Ear, Nose, and Throat

Adapted from Mosbys Guide to Physical Examination, 6th Ed. Ch. 12

Development
Maxillary and ethmoid sinuses
present at birth, though very small

Sphenoid sinus
tiny cavity at birth not fully developed until puberty

Frontal sinus
develops by 7-8 years

Infant
External auditory canal is shorter and has an upward curve Eustachian tube is relatively wider, shorter and more horizontal
Reflux of nasopharyngeal secretions

Child
As the child grows, the eustachian tube lengthens and its pharyngeal orifice moves inferiorly Growth of adenoids may occlude the eustachian tube
Interferes with aeration of the middle ear

 Salivation increases by 3 months

Drools until swallowing is learned

Teeth
20 deciduous teeth appear between 6 and 24 months

Teeth
Eruption of permanent teeth begins about 6 years of age Completed ~14-15 years old

3rd molar (wisdom tooth)

18 years old

Ear, Nose, Mouth Exam

Frequent site of congenital malformation therefore thorough examination is important.

Inspection
Auricle
Well formed, all landmarks present Very flexible
Should have instant recoil after bending

CLINCAL NOTE: Premature infant

May appear flattened with limited incurving of the upper auricle Slower ear recoil

 The tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)

 Low or poorly shaped auricles

Associated with renal disorders and congenital abnormalities

 NO skin tags should be present Preauricular skin tag or preauricular pit

anterior to the tragus remnant of 1st branchial cleft

Internal Ear Exam

1. Lay the infant supine/prone 2. Turn head to the side 3. Hold otoscope so that the ulnar surface of your hand rests against the infants head
*Prevent trauma to auditory canal

4. Other hand stabilizes infants head 5. Pull auricle down to straighten the canal

Newborns
Auditory canal is often obstructed with vernix (newborn) Tympanic membrane may be in an extremely oblique position until 1 month old *Should be examined within the first few weeks of life

In neonates, you may note

Limited mobility Dullness and opacity of a pink or red tympanic membrane Light reflex may appear diffuse
Tympanic membrane is not conical for several months

As the middle ear matures in the first few months, the tympanic membrane takes on the expected appearance.

Hearing
Use a bell, toy, voice, or clap your hands Make sure the infant is not responding to air movement or visual stimulus Remember, responses to repeated sound stimuli will diminish as the infant tunes it out

Expected Hearing Response

Birth to 3 months Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parents voice Turns head toward source of sound but may not always recognize location of sound; responds to parents voice; enjoys sound producing toys

4 to 6 months

Expected Hearing Response

6 to 10 months Responds to own name, telephone ringing, and persons voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound Recognizes and localizes source of sound; imitates simple words and sounds

10 to 12 months

Infant Nose Exam

External Nose Symmetric appearance Positioned in the vertical midline on the face
Deviation of the nose may be related to fetal position

Only minimal movement of the nares with breathing should be apparent

Consider a possible congenital abnormality if

Saddle-shaped nose with a low bridge and broad base Short small nose Large nose

Internal nose Inspect by shining a light inside

Gently tilt the nose tip up with your thumb

In infants, you may see a small amount of clear fluid discharged; crying

 Nasal patency must be determined at the time of birth

Obligatory nose breathers  Mouth closed, occlude one naris and then the other  Observe the respiratory pattern

With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris Consider: Septal deviation
Delivery trauma

Choanal atresia

Infant Sinuses
Maxillary and ethmod sinuses are small during infancy Few problems arise in these areas Examination is generally unnecessary

Infant Mouth Exam

Crying provides an opportunity to examine the mouth Avoid depressing the tongue
Stimulates a strong reflex protrusion Makes visualization of the mouth difficult

 Well formed with no cleft Buccal mucosa

Pink and moist No lesions

NOTE: Secretions that accumulate in the newborns mouth may indicate esophageal atresia

 Scrape any white patches with a tongue blade

Nonadherent
milk deposits

Adherent
candidiasis (thrush)

Drooling Normal from 6 weeks to 6 months Consider a neurologic disorder if it persists >12 months

Gums Should be endentulous

smooth with a serrated edge of tissue along the buccal margins

Teeth Count deciduous teeth Note any unusual sequence of eruption

Tongue fits well in the floor of the mouth protrudes beyond the alveolar ridge
If not, possible feeding difficulties

Frenulum
Usually attaches midway between the ventral surface of the tongue and its tip

