EYE
Amblyopia
DEFINITION
A → in visual acuity in one or both eyes caused by blurred retinal images, which → failure of the visual cortex to develop properly.
Amblyopia has been called “lazy eye.”
ETIOLOGY
Strabismus.
Refractive errors.
Opacity in the visual path (eg, cataract, ptosis, eyelid hemangioma).
Strabismus is the most common cause of amblyopia.
DIAGNOSIS
Diagnosis is made by visual acuity testing.
TREATMENT
Removal of the pathology such as a cataract.
Prescription glasses to correct refractive errors.
Patching the good eye until the ambylopic eye has improved its vision.
Amblyopia is usually asymptomatic and can be detected only by screening examination.
Strabismus
DEFINITION
Deviation or misalignment of the eye (see Figure 18-1).
“To squint or to look obliquely.”
Strabismus can lead to vision loss (amblyopia).
Younger children are more susceptible to the development of amblyopia.
DIAGNOSIS
Corneal light reflex: The child looks directly into a light source and the doctor observes where the reflex lies in both eyes; if the light is off center in one pupil or asymmetric, then strabismus exists.
Alternative cover test: The child stares at an object in the distance and the doctor covers one of the child’s eyes; if there is movement of the uncovered eye once the other eye is covered, then strabismus exists.
For the best results, amblyopia should be treated by age 4.
TREATMENT
Prescription glasses may help if the strabismus is secondary to refraction.
Eye muscle surgery may be necessary.
Amblyopia can be reversed more rapidly in younger children.
Optic Neuritis
DEFINITION
Inflammation of the optic nerve.
Retrobulbar optic neuritis: Without ophthalmoscopically visible signs of disc inflammation.
Papillitis or intraocular optic neuritis: Ophthalmoscopically visible evidence of inflammation of the nerve head.
Neuroretinitis: Inflammation of both the retina and papilla.
A deviated eye is described as being turned “eso” (inward), “exo” (outward), “hypo” (downward), or “hyper” (upward).
FIGURE 18-1. Child with strabismus.
ETIOLOGY
Idiopathic.
Recent immunization or viral infection (measles, chickenpox, influenza).
Extension from an infection involving the teeth, sinuses, or meninges.
Side effect of treatment with vincristine or chloramphenicol.
Secondary to a toxin such as lead.
SIGNS AND SYMPTOMS
Loss of vision.
Pain with extraocular motion.
Pain to palpation of the globe.
Afferent papillary defect.
Bilateral in children (unilateral in adults).
COMPLICATIONS
Color deficits.
Motion perception deficits.
Brightness sense deficits.
TREATMENT
A trial of intravenous (IV) steroids may ↓ the length of time for symptoms but has no effect on the outcome.
In children, optic neuritis is rarely associated with multiple sclerosis.
Conjunctivitis
DEFINITION
Inflammation of the conjunctiva.
TYPES
Allergic
Immunoglobulin E (IgE)-mediated reaction caused by triggers such as pollen or dust.
Signs and symptoms: Include watery, itchy, red eyes with edema to the conjunctiva and lids.
Pruritus and chemosis are common.
Treatment: Includes removal of the trigger, cold compresses, and anti-histamines.
Adenovirus is the most common viral cause of conjunctivitis.
Viral
Adenovirus and coxsackievirus are typical causes.
Adenovirus: Pharyngoconjunctival fever—triad: pharyngitis, fever, and conjunctivitis.
Epidemic keratoconjunctivitis: Fulminant vision threatening condition with the involvement of cornea.
Signs and symptoms: Include watery, red eyes with preauricular lymph nodes.
Treatment: Includes supportive treatment with constant hand washing to prevent transmission.
Conjunctivitis with lymph nodes. Think: Viral etiology.
Bacterial
Three organisms: Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus.
Highly contagious, outbreaks can occur.
Signs and symptoms: Include a mucopurulent discharge, red eyes, and edema of the conjunctiva.
Treatment: Topical antibiotics (drops or ointment).
Episcleritis/Scleritis
DEFINITION
Inflammation of the episclera or sclera.
ETIOLOGY
High association with autoimmune diseases.
SIGNS AND SYMPTOMS
Eye pain.
Photophobia.
Erythema.
↓ visual acuity.
Perforation is associated only with scleritis.
Episcleritis/scleritis is usually unilateral.
