Lesson 13: Common ENT Problems

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Contents

INTRODUCTION

Welcome to this Unit on common Ear, Nose and Throat (ENT) problems. As you may recall, in Unit 12 you learnt that some of the acute respiratory infections such as acute otitis media would be discussed in this Unit. Remember that there are many diseases of the ENT, but in this unit we shall limit ourselves to the common ones which affect children. These are



Objectives

By the end of this unit you should be able to:

  • List the common conditions that affect the ear, nose and throat;
  • Describe the causes of common ENT conditions;
  • Describe the presentation of each of the common ENT conditions;
  • Manage appropriately the common ENT conditions;
  • Prevent each of the common ENT conditions.


13.1: MANAGEMENT OF THE CHILD WITH AN EAR PROBLEM

In this section, we shall discuss how to assess, classify and treat a child with an ear infection. How well do you remember the anatomy of the ear? Start by reviewing the following diagram of the ear in Figure 13.1.


Figure 13.1: Anatomy of the ear

As you well know, the ear is part of the respiratory tract. From figure 13.1 you can see that it is connected to the nose and throat by the Eustachian tube. That is why an infection that starts in the throat can easily spread to the middle ear and cause an ear infection..

What is an acute ear infection?



Definition

An acute ear infection is an infection of the middle ear which lasts for 14 days or less. A chronic ear infection lasts for more than 14 days. Infection in the middle ear is also known as otitis media.



What are the causes of ear infection?

The ears can become infected when there is an infection of the nose or throat. The same microorganisms that cause infection in the nose or throat are also the ones that cause infection of the ear. The bacteria most commonly responsible are Streptococcus pneumoniae and Haemophilus influenzae.


Signs and symptoms of ear problems:

A child with an ear problem has some or all of the following signs and symptoms:

The dangers of ear infection: Infections of the ear rarely cause death. However, they can cause many days of sickness in children. If an ear infection is not identified and treated early, it can put the child in danger of the following:

To diagnose an ear infection, you must assess the child correctly and follow the steps below:

STEP ONE: ASSESS THE CHILD

Assess the child by asking the mother the following questions:

Pus draining from the ear is a sign of infection even if the child no longer has pain.


b. Look and Feel

c. Examine the ear:

To examine the ear, the patient is placed correctly on the mother’s lap. The child is secured firmly by the mother holding the child’s hands with one hand and his head with her other hand. See Figure 13.2a.

If you have an assistant, he/she can help you to hold the child’s head. You should sit at the side of the patient with your eyes at the same level as the child’s ears (the organ to be examined). The distance is usually 30cm from the patients head. The hand holding the otoscope is placed on the child’s head. Should the child move the head, the otoscope moves with the head, thus avoiding perforating an inflamed tympanic membrane.


Figure 13.2 (a) Mother holding a child for otoscopy (b) A healthworker examining the ear

ASSESS
ASK
  • Does the child have ear pain?
  • Does the child have pus draining from the ear?
  • If so, for how long?


LOOK and FEEL
  • Look for pus draining from the ear or for a red, immobile ear drum
  • Feel for tender swelling behind the ear.


STEP TWO: CLASSIFY THE ILLNESS AND TREAT IT:

You need to classify a child with an ear problem as having one of the following:

Let us now discuss how you should manage each of these conditions:

1) Acute ear infection:

A child who has pus draining from the ear for less than two weeks, ear pain, or a red immobile ear drum (seen by otoscopy) is classified as having an Acute Ear Infection, commonly known as acute otitis media. If you find a foreign object lodged in the ear, refer the child to a hospital for removal of the object.

Management of a child with acute ear infection.

Acute ear infection is managed by:

The child with acute otitis media may have mild hearing loss that will probably last for some time after healing. If the child is in school, the teacher should be informed about this temporary hearing loss.

Once the infection has healed, you should ask the patient to come back in about 2-3 months. At this visit, you should do a hearing test. If there is any loss of hearing, you should refer the patient to a doctor.


2. Mastoiditis

This is an infection of the air cavities in the mastoid bone. Mastoiditis results from the spread of the infection from the middle ear. If the patient feels pain when you press or tap on the mastoid bone, then you should assume that the infection has spread to the mastoid cavities. Therefore, a child who has tender swelling behind the ear (in infants, the swelling may be above the ear) is classified as having mastoiditis.

Management of a child with mastoiditis in your health facility. A child with mastoiditis needs antibiotic treatment and may require surgery. The child is URGENTLY referred to the hospital after a first dose of antibiotics (see Table 13.1.)


