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ENT Flashcards

1
Q

If you see speech delay in an infant or toddler, what should you suspect?

A

Hearing loss

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2
Q

What are some clues to hearing loss in older children?

A
  1. Ignoring commands

2. Increased volume of TV or music

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3
Q

What are the 2 types of hearing loss?

A
  1. Conductive

2. Sensorineural

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4
Q

What occurs when sound fails to progress to the cochlea?

A

Conductive hearing loss

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5
Q

Where can obstruction occur in conductive hearing loss?

A

Anywhere from external canal to ossicles

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6
Q

What is the most common cause of conductive hearing loss?

A

Effusion (usually due to OM)

Effusion is present in the absence of inflammation

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7
Q

Which type of hearing loss is often correctable with surgery or hearing devices?

A

Conductive

*Sensorineural are less-often correctable

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8
Q

What is needed to facilitate language development in children with all forms of hearing loss?

A

EI

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9
Q

What syndromes is hearing loss associated with?

A
  1. CHARGE

2. Syndromes involving cleft lip and palate

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10
Q

If you have a patients with an external or middle ear malformation, what else should you consider?

A

Craniofacial, renal, or inner ear malformations

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11
Q

What causes the most severe degree of conductive hearing loss?

A

Small, malformed ears (microtia or aural atresia)

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12
Q

What can large perforations from trauma result in?

A

Significant conductive hearing loss

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13
Q

What is post-taumatic conductive hearing loss usually associated with (besides perforation)?

A

Disruption of ossicles themselves

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14
Q

What is tympanosclerosis?

A

Scarring on TM (usually after recurrent OM)… results in minimal conductive hearing loss

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15
Q

What is the most common cause of conductive hearing loss?

A

OM with effusion

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16
Q

What is the result of keratinization of the epithelial cells in the middle ear?

A

Cholesteatoma

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17
Q

9 year old body, purulent discharge from right ear over several months despite several courses of antibiotics. On PE there is retraction of TM and sqamous debris. What next?

A

Refer to ENT… this is a cholesteatoma

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18
Q

How are cholesteatomas managed?

A

Surgical removal- Technically benign, but they expand and destroy bone

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19
Q

Late recognition of what ear findings is a major cause of permanent hearing loss?

A

Cholesteatome

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20
Q

Foul smeeling discharge despite treatment of a perforated TM is a clue to what?

A

Cholesteatoma

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21
Q

What causes sensorineural hearing loss?

A

Malfunction of cochlea and/or auditor nerve

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22
Q

What are 4 general causes of sensorineural hearing loss?

A
  1. Toxic (drugs)
  2. Infectious
  3. Genetic
  4. Traumatic (physical or acoustic)
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23
Q

What 2 diuretics can cause a temporary hearing loss?

A

Lasix and ethacrynic acid (Loops)

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24
Q

The combination of a loop diuretic with what other type of drug amplifies ototoxic effects?

A

Aminoglycosides

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25
Q

What class of antibiotics and what 2 specific drugs are known to cause hearing loss?

A

Aminoglycosdes, Gentamicin and tobramycin

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26
Q

What drug can cause a reversible sensorineural hearing loss?

A

Salicylates

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27
Q

Upon stopping salicylates due to hearing loss, how long does it take for hearing to return to normal?

A

1 week

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28
Q

High-pitched tinnitus should make you think of hearing loss due to what?

A

Salicylate

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29
Q

Name 6 infectious causes of in utero sensorineural hearing loss

A
  1. CMV
  2. Measles
  3. Mumps
  4. Rubella
  5. Varicella
  6. Syphilis
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30
Q

Sudden onset of bilateral sensorineural deafness should make you think of what?

A

Viral labyrinthitis

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31
Q

What is the prognosis for viral labyrinthitis?

A

Variable

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32
Q

What is treatment for viral labyrinthitis?

A

No treatment, just watchful waiting

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33
Q

True or False: Repeated exposure to loud sounds (music, power tools) can lead to high frequency sensorineural hearing loss

A

True

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34
Q

What is the most common cause of sensorineural hearing loss?

A

Congenital CMV

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35
Q

True or False: Infants with congenital CMV may pass their newborn hearing screen

A

True (and they can develop profound hearing loss by age 1

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36
Q

What is the most common cause of childhood sensorineural hearing loss among acquired infections?

A

Bacterial meningitis

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37
Q

When does sensorineural hearing loss occur during bacterial meningitis?

