ENT Flashcards
What are the indications for a radiologic evaluation of hoarseness?n
Suspicion of a foreign body or a mass
Explanation
Hoarseness in children is generally benign and is typically caused by nodules, polyps, infection, papillomas, hypothyroidism, foreign bodies, congenital anomalies, and vocal fold granulomas (due to gastroesophageal reflux disease, intubation, and vocal cord overuse). Radiologic evaluation is only necessary if you suspect a foreign body or mass. Refer to an otolaryngologist if hoarseness lasts > 2 weeks.
What is the most common infectious cause of congenital sensorineural hearing loss?
Answer
Cytomegalovirus (CMV)
Explanation
Sensorineural hearing loss involves dysfunction of the sensory epithelium, cochlea, or neural pathways leading to the auditory cortex via CN 8. Severe and profound hearing loss is always sensorineural and most often affects the higher frequencies. CMV is the most common infectious cause of congenital deafness, causing sensorineural hearing loss in 30–50% of symptomatic and 8–12% of asymptomatic infants. Other causes of sensorineural hearing loss include other congenital infections (e.g., toxoplasmosis, rubella, syphilis), genetic syndromes (e.g., Jervell and Lange-Nielsen syndrome), prolonged exposure to loud noise, bacterial meningitis, ototoxic drugs, and trauma.
A 2-year-old boy presents with unilateral nasal discharge. The mother notes that the drainage has a bad odor.
What is the most likely diagnosis?
Nasal foreign body
Explanation
Various items can end up in a child’s nostril without anyone’s knowledge of how they got there. These items may include crayons, toys, erasers, paper, beads, beans, stones, pencils, and various foods. Foreign bodies often lead to unilateral, purulent, foul-smelling discharge.
What common cause of midline neck masses is often associated with an ectopic thyroid gland?
Answer
Thyroglossal duct cyst
Explanation
Thyroglossal duct cysts are common cystic midline masses that are often seen with ectopic thyroid glands. The cyst typically moves with swallowing. They are usually asymptomatic unless they become infected. If infection occurs, the cyst can rapidly increase in size, potentially compromising the airway. Surgically remove thyroglossal duct cysts, but if infection is involved, address that first.
A 16-year-old female asthmatic presents with:
A 12-week history of thick, purulent nasal discharge and cough despite multiple courses of antibiotics
Halitosis for 1 month
Intermittent facial pain
What is the most likely cause of this patient’s symptoms?
Chronic sinusitis
Explanation
Chronic sinusitis is defined as an inflammatory process affecting the paranasal sinuses that lasts at least 12 weeks despite medical therapy. Children with chronic coughs are prone to chronic sinusitis. Anatomic abnormalities and nasal polyps also predispose patients to chronic sinusitis.
A 2-year-old girl with a 1-week history of sore throat presents with:
Fever of 104.0°F (40.0°C)
Respiratory rate of 30 breaths per minute without flaring, grunting, retractions, or cyanosis
Severe neck pain/stiffness and drooling
Difficulty opening her mouth on examination
Erythematous bulge visible in the posterior pharyngeal wall on examination
What is the 1st step in evaluating this child’s severe throat pain?
Answer
CT scan with contrast
Explanation
These symptoms suggest a retropharyngeal abscess, which is a medical emergency. Without prompt treatment, pus can extend into the fascial planes or rupture into the pharynx, causing aspiration. CT scan with contrast is the preferred imaging study because it differentiates between retropharyngeal abscess and cellulitis. It can also detect if there is extension of the infection. A lateral neck x-ray can be ordered in cases with no distress and when suspicion of disease is low. A positive result shows a widened retropharyngeal space with anterior displacement of the airway. Additionally, the retropharyngeal soft tissue is > 50% of the width of the adjacent vertebral body. However, false positives with this method are common. For patients who are in moderate-to-severe respiratory distress, forego imaging studies and go straight to the OR for evaluation.
A 5-year-old boy presents with a 2-day history of:
Low-grade fever
Malaise
Runny nose
Congestion
Thick, copious, green nasal discharge
What is the likely diagnosis?
Answer
Viral upper respiratory infection (URI)
Explanation
This is the classic history for a common, everyday URI. Do not immediately choose sinusitis as the diagnosis on seeing “thick, copious, green nasal discharge.” Remember: A diagnosis of sinusitis requires symptoms for at least 7–10 days! The green snot is just an indication that white blood cells are being called in to help fight the infection.
What are the most common bacterial pathogens associated with acute otitis media (AOM)?
S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis
Explanation
AOM is an acute inflammation of the middle ear. While viruses are a significant cause of AOM as well, the most common bacterial etiologies are S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. Note that the serotypes of bacteria responsible for AOM are generally those not included in the pneumococcal and H. influenzae vaccines. The most common age group for AOM is 6–18 months of age. A smaller peak occurs at 5–6 years of age due to school entrance.
