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Royal College Peds 2021 > ENT 2019 > Flashcards

ENT 2019 Flashcards

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1
Q

Epiglottitis What is the clincial picture?

A
  1. high fever/toxic
  2. sudden onset sore throat/drooling + hyperextended neck + tripod position
  3. dyspnea + rapidly progressing respiratory obstruction in an attempt to maintain the airway.
  4. The barking cough typical of croup is rare. Usually, no other family members are ill with acute respiratory symptoms.
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2
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A
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3
Q

1 mo boy presenting with progressively worsening biphasic stridor. No history of intubation. What is the most likely diagnosis? Next step in management? -what if it was inspiratory stridor? Expiratory?

A

Vocal cord paralysis!! Next step: immediate ENT referral and get MRI of the brain!! Need to look at course of recurrent laryngeal nerves from Cranial nerve CN 9/10 to the nerve itself -Insp stridor = think laryngomalacia -exp stridor = think trachomalaceia -biphasic stridor = think vocal cord paralysis

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4
Q

16 month boy has weekly episodes of falling down suddenly and refusing to get up. Remains conscious and eyes are noted to move during the episode. Recovers within a few minutes. Sometimes vomits. What is his diagnosis? -what is one associated condition?

A

Benign paroxysmal vertigo = sudden attack of feeling like the room is moving around you; dizziness, little children will tend to drop to the floor, horizontal nystagmus can occur. Can have nausea and vomiting. Usually seen in children

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5
Q

2 most common causes of swollen midline neck mass? -first step in work-up?

A
  1. Thyroglossal duct cyst = cystic mass 2. Dermoid cyst = solid mass 3. Lymphadenopathy First step in work-up: ultrasound
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6
Q

A patient has recurrent sore throats. What are indications for tonsillectomy?

A
  1. Watchful waiting should be done for recurrent sore throats UNLESS Paradise criteria are met: -7 episodes in preceding year or 5/yr x 2 yrs or 3/yr x 3 yrs PLUS s/s with each episode: fever, lymphadenopathy, recurrent strep infections, etc.
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7
Q

Answer the following questions: 1. Most common cause of nasal obstruction is? 2. Unilateral purulent discharge in a child is most commonly due to? 3. 90% of epistaxis is from the?

A
  1. Nasal obstruction = viral rhinitis 2. Unilateral purulent discharge = foreign body 3. 90% of epistaxis = anterior septum
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8
Q

Branchial cleft cysts How do they present?

A
  1. may be unilateral or bilateral (2-3%)
  2. may open onto the cutaneous surface or drain into the pharynx.
  3. Secondary infection is an indication for systemic antibiotic therapy.
  4. These anomalies may be inherited as autosomal dominant traits.
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9
Q

Branchial cleft cysts and sinuses What are they?

A
  1. 2nd branchial cleft cysts are the most common.
  2. Cysts and sinuses in the neck may be formed along the course of the 2nd branchial clefts as a result of improper closure during embryonic life.
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10
Q

Hearing How common is hearing loss in newborns?

What is the average age of detection if no screening?

A
  1. 2-4 /1000 births
  2. without screening –mean age of detection is 18-30 months
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11
Q

Hearing loss etiology What are the types and which one is most common?

A
  1. Central in origin
  2. Peripheral
    a. conductive…most common
    b. sensorineural, or mixed.
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12
Q

Hearing loss What are causes of SNHL?

A
  1. Damage:
    a. hair cell destruction from noise, disease, or ototoxic agents
    b. lesions of the acoustic division of the 8th nerve.
  2. Malformations:
    a. cochlear malformation;
    b. perilymphatic fistula of the round or oval window membrane;
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13
Q

Hearing loss What are the causes of CHL?

A
  1. Congenital causes:

Anomalies of the pinna, external ear canal, TM, and ossicles.

  1. Genetic -Pierre-Robin, Treacher Collins, Klippel-Feil, OI
  2. Acquired (Most CHL is acquired, OME the most common)
    a. TM perforation (e.g., trauma, OM), OME , tympanosclerosis
    b. ossicular discontinuity (e.g., infection, cholesteatoma, trauma), ,
    c. acquired cholesteatoma, or masses in the ear canal or middle ear (e.g., Langerhans’ cell histiocytosis, salivary gland tumors, glomus tumors, rhabdomyosarcoma)
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14
Q

Hearing loss What are the causes of conductive hearing loss?

