ENT Flashcards
What are the common URI bugs?
H. influenza
M. catarrhalis
Strep Pneumoniae
What are the classic clinical presentation of acute otitis media (AOM)?
unilateral ear pain relieved w/ pulling on pina
AOM physical exam findings
- loss of light reflex (opaque)
- bulging erythematous TM (esp. if yellow or hemorrhagic = bacterial)
- fluid befind TM (bubbles)
- if TM immobile = Dx
How is AOM Dx’d?
Clx: immobile TM
w/ pneumatic insulflation (puff air –> rigid TM = +)
What are signs that an AOM is bacterial in etiology?
- A bulging tympanic membrane, especially if yellow or hemorrhagic
- Perforation of the tympanic membrane with purulent discharge
How is AOM Tx’d?
<6wks:
- Ix bacteremia, go to ED
6wk-6mo:
- analgesics
- Amox x10 days
> 6mo
w/ RFs: Immediate Tx for: - child w/ high fever (>39) - mod-sev systemically ill or - very severe otalgia or - significantly ill >48 hrs
low RFs: - watchful waiting + analgesics OR give Abx Rx to parents to use if child doesn't improve w/in 48hrs Drug: Amoxicillin <2y/o - x10 days >2 y/o - x5 days
- if/ Tx fail = Amox-clav cefprozil, Ceftriaxone im/iv × 3 days ...consider tympanostomy tubes
How do you Tx recurrent AOM (medically and procedurally)?
Amox-clav 10-14 d
- if >3x/6mo or 4x/yr = Tympanostomy tubes
- pen allergic = Clarithromycin or azithromycin
if Tx fail:
Clindamycin
or FQ (levoflox)
How do the presentations of viral, allergic, and bacterial conjunctivitis generally differ?
VIRAL: - red eye - minimal itch - profuse serous d/c "gritty" -affects 2nd eye 24-48 hrs later
BACTERIAL:
- red eye
- minimal itch
- mod, mucopurulent-purulent (all day)
- usually unilateral
HYPER-acute bacterial:
yellow-green purulent discharge, redness, irritation and tenderness to palpation.
ALLERGIC:
- red eye
- VERY ITCHY
- mod, serous or mucoid
TX for conjunctivitis
all etiologies usually self-limiting
supportive:
- throw out contacts
- wash bed sheets
if Viral:
- OTC antihistamines
if Bacterial:
- Abx (polymyxin B/gramicidin drops, 4-6x/day x7-10 days.. continue 2 days after sxs resolve)
- if no improvement 48 hrs, switch to broad spec drops: trimethoprim/polymyxin B, ophthalmic ointments containing erythromycin or bacitracin
Dacryoadenitis definition
blocked lacrimal glands
Dacryoadenitis - signs and symptoms
Signs & symptoms
- Swelling of upper lid
- Lid redness & erythema
- Lid pain
- Excess tearing or discharge -Swelling of preauricular nodes
Darcryoadenitis - Tx
Management
- Warm compresses
- Think malignancy if no improvement
if purulent d/c, start first-generation cephalosporins to cover G+ves (eg, Keflex 500 mg qid) until culture results are obtained
Strabismus (Tropia) - Definition, Ix, Mx
Def: crossed eyed
Ix: light reflex, cover-uncover test
(Affected eye will drift when covered, then moves quickly back if cover is removed)
- Differentiate congenital from acquired (may be vision-threatening or life-threatening)
Mx: refer to ophtho
Otitis Externa - nick name/Etiology
“swimmer’s ear”
(pseudomonas)
digital trauma
Otitis Externa - Clinical presentation
- unilat. ear pain (otalgia)
- worse pain with manipulation of tragus
- hearing loss
- otorrhea
- fullness
- itching
- recent exposure to water
What are the 2 most common pathogens that cause Otitis Externa?
Pseudomonas aeruginosa (20–60%) and Staphylococcus aureus (10–70%) (and strep)
AOE = bacterial 90% of time
How do you treat otitis externa?
TX = NONE, self resolving…
(analgesics)
summary: if doesn’t and prs looks toxic –> abx/steroid drops
Bacterial:
- neo/poly/HC only if TM intact, - FQ ex. cipro (use a wick if canal is swollen),
- systemic therapy if canal is swollen shut or pt is immunocompromised/DM
- Fungal: acetic acid/HC drops, clotrimazole drops
- Bacterial vs fungal? CASH (drying) powder covers both
- Chronic treat eczema with steroid cream, then use vinegar/water washes and avoid Q-tips
- Malignant emergent referral to ENT
What is a potential complication if otitis extern?