A

Early (within first 24 hours)

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38
Q

What screening test is important to remember in all children with meningitis?

A

Hearing test ASAP

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39
Q

True or False: Development of sensorineural hearing loss in bacterial meningitis is directly related to the severity of illness?

A

False: Not related to severity of illness, age, or when antibiotics were started

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40
Q

True or False: More than 500 causes of syndromic hearing loss have been reported

A

True

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41
Q

What is an X-linked condition that has bilateral sensorineural hearing loss and hematuria?

A

Alport Syndrome

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42
Q

What category of disorders are a big cause of genetic hearing loss?

A

Mitochondrial disorders

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43
Q

What are risk factors for sensorineural hearing loss that are associated with prematurity?

A
  1. Extended assisted ventilation
  2. Hyperbilirubinemia
  3. Low birth weight
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44
Q

What type of therapy poses a risk factor for sensorineural hearing loss?

A

Radiation therapy (for head/neck tumors)

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45
Q

What type of anatomical abnormalities are associated with sensorineural hearing loss?

A

Craniofacial

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46
Q

Name 1 specific syndrome associated with sensorineural hearing loss

A

Waardenburg

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47
Q

When should identification of hearing loss be done by?

A

3 month

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48
Q

When is intervention for hearing loss optimal by?

A

6 months

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49
Q

What are the 2 screening tests for newborns in the nursery?

A
  1. Auditory brainstem response (ABR)

2. Otoacoustic emissions (OAE)

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50
Q

True or False: A completely deaf child will have normal language development until 9 months of age

A

True

*Cooing and babbling don’t depend on hearing

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51
Q

What test uses electroencephalographic waveforms to determine a child’s perceptual threshold?

A

Auditory Brainstem Response

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52
Q

After what age would a child likely need conscious sedation for an ABR (auditory brainstem response)?

A

After 6 months

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53
Q

What hearing test is used for infants who are under 6 months of age?

A

BOA- Behavioral Observational Audiometry (BOA)

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54
Q

What type of test is a BOA (behavioral observational audiometry)?

A

Screening

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55
Q

What is the next step for an infant who fails BOA?

A

They need ABR testing

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56
Q

What type of hearing test is used for older infants and toddlers (6 months-2 years)?

A

Visual reinforcement audiometry (VRA)

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57
Q

What test evaluates for bilateral hearing loss?

A

VRA

*This is important to do so that intervention to prevent language development impairment can be started ASAP

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58
Q

What is required is a patient fails a hearing screen or has equivocal results?

A

They need referral to audiology

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59
Q

What is done to assess hearing in a patient with physical, cognitive, or behavioral concerns that may interfere with administration of a hearing screen?

A

Referral to audiology

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60
Q

Who is the conventional pure-tone audiometry screen appropriate for?

A

School-age children (they have to be able to cooperate with commands)

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61
Q

True or False: The conventional pure-tone audiometry screen can test hearing in each ear independently?

A

True

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62
Q

What usually causes results of a tympanometry screen to be normal versus abnormal (on test)?

A

Technique

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63
Q

What is an example of poor technique for a tympanometry screen?

A

Probe being wedged against external canal

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64
Q

True or False: Tympanometry measures hearing sensitivity

A

False

*You can have a normal tympanogram with significant sensorineural hearing loss or an abnormal tympanogram with normal hearing

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65
Q

By what age should infants with significant congenital sensorineural hearing loss receive targeted intervention by?

A

6 months

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66
Q

What are 2 examples of targeted intervention for infants with significant congenital sensorineural hearing loss?

A

Hearing aids (external) or cochlear implant (implantable)

-This will allow them to hear and develop normally.

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67
Q

What does a flat line on a tympanogram mean?

A

Stiff tympanic membrane, middle ear fluid, or obstructed tympanostomy tube

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68
Q

What is another phrase for a flat line on a tympanogram?

A

Low amplitude

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69
Q

What is a high line on a tympanogram associated with?

A

Hypermobile TM

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70
Q

What does the area under the tympanogram curve reflect?

A

Area in the external canal

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71
Q

What does a high volume on a tympanogram curve reflect?

A

Continuity between the middle and outer ear- Perforated TM (trauma, myringotomy tubes)

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72
Q

What will you see on a tympanogram that reflects the absence of pressure and mobility?

A

High volume (from a perforated TM)

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73
Q

What 2 diagnoses fall under otitis media?