A

1. Ear canal: atresia or stenosis, impacted cerumen, or foreign bodies.

  1. middle ear,
    a. perforation of the tympanic membrane (TM),
    b. discontinuity or fixation of the ossicular chain,
    c. otitis media (OM) with effusion,
    d. otosclerosis, and cholesteatoma
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15
Q

Hearing loss What are the causes of Central (or retrocochlear) hearing loss?

A

An auditory deficit originating along the central auditory nervous system pathways from the proximal 8th nerve to the cerebral cortex

a. Tumors or demyelinating disease of the 8th nerve and cerebellopontine angle.
b. Central auditory processing disorders

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16
Q

Hearing loss What are the risk factors?

A

Risk factors (ABCD’s)

A- affected family member

B - bilirubin and hypoxia, Low APGARS, meningitis

C congenital intrauterine infection (TORCH)

D defects of the ear, nose and throat

S small at birth (<1500 g), low apgar, NICU

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17
Q

Hearing loss What are the syndromic to non syndromic causes of Hearing loss?

A

Branchio-otorenal syndromes = (BOR)

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18
Q

Hearing loss What is Connexin 26?

What are the genetics of Connexin 26?

How does it cause hearing loss?

A
  1. most common genetic cause of hearing loss

• AR & mutations in GJB2 gene

  1. How does it cause hearing loss?
    - codes trans-membrane gap junction protein
    - allows fluids and small molecules. to pass
    - recycles K+ between endolymph

and stria vascularis

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19
Q

Hearing screening What are the 3 screening tests?

A
  1. Otoacoustic emissions (OAE) – initial screen
  2. Auditory brainstem evoked responses (ABR) – correlates highly with hearing, more detailed
  3. Audiometry – provides fundamental description of hearing sensitivity
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20
Q

Hearing What % of hearing losss is perinatal vs genetic/hereditary?

A
  • 50 % genetic/hereditary & 50% perinatal/acquired
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21
Q

In a child with recurrent severe chronic epistaxis with normal coags, what is your next step in management?

A

Refer to ENT for endoscopy/possible imaging = need to rule out angiofibroma!

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22
Q

Retropharyngeal abscess What are the complications?

A
  1. upper airway obstruction,
  2. rupture leading to aspiration pneumonia
  3. extension to the mediastinum.
  4. Thrombophlebitis of the internal jugular vein and erosion of the carotid artery sheath can also occur
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23
Q

Sinuses Pneumatized by age?

A
  1. ethmoidal and maxillary sinuses are present at birth, but only the ethmoidal sinuses are pneumatized.
  2. maxillary sinuses pneumatized by 4 yr of age.
  3. sphenoidal sinuses are present by 5 yr of age, whereas the 4. Frontal sinuses begin development at 7-8 yr and completely developed adolescence
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24
Q

Sinusitis What % of viral sinusitis becomes bacterial?

A

2%

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25
Q

Thyroglossal cyst How do they present?

A
  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
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26
Q

Thyroglossal cyst Infected cysts - How do you investigate it?

A
  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
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27
Q

Thyroglossal cyst What are they?

A

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.

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28
Q

Thyroglossal cyst What is the best way to image it?

A
  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.

  1. CT scan is image mode of choice

N.B. Thyroid function should always be assessed preoperatively in all cases of thyroglossal duct cysts

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29
Q

Thyroglossal cyst What is the treatment plan?

A
  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
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30
Q

Tonsillitis Tonsillectomy Clinical features required for paradise criteria

A

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
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31
Q

Tonsillitis Tonsillectomy - What are the Minimum frequency of sore throat episodes

A
  • 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

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32
Q

VCP How is bilat VCP managed?

A
  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
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33
Q

VCP How is the Dx made?

A
  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.
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34
Q

VCP How is unilateral VCP with aspiration managed?

A

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

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35
Q

VCP What are the causes of Unilateral vocal cord paralysis?

