EENT Flashcards
Mild injection of the conjunctiva present several hours after birth
Chemical conjunctivitis
Irritation from the use of opthamalic preparation at birth
APPEARS IN FIRST 24 hours
decrease due to the discontinuation of six silver nitrate.
Last no longer than 3 to 4 days.
No tx
Copious purulent discharge 2 to 5 days after birth from Eyes
Gonococcal conjunctivitis due to the transmission of necessariea gonorrhea
Highlighter green
Mild mucopurulent discharge from eyes few days to 2nd weeks after birth typically day 7 to 14
Chlamydia conjunctivitis
Gonorrhea diagnostic test conjunctivitis
Gram stain of conjunctiva scrapings and Prulent discharge or Gram stain shoes gram negative intercellular diplococci verified by culture either the chocolate agar or thyar Martin medium
Gonococcal conjunctivitis management
Ocular emergency can cause blindness hospitalization is necessary
Irrigation with normal Saline
Systematic antibiotics IV or IM
IV Pen G
Or
Ceftriaxone / cefotaxime x7 days
do you not give Rocephin in newborns with hyperbili
Pneumonia is also associated with this can have increased WOB and mild to moderate injection and Chemosis of conjunctiva
Chlamydia trachomatis conjunctivitis
Chlamydia conjunctivitis test
Giemsa Stain of conjunctival scrapings may reveal intracytoplasmic inclusion bodies
Immunofluorescent in a body staining of conjunctival scrapings highly sensitive and specific
CXR if PNA
Chlamydia tracomatis conjunctivitis management
Erythromycin eye ointment x2-3 week
Oral erythromycin can treat the conjunctivitis and may prevent subsequent pneumonia
Oral sulfonamides (trimethoprim , sulfamethoxazole) if intolerant to erythromycin
Bright red and irritated conjunctiva can also have satellite lesions
HSV conjunctivitis
HSV diagnostics
Fluorescein exam looking for satellite lesions, obtain HSVPCR and culture
First line treatment for her herpes simplex virus conjunctivitis (HSV)
Acyclovir
Warm compress to remove excudate
Hand washing
Hospitalized if conjunctivitis or satellite lesions
Immediate referral to ophthalmologist
Pathogens of bacterial conjunctivitis
Staphylococcus aureus, H.influenzae, streptococcus pneumonia, and Moraxella catarrhalis
Occurs in about 25% of young children less than three years and most often associated with H.influenzae in the ipsilateral (same) eye/ear
Conjunctivitis Otitis syndrome
Primarily due to adenovirus viruses 3,4 and seven
Viral conjunctivitis
Can result from HSV, varicella, herpes zoster
Commonly associated with seasonal allergies Both eyes feel itchy and watery
Allergic and vernal (chronic) Conjunctivitis
Cobblestone appearance of bilateral conjunctiva
Allergic conjunctivitis
Affects both eyes accompanied by nasal congestion, sneezing, I would swelling and sensitivity to light
not contagious
Allergic conjunctivitis management
Decongestants, topical Antihistamines, oral
Viral conjunctivitis has what type of discharge
Watery or thick stringy mucoid
Watery discharge lasting 10 to 14 days scratchy sensation and some URI symptoms affecting one or both eyes
Viral conjunctivitis
Highly contagious AKA PINK EYE
Bacterial conjunctivitis has what type of discharge
Perulent , glued eyes after sleeping
Can I have crusting upon awakening green yellow color
Begins unilateral
Viral conjunctivitis treatment
Symptomatic care
Mild: saline/artificial tears refrigerated is best
Moderate: decongestant/anti-histamines, NSAIDs
Bacterial conjunctivitis management
Erythromycin 0.5% opthamalic ointment
Polytrim (polymyxin B sulfate trimethoprim) Tobramyosin, Vigamox
Use the cover and cover test to see the reflection of light in both eyes
Corneal light reflex
I bought is too long causing the visual image to fall in front of the retina
Myopia
My=me I have this can’t see far away
Occurs during school age can’t see the board
Nearsightedness
Myopia
Pupils should see a crisp Red/orange and round retina
Red light reflex
2.5 years till melynization
Farsightedness
Hyperopia
Eyeball is too short Visual images focus behind the retina ability to see objects clearly at a distance but not in close range
Hyperopia
Mom
Complaints of inability to read
Can I have a headache, ice cream, squinting, Eye rubbing
Hyperopia can resolve by what year