Table 13.1: Oral Antibiotics for Ear Infections


Alternatively: You can use CEFACLOR in a dose of 30 mg per kg per day

3. Chronic Ear Infection: If a child has pus draining from the ear for more than two weeks, you should classify them as having a Chronic Ear Infection, also called chronic otitis media. You manage a child with a chronic ear infection by:

a) Repeatedly instructing the child (if old enough to understand) and the mother or caretaker to:



Key points

REMEMBER to follow up all patients with any ear infection. Adequate treatment of the infection can prevent permanent deafness



b)Instructing the mother on how to carry out dry mopping. Using cotton-tipped match sticks, absorbent paper-strips or a clean cloth rolled like a pin you instruct the mother or other family member how to mop as much pus as one can see. It is important to use good light. Ensure that the cotton-tip is not allowed to enter too deeply. Show the mother or caretaker how mopping is done and offer them a chance to practise it while you observe. Ask the mother to repeat dry-mopping three times daily until the ear is dry.

c)Gentle syringing using sterile, lukewarm saline solution in a 5cc syringe. This should only be done at the clinic. Remember to syringe gently – you are not removing impacted wax! Ensure that the child’s ear is completely dry before they leave the health facility. Also before the mother leaves the clinic, you should check that she has learnt how to mop the ear correctly.

d)Regular controls. See the patient once a week or every second week until the ear is dry.



Key points

  • The most important and effective treatment for chronic otitis media is to keep the ear dry by mopping.
  • The microorganisms that cause an infection of the ear are often different after two weeks from those that caused acute ear infections. Thus, antibiotics are usually not effective against a chronic infection


The chart below summarizes the management of a child with an ear infection:

Table 13.2: Classifying the Illness

SIGNS Tender swelling behind the ear Pus draining from the ear LESS than two weeks, or Red, immobile ear drum (by otoscopy) Pus draining from the ear two weeks or MORE
CLASSIFY AS: MASTOIDITIS ACUTE EAR INFECTION CHRONIC EAR INFECTION
TREATMENT
  • Refer URGENTLY to hospital
  • Give first dose of an antibiotic
  • Treat fever, if present
  • Give paracetamol for pain
  • Give an oral antibiotic
  • Dry the ear by mopping
  • Reassess in five days
  • Treat fever, if present
  • Give paracetamol for pain
  • Dry the ear by mopping
  • Treat fever, if present
  • Give paracetamol for pain

13.2: MANAGEMENT OF A CHILD WITH A SORE THROAT

Sorethroat is a very common infection among children. Often this is not a serious problem. The patient may have a viral infection of the upper respiratory tract (a cold), and the throat may be irritated. If this is the case, you should simply treat the patient for the symptoms and the child will soon get better.


However, sometimes a sore throat can be a warning of a more serious problem. For example:

A SORE THROAT MAY BE A WARNING OF A SERIOUS DISEASE

What causes a sore throat?

The most common causes of a sore throat are:

Signs and symptoms of different kinds of sore throats

It is very difficult clinically to tell the difference between a viral and bacterial throat infection. In this section we will give some helpful hints about recognizing bacterial and viral throat infections.

Viral Throat Infections:

A sore throat caused by a viral infection is usually part of a general upper respiratory tract infection. This means you would expect to find some of the other symptoms of a “cold” such as a runny nose, cough, hoarse voice, or earache. Of course, you will not find all these symptoms in every patient with an upper respiratory tract infection.

Signs you should look for include:


Fig. 13.3: Anatomy of the Throat

Bacterial Throat Infections: Often the sore throat is the only symptom. The patient experiences one or more of the following symptoms:



Activity

1

A mother has brought her 5-year-old son Peter who complains of a sore throat. What would you ask Peter and his mother? …………………………………………………………………………………………………………………………………………

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I hope your list contained the following important questions which you should ask:


Fig. 13.4: Bacterial or Viral?

How to examine a patient with a sore throat:

Children often have quite large tonsils until the age of about 5 years old. Thereafter, the tonsils get smaller. If you see a young child with large tonsils but no inflammation or any other signs of illness, then there is probably nothing wrong with the child’s tonsils. If the neck glands are also swollen, then you should refer the child to a doctor.

After you have taken the history and examined the patient, you will be ready to make the diagnosis.



Key points

It is often impossible to tell the difference between viral and bacterial throat infections. So for management purposes all sore throats in children should be diagnosed as bacterial throat infections



Diagnosing A Sore Throat



Activity

2

Remember that there are two reasons why you should try to tell whether a sore throat has been caused by a virus or by bacteria. What are these two reasons?

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Now compare your answers with mine.

Firstly, you can treat a bacterial infection with antibiotics. Viral illnesses do not respond to antibiotics.