A

surgical treatment for

  1. gastrointestinal (tracheoesophageal fistula)
  2. cardiovascular (patent ductus arteriosis repair) anomalies
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36
Q

Vocal chord paralysis (VCP) What Congenital CNS lesions are associated with bilateral VCP?

A

myelomeningocele, Chiari malformation, and hydrocephalus

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37
Q

Vocal chord paralysis How common is it?

A

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

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38
Q

VCP What is the differnce in presentation between bilateral vs Unilateral chord paralysis?

A

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
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39
Q

VCP What is the natural course?

A

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.

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40
Q

What are 4 indications for tympanostomy?

A
  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
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41
Q

What are the 2 positive predictive factors on whether a T&A will cure OSA in a patient?

A
  1. Age < 7 yo 2. Not obese
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42
Q

What are the 3 parts of the uvea?

A
  1. Iris 2. Choroid 3. Ciliary body -all the same tissue embryologically
43
Q

What are the criteria for admission and overnight observation post T&A? (7)

A
  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
44
Q

What are the features of Treacher-Collins syndrome?

A
  1. Downslanted palpebral fissures 2. Malformed auricles 3. Malar hypoplasia 4. Mandibular hypoplasia
45
Q

What are the guidelines around swimming in a child with tympanostomy tubes?

A

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

46
Q

What are the indications for adenoidectomy? (7)

A
  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
47
Q

What are the indications for tonsillectomy? -absolute (4)? -relative (2)?

A

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

48
Q

What are the key differentiating factors between tonsillitis and peritonsillar abscess?

A

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

49
Q

What condition is a bifid uvula associated with?

A

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

50
Q

What condition is trismus most commonly associated with? -most common organisms? -treatment? -when to consider tonsillectomy? (2) -most serious complication?

A

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

51
Q

What criteria warrant further evaluation in a child presenting with epistaxis?

A
  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
52
Q

What is a pathognomonic sign of a thyroglossal duct cyst?

A

Vertical motion of the mass with swallowing and tongue protrusion

53
Q

What is a possible complication of nasal fracture?

A

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

54
Q

What is a ranula? -treatment?

A

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

55
Q

What is an associated condition that may worsen laryngomalacia?

A

Reflux = may need to treat to see improvement in laryngomalacia

56
Q

What is the best way to diagnose CMV as a cause of congenital hearing loss? Does it matter by age group?

A

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

57
Q

What is the CLASSIC feature associated with the following neck masses: -thyroglossal duct cyst -dermoid cyst -branchial cleft cyst -laryngocele -cystic hygroma

A

-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

58
Q

What is the criteria performing imaging for sinusitis? -when do you start antibiotics?

A
  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

59
Q

What is the ddx for unilateral tonsillar enlargement?

A

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

60
Q

What is the differential diagnosis for torticollis in newborns? (5)

A
  1. Congenital muscular torticollis = uterine positioning 2. Sternocleidomastoid tumor 3. Klippelfeil syndrome (fusion of cervical motion segments) 4. Brachial plexus injury 5. Clavicle fracture
61
Q

What is the management of mastoiditis?

-what is a Bezold’s abscses?

A
  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
62
Q

What is the management of otitis media with effusion?

A

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
63
Q

What is the most objective test to detect a middle ear effusion?

A

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

64
Q

What is the most serious complication of peritonsillar abscess? -what about retropharyngeal abscess?

A

Peritonsillar abscess: aspiration pneumonia Retropharyngeal abscess: airway obstruction

65
Q

What is the order of pneumatization of sinuses?

A

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

66
Q

What is the treatment for prevention of recurrent epistaxis?

A

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

67
Q

What is the treatment of acute epistaxis?

-adolescent male presents recurrently with epistaxis and it is always on the same side.

What is the most likely diagnosis?

A
  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

  1. 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

68
Q

What position worsens stridor in laryngomalacia/tracheomalacia?

A

Worsens when lying supine, improved when prone

69
Q

When does rebound nasal congestion occur after the use of otrivin?

A

Use > 3 days

70
Q

Epistaxis When should referral to an ENT Dr be made?

A
  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.
71
Q

Sinusitis What is the criteria for Dx of acute sinusitis?

A

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. Severe 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.
72
Q

Sinusitis What is the criteria for Dx of chronic sinusitis?

