ENT Pediatric Note

Reason for consultation: Persistent ear infections and hearing loss ASSESSMENT: Emily Johnson is a 5-year-old female with a history of recurrent otitis media, presenting with hearing difficulties, with exam significant for fluid behind the tympanic membrane, with scope demonstrating normal nasopharynx, labs remarkable for elevated white blood cell count, and imaging showing fluid in the middle ear. Clinical picture consistent with chronic otitis media although cholesteatoma is within the differential diagnosis. PLAN: - Tympanostomy tube insertion planned - Audiometry planned - Antibiotic treatment planned - Referral to audiologist for hearing assessment - Follow up outpatient with Otolaryngology - Head & Neck Surgery in 4 weeks - Instructions for follow up placed in the patient's discharge paperwork, will task for follow up unless deemed as needed - Discussed with Dr. Thomas Kelly, who is in agreement with the above SUBJECTIVE: History of Presenting Illness: Emily Johnson is a 5-year-old female presenting with the above chief complaint for which Otolaryngology is consulted. - Emily has been experiencing recurrent ear infections and hearing loss for the past 6 months. - Symptoms have been persistent and have not improved with previous antibiotic treatments. - The hearing loss has been affecting her ability to participate in school activities. - Associated symptoms include occasional ear pain and irritability. - Past medical history includes frequent upper respiratory infections. - Family history of hearing issues in maternal lineage. - Immunizations are up to date. OBJECTIVE: Physical Examination: General: No acute distress Head & Face: Atraumatic, non-syndromic features Eyes: EOMI, no APD Ears: Auricles without abnormality, EACs patent AU, fluid behind tympanic membrane Nose: No external abnormality, septum non-deviated, turbinates non-swollen, no pus Oral Cavity: Mucosa, lips, FOM, and oral tongue without abnormality, tongue normal mobility, dentition good Oropharynx: Soft palate normal elevation, tonsils 2+ Neck: Soft/flat, no cervical/supraclavicular/auricular LAD PULM: No IWOB, no stridor, no stertor CV: RR ABD: Soft Skin: No lesions MSK: Moves extremities NEURO: Cranial nerves grossly intact on limited evaluation Flexible Fiberoptic Nasopharyngolaryngoscopy: After obtaining signed consent from the patient's guardian, timeout performed for verification, and respiratory therapy at bedside, the flexible endoscope was inserted into the right naris, which was grossly normal. Nasopharynx grossly normal without mass or lesion. Posterior pharynx symmetric without mass or lesion. The base of tongue is normal and symmetric. Vallecula is clear. The epiglottis and aryepiglottic folds are crisp and without mass or lesion. The supraglottic inlet is unobstructed. The true vocal folds are fully mobile and symmetric without mass or lesion. The visualized subglottis is patent. The pyriform sinuses are clear and without pooling of secretions. The airway overall is not concerning for acute impending compromise. The patient tolerated the procedure well without complication. Imaging: CT scan of the temporal bone without contrast - Fluid in the middle ear, no evidence of cholesteatoma