A
  1. Acute otitis media (AOM)

2. Otitis media with effusion (OME)

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74
Q

What are common features of presentation between AOM and OME?

A

Fluid behind TM

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75
Q

What distinguishes AOM from OME?

A

AOM: Inflammation (erythema of TM and pain)
OME: No inflammation

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76
Q

How are AOM and OME best diagnosed?

A

Pneumatic otoscopy

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77
Q

True or False: Erythema of the TM is enough to diagnose AOM?

A

False- Multiple things can make TM erythematous (fever, crying, ect.)

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78
Q

What are the most common bacteria to cause AOM?

A
  1. S. Pneumoniae
  2. H. Flu (non-typeable)
  3. Moraxella catarrhalis
  4. Strep pyogenes (Group A Strep)
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79
Q

Which cause of bacterial AOM is increasing in frequency and which is decreasing?

A

Non-typeable H. Flu is increasing

S. Pneumoniae is decreasing

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80
Q

4 year old with chronic purulent drainage through perforated left TM… best treatment?

A

Topical/Otic ofloxacin with daily suctioning of canal (allows abx to reach infection)

This is chronic suppurative otitis media (with chronic drainage this isn’t AOM, with no keratinized epithelial tissue this isn’t cholesteatoma)

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81
Q

What is the most common cause of chronic suppurative otitis media?

A

Pseudomonas

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82
Q

What is treatment for chronic suppurative otitis media?

A

Topical/Otic ofloxacin with daily suctioning of canal (allows abx to reach infection)

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83
Q

Name 3 potential causes of chronic suppurative otitis media

A
  1. Pseudomonas
  2. Staph
  3. Fusobacterium necrophorum
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84
Q

True or False: Cholesteatoma and chronic suppurative otitis media can occur together

A

True

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85
Q

What can result from chronic suppurative otitis media?

A

Cholesteatoma

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86
Q

True or False: Chronic suppurative otitis media can occur without cholestatoma?

A

True

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87
Q

If a chronic suppurative otitis media doesn’t respond to treatment, what should you consider?

A

Cholesteatoma

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88
Q

True or False: Antibiotic prophylaxis is recommended for the prevention of recurrent otitis media

A

False

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89
Q

Antibiotic prophylaxis in the setting of prevention for recurrent otitis media is a risk factor for what?

A

Colonization with resistant pneumococcus

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90
Q

What is the treatment of choice for recurrent otitis media?

A

Tympanostomy tubes

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91
Q

What should you keep in the back of your head with a child being treated for OM who isn’t responding and has symptoms including fever, irritability, lethargy, headache, double vision, and vomiting?

A

Meningitis

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92
Q

What % of the time do intracranial suppurative complications of otitis media occur?

A

1%

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93
Q

True or False: Withholding antibiotic treatment for 48-72 hours to see if symptoms persist in OM is considered correct treatment

A

True

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94
Q

In what % of time does OM resolve in 2 weeks without treatment?

A

80%

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95
Q

What is treatment warranted for OM?

A

Rapid onset of symptoms, severe pain and/or erythema, infants and toddlers under 2 years

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96
Q

True or False: For a child with OM, it is okay to provide a prescription for antibiotics and advise the parents to wait up to 3 days to see if symptoms persist

A

True

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97
Q

What is initial antibiotic choice for OM?

A

High dose amoxicillin (90mg/kg/day)

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98
Q

For a patient with severe OM, what is the first line treatment?

A

Amoxicillin-clavulanate

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99
Q

If a child with OM has a type 1 allergy to PCN, what do you use?

A

Azithromycin or clarithromycin

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100
Q

What should you give for a child with OM who has a treatment failure after 3 days of amoxicillin?

A
  1. High-dose amoxicillin-calvulanate for 1-3 days

2. IM ceftriaxone (50mg/kg)

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101
Q

What can chronic otitis media with effusion result in?

A
  1. Hearing loss

2. Language delay

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102
Q

Which patients have an increased risk of otitis media with effusion?

A
  1. Allergic rhinitis
  2. Adenoidal hypertrophy
  3. Eustachian tube abnormalities
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103
Q

What is management for chronic otitis media with effusion?

A

Monitoring over time (periodic checks of TM mobility)

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104
Q

What situations would you consider prophylactic antibiotics in a child with middle ear effusion?

A

Underlying medical problem…

  1. Cleft palate
  2. Immunodeficiency
    * Have to consider risks of potential bacterial resistance
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105
Q

If otitis media with effusion leads to recurrent acute OM or hearing loss, what may be indicated?

