ENT 2019 Flashcards

Question

Thyroglossal cyst How do they present?

Answer 1

1. In nearly 50% of affected children, the cyst manifests as an infected midline upper neck mass. 2. Unlike branchial cysts, a thyroglossal duct cyst often appears after an upper respiratory infection

Answer 2

1. antibiotics should be directed toward the most common oral organisms, which include various streptococcal species and oral anaerobes. 2. When possible, cultures should be obtained with a FNA for gram stain, aerobic and anaerobic culture, fungal stain and culture, acid-fast bacillus stain, and mycobacterial culture

Answer 3

Thyroglossal cysts and fistulas are similar defects located in or near the midline of the neck; they may extend to the base of the tongue. A pathognomonic sign is vertical motion of the mass with swallowing and tongue protrusion.

Answer 4

1. **US** is a very useful, will reveal the cystic nature of a TGDC but does not provide information about the relationship to surrounding structures including hyoid bone. The presence of infection can change the appearance of TGDCs on US; wall thickening and loss of hypoechoic appearance may be noted. Additionally, the cyst fluid can also contain protein, causing the normal uniform hypoechoic appearance to be lost. 2. **CT scan** is image mode of choice N.B. Thyroid function should always be assessed preoperatively in all cases of thyroglossal duct cysts

Answer 5

1. iv **antibiotics**, followed by definitive surgery once the infection has resolved -cephalexin, amoxicillin-clavulanate or clindamycin (empirical coverage for methicillin-resistant MRSA not recommended unless culture indicates it) 2. Once the infection clears completely, the patient should undergo an elective **Sistrunk procedure**. 3. I & D should only be considered in cases of abscesses that do not respond to antibiotics. Incision and drainage can allow seeding of ductal cells outside the cyst and, in turn, increase chances of recurrence Additionally, definitive surgery is easier in the absence of scar tissue or a cutaneous fistula

Answer 6

Sore throat plus at least 1 of the following features qualifies as a counting episode: 1. **Temperature** of greater than 38.3°C (100.9°F) 2. **Cervical** adenopathy (tender lymph nodes or lymph node size \>2 cm) 3. Tonsillar **exudate** 4. **Culture positive** for group A β-hemolytic streptococcus

Answer 7

- 7 episodes in the previous year, - 5 episodes in each of the previous 2 yr, - 3 episodes in each of the previous 3 yr **Paradise Criteria for Tonsillectomy**

Answer 8

1. temporary tracheotomy. 2. Procedures that widen the posterior glottis to relieve the obstruction include laryngotracheal reconstruction using an endoscopically placed posterior glottis cartilage graft, or arytenoidectomy, or arytenoid lateralization

Answer 9

1. awake flexible laryngoscopy. 2. investigation for the underlying primary cause a. neurology (MRI) and cardiology (Echo) b. diagnostic endoscopy of the larynx, trachea, and bronchi.

Answer 10

**injection laterally** to the paralyzed vocal cord moves it medially to reduce aspiration and related complications.

Answer 11

surgical treatment for 1. gastrointestinal (tracheoesophageal fistula) 2. cardiovascular (patent ductus arteriosis repair) anomalies

Answer 12

myelomeningocele, Chiari malformation, and hydrocephalus

Answer 13

Vocal cord paralysis is the **third** most common congenital laryngeal anomaly that produces stridor in infants and children

Answer 14

**Bilateral** - high-pitched inspiratory stridor - phonatory sound or inspiratory cry. **Unilateral paralysis** - causes aspiration, coughing, and choking - the cry is weak and breathy - stridor and other symptoms of airway obstruction are less common

Answer 15

Vocal cord paralysis in infants usually resolves spontaneously within 6-12 mo. If it does not resolve within 2-3 yr, it is unlikely to do so.

Answer 16

1. Recurrent AOM with middle ear effusion 2. Bilateral OM with chronic effusion \> 3 months with conductive hearing loss (most common) or school problems/discomfort

Answer 17

1. Age \< 7 yo 2. Not obese

Answer 18

1. Iris 2. Choroid 3. Ciliary body -all the same tissue embryologically

Answer 19

1. Poor PO intake/vomiting or hemorrhage immediately post-op 2. Age \< 3 yo 3. Poor socioeconomic condition 4. Comorbid medical issues: ie. sickle cell, craniofacial abn 5. Indication for T&A was OSA or PTA 6. Bleeding disorder 7. Long drive home

Answer 20

1. Downslanted palpebral fissures 2. Malformed auricles 3. Malar hypoplasia 4. Mandibular hypoplasia

Answer 21

No deep sea diving, no swimming in dirty water (lakes/oceans) -can swim in pools/be in a bath but need ear plugs