Resolves by 6 years
Passing vision screen for a three-year-old
20/50
Passing vision screen for a four-year-old & 5 year old
20/40
20/30
Amaurosis
Blindness
And ability to distinguish light from darkness to partial vision
Legal blindness
Distant visual acuity of less than 20/200 corrected
Low vision
Visual cue between 20/70 and 20/200 corrected
Primary blindness
Present at birth
First symptom of blindness
Can I have nystagmus
Enlarged or clouded cornea
Abnormal or absent red light reflex
Fixed or intermittent strabismus be on six months
Developmental delays, increased anxiety around strangers, increase self stimulating behavior hand flapping rocking
Wondering eye
Chronic tearing
Diagnostic test of blindness
Ophthalmologist exam showing abnormal vision
Developmental testing
CT or MRI to rule out pathologic abnormalities
Causes of amblyopia
Trauma, organic lesion, cataract
Sensory stimulation deprivation or disuse during infancy and early childhood
Rarely bilateral
Can occur with strabismus
Diagnosis and management of amblyopia
Specific ophthalmology findings rule out underlying causes like cataracts diseases of that eye
Early detection, part referral to ophthalmologist
Corrective lenses
Patch use focusing on stimulation of the amblyopic eye
Involuntary rhythmic or jerky movements of the eyes
Nystagmus
Normal until one month of age , acute acquired nystagmus is concerning
Associated with albinism, refractive errors, central nervous system abnormalities , may be familial
Treatment for nystagmus
Referred to ophthalmologist three underline problem as possible
Crossed eye
Muscles of iron not coordinated
Strabismus
Esotropia
Eye turned inwardly
Exotropia
Eye turned outward
Hypertropia
Eye turned upward
Hyper =UP
Hypertropia
Eye turned downward
Hypo=down
What is the evaluation test for strabismus
Cover and uncover test
EOM testing
Vision acuity
Pupil test hirschburg Looking for lateral motion of the covered Eye
Hirschburg test
Pupillary light reflex looking for the lateral motion of the eye Will be unequal if strabismus is present
Treatment for strabismus
Treat once ocular misalignment > 6 months of age or if Constant or fixed strabismus at any age or hyper/hypertropia immediately, and urgent referral if any underlying CNS abnormality is suspected
Treatment may include:
surgery between six months and two years of age
patching or covering of the unaffected known as occlusion therapy
Correct of lenses
Orthotic exercises
Medication atropine sulfate (dilates unaffected eye forces you said the deviating Eye)
Lazy eye or decrease visual acuity and one or both eyes caused by an inadequate or an unequal visual stimulation
Amblyopia
Dad has this!!!
Occurs in visually immature children lack of clear image on the retina due to immature visual system
When does a child reach visual maturity
7-9 years
Automated vision screening including photo screening an auto refraction is preferred for children at what age to test vision
6 months to 3years
Visual acuity charts are the reliable method of screening for vision and children’s at what age
Ages 4 to 5 years
If unable to test visual acuity how long should the provider wait to reattempt
4 to 6 months
If four years of age and unable to test visual acuity when should the provider attempt again
One month
Each eye with a different refractive error variation axle or curvature of the cornea light focus front or behind cornea
Anisometropia
Results on there is an uneven curvature of the cornea causing blurred vision at near and far distances
Astigmatism
Opacity of the lens
Cataract
Sign and symptoms of Cataracts
Gauze over the lens Poor visual acuity Dim vision PAINLESS photophobia May be associated with hypoglycemia, hypo parathyroidism, galactosemia, microphathlmos
Black dots surrounded by red reflex, white plaque opacities, leukocoria
Causes of Cataract in children
A. Trauma to the eye, possibly due to child abuse
B. Systematic disease like DM, trisomy 21, hypo parathyroidism, a topic dermatitis, Marfan syndrome
C. Complication of other ocular abnormalities E.G. glaucoma, strabismus
D. 30% hereditary
Leukocoria
Absent red reflex
Seen in Cataracts
Cataract treatment
Prompt referral to ophthalmologist, surgery indicated for visual correction
