Pediatric Primary Care (46 page)

D.  Clinical manifestations.

1.  Double, blurred, or decreased vision.

2.  Eye pain or pain in surrounding area.

3.  Tearing.

E.  Physical findings.

1.  Unable to open eye.

2.  Tearing.

3.  Corneal redness.

F.  Diagnostic tests.

1.  X-rays if orbital fracture or nasal fracture is suspected.

G.  Differential diagnosis.

1.  Laceration to ocular globe or orbit.

2.  Perforation to ocular globe or orbit.

3.  Orbital wall fracture.

H.  Treatment.

1.  Referral to ophthalmologist.

I.  Follow up.

1.  Per ophthalmologist.

J.  Complications.

1.  Extensive ocular injury.

2.  Blindness.

3.  Infection.

K.  Education.

1.  Prevention: use of goggles or glasses when spraying.

2.  Do not instill any medication.

3.  Immediate referral to ophthalmologist.

XV. PRESEPTAL CELLULITIS (PERIORBITAL CELLULITIS)

A.  Definition.

Inflammation and infection of eyelids and periorbital tissue.

B.  Etiology.

1.  Staphylococcal aureus.

2.  Streptococcus pneumoniae.

3.  Streptococcus pyogenes.

4.  Haemophilus influenzae type B.

C.  Occurrence.

1.  Common in young children secondary to trauma, infected wound or insect bite, severe sinusitis, dental abscess.

D.  Clinical manifestations.

1.  Red, painful swelling around eye.

2.  May or may not have fever.

3.  History of local trauma to area, insect bite, sinusitis, dental abscess.

E.  Physical findings.

1.  Erythematous, edematous, tender, warm area around eye.

2.  Regional adenopathy.

F.  Diagnostic tests.

1.  CBC (will indicate leukocytosis in severe cases).

2.  Blood culture.

3.  Head CT scan (helps delineate extent of disease).

G.  Differential diagnosis.

1.  Severe contact dermatitis.

2.  Severe conjunctivitis.

3.  Ophthalmic malignancy or tumor (retinoblastoma, rhabdomyosarcoma, neuroblastoma).

H.  Treatment.

1.  Uncomplicated and older than 2 months of age: ceftriaxone then oral antibiotics, oral antiinfective (amoxicillin-clavulanate, cephalexin, or erythromycin).

2.  Complicated/extensive or younger than 2 months of age: requires hospitalization and intravenous antibiotics.

I.  Follow up.

1.  Daily follow up is necessary to monitor for rapid improvement.

J.  Complications.

1.  Spread of infection with possible abscess formation.

2.  Loss of vision.

K.  Education.

1.  Frequent handwashing.

2.  Teach prevention (avoid trauma, use insect repellent, cleanse wounds).

BIBLIOGRAPHY

American Academy of Ophthalmology.
Preferred Practice Patterns.
http://one.aao.org/CE/PracticeGuidelines/PPP.aspx
. Accessed September 8, 2010.

Ehlers JP, Shah CP, eds.
The Willis Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye
Disease.
5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.

Hunter A. Problems related to the head, eyes, ears, nose, throat or mouth. In: Barnes K, ed.
Paediatrics–A
Clinical Guide for Nurse Practitioner
s. Philadelphia, PA: Butterworth-Heinemann; 2003.

Kliegman RM, Behrman RE, Jenson HB, et al.
Nelson Textbook of Pediatrics.
18th ed. Philadelphia, PA: Saunders; 2007.

Nelson LB, Olitsky SE, eds.
Harley's Pediatric Ophthalmology.
5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

Trobe JD.
The Physician's Guide to Eye Care.
3rd ed. San Francisco, CA: American Academy of Ophthalmology; 2006.

CHAPTER 22

Ear Disorders

Jane A. Fox

I.  FOREIGN BODY

A.  Etiology.

1.  Usually results from young children or their companions placing stones, erasers, vegetables (beans, peas, string beans), paper, jellybeans, toy parts, or small alkaline batteries in their ear(s).

2.  Insects may become lodged in ear.

3.  Chronic irritation or inflammation (e.g., otitis externa may result from putting objects in ear).

B.  Occurrence.

1.  Most common between 2 and 4 years of age.

C.  Clinical manifestations.

1.  Presenting complaints may include:

a.  Pain or itching.

b.  Decreased hearing.

c.  Buzzing if insect is in ear canal.

d.  Feeling of fullness in ear or pressure.

e.  Discharge from ear.

D.  Physical findings.

1.  Foreign object or insect visualized on otoscopic exam.

2.  Check all body orifices if foreign body found in one.

3.  Carefully check ear after removal of foreign object for additional ones.

E.  Diagnostic tests.

1.  Usually none.

F.  Differential diagnosis.

1.  Foreign body: object or insect is visualized on otoscopic exam.

2.  Otitis media (OM).

3.  Otitis externa.

4.  Trauma.

5.  Impacted cerumen.

6.  Dermatologic disorders (psoriasis or eczema).

G.  Treatment.

1.  Remove foreign body. If bleeding occurs, object must be removed.

2.  Have child lie down, restrain head if needed.

3.  
Do not irrigate
if foreign body is vegetable or wood and/or suspect perforation of tympanic membrane.

4.  Insect in ear: Kill insect by filling ear canal with mineral oil or alcohol before removal. Ticks: Dislodge ticks by filling canal with 70% alcohol and then remove.

5.  Removal of objects.

a.  Best: Remove objects using an otoscope with an opening head for visualization.

b.  Objects that are soft and unwedged.

•  Remove by irrigation with tepid water (body temperature) and water pik on low setting or an 18-gauge butterfly catheter with needle cut off. Pulsating water should help dislodge object.

•  Insert pliable tubing into ear canal behind foreign body.

6.  If object does not completely occlude canal, can use ear loop, curette, forceps for removal.