TREATMENT
Topical steroids.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Immunosuppressive drugs in case of failure of steroids.
Surgery for thinning or perforated sclera
Blepharitis
DEFINITION
Inflammation of the eyelid margins.
ETIOLOGY
Staphylococcus aureus.
Staphylococcus epidermidis.
Seborrheic.
A combination of the above.
SIGNS AND SYMPTOMS
Burning.
Itching.
Erythema.
Scaling.
Ulceration of the lid margin.
TREATMENT
Daily eyelid cleansing to remove scales.
Topical antibiotics.
Dacryostenosis
A 4-month-old child presents with an exudative eye discharge and a painful, red lacrimal sac. Think: Dacrocystitis.
Dacrocystitis is the most common infection of the lacrimal system. It is often a complication of dacryocystocele. Excessive tearing, purulent eye discharge, and fever are the common symptoms. S aureus and streptococci are the common organisms. Most patients require admission for intravenous antibiotics. An incision and drainage may be needed in the presence of a lacrimal sac abscess.
DEFINITION
A congenital nasolacrimal duct obstruction.
Dacryostenosis is the most common disorder of the lacrimal system.
EPIDEMIOLOGY
Occurs in 5% of infants; appears a few weeks after birth.
ETIOLOGY
Failure of the epithelial cells of tear duct to come apart.
SIGNS AND SYMPTOMS
Chronic tearing.
Erythema occurs secondary to rubbing the tears.
COMPLICATIONS
Dacrocystitis—inflammation of the nasolacrimal sac; this must be treated with topical or systemic antibiotic and warm compresses.
TREATMENT
Digital massage of the lacrimal sac.
Eyelid cleansing.
Probing if still present after 1 year of age to rupture the membrane.
Most dacryostenosis will resolve by 8 months of age.
Chalazion
DEFINITION
Inflammation of a meibomian (tarsal) gland leading to the formation of a granuloma.
SIGNS AND SYMPTOMS
Firm nodule on the eyelid.
Nontender.
TREATMENT
Warm compresses.
Excision if necessary.
Most subside spontaneously over months.
Hordeolum
TYPES
External hordeolum, or stye, is an infection of the glands of Zeis or Moll.
Internal hordeolum is infection of the meibomian gland.
ETIOLOGY
S aureus.
SIGNS AND SYMPTOMS
Localized swelling
Tenderness
Erythema
TREATMENT
Warm compresses.
Topical antibiotics (eg, erythromycin).
Incision and drainage if there is no spontaneous rupture.
Orbital Cellulitis
DEFINITION
Inflammation of the orbital tissues behind the septum.
Orbital cellulitis is postseptal.
ETIOLOGY
Extension of a local infection including paranasal sinusitis, facial cellulitis, or dental abscess.
Trauma.
The most common organisms are H influenza, S aureus, and S pneumoniae.
Most common site: Medial orbital wall.
↑ incidence secondary to ↑ in methicillin-resistant S aureus (MRSA).
Orbital cellulitis is caused most commonly by ethmoid sinusitis.
Periorbital cellulitis is much more common than orbital cellulitis.
SIGNS AND SYMPTOMS
Proptosis, ophthalmoplegia, and ↓ vision differentiate it from preseptal cellulitis.
Painful extraocular motion.
Proptosis.
↓ vision.
Erythema.
Edema.
COMPLICATIONS
Loss of vision.
Meningitis.
Central nervous system (CNS) abscess.
TREATMENT
Orbital computed tomography (CT) scan.
Ophthalmology consultation.
Intravenous antibiotics, possible surgical drainage.
Periorbital Cellulitis
DEFINITION
Inflammation of the eyelids and periorbital tissue anterior to the septum.
Periorbital cellulitis is preseptal.
ETIOLOGY
Extension of local infections including upper respiratory infection (URI), sinusitis, facial cellulitis, or eyelid infection.
Trauma: Skin trauma is the most likely etiology.
SIGNS AND SYMPTOMS
Erythema.
Edema.
No pain with extraocular movements.
The most common organisms causing both preorbital and orbital cellulitis—
SHIP
S aureus
H influenzae
S Pneumoniae
COMPLICATIONS
Development of an orbital cellulitis.
TREATMENT
Oral or IV antibiotics (eg, ceftriaxone).
The most common cause of leukocoria is a cataract.