Increased intraocular pressure from disruption of aqueous fluid involving one or both eyes in can result in optic nerve damage
Glaucoma
Glaucoma that occurs within the first three years of life; 40% present at birth; 85% by one year of age
Congenital glaucoma
Glaucoma that begins between three and 30 years
Juvenile glaucoma
Causes of glaucoma
Secondary causes include trauma, intraocular hemorrhage, tumor, cataracts, corticosteroid use
classic triad photophobia, abnormal overflow of tears (Epiphora), Eyelid spasm (blepharospasm)
May also have decreased vision and persistent ACUTE extreme pain of eye
Signs and symptoms of glaucoma
Deep cupping of optic disc, corneal haziness in Edema, conjunctival injection, corneal enlargement > 12 mm
What is the management of glaucoma
Glaucoma pressure test will show increased pressure
Immediate prompt referral to ophthalmologist to confirm diagnosis and initiate therapy surgery is often the first line
Granulomatous inflammation of the Meiobian glands occurring on the conjunctiva aspect the inner lining of the eyelid, nontender cyst
Chalazion
Signs and symptoms of a Chalazion
Slow growing painless, mass on eyelid most often upper eyelid Minimal redness/slight edema Firm nontender localized nodule often midline
Mangement chalazion
Small ones may resolve without treatment
Apply warm compresses 2 to 3 times a day for 20 minutes
Integrity of the eye is disruptive loss of vitreous humor
Ruptured globe
Signs and symptoms of a ruptured globe
Pain, photophobia, injection, hyphema
Distortion of eye “pupil leaking”
Management of ruptured globe
Emergent referral to ophthalmology
Loss of epithelial lining from corneal surface of one or both eyes
Corneal abrasion
Sensation of a foreign body, pain, photophobia, tearing, decreased vision, may have mild sclera erythema
Corneal abrasion symptoms
What antibiotic is used for corneal abrasion ?
Polytrim (Bactrim) Antibiotic drops also symptomatic care
How do you diagnose and evaluate a corneal abrasion?
Fluorescein staining cobalt blue light (woods lamp)
Dye shows scratches
Blood in anterior chamber of eye
Hyphema
Opthamalic emergency , reduced activity
Unilateral or bilateral obstruction nasal lacrimal duct
Dacryostenosis
Blocked tear ducts
Dacryostenosis
Spontaneous resolution by 12 months
Constant wet / tearing eye no redness
Dacrocystitis
Dacro =lacro
Infection of obstructed duct
Fever, erythema, edema, tenderness pver NLD
Dacrocysitis
Dacrocystitis treatment
ED IMMEDIATELY
ABx drops
Cats eye / Leukocoria
Retinoblastoma
Whiteness in picture
Retinoblastoma
Cats eye
Hereditary-bilateral
Non hereditary- unilateral
Cancer
Refer to opthomologist
Vascular pathologic disease of retina
Retinopathy of prematurity
Increased vascularization of the eye refer to pediatric opthamology
Laser therapy
An acute / Sudden localized inflammation of the sebaceous glands of the eyelids
Hordeolum ( stye)
Red tender papule
Most common infectious pathogen for a stye?
S. Aureus
P. Argunosia
Stye treatment
Spontaneous rupture common
Warm compresses
Sulfacetamide 10%
Polymyxin B -bacitracin
Or erythromycin
Inflammation infection of the soft tissues of the orbit posterior of the orbital septum can involve the ocular muscles and optic nerve
Orbital cellulitis
Inflammation infection of the skin and subcutaneous tissue surrounding the eye
Unilateral eyelid edema
Periorbital cellulitis
Warmth redness fever may occur
Vision normal
Acute infection of the external auditory canal
Swimmers ear
External Otitis media EOM
Management of EOM
Otis drops
Ofloxacin , ciprodex, neomycin, polymyxin,fluoroquinolone
Sensorineural hearing loss
Resulting damage to the cochlear structure of the inner ear were auditory nerve
Can be caused by torches, prematurity, medication exposure, or inherited
Conductive hearing loss
Normal bone conduction and reduced air condition due to the obstruction Results from blocked transmission soundwave from external auditory canal to inner ear
this is more common
Causes include OME, wax, foreign body
Causes of conductive hearing loss
Hearing screening
Screen at birth
Repeat screen by 1 month
DX @3 months
Treated at six months or sooner
Symptomatic infection of the middle ear