What is the most commonly prescribed 1st line therapy for acute bacterial sinusitis?n
Amoxicillin
Explanation
Almost all cases of acute sinusitis are viral in origin. Bacterial causes include S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. Rarely, fungal organisms (e.g., Aspergillus, Candida, mucormycosis) can be isolated in immunocompromised patients. To treat acute bacterial sinusitis, cover the most common organisms. Amoxicillin with or without clavulanic acid is the first-line treatment for acute bacterial sinusitis. Clavulanic acid is often added because of the increasing rate of β-lactamase production by H. influenzae and M. catarrhalis. Amoxicillin without clavulanic acid is often the first choice (80–90 mg/kg/day) especially in areas with high resistance rates to S. pneumoniae. Some centers recommend amoxicillin/clavulanic acid, extended-spectrum macrolides, or second and third generation cephalosporins as first-line of treatment, due to increased β-lactamase production by H. influenzae and M. catarrhalis. A 10- to 21-day course of antibiotics is recommended.
A 13-month-old girl presents with:
Coryza
Postnasal discharge
High fever (103.9°F [39.9°C])
Poor appetite
Tender cervical lymphadenitis
What is a possible bacterial diagnosis?
Answer
Streptococcosis
Explanation
Although most likely a viral pharyngitis, this presentation could be consistent with streptococcal disease in a child < 2 years of age. Streptococcosis is a persistent illness in these younger children. After laboratory confirmation, treat with penicillin. Use erythromycin, clindamycin, or azithromycin for those allergic to penicillin.
A 9-month-old boy presents to your office with:
A 7-day history of upper respiratory symptoms
Low-grade fever for 2 days
Nighttime waking with daytime fussiness for 2 days
Anorexia for 2 days
Tugging at both ears for 3 days
What is the likely cause of this child’s fussiness?
Acute otitis media (AOM)
Explanation
Usually AOM is proceeded by a URI, causing blockage of the eustachian tube. Ear pain is the most common symptom, though younger children tend to have nonspecific symptoms (e.g., fever, anorexia, irritability, ear tugging). Risk factors include 6–18 months of age, family history, day care, exposure to tobacco smoke, and lack of breastfeeding.
A newborn presents with:
Intermittent cyanosis, especially when being fed
Inability to pass a firm catheter through either nostril to a depth of 3 cm
What is the diagnosis?
Choanal atresia
Explanation
Choanal atresia is the most common congenital anomaly of the nose. Classically, infants present with cyanosis that resolves with crying and worsens when feeding. Some infants suck in their lips when they inspire. Failure to pass a firm catheter suggests the diagnosis. CT scan confirms the abnormality and location. Due to the high association of other anomalies, cardiology and ophthalmology consultations are warranted.
A 5-year-old girl presents with:
A 12-day history of upper respiratory infection
Worsening cough over the last few days—worse at night when supine
Sore throat worsening the last few days
Clear nasal discharge
What is the most likely diagnosis?
Acute bacterial sinusitis
Explanation
For children ≤ 6 years of age with persistent respiratory symptoms that have not improved for > 10 but < 30 days, the diagnosis of acute bacterial sinusitis can be made on clinical grounds without imaging. The nasal discharge “color” does not matter. The key is the duration of the symptoms. Cough is much more common in younger children than in adults with sinusitis. Commonly, it is made worse at night when the child is in the supine position.
A healthy 16-year-old male competitive swimmer presents to your office with:
Drainage from his right ear
Muffled hearing
Pain with movement of his right ear
What organisms are the likely cause of this teen’s discomfort?
Answer
Pseudomonas aeruginosa and Staphylococcus aureus
Explanation
Otitis externa (a.k.a. swimmer’s ear) is an inflammation of the outer ear canal. It is usually caused by water remaining in the ear canal following swimming, providing a ripe environment for bacterial overgrowth. P. aeruginosa and S. aureus are the most commonly involved organisms. Symptoms include ear pain, drainage, redness, pruritis, and muffled hearing. Pain is worsened by manipulating the pinna. Treatment includes topical antibiotic drops and topical glucocorticoids.
What organisms are usually responsible for acute unilateral cervical lymphadenopathy (LA)?
Bacteria (Staphylococcus aureus or Streptococcus pyogenes)
Explanation
Acute LA is common in childhood. It is usually self-limited but is sometimes a sign of a more serious disease process. Viruses generally cause acute bilateral LA, which does not require treatment, while bacteria (typically S. aureus or S. pyogenes) tend to cause unilateral LA, which generally responds well to oral antibiotics. Subacute/chronic LA can also be unilateral (usually caused by nontuberculous mycobacteria or Bartonella henselae) or bilateral (usually caused by EBV or CMV). Always consider malignancy in a subacute/chronic workup, which should include CBC with differential, tuberculin skin testing, and serologic tests for B. henselae, CMV, EBV, and HIV. If no etiology is found, an excisional biopsy is necessary.