Answer 22

1. Chronic nasal obstruction or obligate mouth breathing 2. OSA with FTT, cor pulmonale 3. Dysphagia 4. Speech problems 5. Severe orofacial/dental abn 6. Recurrent/chronic adenoiditis/sinusitis if medical management failed (3 or more episodes/yr) 7. Recurrent/chronic OME

Answer 23

Absolute (4): 1. OSA: AHI \>1 -get the child on nasocorticosteroid sprays asap! Can decrease AHI by 50% 2. Suspected malignancy 3. Recurrent hemorrhagic tonsillitis (usually seen in teen girls) 4. Severe dysphagia Relative (2): 1. Recurrent acute tonsillitis: 3-7 episodes per year depending on different organizations 2. Recurrent peritonsillar abscess

Answer 24

Peritonsillar abscess: should have TRISMUS, UVULAR DEVIATION and symptoms should be present for AT LEAST 48 hrs! -if none of these things, even if 1 tonsil looks bigger than the other, can still be tonsillitis

Answer 25

Submucosal cleft palate -may not be able to see it so need to palpate -can present with hypernasal speech, eustacian tube defects, chronic middle ear disease

Answer 26

Peritonsillar abscess!!!!! Remember that in the 20 yo girl you saw at Civic Hospital whose peritonsillar abscess you drained! -most common in adolescents -GAS most common cause; can also be from oral anaerobe -treatment: 1. Surgical drainage (needle aspiration) 2. Abx against GAS and anaerobes (Amoxi-clav) Consider tonsillectomy if: 1. Recurrence 2. No improvement after abx or needle aspiration Most serious complication: aspiration pneumonia if BURSTS

Answer 27

1. Prolonged epistaxis \> 30 minutes despite pressure 2. Refractory to acute measures 3. Less than 2 yo 4. More than 2 per week 5. History or exam findings of bleeding disorder

Answer 28

Vertical motion of the mass with swallowing and tongue protrusion

Answer 29

Septal hematoma = may get infected OR if bilateral, may cause ischemia to the nasal septum resulting in saddle nose deformity

Answer 30

Cyst associated with a major salivary gland in the sublingual area. Bluish, fluctuant, can affect the opening of the mouth -it is a large, soft mucus containing swelling in the floor of the mouth -cyst should be excised

Answer 31

Reflux = may need to treat to see improvement in laryngomalacia

Answer 32

Yes! -in 3 wks of age: urine will no longer be positive so need a neonatal dry blood spot or MRI

Answer 33

-thyroglossal duct cyst: moves with tongue protrusion and is midline -dermoid cyst: midline, see calcifications on plain films -branchial cleft cyst: smooth along the SCM border (lateral) -laryngocele: enlarges with valsalva -cystic hygroma: transilluminates and is compressible

Answer 34

1. Symptoms and signs consistent with sinus inflammation: rhinorrhea, headache, facial tenderness 2. Fever 3. Purulent nasal discharge \> 3 days 4. No improvement after \> 10 days after watchful waiting or worsening symptoms despite antibiotics \*\*\*\*Only start antibiotics at 14 days of symptoms and also start nasal decongestants at the same time so that it opens up the nose and allows the abx to absorb from the vessels \*\*\*\*Can start with xray or do CT sinuses

Answer 35

Apparent enlargement (tonsil is rotated) vs. true enlargement True enlargement 1. Infectious: tonsillitis, peritonsillar abscess 2. Benign hypertrophy (chronic) 3. Neoplastic: lymphoma -rapid growth -dysphagia -cervical nodes -night sweats

Answer 36

1. Congenital muscular torticollis = uterine positioning 2. Sternocleidomastoid tumor 3. Klippelfeil syndrome (fusion of cervical motion segments) 4. Brachial plexus injury 5. Clavicle fracture

Answer 37

1. Do CT scan to r/o sub periosteal or intracranial abscess first 9 if present, then for immediate drainage) 2. Start on IV abx asap (most of the time, there is response) 3. MAY require surgical drainage IF no improvement on IV abx x 48 hrs - Bezold's abscess: pus from mastoiditis escapes into SCM muscles

Answer 38

See middle ear fluid without signs or symptoms of inection -management: 1. Observation = 90% resolve after 3 months 2. Document degree of hearing loss if \> 3 mo and consider myringotomy for ear tubes

Answer 39

Tympanometry: looks at how much TM moves -if stiff with effusion, moves less

Answer 40

Peritonsillar abscess: aspiration pneumonia Retropharyngeal abscess: airway obstruction