 Insert your finger into the infants mouth

Fingerpad to the roof of the mouth

Evaluate the infants suck Palpate the hard and soft palates Stimulate a gag reflex by touching the tonsillar pillars

Normally
Should have a strong suck
Tongue pushing vigorously upward against the finger

Palatal arch should be dome shaped Neither hard nor soft palate should have palpable clefts Soft palate should rise symmetrically when the infant cries

Note in records if
Narrow, flat palate roof OR High, arched palate
affect the tongues placement feeding and speech problems *Associated with congenital anomolies

Child ENT Exam

Modifying Your Instruments

Oto/ophthalmoscope
Decorative covers

http://quickmedical.com /pediapals/products

 Postpone until the end

often resist otoscopic and oral exams

Be prepared to use restraint if encouraging the child fails

Ask parent to restrain the child

Restraining a Child Oral Exam

Seated in the parents lap, back to the parent and legs between the adults legs Parent can reach around to restrain the childs arms with one arm and control the childs head with the other Can usually be accomplished without forcing
Force only makes them more angry

Restraining a Child - Otoscope

Face the child sideways with one arm placed around parents waist Parent holds the child firmly against his/her trunk
One arm restrains the head One arm restrains the body

Doctor further stabilizes the childs head while inserting the otoscope

Restraining a Child - Supine

If the child actively resists Place child supine on the exam table Parent holds arms extended above the head and assists in restraining the head Doctor lies across the childs trunk and stabilizes the childs head Third person may need to hold the childs legs

Remember
Children of any age who are not too big to sit on a parents lap are better examined there than in a prone or supine position on the examining table.

Child Ear Exam

Otoscopic exam Pull auricle either down and back OR up and back
gain best view of the tympanic membrane

As the child grows, the shape of the auditory canal changes to the S-shaped curve of the adult.

 If the child is crying or has recently cried vigorously

Dilation of blood vessels in the tympanic membrane can cause redness red reflex

Cannot assume that redness of the membrane alone is a middle ear infection

Pneumatic Otoscope needed to differentiate

Crying Infection Red Moveable Red No mobility
*see common conditions at the end of this ENT section

Tympanometry
Accurate way to identify middle ear effusion
Ear piece must be sealed in the canal to provide accurate reading Wax, ruptured membrane, tubes

Toddlers Hearing
Observe response to a whispered voice and various noise makers
Rattle, bell, tissue paper Outside of the childs vision

As they get older, ask child to perform tasks in a soft voice

May want to have a parent do it Avoid visual cues

Use words that have meaning for them

Big Bird, Mickey Mouse, Barney

Childs Hearing
Weber, Rinne, and Schwabach tests Used only when a child understands directions and can cooperate with the examiner
Usually 3-4 years of age

Refer for audiometric screenings

Nose Exam
Inspect internal nose Usually adequate to tilt the nose tip upward
Largest otoscopic speculum may be used
Visualization of larger area

Adenoidal or Allergic Salute

Children often wipe their noses with an upward sweep of the palm of the hand
If repeated often enough, causes a crease

Transverse crease at the juncture between the cartilage and the bone of the nose

Sinuses Child
Maxilary sinuses should be palpated Few sinus problems occur since the sinuses are still developing
Wide variation however Do not rule out sinusitis simply on the basis of age

Child Mouth Exam

Getting cooperation Let the child hold and manipulate the tongue blade and light
Reduce fear of the procedure

Start by asking to see their teeth

Usually not threatening

 Ask child to protrude the tongue and say ah

Tongue blade is often unnecessary

Ask the child to pant like a puppy

Raises the palate

If child refuses to open mouth

Insert a tongue blade through the lips to the back molars Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue This should stimulate the gag reflex
Gives you a brief view of the mouth and oropharynx

Inspection
Highly arched palate
Children who are chronic mouth breathers

Why are they breathing through their mouth?

 Flattened edges on the teeth

Bruxism
Unconscious grinding of the teeth

Why are they grinding?

 Baby bottle syndrome

Multiple brown areas (caries) on upper and lower incisors d/t bedtime bottle of juice/milk

 Black or grey colored teeth

Pulp decay Oral iron therapy

Mottled or pitted teeth

Tetracycline treatment during tooth development Enamel dysplasia

Tonsils Should blend with the color of the pharynx Gradually enlarge to their peak size between 2 - 6 years
should retain an unobstructed passage

Graded to describe their size

Grading Tonsils
1+ 2+ -visible -halfway between tonsillar pillars and the uvula -nearly touching the uvula -touching each other

3+ 4+

Common Abnormalities

Choanal Atresia
Congenital nasal obstruction of the posterior nares
Junction between nasal cavity and nasopharynx

Newborns may experience respiratory distress

Obligatory nose breathers
Copyright 2006 University of Washington.