A

Tympanostomy

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106
Q

Name 8 conditions associated with recurrent otitis media

A
  1. Under 2
  2. Atopy
  3. Bottle propping
  4. Ciliary dysfunction
  5. Craniofacial abnormalities
  6. Child care attendance
  7. Immunocompromising conditions
  8. Sinusitis
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107
Q

True or False: Antihistamines, decongestants, and OTC cold remedies as treatment for or prevention of AOM have no proven value

A

True

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108
Q

Oral decongestants should not be used in children younger than what age?

A

6 years

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109
Q

Why can nasal decongestants be harmful to infants younger than 6 months of age?

A

Rebound nasal congestion can impact respiratory function (infants are nasal breathers)

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110
Q

5 year old with tympanostomy tubes has 3 days bloody otorrhea and nasal congestion, PE shows a large erythematous mass…most likely cause?

A

Tympanostomy tube granuloma (common complication of tympanostomy tubes)

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111
Q

What are 2 tumors that occur in the middle ear and can cause bloody otorrhea?

A
  1. Rhabdomyosarcoma

2. Eosinophilic granuloma

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112
Q

True or False: Otorrhea can occur after tympanostomy tubes are in place

A

True- Tympanostomy tubes don’t prevent URIs, they only equalize pressure

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113
Q

What are 3 sources of otalgia that don’t involve the ear?

A
  1. TMJ dysfunction
  2. C-spine abnormality
  3. Sore throat
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114
Q

What is a clue in history that could point to a foreign body in the ear?

A

Child with developmental delay

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115
Q

What are 2 findings you might see with a foreign body in the ear?

A
  1. Pain on movement of the pinna (similar to otitis externa)

2. Otorrhea

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116
Q

“Pain when the pinna is manipulated”

A

Otitis externa

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117
Q

What activity would you associate with otitis externa?

A

Swimming

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118
Q

True or False, you can see purulent discharge in otitis externa?

A

True

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119
Q

What is the usual cause of otitis externa?

A

Pseudomonas

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120
Q

What is treatment for otitis externa?

A

Antibiotic/steroid drops

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121
Q

How can you prevent swimmer’s ear?

A

Acidify ear canal (OTC boric acid or acetic acid solutions) before and after swimming

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122
Q

What should you do for a patient with swelling and deformity of the external ear following blunt trauma?

A

Needle aspiration to evacuate hematoma

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123
Q

What is the most common suppurative complication of AOM?

A

Mastoiditis

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124
Q

What are 3 findings commonly seen in mastoiditis?

A
  1. Postauricular swelling and erythema
  2. Tenderness over mastoid
  3. Outwardly displaced pinna
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125
Q

What are 4 most common bacteria to cause mastoiditis in children?

A
  1. Strep pneumo
  2. H. Flu (non-typeable)
  3. S. Pyogenes
  4. S. Aureus
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126
Q

How do you diagnose mastoiditis?

A

Confirmed by CT and tympanocentesis with culture

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127
Q

True or False: A negative culture rules out mastoiditis

A

False (especially if patient was already started on antibiotics)

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128
Q

What is treatment for mastoiditis?

A

IV antibiotics and surgery

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129
Q

Acute onset of self-limited vertigo in the absence of vomiting or loss of consciousness?

A

Benign paroxysmal vertigo

usually a brief episode presenting in a toddler

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130
Q

What are two additional symptoms you can see with benign paroxysmal vertigo?

A

Nystagmus and pallor

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131
Q

True or False: If vertigo lasts hours-days, benign paroxysmal vertigo is unlikely

A

True

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132
Q

If you see hearing loss with vertigo, what is the more likely diagnosis

A

Labyrinthitis

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133
Q

What are the most common causes of rhinitis?

A

Allergy, sinusitis, polyps, cystic fibrosis, foreign body

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134
Q

A nasal smear with lots of eosinophils is most likely what?

A

Allergic rhinitis

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135
Q

In an adolescent with nasal congestion, what should you remember to think of?

A

Cocaine use

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136
Q

Cyanosis with feeding that resolves with crying?

A

Choanal atresia

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137
Q

What syndrome is associated with choanal atresia?

A

CHARGE

[Coloboma, heart defects, atresia choanae, retardation of growth/development, GU problems, ear abnormalities]

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138
Q

In pre-adolescents, how can sinusitis present?