Acute otitis media AOM
6-36 months most common
Causes of AOM
Viral
S.pneumoniae
M.catarrhalis
H.Flu (PCN resistance)
What is the gold standard for diagnosing AOM
Pneumatic Otoscopy
Tympanometry confirms
Red TM, distorted landmarks, rupture with drainage
AOM
Treatment for AOM
Amoxicillin 80-90 mg/kg/day BiD divided
2nd line augmentin
<2 x10 days
>6 5-7 days
No improvement of AOM in 72 hours of amoxicillin treatment
Assume beta lactamase
Augmentin , Cefdinir
OME
Otitis media with effusion
AKA serous otitis media
Fluid in middle ear space (thickened mucus production)
Decreased mobility with no signs of AOM
Bubbles
Yellow/dull color or translucent TM, appears retracted to the negative pressure and middle ear, no vascularity
This case is resolved on own without anabiotic‘s, refer if longer than three months or associated hearing loss
What’s causes OME
Caused by viral illness/allergies , hypertrophic adenoids
Eustachian tube dysfunction
Sequel to AOM 25% to 35% of all cases
Most common cause of conductive hearing loss
OME
Tympanostomy tubes
Surgical incision of the eardrum and placement of ventilation tube to relieve pressure and drain pus/fluid from middle ear
Mastoiditis
Infection of mastoid cells
Redness behind ear (post auricular swelling)
Concurrent/recurrent AOM occurs secondary to this
fever , otalgia
Mastoiditis management
CT bony involvement
CBC elevated WBC‘s
Culture to rule out sepsis
Refer ent, po / I’ve abx and mastiodectomy
FB in ear mangement
Remove
Refer ent
Otic abx drops
FB nose
Remove object
Angel kids parents mouth to mouth
Ent if unable to get out
Initial symptoms of sneezing, mild discomfort can lead to infection
Pressure at kiesselbachs triangle
Management of epitaxis
Epitaxsis
Common and dry climates
Usually benign or mechanical nasal picking
Chronic use of nasal decongestion AFRIN
Apply ice
CBC, platelets, PT, PTT if bleeding disorder suspected
Rhinitis
“AR”
URI
Caused by a variety of viruses most common rhinovirus a.k.a. the common cold
7 to 10 days; Day 1 to 3 ramping up; day 5 to 7 worst; day 10 to 14 resolution signs and symptoms
Acute onset of symptoms low-grade fever, pharyngitis, rhinorrhea, conjunctivitis, cough (nonproductive) worsens at night due to postnasal drip, allergic shiners and salute with nasal crease, nasal mucosa pill, boggy and Edematous , sinus h/a
Rhinitis management
Symptomatic, no cold medications under the age of 6, hydration, nasal bulb suctioning, rest
Anti- histamine, Benedryl, nasal spray (beclomethasone /fluticasone) , normal saline
Sinusitis
Common in school agers
Do not diagnose b4 9 years
S/s: sinus pressure, purlent drainage
The diagnosis of acute bacterial sinusitis is made when______.
Diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection presents with:
- persistent illness nasal discharge or daytime cough or both lasting more than 10 days without improvement
- A worsening course Or new onset of nasal discharge, daytime cough, or fever after initial improvement
- Severe onset concurrent fever and nasal discharge for at least three consecutive days
Sinusitis management
Amoxicillin clavulanate (augmentin)x10 days Levaquin if no improvement
Decongestants/Anna histamines are not useful
Pain management
humidification
Nasal spray budesonide is a topical inhaled steroid
Use with caution for no more than three days
Swimming in moderation
Centor criteria
Pharyngitis/tonsillitis clinical features most suggestive of group a beta-hemolytic streptococci (GABHS) =FLEA
- fever
- lack of cough
- pharyngal tonsillar excudate
- anterior cervical adenopathy
2 or more do a strep test!!!!
Group a beta-hemolytic Streptococcus GABHS
Strep pharyngitis
Abrupt onset of sore throat, no nasal symptoms, or cough, fetid breath, fever common , headache, nausea, belly pain, vomiting
Why do we treat strep pharyngitis
Treating to prevent rheumatic fever
Scarletintinform rash
Scarlet fever secondary to strep pharyngitis
Treatment of choice for strep pharyngitis
Penicillin or amoxicillin 50 mg /kg/day PO q day or divided twice a day
Change tooth brush after 48 hours
Pain meds
Hydrate I
Treatment for strep pharyngitis in penicillin allergic
Keflex cephalexin 25 to 50 mg/kilogram/day divided b.i.d.