Malignant otitis externa = osteomyelitis of temporal bone as a result of chronic infection in DM, not cancerous!
What are the risk factors/causes for oral candidiasis?
Newborns Uncontrolled Diabetes HIV/AIDS Chemotherpy Side effect of inhaled steroids Side effect of antibiotics Dentures or poor hygiene
What are the Signs & symptoms of oral candidiasis? aka- “thrush”
Signs & symptoms:
-Pseudomembranous form is most common: white plaques
(when you scrape, either red sore or still white under)
-Angular cheilitis with chronic lip-lickers
-Glossitis with broad spectrum antibiotic use
-Cottony feeling in mouth
-Loss of taste
-Pain with eating and swallowing
-May be asymptomatic
Tx for oral candidiasis?
Address underlying cause
Fluconazole 100mg x 7 days for non-immunocompromised patients
½ hydrogen peroxide mouth rinse
OR
-Infants: oral NYSTATIN swabs for 7-14 days, boiling of bottle nipples and pacifiers
-Older children: oral NYSTATIN rinses x14 days or systemic fluconazole PO if severe
(200mg po x1 day, then 100mg po x7 days)
What Ix do you do for oral candidiasis?
Workup
- Lesions can be scraped off and may bleed
- Culture of scrapings (KOH prep)
- Microscopic examination of scrapings
What is Samter’s triad?
syndrome of:
aspirin sensitivity,
nasal polyposis, and
asthma
often seen with allergic rhinitis, frequently leading to severe pansinusitis
What are the S/Sxs of allergic rhinitis?
repetitive sneezing, pruritus of nose, eyes, palate, ears, clear rhinorrhea, nasal congestion, postnasal drip, epistaxis, allergic shiners, Dennie’s lines, allergic salute, retracted TMs, serous effusions, swollen or boggy turbinates, hyperplasia of palate or posterior pharynx
Allergic rhinitis management is….?
- Instruct patients in allergen avoidance: closed windows, bed cases, washing linens weekly, removing stuffed animals, cockroach poison, mould precautions, HEPA filters
- Nasal saline sprays or rinses
- Oral decongestants
- Nasal steroids: fluticasone, flunisolide
- 1st or 2nd gen antihistamines: cetirizine and fexofenadine ok for infants > 6 mo
- Leukotriene inhibitor
- Refer to allergist for kids with mod-severe disease, prolonged rhinitis despite intervention, coexisting asthma or nasal polyps, recurrent otitis media or sinusitis
What are the possible etiologies of nasal polyps?
- Usually a reaction to bacterial infection in kids
- Allergies
- Chronic sinusitis
What are the S/Sxs of nasal polyps?
- Stuffiness
- Feelings of pressure or fullness in the face
- Trouble smelling
What is the Tx/Mx of nasal polyps?
- Steroid nasal spray 1-3mo
- Saline rinses
- Refer for surgical excision but may recur
List 2 complications of untreated Group A strep Pharyngitis
rheumatic fever
glomerulonephritis
What is the clinical presentation of viral pharyngitis?
sore throat, odynophagia
- Concurrent rhinorrhea
- Erythema, edema, dysphagia, fever, lymphadenopathy, diffusely pink throat, cough, fever
What is the clinical presentation of GAS pharyngitis?
common ages, s/sxs, dx criteria
- Uncommon in kids under 2-3
- Sore throat, dysphagia, odynophagia, erythema, airway obstruction, bright beefy red demarcated splotches
- Centor criteria: tender cervical adenopathy, fever > 100.4, no cough, tonsillar exudate
- Abdominal pain and vomiting in peds
What is the CENTOR criteria?
Dx of GAS pharyngitis:
Cough +1 Exudates +1 Nodules (LN) +1 Temp (fever >100.4/>38) +1 OR Age <14 (+1) >44 (-1)
<1 observe, supportive care 2-3 - rapid strep test - if -ve and not concerned, observe - if -ve but concerned = Cx in kids - if +ve = Tx 4+ = Tx
1) What is sore throat + splenomegaly pathonemonic for?
2) what are other s/sxs?