A

Persistent URI (not necessarily facial pain like in teens/adults)

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139
Q

Persistent nighttime cough, foul breath with persistent nasal congestion, toothache, sore throat, poorly controlled asthma, symptoms lasting longer than 7-10 days?

A

Acute sinusitis

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140
Q

Name 4 things nasal polyps are associated with

A
  1. CF
  2. Asthma
  3. Chronic allergic rhinitis
  4. Chronic sinusitis
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141
Q

You have a patient with nasal polyps, what test should you order next?

A

Sweat chloride test

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142
Q

What two sinuses are present at birth?

A

Maxillary and ethmoid

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143
Q

What age to the sphenoid and frontal sinuses develop?

A

5-6 years

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144
Q

What organisms cause most sinus infections?

A
  1. Pneumococcus
  2. Non-typeable H. Flu
  3. Moraxella catarrhalis
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145
Q

What is first line antibiotic for sinus infections?

A

Amoxicillin

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146
Q

Child with a sinus infection who recently got amoxicillin and/or goes to day care, what antibiotic should you consider?

A
  1. Amoxicillin/clavulanate

2. IM ceftriaxone

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147
Q

True or False: Sinusitis is usually a clinical diagnosis

A

True

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148
Q

Why are sinus XR not a good diagnostic tool?

A

Cannot distinguish between URI and sinusitis

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149
Q

What is orbital cellulitis a direct result of?

A

Ethmoid sinusitis (Eye/Ethmoid)

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150
Q

What could result from frontal sinusitis?

A

Brain abscess (frontal assault)

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151
Q

What is needed for any trauma that involves a fracture of the frontal sinus?

A

Surgical consult and repair

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152
Q

Why must fractures that involve the frontal sinus be repaired?

A

Avoid a CNS infection

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153
Q

True or False: Nasal swab cultures and throat cultures correlate well with sinus cultures

A

False

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154
Q

True or False: Oral decongestants, nasal steroids, and antihistamines provide significant help in acute sinusitis?

A

False

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155
Q

How does chronic sinusitis present?

A

Profuse nasal discharge, tenderness over sinuses, fever, nighttime cough

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156
Q

Name predisposing factors for chronic sinusitis

A

Allergy, exposure to tobacco smoke, recurrent viral URIs, GER, anatomic abnormalities, immune deficiency, primary ciliary dyskinesis (immotile cilia syndrome), and CF

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157
Q

What is the treatment for chronic sinusitis?

A

Antibiotics

+ Surgery if needed

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158
Q

How long might chronic sinusitis take to resolve?

A

2-3 months (of treatment)

159
Q

What should you think of with unilateral, blood-tinged, foul-smelling nasal discharge?

A

Nasal foreign body

160
Q

What is the study of choice for chronic recurrent sinusitis?

A

CT

161
Q

When is MRI indicated in chronic recurrent sinusitis?

A

If an intracranial complication is suggested in the history

162
Q

What is epistaxis due to?

A

Dry air

163
Q

What is the treatment for epistaxis?

A

Largely supportive

164
Q

What 4 things should you think to question in epistaxis?

A
  1. Could it be foreign body
  2. Vascular anomalies
  3. Bleeding disorders in family history
  4. Bleeding/bruising elsewhere
165
Q

What is required to identify a posterior bleeding source for epistaxis?

A

Nasopharyngoscopy

166
Q

How do you identify an anterior bleeding source for epistaxis?

A

Often visible on exam

167
Q

13 year old boy with recurrent epistaxis that is increasing in frequency and severity and takes more time to stop. Next step in management?

A

CT scan- Rule out posterior nasopharyngeal mass like a nasopharyngeal angiofibroma

168
Q

Worsening epistaxis?

A

Consider a nasopharyngeal mass, consider CT

169
Q

Malaise, anorexia, chills, pharyngitis with exudate, fever, palpable cervical lymph nodes, hepatosplenomegaly?

A

Mono

170
Q

Generalized symptoms, gets ampicillin, develops a rash…?

A

Think Mono (this is not a penicillin allergy)

171
Q

What virus causes Mono?

A

EBV

172
Q

True or False: EBV is usually asymptomatic in preschool children

A

True

173
Q

How long is the incubation period for mono in school age children (and beyond)?

A

2-7 weeks

174
Q

What are the common features between strep pharyngitis and EBV mono?

A

Pharyngitis with exudate, enlarged tonsils, fever

175
Q

How can you distinguish strep pharyngitis from EBV mono?

