ENOT/OPHTHALMOLOGY (Seth's Additional info) (15%) Flashcards
What is the MC reason children receive ABX in the US?
AOM
More than 90% of all antibiotic use in the first 2 years of life is due to OM
what is the pathophys of AOM
Inflammatory fluid and pathogenic respiratory bacteria that reflux into the middle ear space do not drain properly
This process effectively leads to the formation of an abscess in the middle ear
Exposure to this environmental hazard is a RF for AOM
Second hand smoke exposure
The _______ is shorter and more horizontal in infants and small children, which is a RF for AOM
Eustachian tube
This common action in young kiddos increases the likelihood of AOM
Pacifier use
Why can Pacifier use lead to AOM?
sucking on a pacifier increases the reflux of nasopharyngeal secretions into the middle ear, i.e. during a common cold pathogens can enter the middle ear more easily through this route.
the use of a pacifier may induce changes in dental structure and thereby dysfunction of the Eustachian tube
What age involves immediate treatment of AOM?
< 6 months
6-24 months can observe, but will need traetment
For AOM, if you are over the age of ___ you have the option of initially observing if mild s/s
24 months
1st line treatment of AOM and 2nd line if that does not work
Amoxicillin
Augmentin if refractory
Treatment for AOM if non IgE mediated reaction vs IgE mediated reaction
for allergies
Cefdinir (non-IgE)
Macrolide/clinda/bactrim (IgE)
If you do not have systemic symptoms and you have ______, you can use drops (cipro/ofloxacin) for AOM
tympanostomy tubes
Two complications of AOM
Tympanosclerosis (white plaque on TM from chronic inflammation)
Cholesteatoma (a greasy-looking or pearly white mass seen in a retraction pocket,
Occasionally with perforation, a temporary conductive hearing loss may be present)
for cholesteatoma
- Most perforations heal within 2 weeks
- When fail to heal within 3-6 months, surgical repair is indicated
If OM lasts > ___ it is chronic
3 months
treatment of recurrent OM and MOA
Tympanostomy tubes
Allows for drainage and decreases OM episodes; creates an airway that ventilates the middle ear and prevents the accumulation of fluid behind middle ear
MCC of strep pharyngitis is group ___ strep
Group A
pathophys of allergic rhinitis
Complex inflammatory disease of the upper airways, mediated by Immunoglobulin E (IgE)
type 1 hypersensitivity reaction
very strong RF for alergic rhinitis
Asthma
In patients with asthma, allergic rhinitis prevalence is > 80%
T/F, as you enter middle adulthood, allergic rhinitis worsens
FALSE
Peak in childhood and adolescence before the 4th decade
diminishes gradually with aging
MC gender for allergic rhinitis
Male
Accentuated lines of the eyes seen in allergic rhinitis are called:
Dennie-Morgan lines
The Nasal mucosa of allergic rhinitis is pale, with a ___ hue and ___ d/t venous engorgement
The Nasal mucosa of allergic rhinitis is pale, with a bluish hue and boggy d/t venous engorgement
also see Cobblestoning and nasal polyps (think obstructive symptoms)
What is a positive pick test for allergic rhinitis (basically allergies in general)
wheal 5 mm or greater
NO ANTIHISTAMINES PRIOR TO TESTING for at least 5 days
What is a mild, intermittent allergic rhinitits?