*Will breathe when crying

Suckling Callus
Newborns upper lips (other body parts)
First few weeks

Plaques or crusts

Natal Teeth
Teeth or tooth buds in a newborn If loose, potential for aspiration
May be removed

Retention Cysts
aka Epstein Pearls

Appear along the buccal margin Pearl-like retention cysts Disappear in 1-2 months

Macroglossia
Abnormally large tongue

Associated with congenital anomalies

Congenital hypothyroidism Down Syndrome

Short Frenulum

Associated with Feeding problems Speech difficulties

Cleft Lip and Palate

Fissure in the upper lip and/or palate
Congenital malformation

Complete cleft
Extends through the lip and hard and soft palates to the nasal cavity

Partial Cleft
Any of the tissues

Long term issues:

feeding problems chronic otitis media hearing loss speech difficulties improper tooth development and alignment

Otitis Externa (swimmers ear)

Infection of the auditory canal

trauma or moist environment

favor bacterial or fungal growth

 Initial Symptoms Itching in the ear canal Pain Intense with movement of pinna Chewing Discharge Watery, then purulent & thick mixed with pus and epithelial cells Musty, foul-smelling Hearing Conductive loss caused by exudate and swelling of ear canal Inspection Canal is red, edematous; tympanic membrane obscured

Bacterial Otitis Media

Infection of the middle ear
Often follows or accompanies an upper respiratory tract infection

Most common infection in childhood

 Initial Symptoms Fever, feeling of blockage, tugging earlobe, anorexia, irritability, dizziness, vomiting & diarrhea Pain Deep-seated earache Discharge Only if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling Hearing Conductive loss as middle ear fills with pus Inspection Tympanic membrane may be red, thickened, bulging; full, limited, or no movement to +/- pressure

Otitis Media with Effusion

Inflammation of the middle ear resulting in the collection of liquid (effusion)
Serous, mucoid, or purulent

Causes:
Allergies Enlarged lymph tissue (nasopharynx) Obstructed or dysfunctional eustachian tube

Once the obstruction occurs middle ear absorbs the air, creating a vacuum mucosa secretes a transudate into the middle ear Average duration: 23 days

 Initial Symptoms Sticking or cracking sound on yawning or swallowing; no signs of acute infection Pain Uncommon; feeling of fullness Discharge uncommon Hearing Conductive loss as middle ear fills with fluid Inspection Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles

Sinusitis
Infection of or more paranasal sinuses
May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose Blockage of the sinus meatus prevents drainage

Symptoms:
Fever, headache, local tenderness, and pain

Signs:
May be swelling of the skin overlying the involved sinus and copious nasal discharge

 Children may alternatively suffer from:

upper respiratory symptoms nasal discharge low-grade fever daytime cough malodorous breath cervical adenopathy intermittent painless morning eye swelling NO facial pain or headache

Tonsillitis
Inflammation or infection of the tonsils
Frequently caused by streptococci

Symptoms:
Sore throat, referred pain to the ears, dysphagia, fever, fetid breath, and malaise

Signs:
Tonsils appear red and swollen; purulent exudate yellow follicles are associated with streptococcal infection Anterior cervical lymph nodes enlarged

Peritonsillar Abscess
Infection of the tissue between the tonsil and pharynx
*Complication of tonsillitis

Symptoms:
Dyphagia, drooling, severe sore throat with pain radiating to the ear, muffled voice, fever

Signs:
Tonsil, tonsillar pillar and adjacent soft palate become red and swollen Tonsil may appear pushed forward or backward, possibly displacing the uvula

Epiglottitis
Impending airway obstruction d/t acute inflammation of the epiglottis Though rare, it should always be considered!

Suspected with Sudden high fever Croupy cough Sore throat Drooling Apprehension Focus on breathing
Tripod position, neck extended

Caution!
Inserting tongue blade may be deadly!
may result in complete airway obstruction

Treat this as a medical emergency No one should examine the childs mouth until intubation equipment is available

Obstructive Sleep Apnea

Periodic cessation of breathing during sleep d/t airflow obstruction
Can be seen in children with excessively large tonsils Loud snoring, restless sleep Daytime sleepiness Developmental delay Morning headaches Frequent infection