A

Hepatosplenomegaly is only with mono

176
Q

True or False: A positive rapid strep or throat culture rules out mono

A

False- Make sure to watch out for signs that the patient is an asymptomatic carrier of strep

177
Q

Whenever you have a patient with a positive strep, what is something you need to consider?

A

If they are an asymptomatic carrier and it is actually another diagnosis (Mono, ect.)

178
Q

What 2 viruses can cause mono?

A

CMV and EMV

179
Q

What is the difference between EBV mono and CMV mono?

A

CMV mono kids are older with mainly fever and malaise

180
Q

3 year old with high fever, swollen lymph nodes, other signs suggestive of mono. Monospot is negative, next step?

A

Obtain EBV IgM/IgG titers- Monospot screen frequently negative in young children

181
Q

In what age group is the monospot not as sensitive?

A

Children younger than 4

182
Q

True or False: Patients with an initial negative monospot can become positive 2-3 weeks into their illness

A

True

183
Q

How long can antibody titers for mono be detectable?

A

Up to 9 months after onset of illness

184
Q

True or False: A positive monospot test means active/current illness?

A

True

185
Q

What needs to be done for kids under 4 with a negative monospot and consistent symptoms?

A

Viral specific IgM

186
Q

What are 2 lab findings consistent with mono?

A

Lymphocytosis and thrombocytopenia

187
Q

What makes a definitive diagnosis of mono?

A

IgM antibodies (not isolation of the virus)

188
Q

What are 2 components of treatment for mono?

A
  1. Restricted activity is spleen is big

2. Steroids if there is airway obstruction

189
Q

What is the most common cause of pharyngitis in kids with fever and sore throat in absence of URI symptoms?

A

Group A beta hemolytic strep

190
Q

Name cause of pharyngitis

A
  1. Strep
  2. EBV
  3. Neisseria
  4. Adenovirus
191
Q

How is strep pharyngitis diagnosed?

A

Culture or rapid strep

192
Q

What is the treatment of choice for strep?

A

PCN

193
Q

True or False: Waiting for culture results doesn’t affect treatment outcome in strep pharyngitis

A

True

194
Q

What is the purpose of treating strep?

A
  1. Shortens the course

2. Prevents development of complications (rheumatic fever or abscess)

195
Q

True or False: Negative rapid strep needs a throat culture due to high rate of false negatives

A

True

196
Q

What should be done for a patient with recurrent symptoms after treatment for strep throat?

A

Repeat culture

197
Q

Why might a patient who was recently treated for strep throat have a repeat culture that is positive?

A
  1. Chronic carrier state
  2. Second infection (another group A strain)
  3. Noncompliance
198
Q

Typical presentation for gonococcal pharyngitis?

A

Sexually active teen with history of STIs

199
Q

What is seen on the physical exam in gonococcal pharyngitis?

A

Erythematous patches

200
Q

If you are suspicious of gonococcal pharyngitis, what else should you test for?

A

Other STDs

201
Q

Dysphagia, difficulty opening mouth, unilateral swelling around the tonsil, deviation of uvula to one side, exudate?

A

Peritonsillar abscess

202
Q

Trismus, drooling, muffled “hot potato” voice, cervical adenopathy?

A

PTA

203
Q

What typically causes a PTA?

A

Varies- Group A strep, mouth anaerobes

204
Q

What are some antibiotic choices for PTA?

A
  1. Ampicillin/sulbactam
  2. Clindamycin
  3. Amoxicillin/clavulanate
205
Q

How is a PTA diagnosed?

A

CT

206
Q

What lab findings can you see with a PTA?

A

Elevated WBC

207
Q

What is needed to protect the airway and provide symptomatic relief in a PTA?

A

Needle aspiration and drainage

208
Q

Name indications for tonsillectomy

A
  1. Repeated throat infections
  2. Airway obstruction
  3. Malignancy
209
Q

Name indications for adenoidectomy

A
  1. Chronic sinusitis and/or adenoiditis

2. OSA

210
Q

What is velopharyngeal insufficiency?

A

Complications of tonsillectomy and/or adenoidectomy (presents with a hypernasal voice)

211
Q

Young child with enlarged lymph nodes, high fever, difficulty swallowing, refusal of feedings, drooling, respiratory difficulties?

A

Retropharnygeal abscess (RPA)

212
Q

How is a RPA diagnosis confirmed?

