent bedding changes, wash after playing outside or petting animal
tx: antihistamines? don't take them off if they're stable, work on other stuff until not needed

sinusitis
usudt URI
tx: if kid is doing well then saline rinses, immune support, wet sox, topical applications, same tx as for a bad cold, horseradish and oregon grape, ligusticum
abx: amox is 1st line but doesn't cover all bugs, augmentin if suspect hflu type b, she's never had to

THROAT
viral or bacterial?
presentation: older kids complain of sore throat
younger kids stick out tongue, complain of stomach ache, roll food around in mouth or won't eat
shallow cough
PE: not easy to get a good look, start with head, eye, ear, etc, then mouth
have flashlight ready, kids may fear that you'll stick it in their mouth
"show me your teeth, show me your tongue, stick your tongue out"
if kid not ready then go to rest of exam, heart, lungs, abd
when laying down try again to look in mouth
if still no go then give choices: what we still have to do is abdomen, weigh you, and look in your mouth
"which one do you want to do first?"
crying kid: look in mouth, upside down kid laughing, same thing
have parent lay kid across lap with head extended, can get good look if head is extended
do exams on parents, sibs, "now it's your turn"
put finger in mouth and open it

coxsackie-hand foot and mouth lesions, also diaper area mb 1st, papules and vesicles lasting a week, tx: gen
may cause herpangina on posterior pharynx, ulcers on erythematous base, assoc w high fever, brutal sore throat
this is not herpes, lasts about a week regardless of tx, throat is painful
tx for painful throat: licorice, althea, slippery elm, calendula gargle, lidocaine cough syrup "hurricane"
tx: frozen fruit, smoothies, cold, or warm
tx: probx powder?

mononucleosis
unlikely in young children, usu in teens
pharyngeal injx with exudate, looks like strep, fever, LAD, HSM can appear in 1st week
do rapid strep: neg, not that accurate in kids under 10 so you may have to do antigen test

bacterial pharyngitis
strep, staph, hflu

strep
mc in kids 5-15, petechial stippling of soft palate
strep sx: fever, headache, sorethroat, LAD, poss N/V, stomach ache in 10-20%
no sig rhinitis, cough
PE: sig erythema & edema, tonsillar enlargement, mb exudate, petechiae
dx: rapid strep test, positives are pretty sure, negatives mb false
she takes 2 swabs the 1st time in case she wants an aerobic culture
swabs both sides of throat, make em gag and get a good sample
tx: oral pendee ? 1st choice amox is 2nd choice, no documented resistance? she sees some resistance
tx: backup abx is keflex/cephalosporin if can't do penicillins, can have cross reacting allergic rxns, she won't get ceph if hx of anaphylaxis with pens
erythromycin is standard nonpen but famously hard on gut and you have to take it 4x/day, people don't like it
tx: bemp tincture, hard time getting kids to take it
bemp = berberis/mahonia, ech, myrr, phytolacca "plus" is added stillingia
followup: if afebrile and throat is improving can go back to school after 2 days
complications: risk of rheumatic or scarlet fever, glomerulonephritis acute resolves on its own

scarlet fever
strawberry tongue (also w Kawasaki)
sandpaper rash dt allergy to strep pyrogenes toxin, begins on trunk, blanches wth pressure
desquamation: kids will peel, esp hands and feet, whole layer

rheumatic fever
joint swelling, subcu nodules, murmur
usu in 5-15yo kids
pastia's lines?

peritonsillar abscess
another possible complication of strep
exquisitely tender lump in neck, mb feverish, may compromise airway
also retropharyngeal abscess, needs referral for drainage

epiglottitis
abrupt onset, high fever, no other resp sx, kid looks v sick
sits forward, drools, refer to er

EARS

OM
responsible for 80% of ped abx prescriptions

acute OM
TM erythematous and bulging
by age 6 90% of kids have had at least one infx
tx: garlic mullein ear drops help for pain
tx: herbs, homeop
tx: eustacian tube massage, external or internal, sucking and chewing
tx: onion poultice around head or in ear, sautee thick slice of onion, get it warm, put in thin cloth and over ear, has to be warm to get sulphur vapors from it, can also use fresh onion juice straight in ear, warm olive oil, warm garlic infused olive oil, sauteed garlic, warm or cold compresses
tx: if she thinks its past its peak she lets it roll, if TM is slackened from reduced pressure

chronic
more if chronic inflam of adenoids, tonsils
may end up with serious OM and hearing loss

when give abx
abx for kids under 2 with bl om
or in older kids if persistent over 3 days
amoxicillin, augmentin if not work, eryth if pen allergic
doesn't help to use decongestants, antihist
she uses homeop 200c repeating ev 15 mins for an hour then take an hour off
don't repeat remedy if sx not exhibited
24-48 hours expect response, if none then change course
must address pain
after perforation don't put anything in
should close up within a week or so
infx will resolve, no risk of hearing loss unless perfed many times-->scar tissue, cholesteatoma

mucoid or serous OM "glue ear"
on the rise dt abx use
tm clear or amber, retracted, may see fluid line or bubbles
no risk of hearing loss

OM with effusion
chronic plugged eustacian tubes
more risk of hearing loss
no infx, no abx needed