< __ days/week
< ___ weeks
abscence of ___
<4 days/week
<4 weeks
does not greatly affect QOL
if different timing, then persistent
if affects QOL, then mod/severe
Most effective treatment for allergic rhinitis (suffix?) and when to treat
intranasal glucocorticoids (-asone)
if persistent or mod/severe
Down regulates inflammatory response - decreases swelling of nasal mucosa
Although not as effective, this class of meds is first line for mild/intermittent symptoms (suffix)
H1 antihistamines (not as sedating)
-adine
MC organisms for bacterial conjunctitivitis
S pneomo
H flu
M Cat
MCC of viral conjunctivitis
Adenovirus
watery d/charge and HIGHLY contagious
starts in one eye and spreads to the other
t/f both allergic conjuntivitis and allergic rhinitis are type 1 hypersensitvity reactions
TRUE
treat allergic conjunctivitis with -tidine
most common in Spring
what is it called when there is a severe allergic reaction in the eyes, leading to:
Severe itching, tearing, mucus production
Giant papillae of upper tarsal conjunctiva
Ptosis and keratitis common, resulting in squinting in bright light
Papillae found at limbus (junction of sclera and cornea)
With characteristic white dots (represent accumulation of inflammatory cells, mostly eosinophils)
Vernal Keratoconjunctivitis
t/f the treatment for Vernal Keratoconjunctivitis is the same as viral conjunctivitis
True
Worry about untreated Vernal Keratoconjunctivitis
Permenant vision loss
what is atopic conjunctivitis associated with?
Eczema
Tx same as allergic conjunctivitis
what oropharyngeal disease can be prevented with HIB vaccine
Epiglottitis
MCC is H flu, remember
What confirms the diagnosis of epiglottis
treatment?
Direct visulaization
xrays are NOT mandatory for dx
VR = treatment (vanc rocephin)
Steps of mng for anterior epistaxis (5)
to stop bleed
- Pressure on site for 15 min + lean forward
- Short acting nasal decongestants/vasconstricors (phenylephrine)
- Topical anesthetic vasoconstrictor (cocaine/lidocaine and epi)
- Identified location, chemical cauteriaztion with silver nitrate or thermal cauterization
- Nasal packing with sponge/balloon OR absorable material like oxidized cellulose/gelatin
Steps of mng for posterior epistaxis
to stop bleed
- ENT consult
- Packing/narcotic analgesics, ligation of nasal arterial supply, endovascular emobilaztion of internal maxillary artery
- ABX prophilaxis with Augmentin/clinda/keflex for antistaph TSS
After control of epistaxis, what is some patient education to reduce instance of future bleeds
- Avoid vigorous exercise
- Avoid hot/spicy foods and tobacoo
- Lubrication with petrolatum or Bacitracin ointment
- Increase home humidity
treatment of preseptal/periorbital cellulitis
Augmentin/cefdinir PLUS Bactrim/clinda
For preseptal, think preschool, where you learn your ABCs
(Augmentin, Bactrim, Clinda/cefdinir)
treatment of peritonsillar abscess
I&D
IV Unasyn or IV clinda
IV Vanc if refractory
switch to oral abx later
RFs that mean a neonate should be screened for hearing loss
infections
FHx
ENT defects
Hearing Interventions should be in place by () age for social/language development
6 months of age
All infants with or without risk factors should receive ongoing surveillance of communicative/ language development beginning at _ of age during well-child visits
2 months
MCC of hearing loss in 2-5 yo
Recurrent OM
Up until this age () behavioral and language responses are the gold standard of hearing screening. Once a child is () auidometry is preferred
birth to 3 = behavioral
4+ = auidometry
at 5 yo kids are often screened at school
tympanic membrane ruptures typically resolve within () but a () may be necessary if no resolution
months
tympanoplasty (plastic on eardrum)
r/o infection as well and can treat with same ABX as AOM (amoxicillin, augmentin, cefdinir, oflaxacin, ciprodex)
What cannot be used with an ruptured TM?
Cortisporin (Neomycin-polymyxin B-hydrocortisone)
Numbing drops
Olive oil
what is mastoiditis typically a complication of?
several weeks of poorly treated AOM
same pathogens as a result
What do mastoid air cells connect to?
Middle ear
fluid build up here without drainaige can lead to mastoiditis
If ABX (VR) do not resolve mastoiditis, what is the next treatment plan?
Myringotomy
Surgical drainage of TM to allow drainage of middle ear fluid
If ABX and myringotomy are refractory, what is the last resort treatment option of mastoiditis?
mastoidectomy and debridement of infected and necrotic bone
MCC of ped visual impairment
Amblyopia
What is amblyopia?