Secondly, streptococcal throat infections may cause rheumatic fever. Rheumatic fever can cause damage to the heart valves. This is called rheumatic heart disease. It is important to treat all cases of streptococcal throat infections with penicillin. Once you have made the diagnosis, you need to decide how to manage the patient.

Managing a Patient with Sore Throat:

For any child with sore throat (viral or bacterial):



Key points

Children are most likely to get rheumatic fever at ages 3-15 years. It is better not to take a chance so always give an antibiotic for a serious throat infection



Complications of Throat Infections: There are two important complications of throat infections that you should be able to recognize: peritonsillar abscess and epiglottitis.


1) Peritonsillar abscess (Quinsy): Peri means around, so a peritonsillar abscess is an abscess around or near the tonsils. A large swelling forms around the tonsils. The patient usually cannot open the mouth very widely. You may see pus on the very swollen area around the tonsils. Give the patient procaine penicillin and REFER URGENTLY to a doctor. The danger is that the swelling may grow so large that the patient will have difficulty in breathing.

2) Epiglottitis: Epiglottitis is the infection of the epiglottis, the flap of tissue that covers the larynx when we swallow food. If the epiglottis is swollen it can seen at the back of the throat, looking like a small red marble.

Epiglottitis is very dangerous, because the swollen epiglottis can block the airway and cause the patient extreme difficulty in breathing. It can also cause death.

A patient with epiglottis looks very ill, has a high fever and may have saliva dripping out at the side of his/her mouth. As the patient breathes, he/she produces a stridor as if he has croup.



Key points

If you suspect that the patient has epiglottitis, do not make the situation worse by looking repeatedly at his throat. This might cause more swelling. Give the patient chloramphenical and REFER URGENTLY to hospital



3) Other Complications of throat infection include:

13.3: MANAGEMENT OF A CHILD WITH NASAL DISCHARGE OR A BLOCKED NOSE

A runny or blocked nose is a common complaint in any primary health care clinic. It is also the most obvious symptom of an upper respiratory tract infection or allergy. A clear nasal discharge is almost never a serious problem. It can, however, develop into sinusitis, which needs to be taken seriously.

A nasal discharge occurs when the mucous membranes of the nose or the sinuses produce large amounts of mucus. This mucus is discharged through the nose. The discharge is usually clear but can become yellow-green if there is a bacterial infection.

Nasal discharge is also called rhinorrhoea. It occurs when an infected mucous membrane of the nose or the sinuses produce large amounts of mucus.

Inflammation of the nose is called rhinitis and can be caused by infection or allergy. So, rhinorrhoea is a symptom of rhinitis.

The infection of the sinuses is called sinusitis and needs to be taken seriously. In both rhinitis and sinusitis, the mucus is discharged through the nose. The discharge is usually clear, but can become yellow green if there is bacterial infection.

Allergies can give a patient quite a lot of discomfort and may need treatment.

Common Causes of rhinitis

Before you read on do the following activity. It should take you less than 5 minutes to complete.



Activity

3

List some of the common causes of rhinitis

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Well done! I believe your answer included the following common causes of rhinitis:

A foreign body stuck in the nose may resemble rhinitis by causing a nasal discharge. Although it is unusual, it however does happen sometimes especially with young children. It is characterized by a nasal discharge of one side of the nose only.

You now know the most common causes of rhinitis. Next we will describe how these conditions present and how to manage them.

Signs, symptoms and management of rhinitis: Remember that rhinitis is an inflammation of the nose and causes nasal discharge.

Symptoms of rhinitis include:

The symptoms may vary slightly depending on whether the cause is viral or bacterial. Basically, the above are the signs and symptoms of a cold. However, remember that you will not find all these signs and symptoms in each case.

Management:

1) Supportive treatment



Key points

When you are examining a patient with a purulent nasal discharge, you should check to see whether they also have sinusitis. Sinusitis can develop serious consequences and should be treated with antibiotics.



13.4 MANAGEMENT OF A CHILD WITH SINUSITIS

What is sinusitis?


Definition

Sinuses are empty spaces in the skull. They are found behind the nose, behind the cheeks, and above the eyes. See figure 13.5.



Figure 13.5: Sinuses

The sinuses are lined with mucous membranes. Normally the sinuses produce a small amount of mucus that drains into the nose. A bacterial infection of the upper respiratory tract can spread to the sinuses. When this happens, the mucous membranes in the sinuses become inflammed and produce large amounts of mucus. We call this sinusitis.

The outlet of the sinus may become blocked. This causes a build-up of mucus and pus in the sinus.

Symptoms of sinusitis include:

Signs of sinusitis include:

Management of Sinusitis:

The aims of treating sinusitis are:

These aims are achieved through:

Complications of sinusitis: If sinusitis does not clear up, it can lead to some dangerous complications. These complications result from the spread of the infection to the neighbouring tissues and include:

Some of these complications may require surgery. A complication must be suspected if a patient with sinusitis develops any of these symptoms:

Give the patient an injection of benzyl penicillin, and REFER him to a doctor immediately.