Mono
- Fatigue, malaise, sore throat with tonsillar edema, erythema, and shaggy white-purple tonsillar exudate, lymphadenopathy, hepatosplenomegaly
- Many will have 2° Strep tonsillitis
What is the likely pathogen in Mono?
EBV
How do you test for Mono?
Monospot
-CBC to look for atypical lymphocytes
Clx: shaggy white tonsillar exudate
How do you proceed after doing a Monospot test?
-ve = Cx \+ve = Tx
How do you Tx GAS pharyngitis?
Penicillin 500 mg BID
Amoxicillin 500 mg TID
How do you tx mono?
- OTC pain control
- ? steroids
- Splenic precautions
- Treat tonsillitis (if have 2e strep tonsillitis) but avoid ampicillin due to rxn with mono rash
What is the CP of tonsillitis?
-Swollen tonsils with white plaques
What are the pathogens responsible for tonsillitis?
Viral (can be mono) or bacterial (usually GAS)
What is the workup for ?tonsillitis?
- Rapid Strep
- Monospot
Tx for tonsillitis?
Abx - Amox
What is a surgical emergency/complication of otitis externa?
Mastoiditis
What pathogens cause mastoiditis?
URI bugs (M.cat, S.pneumo, S aureus)
How does Mastoiditis present?
looks like AOM
+ swelling behind the ear
+ anteriorly rotated ear
How is mastoiditis Dx’d and Tx’d?
Dx is Clx (don’t do CT)
Tx: surgical decompression (+ way you were already tx’ing for AOM)
How do you Tx viral pharyngitis?
Symptomatic treatment
NSAIDS or tylenol
Fluids
- Salt water gargles
- Lozenges or hard candy for kids over 4
- Acetaminophen or ibuprofen
- Oral rinse with equal parts lidocaine, diphenhydramine, and Maalox
- Benzydamine HCl mouth rinse
How does a peritonsillar abscess present?
- Severe, one sided sore throat
- Odynophagia – difficulty swallowing
- Fever
- Tender glands – pain in head and neck
- Trismus – difficulty opening the mouth
- HOT Potato Voice – muffled voice
How do you Tx peritonsillar abscess?
-Urgent referral to ENT for I&D
Needle aspiration
Incision and drainage
Tonsillectomy
Antibiotic therapy:
- Amoxicillin – though likely resistant to PCN
- Clindamycin – probably the better choice here.
What are the two kinds of epistaxis?
1) Anterior nosebleed is the most common and originates from Kiesselbach’s plexus.
2) Posterior nosebleed is less common and much more difficult to treat.
What causes epistaxis?
Trauma Dry mucosa Chronic rhinitis Foreign body Clotting issue HTN
Epistaxis Ix
Initially a clinical diagnosis, but you may want to work up other suspicious medical issues
Epistaxis Tx
- Direct pressure – pinch the bridge of the nose for 15 minutes
- Have patient lean forward to avoid swallowing blood leading to nausea and vomiting
- Topical vasoconstrictor ie cocaine or oxymetazoline
- If you can visualize the source silver nitrate may be used to cauterize the vessels
- Packing for 24 hrs if necessary
- Pneumatic tamponade
- Surgical correction
Nasal polyps Ix
Endonasal Cope
CT
What are the usual chief complaints of patient’s with acute pharyngitis?
Sudden onset Fever/chills Difficulty swallowing Tender, swollen throat No cough Typically younger than 15 years old
Ix/PE findings of peritonsillar abscess:
Erythematous pharynx
Uvula displaced towards unaffected side
Ultra sound
CT with contrast
What causes epiglotitis?
Viral infection
Bacterial infection
Haemophilus influenzae – now less likely due to vaccination
What are the chief complaints of pt’s w/ epiglotitis?
High fever Sore throat Difficulty moving air Difficulty swallowing Drooling
labs, Ix, PE findings of epiglotitis?
Stridor Cyanosis Laryngoscopy in OR as it may cause spasms Throat culture X-ray – Thumbprint sign on c-spine film CT
Tx for epiglotitis?
Be prepared for intubation
Keep patient calm and breathing easily
Antibiotics may be necessary
Cephalosporins
Hot potato voice – associated w/?
peritonsilar abscess
Thumb print sign – associated w/?
x-ray finding associated with epiglotitis
White adherent plaque in the mouth – associated w/? (Adults)
– leukoplakia
White non adherent plaque in the mouth – associated w/?
candida