A

CT

213
Q

How might a child with an RPA hold their neck?

A

Hyperextended, stiffly

214
Q

Lateral neck film with widening of the retropharyngeal space or of the paravertebral soft tissues?

A

RPA

215
Q

How can you distinguish epiglottitis versus RPA?

A

Epiglottitis is more toxic, scared and leaning forward (verus neck hyperextension or stiffness)

216
Q

What usually causes epiglottitis?

A

H. Flu type B

217
Q

What 3 things in history could make you think epiglottitis?

A
  1. Unknown immunization record
  2. Parental vaccine refusal
  3. From a developing country
218
Q

True or False: RPA is a surgical emergency

A

True

219
Q

What is management for RPA?

A

Needle aspiration under general anesthesia

220
Q

What bacteria cause RPA?

A
  1. Strep viridans
  2. Group A strep
  3. S. Aureus
  4. Anaerobic bacteria
221
Q

What are the best antibiotics for RPA?

A
  1. Clindamycin

2. Ampicillin/Sulbactam

222
Q

True or False: Throat swab culture is helpful in RPA management

A

False

223
Q

Which age group is RPA more common in?

A

Children under 4

224
Q

Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?

A

Coxsackievirus Group A herpangina

225
Q

Vesiculiopapular lesions on the hands and feet +/- Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?

A

Hand-Foot-Mouth (Coxsackievirus Group A herpangina)

226
Q

Vesicles on the vermillion border of the lips and possibly in the anterior mouth, gums, and tongue with mucosal pain, fever, and adneopathy?

A

HSV gingivostomatitis

227
Q

What is the name for a canker sore?

A

Apthous ulcer

228
Q

Grayish-white coagulum surrounded by a thing rim of bright erythema in the mouth?

A

Apthous ulcer

229
Q

What is the natural course of an apthous ulcer?

A

Resolve on their own over a week or so

230
Q

Infant under 1 with tender red nodules on the cheek, afebrile, good PO intake?

A

Cold-Induced Panniculitis

231
Q

What is a common cause of cold-induced panniculitis?

A

Sleeping with a water-filled pacifier or something else very cold

232
Q

What is the description of the lesions in cold-induced panniculitis?

A

Deep-seated plaques and nodules that are tender and red on the cheeks

233
Q

What is the treatment for cold-induced panniculitius?

A

None necessary. lesions clear on their own within weeks without scarring

234
Q

Up to what age is the normal waiting time for a first tooth to erupt?

A

16 months (no intervention needed up to this point in the absence of other findings)

235
Q

Name 5 common causes of delayed eruption of teeth

A
  1. Hypothyroidism
  2. Hypopituitarism
  3. Hypoplasia (ectodermal)
  4. Hypohidrosis (decreased sweating)
  5. Rickets
236
Q

How long do you have to get an avulsed permanent tooth back into the socket to give it an excellent chance to survive?

A

5 minutes

237
Q

True or False: Any capable adult should reimplant and avulsed tooth?

A

True

238
Q

If you need to transport a permanent tooth, what should you transport it in?

A

Saliva (patients) or milk (chilled)

239
Q

Should you attempt to replace an avulsed baby (deciduous) tooth?

A

No- this can cause damage to incoming permanent tooth

240
Q

How can a maxillary dental abscess present?

A

Facial swelling- Impacts periorbital tissue which impacts ability to open eye

241
Q

How does a mandibular dental abscess present?

A

Swelling below the jaw

242
Q

What is the antibiotic of choice for a dental abscess?

A

PCN

243
Q

In a PCN allergic patient, which antibiotic would you choose for a dental abscess?

A

Clindamycin or erythromycin

244
Q

Which ethnic group are cleft palates most common in?

A

Native Americans and Asians

245
Q

Which ethic group are cleft palates least common in?

A

African Americans

246
Q

What should you always think of with a cleft palate?

A

Pierre-Robin Sequence (PRS)

247
Q

What is involved in Pierre-Robin Sequence?

A
  1. Micrognathia
  2. Posteriorly-displaced tongue
  3. U-shaped cleft palate
248
Q

What is the initial defect in Pierre-Robin Sequence?

A

Failure of mandible to grow properly

249
Q

True or False: Cleft lip (with or without cleft palate) is more common in males

A

True

250
Q

What proportion of children with a cleft lip have an associated cleft palate?

A

2/3

251
Q

When is repair of a cleft lip done?

A

Around 10 weeks of age

252
Q

Which gender is cleft palate alone more common in?