Answer 41

Ethmoid at birth, then maxillary at 1 yo, then sphenoid at 4 yo, then frontal in preadolescent

Answer 42

Medical therapy: 1. 2 weeks of ointment (polysporin ointment, rhinaris, citaris) BID snorted up the nose -if this doesn't work- 2. Transexamanic acid or cautery -if this doesn't work- 3. THEN do bloodwork to rule out coagulopathy

Answer 43

1. **Pressure** first x 5 minutes - upright position with the head tilted forward 2. If that doesn't work, local application of a solution of **oxymetazoline** -0.25-1% 3. During the winter, or in a dry environment, a room humidifier, saline drops, and **petrolatum (Vaseline)/mupirocin cream** applied to the septum can help to prevent epistaxis. 4. If bleeding persists, an **anterior** nasal pack may need to be inserted; if bleeding originates in the **posterior** nasal cavity, combined anterior and posterior packing is necessary 5. After bleeding is under control, and if a bleeding site is identified, its obliteration by **cautery with silver nitrate** may prevent further difficulties (only 1 side of the septum should be cauterized at a time to reduce the chance of a septal perforation) then pack with vaseline strip gauze or gel foam 3. If that doesn't work: then call ENT to do nasal packing \*\*\*cautery may not be great because it might traumatize the tissue around the bleed so if you do cauterize, need to do medical therapy x 2 wks post Most nosebleeds originate from septal wall: Little's area **Most likely Dx:** Adolescent male: **Juvenile angiofibroma** = usually unilateral, always same side, may have element of nasal obstruction

Answer 44

Worsens when lying supine, improved when prone

Answer 45

Use \> 3 days

Answer 46

1. severe epistaxis despite conservative medical measures -surgical ligation techniques or embolization. 2. severe or repeated epistaxis, blood transfusions may be necessary. 3. ENT evaluation is indicated for these children and for those with bilateral bleeding or with hemorrhage that does not arise from the Kiesselbach plexus.

Answer 47

The clinical diagnosis of acute bacterial sinusitis is based on history. 1. Persistent symptoms of **URTI** including _nasal discharge_ and _cough_ \> **10 days** without improvement, OR 2. S**evere respiratory symptoms**, including _temperature_ of at least 39°C (102°F) and _purulent nasal discharge_ for **3-4 consecutive days,** suggest a complicating acute bacterial sinusitis.

Answer 48

history of persistent respiratory symptoms, including _cough, nasal discharge, or nasal congestion_, **lasting \> 90 days.**

Answer 49

1. amoxicillin (45 mg/kg/day divided bid 2. penicillin-allergic patient include cefdinir, cefuroxime axetil, cefpodoxime, or cefixime. 3. older children, levofloxacin is an alternative antibiotic. N.B. Azithromycin no longer indicated because of a high prevalence of antibiotic resistance

Answer 50

1. antibiotic treatment in the preceding 1-3 mo 2. fail to respond to initial therapy with amoxicillin within 72 hr 3. daycare attendance/age younger than 2 yr) 4. children with severe sinusitis

Answer 51

Ceftriaxone (50 mg/kg, IV or IM)-should be followed by a course of oral antibiotics.

Answer 52

erythema and swelling of the tissues surrounding the globe,

Answer 53

1. Proptosis, chemosis, and eye pain 2. decreased visual acuity, double vision and impaired extraocular movements,

Answer 54

visualization y laryngoscopy of red, swollen epiglottis

Answer 55

lateral radiographs of the upper airway first -the thumb sign

Answer 56

1. **ETT/tracheostomy** is indicated in ALL patients with (regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with \<1% of those with an artificial airway) 2. All Px should receive **O2** unless it causes distress 3. C**efotaxime, ceftriaxone,** or meropenem (10-40% of H. influenzae type b cases are resistant to ampicillin)

Answer 57

1. not routinely recommended for household, childcare, or nursery contacts of patients with invasive H. influenzae type b infections, but careful observation is mandatory, with prompt medical evaluation when exposed children develop a febrile illness. 2. Indications for rifampin prophylaxis (20 mg/kg orally once a day for 4 days; maximum dose: 600 mg) for all household members include a child within the home who is **younger than 4 yr** of age and incompletely immunized, **younger than 12 mo** of age and has not completed the primary vaccination series, or **immunocompromised**.

Answer 58

Bacterial tracheitis is an acute bacterial infection of the upper airway that is potentially life threatening.

Answer 59

**Aerobic:** 1. S. aureus most commonly (+/- MRSA) 2. S. pneumoniae, S. pyogenes, 3. Moraxella catarrhalis & nontypeable H. influenzae **Anaerobic organisms**

Answer 60

- mean age 5 and 7 yr, M\>F - often post laryngotracheitis (bacterial complication of a viral disease), - more common than epiglottitis in vaccinated populations.