13.5. MANAGING A CHILD WITH ALLERGIC RHINITIS OR HAY FEVER:

What is allergic rhinitis or hay fever?

Allergic rhinitis or hay fever is inflammation of the mucous membrane of the nose caused by an abnormal reaction to certain substances called allergens. When some people come into contact with these substances (allergens) they react by sneezing, developing a running nose and watering of the eyes.

Causes of allergic rhinitis

These include the following

Signs and Symptoms of allergic rhinitis

The symptoms and signs of allergic rhinitis are:




Activity

4

How do you manage a patient with severe rhinitis? _____________________________________________________________________

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When patients suffer from chronic allergies and the accompanying rhinitis, there are a number of things you can suggest that can make them more comfortable. Above all, be supportive and explain what the condition is all about.

You should advise patients to

Preparations like chloropheniramine (piriton) have antihistaminic and decongestant effects. These preparations reduce sneezing and rhinorrhoea in mild intermittent allergic rhinitis. Pseudoephedrine, a vasoconstrictor may be used to treat nasal congestion if it is given for less than 5 days, once a month. Patients with severe persistent symptoms are referred to the doctor.

Very bad hay fever can make life very uncomfortable for a patient. Bad, chronic cases of allergic rhinitis should be referred to a doctor. The doctor may do tests, but quite often they are unnecessary. Medicine for allergic rhinitis is quite expensive and it is best if prescribed by a specialist.

Well, you have come to the end of this unit. Let us quickly review what it was all about.

SUMMARY

In this unit you have learned about common ENT conditions that affect children. These were ear problems, sore throat, nasal discharge and blocked nose, sinusitis and rhinitis. For each diseases you have learnt how it presents, how to diagnose and treat it, and how it can be prevented. Remember that viral and bacterial rhinitis, sinusitis and allergies can all cause nasal discharge. Foreign bodies stuck in the nose can also cause a nasal discharge. We hope you are now able to recognise and manage these problems.

Now go back to the objectives at the beginning of this unit and review them again. Have you achieved them all? If there is any you are not sure about, please review the relevant section again. If you feel confident that you have achieved them all, take a rest and then complete the attached Tutor Marked Assignment.



Assignment

DIRECTORATE OF LEARNING SYSTEMS DISTANCE EDUCATION PROGRAMME

Student Number: _________________________________

Name:__________________________________________

Address_________________________________________

________________________________________________



CHILD HEALTH COURSE

UNIT 13: ASSIGNMENT

Common Ear, Nose and Throat Conditions


Instructions: Answer all the Questions in this Assignment.

1. Lucia who has been brought to your clinic is 7 years old and has a hearing impairment. Whenever she goes to swim or puts her head in water, her ears get discharge. She has been seen in your clinic where they cleaned her ears and put in some drops. On examination, you find she has pus in both ears.

a) What do you think is the problem with Lucia?

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b) How will you manage her case?

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2. Bosco is 4 years old. His ear has been running for quite some time and he complains of pain and buzzing in the right ear. He has no upper respiratory problems and he seldom has a running nose.

a. What else would you ask the mother?

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b. What would you examine the child?

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c. What do you think is the problem with Bosco?

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d. How would you manage the case?

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3. Salome is 6 years old and has had a discharging ear for some time. For the last 3 days has had a severe headache, fever and is rather sleepy.

a. What else would you ask Salome?

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b. How would you examine her?

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c. What do you think is her problem?

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d. How would you manage the case?

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4. A 5 year old is brought to your clinic by his older sister. The child has a nose bleed, and his shirt is covered with blood. a) What measures would you take to stop the bleeding?

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b) If that does not work what would you do next?

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5. A mother brings her 30 month old child to your clinic because she has had a sore throat and fever for 3 days. The child has refused to eat and has vomited a few times. When you examine her, you find she has a fever of 40 C. Her eyes are clear, her ear drums look normal, the throat is very red and the tonsils are swollen with pus on their surface. The neck is not stiff, but there are big tender lymph glands near the angles of the jaw. The mother tells you that this is the third time this year that the child has had this problem.

a) What do you think is wrong with the child?

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b) How would you manage this child?

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Congratulations! You have now come to the end of this unit.


Once you complete this assignment, post or bring it in person to AMREF Training Centre. We shall mark it and return it to you with comments.

Our address is as follows:

Directorate of Learning Systems

AMREF Headquarters

P O Box 27691-00506

Nairobi, Kenya

Email: amreftraining@amrefhq.org

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