Azithromycin 12 mg/kilogram/day x5 day
Caused by the Epstein bar virus EBV
Mononucleosis
Signs and symptoms Low grade fever, cervical lymph nodes swelling, sore throat, fatigue, anorexia, slow onset, possible excudate
Mononucleosis
Can I also have splenomegaly, and maculopapular for Petechial rash
Classic triad of MONO
Fever, pharyngitis, lymphadenopathy
IGM versus IgG in EBV
Mother’s before grandmother
Early rise IgM (positive) permanent rise IgG
+IGM = early primary infection
+ IGG = past infection
+IGM & IGG = acute primary infection
-IGM &IGG= negative EBV status
How long should a person with infectious mononucleosis avoid sports or activity
3 weeks due to the risk of splenomegaly and splenic rupture
What drugs do not treat infectious mononucleosis with?
Amoxicillin it will give a rash
Left upper quadrant pain in infectious mononucleosis
Complication of mono =ruptured spleen
A 15-year-old male presents with complaints of general malaise and fatigue for the past few weeks without resolution. He has also had a fever and sore throat. All the final exam findings with support the diagnosis of infectious mononucleosis except:
White excudate on tonsils
Hepatomegaly
Maculopapular rash
Diffuse cervical lymphadenopathy
Hepatomegaly
Mono has splenomegaly not hepatomegaly all the other are findings of mononucleosis
Sore throat with bulging posterior soft palate and deviation of you allowed to opposite side that’s unilateral
Peritonsillar abscess
Airway emergency!!!
What causes a peritonsillar abscess?
Complication of pharyngitis due to the accumulation of purulence in a tonsillar fossa causing a cellulitis that leads to abscess
Treatment of peritonsillar abscess
Needle aspiration, IV anabiotic‘s penicillin, nafcillin,oxacillin
Hydration
Lateral neck radiography or CT shows a widen retropharyngeal space
Diagnostic study indicative of retropharyngeal abscess
Retropharyngeal abscess
Inflammation of the posterior aspect of the pharynx and retropharyngeal lymph nodes causing sore throat with bulging pharynx can be an airway emergency
Fever , pain swallowing and refusal
Turn head
Emergency referral to ENT
Seal like cough
Croup
What causes croup
Para influenza virus of the Larynx
Steeple sign
Diagnostic x-ray finding indicative of croup
Not necessary dx test
What is the management of croup?
Symptom Medicare, single dose Decadron 0.8 mg/kilogram PO x once
Following a URI in a 3 to 10 year old, unable to swallow sitting in a tripod position and breathing really fast
Epiglottitis
Bacterial infection
Thumbs sign
X-ray finding indicative of epiglottitis steeple sign would show croup
High fever , drooling, sore throat, unable to swallow
Epiglottitis
Oral Candidiasis
Thrush common used infection of the oral Mucosa
White patches in mouth can be painful or not
Treat with Mr. and oral suspension four times a day times 10 days
Treat breast feeding mother (cross infection)
Sterilize pacifiers /nipples
What pathogens cause epiglottis
Beta-hemolytic streptococci, pneumococci, H influenzae
Decreasing of influenzae with the use of HiB vaccine
What finding may accompany macrocephaly?
- pulsating anterior fontanelle
- Sunken Fontanel
- premature closure suture lines
- Widened suture lines
Widen suture lines
Pulsating anterior fontanelle can be a normal variant or due to increased ICP. Sunken fontanelle can accompany dehydration and premature closure of suture lines = small head
Which of the following conditions increases the risk of developing hydrocephalus?
Bilateral cephalohematoma‘s
Craniostenosis
Prematurity
familial microcephaly
Prematurity
Bilateral cephalohematoma as a result of underline skull fracture
Craniostenosis (premature closure of the sutures) can result in increase cranial pressure if severe and family macrocephaly is normal and not associated with pathology
Confirming the diagnosis of chlamydia Conjunctivitis in the newborn would best be done by obtaining which of the following?
Cervical swab of the mother
You’re in PCR from the mother
Culture from the eye discharge
Culture of the conjunctival scrapings
Culture of conjunctival scrapping
Chlamydia is a intracellular organism and needs epithelial cells test sample
Testing the mother would not directly tell us what is causing the newborn symptoms
Automated vision screenings including photo screening and auto reflection is preferred for children aged ____ to _____. Visual acuity charts continue to be a reliable method of screening for children aged _____ to ____ years.
6 months to 3 years