Corneal Ulcer
ETIOLOGY
Trauma (sand, contact lens, etc.) with secondary infection. Often preceded by a traumatic corneal abrasion.
Bacterial: Pseudomonas aeruginosa, Neisseria gonorrhoeae.
Fungal: Especially in contact lens users.
SIGNS AND SYMPTOMS
Corneal haze
Painful
Photophobia
Tearing
COMPLICATIONS
Perforation
Scarring
Blindness
DIAGNOSIS
Slit-lamp exam: Fluorescein staining reveals an epithelial defect.
Scraping of the cornea to identify infectious etiology.
Retinoblastoma gene: Mutation in the long arm of chromosome 13.
TREATMENT
Local antibiotics.
In some cases, systemic treatment may be required.
Retinoblastoma
The most common primary ocular malignancy in children.
Average age: 18 months (90% < 5 years).
Must evaluate for the presence of retinoblastoma in a child presenting with strabismus.
SIGNS AND SYMPTOMS
Leukocoria: White pupillary reflex is the most common presentation.
Strabismus is the second most common presentation.
Orbital inflammation.
Hyphema: Blood layering anterior to the iris.
May be bilateral (40%).
DIAGNOSIS
Direct visualization during eye exam.
Computed tomography (CT) or ultrasound (US) can help confirm and evaluate spread.
Retinoblastoma is the most common primary malignant intraocular tumor in children.
TREATMENT
Chemotherapy.
Laser photocoagulation.
Cryotherapy.
Enucleation for unresponsive tumors.
Referral for genetic counseling in parents with a family history of retinoblastoma.
Family members of a patient with retinoblastoma should be checked because it may be hereditary.
EAR
Otitis Media
DEFINITION
Inflammation of the middle ear.
EPIDEMIOLOGY
The incidence of otitis media is higher in:
Boys.
Children in day care.
Children exposed to secondhand smoke.
Non-breast-fed infants.
Immunocompromised children.
Children with craniofacial defects like cleft palate.
Children with a strong family history for otitis media.
The incidence of infection is higher in children because of their eustachian tube anatomy:
Horizontal
Short in length
↓ tone
ETIOLOGY
S pneumoniae
H influenzae
Moraxella catarrhalis
The most common overall complication of otitis media is hearing loss.
COMPLICATIONS
Hearing loss.
Perforation.
Mastoiditis.
Cholesteatoma: Saclike epithelial structures.
Facial nerve paralysis: The facial nerve may not be completely covered with bone in the middle ear; therefore, infection can spread to the nerve.
Labyrinthitis.
Abscess formation.
Tympanosclerosis: Scarring of the tympanic membrane.
Meningitis.
The most common intracranial complication of otitis media is meningitis.
Acute Otitis Media
Eustachian tube dysfunction is the most important factor.
SIGNS AND SYMPTOMS
Ear tugging
Ear pain
Fever
Malaise
Irritability
Hearing loss
Nausea and vomiting
Remember that younger children who are unable to communicate may have only nonspecific signs like nausea and vomiting with an acute illness such as acute otitis media.
DIAGNOSIS
Diagnosis is made with a pneumatic otoscope—the tympanic membrane will have ↓ mobility and will appear hyperemic and bulging with loss of landmarks.
Tympanocentesis should be used as an adjunct in patients who are < 8 weeks old, are immunocompromised, have a complication, or were treated with multiple courses of antibiotics without improvement; the fluid is sent for culture and sensitivity.
A red eardrum in a crying child is normal; the most specific sign of acute otitis media is ↓ mobility of the tympanic membrane.
TREATMENT
Typically, the first-line antibiotic is amoxicillin. High dose can be used for cases most likely to be resistant.
Antipyretics: Ibuprofen and/or acetaminophen.
Topical anesthetic eardrops (eg, benzocaine).
For healthy children > 2 yr old with milder case, watchful waiting for 24–48 hr is an option.
Pneumococcal vaccine has reduced the incidence of acute otitis media.
Recurrent Acute Otitis Media
DEFINITION
Three to four episodes of acute otitis media in 6 months or six episodes in a year.
TREATMENT
Prophylactic antibiotics.
Myringotomy and ventilating tubes should be considered.
Otitis Media with Effusion
SIGNS AND SYMPTOMS
Hearing loss
Dizziness
No fever
No ear pain
DIAGNOSIS
Pneumatic otoscope shows a retracted eardrum with loss of landmarks and air-fluid levels or bubbles.
