ENT Flashcards
What is the pathophysiology of vocal cord dysfunction?
Episodic unintentional adduction of the vocal folds on inspiration - plus anterior-superior laryngeal compression during phonation
In a child diagnosed with exercise induced asthma, what features would be consistent with vocal cord dysfunction?
Laryngoscopy-vocal cord adduction with inspiration
Truncated inspiratory flow volume loop
Poor response to medications for asthma
Prominent report of stridor at the time of symptoms
What is the treatment of nasal septal hematoma?
Refer to ENT
URGENT I&D to avoid cartilage necrosis and saddle nose deformity
Nasal packing +biaxin
How do you remove a nasal foreign body?
Positive pressure technique (occlude nostril and blow nose, parent’s kiss)
Direct instrumentation
Indications for ENT referral for nasal foreign body
Posterior FBs (ie, not readily visualized by anterior rhinoscopy)
Chronic or impacted FBs
Button batteries which warrant urgent removal
Penetrating or hooked FBs
Any FB that cannot be removed at initial attempt
What is pyriform aperture stenosis?
Overfusion of midline
Other midline defecits
Associated with Aperts and Crouzon
How do you establish an airway in choanal atresia?
McGovern nipple
Intubation
Dilation
Tracheostomy
How does encephalocele present?
Blue, soft, compressible, pulsatile mass in nares
Enlarge with crying
May present with meningitis
Name 3 components of Pierre Robin sequence
Retognathia
Glossoptosis (tongue falling back)
High arched palate
How do you distinguish Apert and Crouzons?
Syndactyly with Aperts
Name 4 clinical features of Apert syndrome
Bicoronal synostosis Maxillary hypoplasia Hypertelorism Protruding eyes Cleft palate Syndactyly
Name 4 clinical features of Crouzon syndrome
Same as Aperts, but less severe, less clefting and no syndactyly
Spot diagnosis: http://www.neurologyindia.com/articles/2010/58/5/images/ni_2010_58_5_815_72206_f1.jpg
Pott’s puffy tumour (frontal osteomyelitis)
How does invasive fungal sinusitis present?
Acute sinusitis with fever Nasal congestion Purulent nasal discharge, headache Sinus pain Nasal ulceration Periorbital swelling Facial numbness dipliopia
Suspect in immunocompromised patients and diabetes
Name 4 conditions with nasal polyps
Antrochoanal polyp
Wegener’s
CF
PCD
Male, teenager with unilateral epistaxis. Mass in nose. What is the diagnosis?
Juvenile nasal angiofibroma
Management of epistaxis
- Direct compression x 5 minutes, bent forward
- Topical vasoconstrictor (e.g. oxymetazoline)
- Nasal packing
- Cautery with silver nitrate if hemostasis has been achieved
- If persistent posterior bleeding, ENT for posterior packing
Name 5 clinical signs of peritonsillar abscess
Unilateral tonsil bulge
In palate
Uvula deviated to one side
Trismus***
Name 2 clinical signs of RPA
Midline bulge in retropharynx
Torticollis
How do you distinguish button battery from coin on xray?
Step deformity
Halo signs
Indications for tonsillectomy
- Recurrent tonsillitis
>7 episodes in 1 year
>5 episodes/yr in each of 2 years
>3 episodes/yr in each of 3 years
Each episode must have sore throat +one of exudate/adenopathy/swab positive/>T38.3
- PFAPA
- Peritonsillar abscess
- Antibiotics intolerance
- OSA
Complications of RPA
Airway obstruction
Septicemia
Aspiration pneumonia if the abscess ruptures into the airway
Internal jugular vein thrombosis***can cause H/A
Jugular vein suppurative thrombophlebitis (Lemierre’s syndrome)
Carotid artery rupture [53]
Mediastinitis (suggested by widening of the mediastinum on chest radiograph)
Atlantoaxial dislocation
Name 3 clinical features of Lemierre’s disease
Fever
Localized neck/throat pain (antecedent pharyngitis)
Tenderness, swelling induration overlying the jugular vein, over the angle of the jaw or along the sternocleidomastoid muscle (thrombophlebitis of jugular vein)
Respiratory distress (septic pulmonary emboli)
What antibiotics for RPA?
Clindamycin
At what age does RPA typically present?
2-4 years
How do you diagnose RPA on lateral neck x-ray?
If prevertebral soft tissue is greater than 1/2 width of vertebral body
Name 5 symptoms of EoE
- Feeding dysfunction (median age 2.0 years)
- Vomiting (median age 8.1 years)
- Abdominal pain (median age 12.0 years)
- Dysphagia (median age 13.4 years)
- Food impaction (median age 16.8 years)
- Gastroesophageal reflux disease-like symptoms/refractory heartburn
- Associated with atopic disease
Name 5 causes of vocal cord paralysis
Iatrogenic, most commonly associated with cardiothoracic surgery, thyroidectomy, and tracheoesophageal fistula repair
Idiopathic, probably the result of viral infection and autoimmune disease
Neurologic, including Arnold-Chiari malformation, posterior fossa tumor, meningomyelocele, cerebral agenesis, and hydrocephalus
Breech delivery (stretching of RLN)
Intrathoracic lesions (eg, aberrant great vessels, left heart failure, tumors)
What workup is required for vocal cord paralysis?