A

history of persistent respiratory symptoms, including cough, nasal discharge, or nasal congestion, lasting > 90 days.

73
Q

Sinusitis What is thr Rx?

A
  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

74
Q

Sinusitis Whaich Px have risk factorts for risk factors for presence of resistant bacterial species?

A
  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)
  3. children with severe sinusitis
75
Q

Sinisutis Which Abx should be given to children who are vomiting or who are at risk for poor compliance?

A

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

76
Q

Sinusitis Periorbital cellulitis - What are the features?

A

erythema and swelling of the tissues surrounding the globe,

77
Q

Sinusitis Orbital cellulitis - What are the features?

A
  1. Proptosis, chemosis, and eye pain
  2. decreased visual acuity, double vision and impaired extraocular movements,
78
Q

Epiglotitis How do you Dx it?

A

visualization y laryngoscopy of red, swollen epiglottis

79
Q

Epiglotitis What Xray should be taken if unsure of Dx?

A

lateral radiographs of the upper airway first -the thumb sign

80
Q

Epiglottitis What is the approach to management in epiglottitis?

A
  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. Cefotaxime, ceftriaxone, or meropenem (10-40% of H. influenzae type b cases are resistant to ampicillin)
81
Q

Epiglottitis What is the approach to chemoprophylaxis?

A
  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.
82
Q

Bacterial tracheitis What is it?

A

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

83
Q

Bacterial tracheitis What bacteria cause it?

A

Aerobic:

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

Anaerobic organisms

84
Q

Bacterial tracheitis What is the epidemiology?

A
  • mean age 5 and 7 yr, M>F
  • often post laryngotracheitis (bacterial complication of a viral disease),
  • more common than epiglottitis in vaccinated populations.
85
Q

Bacterial tracheitis What is the clinical presentation?

A
  • brassy cough (viral laryngotracheobronchitis).
  • High fever + “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.
86
Q

Bacterial tracheitis What is the role of intubation?

A

-only 50-60% of patients require intubation for management

–younger patients are more likely to need intubation

87
Q

Bacterial tracheitis What is the pathological feature?

A
  • mucosal swelling at the level of the cricoid cartilage,
  • with copious, thick, purulent secretions, sometimes causing pseudomembranes
88
Q

Bacterial tracheitis How is the Dx made?

A
  • 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.
89
Q

Bacterial tracheitis What is the management?

A
  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.
90
Q
A
91
Q

Bacterial tracheitis List complications?

A
  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
92
Q

Croup What organisms?

A
  1. Viral:

The parainfluenza viruses (types 1, 2, and 3)- 75% o

influenza A + B, adenovirus, RSV and measles.

  1. Bacterial: Mycoplasma pneumoniae
93
Q

Croup What is the epidemiology of croup?

A
  • 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.
94
Q

Croup What are the Sx?

A

1- URTI Sx -(coryza, pharyngitis, cough), and low-fever for 1-3 days before the signs and symptoms of upper airway obstruction become apparent.

  1. Then “barking” cough, hoarseness, and inspiratory stridor.
  2. Sx worse at night and often recur with decreasing intensity for several days and resolve completely within a week.
  3. Agitation and crying greatly aggravate the symptoms and signs.
95
Q

Croup What are the physical Signs?

A
  • 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.
96
Q

Croup What is the role of lat neck XRay?

A
  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. Sensitivity 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 only after airway stabilization in children who have an atypical presentation or clinical course.
97
Q

Croup What are the Rx modalities in croup?

A
  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
98
Q

Croup What are the benefits of steroids?

A
  1. reduced hospitalization,
  2. shorter duration of hospitalization
  3. reduced need for subsequent interventions such as epinephrine administration.
99
Q

Croup

Croup How can steroids be given?

A
  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.

100
Q

Croup

Croup Which patients should not receive steroids?

A

Px with varicella or tuberculosis

101
Q

Croup What are the indications for hospitalisation?

A
  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.
102
Q

Croup

Croup Spasmodic croup What is it?

A
  • 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.
103
Q

Croup Spasmodic croup How does it present?

A
  • 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.
104
Q

Croup Spasmodic croup What is the course?

A
  • 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.

Royal College Peds 2021 (55 decks)

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