TREATMENT
If asymptomatic, a child is observed for 3 months to see if effusion resolves.
If symptomatic after 3 months of observation, treatment includes antibiotics and possibly myringotomy and insertion of tympanostomy tubes.
Otitis Externa
A 4-year-old boy presents with what looks like herpetic vesicles in the ear canal and tympanic membrane. Think: Ramsay Hunt syndrome (facial paralysis + herpes zoster oticus). CN VIII involved = sensorineural hearing loss or vertigo.
It is due to herpetic involvement of the facial (geniculate), vestibulocochlear, or trigeminal ganglia which results in pain and vesicular eruptions about the auricle and external ear canal.
DEFINITION
Inflammation of the external auditory canal.
Occurs when trauma introduces bacteria into an area that is excessively wet or dry.
Otitis externa is known as “swimmer’s ear.”
ETIOLOGY
Bacterial: P aeruginosa, S aureus, Proteus mirabilis, Klebsiella pneumoniae.
Viral: Herpes.
Fungal: Candida.
SIGNS AND SYMPTOMS
Ear pain with movement of the pinna.
Pruritus of the ear canal.
Edema of the ear canal.
Otorrhea: Usually white in color.
Palpable lymph nodes: Peri- and preauricular.
Normal tympanic membrane.
COMPLICATIONS
Malignant otitis externa leads to hearing loss, vertigo, and facial nerve paralysis.
Temporary hearing loss secondary to swelling.
Necrotizing otitis externa:
Pseudomonas osteomyelitis in the temporal bone.
Risk factor: Diabetes, immunocompromised (Aspergillus fumigatus).
DIAGNOSIS
Diagnosis is made by otoscopic examination.
TREATMENT
Topical antibiotics and steroids to reduce edema (eg, Cortisporin suspension [hydrocortisone-polymyxin-neomycin-bacitracin]).
Malignant otitis externa is caused by P aeruginosa.
Mastoiditis
DEFINITION
Inflammation of the mastoid air cells in the temporal bone.
Most common pathogen: S pneumoniae.
ACUTE MASTOIDITIS
Mostly seen in children after/with an acute otitis media.
If resolution does not occur, may → acute mastoiditis with periosteitis, acute mastoid osteitis, or chronic mastoiditis.
Fever.
Pain behind the ear.
Erythema and tenderness over the mastoid area.
ACUTE MASTOIDITIS WITH PERIOSTEITIS
Includes the involvement of the periosteum.
Treatment: Includes myringotomy with ventilation tube placement and IV antibiotics.
ACUTE MASTOID OSTEITIS
Occurs when there is destruction of the mastoid cells and empyema is present.
The child will have a tender, swollen, red mastoid process with the ear displaced down and out.
Treatment: Includes IV antibiotics, and mastoidectomy may be necessary.
CHRONIC MASTOIDITIS
Involves treatment with antibiotics and possibly a mastoidectomy if osteitis is present.
COMPLICATIONS
Hearing loss.
Facial nerve palsy.
Subperiosteal abscess.
Cranial osteomyelitis.
Labyrinthitis.
Intracranial spread (meningitis, epidural or cerebellar abscess, subdural empyema).
Dural sinus thrombosis.
Tinnitus
DEFINITION
Ringing heard in the ear.
Commonly found in children who have middle ear disease or hearing loss.
Vertigo
DEFINITION
Dizziness with the feeling that one’s body is in motion.
Benign positional vertigo (BPV) will present with ataxia and horizontal nystagmus.
SIGNS AND SYMPTOMS
Difficulty walking straight or stumbling.
Spinning sensation.
ETIOLOGY
May occur secondary to the following conditions:
Otitis media
Labyrinthitis
Trauma
Cholesteatoma
BPV
Ménière disease
CNS disease
Ménière’s triad includes vertigo, tinnitus, and hearing loss.
TREATMENT
Address the underlying cause.
Ototoxic Drugs
See Table 18-1.
TABLE 18-1. Ototoxic Drugs
NOSE
Sinusitis
DEFINITION
Inflammation of the membranes covering the sinuses.
SINUS DEVELOPMENT
Ethmoid sinus at birth.
Maxillary sinus at birth.
Sphenoid sinus 5 yr.
Frontal sinus 7 yr.
ETIOLOGY
A child may be at ↑ risk for sinusitis if there is an obstruction or cilia impairment.