CXR
UGI
MRI head and neck
CT chest
Name 5 conditions that can cause stridor in an infant (inspiratory, biphasic and expiratory)
Inspiratory Laryngomalacia Vallecular cyst Saccular cyst FB epiglottitis
Biphasic Subglottic stenosis Subglottic hemangioma Larygngeal cleft Papillomatosis Bilateral VCP
Expiratory Complete tracheal ring Vascular ring Tracheomalacia TEF
Name 3 differentials for congenital midline neck mass
Thyroglossal duct cyst Dermoid cyst Teratoma Cervical cleft Foregut duplication cyst Vascular malformation Plunging ranula
Name 3 differentials for a lateral neck mass
Branchial cleft cyst Laryngocele Fibromatosis Colli (soft tissue mass in SCM) Hemangioma Lymphatic malformation Thymic cyst
What is the treatment and prognosis of fibromatosis colli?
Physiotherapy
80% complete resolution by age 1
20% require surgery if progress to congenital muscular torticollis
How do you diagnose fibromatosis colli?
US
Name 5 risk factors for SNHL
Hereditary SNHL Congenital infections (TORCH) Hyperbilirubinemia Prematurity Ototoxic medications Infection (meningitis) Congenital malformations of inner ear Perilymph fistula Tumours (acoustic neuroma) Trauma Noise exposure
Without newborn screening, what is the mean age of detection of hearing loss?
18-30 months
What audiologic test is used in newborn screening (for patients with NO risk factors)?
Otoacoustic emissions
- Measures outer hair cell loss
- Can have false positive in middle ear effusion
- Does not tell you degree of hearing loss
- If fail, send for automated auditory brainstem response testing (AABR)
What audiologic testing can you use in older kids?
Audiogram
- Visual reinforced audiometry (8 months to 3 years, can miss unilateral hearing loss)
- Play audiometry (3-4 years)
- Conventional (4-6 years)
What automated audiologic testing (AABR) is used for newborn screening in newborns WITH risk factors?
Auditory brainstem response testing
If positive, refer for diagnostic ABR
In tympanometry, what do Type A, Type B, and Type C represent?
Type A-normal
Type B-flat (OME)
Type C-retraction
In a patient with SNHL and delayed walking (18-24 months), what is the cause?
Vestibular dysfunction
Name 3 characteristics of SNHL secondary to CMV
High frequency
Progressive (in 1st 5 years)
Unilateral
What investigations should you order for SNHL?
MRI/CT-before cochlear implant CMV on neonatal blood spot (if >3 weeks, if <3 weeks, can send urine CMV PCR) Genetic panel Consider ECG (congenital long QT) Consider abdominal ultrasound (BOR)
Name 4 causes of conductive hearing loss
OME
Aural atresia
Ossicular chain anomalies
Syndromes (e.g. crouzons, MPS, treacher collins)
How months after AOM do most effusions clear?
90% cleared after 3 months
Name 5 indications for myringotomy tubes
Recurrent AOM with middle ear effusion Bilateral OME >3 months with CHL, vestibular, behavioural problems, school performance Mastoiditis Chronic retraction of TM Lack of response to medical therapy
How do you manage tube otorrhea?
Ciprodex BID x 7 days
Water precautions
Name 10 extracranial complications of AOM
TM perforation Mastoiditis Post-auricular abscess Labyrinthitis Labyrthinthine fistula Facial nerve palsy Bezold's abscess Cholesteatoma
Over what time period do most TM perforations heal?
Within 6 weeks
When do you refer perforated TM to ENT?
Otorrhea persistent/visible perf for months after
When are perforated TMs typically repaired?
9-10 years of age
What is Bezold’s abscess?
Abscess in SCM
Name 5 intracranial complications of AOM
Meningitis Brain abscess SVT Gradenigo's syndrome (petrositis) CSF leak Otic hydrocephalus
In pneumococcal meningitis with otogenic source, what condition should you look for?
Inner ear dysplasia
Name 4 risk factors for developing SNHL after meningitis
Raised ICP Seizures S. pneumonaie Low glucose level/high protein in CSF Length of hospital stay
Name 4 clinical features of Gradenigo Syndrome
Retro-orbital pain
Otorrhea
Abducens palsy
Fever
When should you suspect cholesteatoma in a patient with otorrhea?
Unilateral
Recurrent
Foul smelling
Responds to ototopicals but recurs
What clue on physical exam is suggestive of a subglottic hemangioma?
Facial hemangioma in beard distribution
What is the natural history of laryngomalacia?
Presents in first few days of life
Worsens over first 6 months
Plateaus from 6-12 months
Resolves by 18-24 months
What chest x-ray views should you order if you suspect foreign body?
Inspiratory/expiratory views
Right and left lateral decubitus
When do you suspect mycobacterial avium adenitis?
Bluish hue
Over partoid or submandibular
How do you treat atypical mycobacterium lymphadenitis?
Biaxin x 7 days
Name 3 clinical features that suggest laryngomalacia as an etiology of stridor
Worse in supine position
Improves when prone
Loudest with feeding/sleeping
Intermittent low-pitched “wet” inspiratory stridor
What are the clinical features of BPPV in young children?
Child appears frightened and off balance, often reaching out to steady him or herself Nystagmus Diaphoresis Nausea Vomiting
What condition is associated with BPPV?
Later develop typical migraine headaches
What is cherubism?
- AD genetic condition
- Age 2-5 years
- Progressive, painless, bilateral, symmetric enlargement of mandible and/or maxilla, from replacement of bone with multilocular cysts
What is Caffey disease? (past question)
- Presents with massive subperiosteal new bone formation
- Usually involves diaphyses of long bones, ribs, mandible***, scapulae, clavicles
- Fever and pain
- X-ray: subperiosteal cortical hyperostosis***
- -Onset around 2 mo → spontaneous resolution by 2 yo
