ENT Flashcards
What can ptosis cause in children?
- Obstructs visual axis
- Can cause permanent visual acuity loss (from deprivation amblyopia)
Treatment of nasolacrimal duct obstruction
Most clear spontaneously in 1st year
- Massage over sac
- Clean lids and medial canthal area
- Topical abx if superinfection
- Probing (80% success rate)
What is dacryocyctitis?
- Infection of nasolacrimal sac
- Usually caused by upper respiratory tract bacteria (S aureus, S pneumo, S pyogenes, etc.)
How can dacryocyctitis be prevented?
Treat nasolacrimal duct obstruction
Describe hyphema
- Layer of blood in anterior chamber
- Can be microscopic or fill entire chamber
What are hyphemas caused by?
Blunt trauma to globe
Who is at high risk for hyphema?
Sickle cell anemia or trait
Potential complications of hyphema
- Increased IOP
- Glaucoma
- Permanent corneal staining
- Vision loss
Treatment of hyphema
- Shield placed over eye
- Head elevated
- Ophtho referral
What is an iris coloboma?
Developmental defect due to incomplete closure of the anterior embryonal fissure
PE finding of iris coloboma?
Pupils reveal “keyhole” shape on penlight exam
What indicates retinal involvement of an iris coloboma?
Poor vision upon exam
What is aniridia?
- Absence of majority of the iris
- Autosomal dominant disorder OR can be a/w Wilms tumor
What can aniridia be associated with?
Wilms tumor
What is glaucoma caused by and what does it result in?
- Caused by increased IOP
- Results in vision loss d/t optic nerve injury, corneal scarring and amblyopia
Signs of glaucoma in the 1st year of life
- Buphthalmos (enlargement of globe d/t low scleral rigidity in the infant eye)
- Tearing
- Photophobia
- Blepharospasm
- Corneal clouding
Signs of glaucoma after 3 yo
Usually only optic nerve changes occur
What is iridocyclitis and what is it associated with?
- Inflammation of iris and ciliary body
- Juvenile idiopathic arthritis (MC girls w/pauciarticular arthritis)
- IBD (MC Crohn’s)
Clinical presentation of iridocyclitis
- May be asymptomatic
- Injection, photophobia, pain,
What is the MC primary intraocular malignancy of childhood?
Retinoblastoma
Clinical presentation of retinoblastoma
- Most present before 3 yo
- MC presenting sign is leukocoria
What is papilledema characterized by?
- Blurred optic disc edges
- Flame hemorrhages
- Enlarged physiologic blind spot
- Visual acuity NORMAL
Purpose of orbital septum?
Helps to decrease risk of an eyelid infection from extending into the orbit
Define orbital cellulitis
Infection posterior to orbital septum
What conditions can cause nystagmus in children?
- Esotropia (crossed eyes)
- Ocular lesions that cause deprivation amblyopia (e.g. ptosis)
- Hypoplastic visual pathways (aka “sensory” nystagmus)
- Can also occur with normal ocular structures (called “motor” nystagmus)
What is the MC origin of nystagmus in childhood?
Ocular
but CNS and inner ear disease can be causes
Define strabismus
Misalignment of the eyes
What can cause strabismus?
Amblyopia
Describe pseudoesotropia
Results from prominent epicanthal folds that give the appearance of crossed eyes when they are actually straight
What needs to be ruled out if there is acute onset of esotropia after 5 yo?
CNS disease
Treatment of esotropia
- Glasses with or w/o bifocals
- Amblyopia treatment
- Surgery
How can strabismic amblyopia occur?
In nondominant eye of a strabismic child
How can refractive amblyopia occur?
In both eyes if significant refractive errors are untreated
How can deprivation amblyopia occur?
Dense cataracts or complete ptosis prevents formation of a formed retinal image
Define amblyopia
Unilateral or bilateral reduction in vision due to strabismus, refractive errors and/or visual deprivation
When does amblyopia occur?
Only during critical period of visual development (1st decade of life) when the visual nervous system is plastic
Treatment of amblyopia
Patching or fogging of the sound eye with cycloplegic drops/lenses/filters (forces nervous system to process input from the amblyopic eye)
MC bacteria causing otitis externa?
S aureus
P aeruginosa
Prevention of otitis externa?
- One footed dance
- 1:1 solution of white vinegar/70% ethyl alcohol before AND after water exposure
- 2% acetic acid drops
Ear plug prevention of otitis externa?
Potentially cause OE more than prevent
How to determine presence of middle ear effusion (MEE)?
- Bulging TM
- Limited or absent mobility of TM
- Air-fluid level behind TM
- Otorrhea
Risk factors for otitis media
- Bacterial colonization of UR tract (children in daycare)
- Viral URI
- Smoke exposure
- ET dysfunction
- Impaired host immune defenses
- Bottle feeding/pacifier
- Genetic susceptibility
What must be assessed upon examination for otitis media?
Mobility of TM!
Treatment of otitis media
- Pain management
- Watchful waiting
- Abx (Amoxicillin 1st line, Augmentin 2nd line)
Prevention of otitis media
- Abx prophylaxis (maybe)
- Lifestyle modifications (tobacco, breast feeding, pacifiers, daycare)
- Surgery (but WAIT at least 3 months)
- Immune evaluation (allergy testing)
- Vaccines (PCV13, influenza)
Indications for PE tubes?