Answer 61

- brassy cough (viral laryngotracheobronchitis). - High f**ever + “toxicity”** with **Resp distress** can occur after a few days of apparent improvement. - The patient can lie flat, **does not drool,** **NO dysphagia** associated with epiglottitis. - usual treatment for croup (racemic epinephrine) **is ineffective.**

Answer 62

-only 50-60% of patients require intubation for management --younger patients are more likely to need intubation

Answer 63

- mucosal swelling at the level of the cricoid cartilage, - with copious, thick, purulent secretions, sometimes causing pseudomembranes

Answer 64

- evidence of bacterial upper airway disease, which includes: 1. high fever, purulent airway secretions, and an absence of the classic findings of epiglottitis. 2. X-rays are **NOT** needed but can show the classic findings 3. purulent material is noted below the cords during endotracheal intubation & Thick tracheal membranes seen on rigid bronchoscopy.

Answer 65

1. iv vancomycin or clindamycin AND a 3rd cephalosporin (e.g., cefotaxime or ceftriaxone). 2. **artificial airway** should be strongly considered. 3. Supplemental **oxygen** is usually necessary.

Answer 66

1. **CXR** a. patchy infiltrates and focal densities. b. Subglottic narrowing and a rough and ragged tracheal air column can often be demonstrated radiographically. 2. If airway management is not optimal, **cardiorespiratory arrest** can occur. 3. **Toxic shock syndrome** has been associated with staphylococcal and group A streptococcal tracheitis

Answer 67

1. **Viral**: The parainfluenza viruses (types 1, 2, and 3)- 75% o influenza A + B, adenovirus, RSV and measles. 2. **Bacterial**: Mycoplasma pneumoniae

Answer 68

- 3 mo and 5 yr, with the peak in the 2nd yr of life. - higher in boys., late fall and winter - Recurrences are frequent from 3-6 yr - 15% of patients have a strong family history of croup.

Answer 69

1- URTI Sx -(coryza, pharyngitis, cough), and low-fever for 1-3 days before the signs and symptoms of upper airway obstruction become apparent. 2. Then “barking” cough, hoarseness, and inspiratory stridor. 3. Sx worse at night and often recur with decreasing intensity for several days and resolve completely within a week. 4. Agitation and crying greatly aggravate the symptoms and signs.

Answer 70

- hoarse voice, coryza, inflamed pharynx, and a slightly increased respiratory rate. P - The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management.

Answer 71

1. Croup is a clinical diagnosis and does not require a radiograph of the neck. 2. Radiographs of the neck can show the **typical subglottic narrowing, or steeple sign,** of croup on the PA view 3. S**ensitivity and specificity:** - steeple sign may be absent in patients with croup - may be a normal variant, in epiglottitis. 4. The radiographs **do not correlate well** with disease severity. 5. Radiographs should be considered o**nly after airway stabilization** in children who have an **atypical presentation** or clinical course.

Answer 72

1. Oxygen 2. Steroids 3. Adrenaline 4. Helium-oxygen mixture (heliox) may be considered in the treatment of children with severe croup for whom intubation is being considered although the evidence is inconclusive

Answer 73

1. reduced hospitalization, 2. shorter duration of hospitalization 3. reduced need for subsequent interventions such as epinephrine administration.

Answer 74

1. oral dexamethasone used a single dose of 0.6 mg/kg, 2. Intramuscular dexamethasone and nebulized budesonide have an equivalent clinical effect; N.B. A single dose of oral prednisolone is less effective.

Answer 75

Px with varicella or tuberculosis

Answer 76

1. progressive stridor, severe stridor at rest, 2. respiratory distress, hypoxia, cyanosis, 3. depressed mental status, 4. poor oral intake, or the need for reliable observation.

Answer 77

- Age 1-3 yr - similar to acute croup, except that the Hx of a viral prodrome and fever in the patient and family are often absent. - The cause is viral in some cases, but allergic and psychologic factors may be important in others - Spasmodic croup might represent more of an allergic reaction to viral antigens than direct infection, although the pathogenesis is unknown.

Answer 78

- awakens with a barking, metallic cough, noisy inspiration, and respiratory distress and appears anxious and frightened. - may be preceded by mild to moderate coryza and hoarseness. - The patient is usually afebrile.

Answer 79

- symptom severity diminishe within several hr, - next day well except for slight hoarseness and cough. - Similar, less severe, attacks for next 1-2 days - Such episodes often recur several times.