A functional reduction in the visual acuity of an eye, either unilaterally or bilaterally, caused by disuse or misuse during the critical period of visual development
What are the 3 types of amblyopia
Strabismus
Refractive
Deprivational
What is strabismus?
Type of amblyopia invloving misalignment of visual axes of the two eyes
What is refractive amblyopia?
One or both eyes having a refractive error causing an imbalance between the eyes
What is deprivational amblyopia?
Obstruction by a cataract or complete ptosis prevents formation of a formed retina
interruption of the visual axis or severe distortion of the foveal image
least common but most severe - cam lead to permenant visual impairment
Pathophys of strabismic amblyopia
Dsicrepancy in the foveas of two eyes leading to unfusable images. The visual cortex suppresses the image from one eye in order to avoid having diplopia; long-term suppression of one eye results in strabismic amblyopia.
Is refractive amblyopia MC in hyper/hypoopia?
hyperopia
far-sighted (where up-close images are out-of-focus)
the people that need reading glasses
How do you check for amblyopia/strabismus in a pre-verbal child?
positive result?
Fixation reflex
amblyopia don’t fix on obj with amblyopic eye when both eyes uncovered
testing involves moving a visual target to and from the child’s visual space, each eye being tested by occluding the fellow eye
How do you check for amblyopia/strabismus in a verbal child/ 3 and older?
Allen/snellen charts
eyes should be checked at three!!!
Visual acuity is 20/40 at ____.
Visual acuity worse than 20/30 at ____ warrants evaluation/ referral.
20/40 at 3-5 yo = normal
worse than 20/30 at 6 = reffer
should have normal vision at 6 yo
when does ocular instability of infancy resolve by?
3 months
may look like strabismus, but after 3 months you should be able to fix on an obj, making it go away
What do you use to evaluate strabismus?
Corneal light reflex
Cover test
Cover/uncover test
Explain the corneal light reflex
Accommodation target using a small toy used w/ the ophthalmoscope light standing several feet from the child.
Hold the light and toy in the same hand and use the light to reflect on both eyes at the same time
AKA: Hirschberg test
A normal test will reveal that the light reflects off the same position on each eye
Explain the cover test associated with strabismus
The child is asked to visually fixate on a target at distance or near
The examiner briefly covers one eye while observing the opposite eye for movement
No movement is detected when covering either eye if the child has normal ocular alignment
Strabismus present if the eye that is not occluded with the cover test shifts to re-fixate on the target when the fellow, previously fixating eye is covered
Explain the cover uncover test associated with strabismus
Child asked to visually fixate on a target at distance or near. A cover is placed over one eye for a few seconds and then it is rapidly removed
The eye that was under the cover is observed for refixation movement
If strabismus present, this previously covered eye will shift back into the straight-ahead position to re-establish sensory fusion with the other eye
A positive test occurs when the cover is rapidly removed and the affected eye is deviated. This eye will realign after the cover is removed to fixate on the object
What is the reflex seen on opthalmoscope that is associated with strabismus on PE?
Describe it
Bruckner Red Reflex
AKA the simultaneous red reflex test
Positioned 18-20 inches from the child’s face, the ophthalmoscope with the largest diameter light is used to visualize both of the child’s red reflexes at the same time
The light should be positioned just around the skin of the child’s eyes and the child should be looking directly at the ophthalmoscope. The red reflexes should be equal in size, shape, color, and hue
t/f constant strabismus in new borns is normal and does not merit referral
FALSE
intermittent is normal, not constant
Constant strabismus at any age merits a referral. At what age do you refer if intermittent strabismus does not go away?
> 6 months of age
t/f a positive corenal light reflex, cover, or cover/uncover test at any age merits a referral
TRUE
if negative, you can obs until 6 months
Treatment of strabismus
Corrective lenses
Patching
consider sugery via recession (reposition muscle) or resection (shorten muscle)