S pneumoniae.
H influenzae.
M catarrhalis.
Rhinovirus is the most common viral pathogen.
Bacterial sinusitis is usually preceded by a viral upper respiratory infection.
PREDISPOSITIONS
Occlusion of the sinus ostium.
Cystic fibrosis.
Allergy/asthma.
Cyanotic congenital heart disease.
Dental infections.
SIGNS AND SYMPTOMS
Headache.
Sinus tenderness to palpation.
Persistent nasal discharge (purulent) > 10 days’ duration.
Halitosis.
Cough secondary to postnasal drip.
At birth, only the maxillary and ethmoid sinuses are present.
COMPLICATIONS
Cellulitis.
Abscess formation.
Osteomyelitis.
Meningitis may occur through spread of the ethmoid, sphenoid, or frontal sinuses.
DIAGNOSIS
Diagnosis is made clinically.
If a test is required, a CT scan is preferred over plain films, which are not as sensitive.
The most common location for epistaxis in children is from the anterior nasal septum because Kiesselbach’s plexus is located there.
TREATMENT
Antibiotics (eg, amoxicllin) for 14–21 days.
If no improvement, a macrolide or amoxicillin-clavulanate may be used.
Decongestants.
Nasal saline drops/mist.
Epistaxis
DEFINITION
Nosebleed.
Common age: 2–10 yr.
Unusual during infancy. Must consider coagulopathy or nasal organic causes (eg, choanal atresia).
Blood in vomit may be present if a child has swallowed blood from an epistaxis; always ask about epistaxis if a patient presents with hematemesis.
ETIOLOGY
The most common location for a nosebleed in children is the anterior septum.
The most common cause is trauma secondary to a fingernail.
Other causes may include foreign bodies, inflammation, or dry air.
If a child has recurrent, severe epistaxis, other, more serious causes should be looked into such as thrombocytopenia, clotting deficiencies, and angiofibromas.
Allergic rhinitis is the most common atopic disease.
SIGNS AND SYMPTOMS
Bleeding may occur from one or both nostrils.
TREATMENT
Compression for 10 min with head tilted forward.
Cold compresses to the nose.
Topical vasoconstrictors may allow visualization of the bleeding site.
Cauterization using silver nitrite.
Packing the nose.
The “allergic salute,” seen in allergic rhinitis—horizontal crease on the nose that occurs from constant rubbing.
Allergic Rhinitis
DEFINITION
An IgE-mediated response to an allergen causing an inflammation of the nasal mucous membranes.
SIGNS AND SYMPTOMS
Generally don’t develop until 2–3 yr of age.
Sneezing.
Watery nasal discharge.
Red, watery eyes.
Itchy ears, eyes, nose, and throat.
Nasal obstruction secondary to edema.
Children with allergic rhinitis may exhibit rabbit-like nose wrinkling because of pruritus.
DIAGNOSIS
Characteristic findings on physical exam, including:
Boggy, bluish mucous membranes of the nose.
Dark circles under the lower eyelids (“allergic shiners”).
Allergic salute.
Rabbit nose.
A smear of nasal secretions will show a high number of eosinophils.
Allergic rhinitis in children may be a precursor for the development of asthma.
TREATMENT
Avoid triggers
Antihistamines
Decongestants
Cromolyn nasal solution
Topical steroids
Choanal Atresia
DEFINITION
A separation of the nose and pharynx by a membrane or bone (90%); may be unilateral or bilateral.
The most common congenital anomaly of the nose.
Fifty percent of children with choanal atresia have other associated congenital anomalies—
CHARGE syndrome
Coloboma
Heart disease
Atresia choanae
Retarded growth
Genital anomalies
Ear involvement
SIGNS AND SYMPTOMS
Each child’s presentation will differ depending on his or her ability to mouth breathe.
Respiratory distress that improves as the child cries because the mouth is open.
Cyanosis, especially when the child is feeding or sucking. Crying relieves the cyanosis.
DIAGNOSIS
Inability to pass a catheter through one or both nostrils.
CT will show the extent of the atresia.
TREATMENT
Prompt placement of an oral airway, maintaining the mouth in an open position or intubation.
The ultimate treatment is surgical correction.
Maintaining an open airway by an orogastric tube or large nipple.
Tracheostomy or intubation may be required depending on the severity.
Restenosis of corrected choanal atresia is common.