- MEE persists for 4 or more months
- Bilateral hearing impairment of 20 dB or more
Describe mastoiditis
Complication of otitis media BUT often no prior history of it (only 35%)
MC clinical presentation of mastoiditis
- Postauricular pain
- Down or outwardly displaced pinna (Dumbo ear)
Treatment of mastoiditis
- Myringotomy with or w/o tube followed by IV abx and (cipr)ofloxacin ear drops
- Surgical drainage if no improvement in 24-48 hrs
- Cortical mastoidectomy
Congenital ear malformations:
- Agenesis (atresia)
- Microtia
- Lop ears
- Low set ears
- Preauricular tags
Define microtia
- Congenital ear formation
- External ear that is small, collapsed or only has an earlobe present
- Often associated with aural atresia
Describe “lop ears”
- Congenital ear malformation
- Folded down or protruding (Dumbo ears)
- Taping is effective in 1st 72-96 hrs of life
- Incisionless otoplasty
Describe low set ear
- Congenital ear malformation
- Upper pole is below eyebrow level
- Often a/w renal malformations (so renal US is recommended)
How many URIs occur in young children?
Average 6-7 colds/year
What increases the occurrence of URIs in young children?
Daycare attendance increases # of colds in a year
Treatment of URI in children under 4-6 yo
OTC cold and cough have higher side effects than benefit - NOT recommended
How does sinusitis present?
Persistent URI symptoms lasting 10 or more days OR worsening symptoms after initial period of improvement
Evaluation of sinusitis
- Gram stain of nasal discharge may not correspond
- Xray findings are non-specific
Potential complications a/w sinusitis
- Orbital preseptal/orbital cellulitis
- Osteitis of the frontal bone (Pott’s puffy tumor)
Treatment of sinusitis
- If mild/mod symptoms, not in daycare, no recent abx: amoxicillin
- Severe symptoms, in daycare or on abx within 90 days: HIGH dose Augmentin
Treatment of sinusitis if toxic or signs of CNS or invasive infection?
Hospitalized with nafcillin and 3rd generation cephalosporin
What is choanal atresia?
- Congenital disorder of the nose
- Back of nasal passage is blocked usually by abnormal bony or soft tissue
How does bilateral choanal atresia present?
Severe respiratory distress at birth
How does unilateral choanal atresia present?
Usually appears later in life as a unilateral chronic nasal discharge
What is bilateral choanal atresia associated with?
50% a/w CHARGE
- Coloboma
- Heart disease
- Atresia of choanae
- Retarded growth and development
- Genital hypoplasia
- Ear anomalies
Symptoms of allergic rhinoconjunctivitis
- Itching of nose, eyes, palate, pharynx
- Paroxysmal sneezing, epistaxis, nasal crease
- Nasal obstruction
- Postnasal drip
- Tearing, periorbital edema
- Infraorbital cyanosis (allergic shiners)
Treatment of allergic rhinoconjunctivitis
- Avoidance of allergens
- Antihistamines, mast cell stabilizers, decongestants, montelukast, corticosteroids, immunotherapy
What is the only form of therapy that alters disease process of rhinoconjunctivitis?
Immunotherapy (3-5 yr duration)
Clinical presentation of infectious mononucleosis (EBV)
- Exudative tonsillitis
- Generalized cervical adenitis
- Fever
- Over 10% atypical lymphocytes on blood smear
- EBV serology
What is herpangina?
- Acute febrile illness that causes pharyngitis
- Caused by Coxsackie group A virus
Clinical presentation of herpangina
Herpanging ulcers (3 mm in size) surrounded by a halo on anterior tonsils, soft palate, uvula
Describe hand, foot, and mouth disease
- Caused by several enteroviruses
- Vesicles, pustules, papules on palms, soles, interdigital, buttocks
What causes pharyngoconjunctival fever and how does it present?
- Adenovirus (often epidemic)
- Exudative tonsillitis, conjunctivitis, lymphadenopathy
About 10% of children with a sore throat and fever have what type of infection?
Group A strep
What is the only way to make a definitive diagnosis of strep pharyngitis?
Throat culture or rapid antigen test
Rapid antigen tests for strep pharyngitis
- Very specific but 85-95% sensitivity
- Positive indicates S pyogenes
- Negative result requires confirmation by culture
Untreated group A strep infection may result in:
Scarlet fever
Possible complication of strep pharyngitis
PANDAS (pediatric autoimmune neuropsych disorders associated with strep) - OCD and/or tics
Describe the strep pharyngitis carrier state
- Harmless
- Self limited (2-6 months)
- Not contagious
What do most unilateral, solitary anterior cervical nodes indicate?
70% due to hemolytic strep infection
20% due to staph
What is the MC cause of indolent mildly tender adenopathy?
Cat scratch disease (caused by B henselae)
What is the pathogen of cat scratch disease?
Bartonella henselae
over 90% of pts have history of contact with kittens
Define early childhood caries (ECC)
Presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child 6 or under
Who is MC affected by early childhood caries?
- Children who have routinely been given a nursing bottle when going to sleep
- Prolonged at-will breast feeding
Define caries
- Bio-film (plaque) induced acide demineralization of enamel or dentin
- Interaction of cariogenic organisms and fermentable carbs may induce demineralization
What is most important when determining ECC risk?
FREQUENCY of sugar ingestion rather than quantity
Cariogenic bacteria:
Mutans strep and lactobacilli
How do children receive the most cariogenic bacteria?
Mother’s or primary caregiver’s mouth (kissing, sharing utensils, orally cleaning pacifier)
Cariogenic vs. periodontal bacteria
- Cariogenic: acid producing and tolerant
- Periodontal: Gram negative, anaerobic, effects tissue health through inflamm host response or by producing proteases and cytotoxins
Role of fluoride with teeth
Inhibits loss of minerals from tooth enamel and encourages remineralization
Describe water fluoridation
CDC recognized as one of 10 great public health achievements of 20th century