A

Females

253
Q

True or False: Cleft palate alone has the highest risk of being associated with a syndrome

A

True

254
Q

When is a cleft palate alone usually repaired?

A

Between 9-12 months of age

255
Q

What is usually part of the surgery to correct a cleft palate?

A

PET placement (pressure equalizing tubes)

256
Q

Which specialist should see any newborn with a cleft?

A

Genetics

257
Q

What are some risks and complications that children with cleft palate have?

A

Eustachian tube dysfunction, vision, hearing, dental, and speech complications

258
Q

What is needed for children with cleft palate to feed?

A

Special nipples initially

259
Q

Name 3 syndromes besides Pierre-Robin Sequence that are associated with cleft palate

A
  1. Crouzon Syndrome
  2. Apert
  3. Tracher Collins Syndrome
260
Q

What are 3 things a bifid uvula can be assocaited with?

A
  1. Submucous cleft palate
  2. Velopharyngeal insufficiency
  3. Middle ear effusion
261
Q

What is it called when airflow ceases because the upper airway is occluded?

A

Obstructive apnea

262
Q

What should you consider with behavior problems, FTT, developmental delay, or poor academic performance in a kid who snores or has restless sleep?

A

OSA and sleep-disordered breathing

263
Q

Name 5 clues for underlying OSA or SDB

A
  1. Dysmorphic facies
  2. Persistent mouth breathing
  3. Hyponasal speech
  4. Cleft palate
264
Q

What are 2 things that can result from untreated OSA?

A
  1. Cor pulmonale

2. Death

265
Q

What is OSA often due to?

A

Adenoid hypertrophy

266
Q

True or False: the adenoids are not typically visible on a routine exam

A

True- So still consider OSA even if there is no tonsillar hypertrophy

267
Q

How is OSA usually diagnosed?

A

Clinically

268
Q

What image may help confirm adenoid hypertrophy in diagnosing OSA?

A

Lateral neck radiographs

269
Q

What is the gold standard for diagnosing OSA?

A

Polysomnography

270
Q

True or False: Lab tests aren’t usually helpful in diagnosing OSA

A

True

271
Q

What lab findings can be seen in severe cases of OSA?

A
  1. Polycythemia
  2. Respiratory acidosis
  3. Compensatory metabolic alkalosis
272
Q

What EKG finding may be seen in severe OSA?

A

RVH

273
Q

What is the treatment of choice for OSA?

A

Adenoidectomy

274
Q

What is treatment if OSA is complete (complete laryngeal atresia or severe web)?

A

Tracheotomy

275
Q

What are two examples of causes of OSA that may require a permanent tracheostomy?

A

Subglottic stenosis and complete vocal cord paralysis

276
Q

Post-op patient from a T&A who is in respiratory distress (history of severe OSA)… most likely cause for acute distress?

A

Pulmonary edema (common post-op complication in severe OSA)

277
Q

What causes stridor?

A

Turbulent flow through a narrowed segment of the respiratory tract

278
Q

Why is stridor a prominent feature of respiratory disease of the newborn?

A

Because the normal airway in a newborn is so narrow (Kids over 2 will have stridor for other reasons)

279
Q

What is important to note in the history of a kid with stridor?

A

Age

280
Q

Name 4 causes of stridor in a neonate

A
  1. Choanal atresia
  2. Larngeal web/stenosis
  3. Vascular ring
  4. Vocal cord paralysis
281
Q

Name 2 causes of stridor in a child who is 4-6 weeks old

A
  1. Laryngomalacia

2. Tracheomalacia

282
Q

Name 3 causes of stridor in a child who is between 1 and 4

A
  1. Croup
  2. Epiglottitis
  3. FBA
283
Q

Name 3 causes of stridor in a child over 5

A
  1. Vocal cord dysfunction
  2. PTA
  3. Anaphylaxis
284
Q

What causes inspiratory stridor?

A

Extrathoracic (above the thoracic outlet) obstruction- All of these structures are soft and collapse inward with pressure of inspiration

285
Q

Where are supraglottic, glottic, and subglottic areas located?

A

Extrathoracic (inspiratory stridor)

286
Q

If the supraglottic, glottic, and subglottic areas are affected, what type of stridor will you have?

A

Prominent inspiratory (extrathoracic structures)

*If you are lower down there is a chance for expiratory stridor too

287
Q

What is assocaited with swelling and inflammation of the tonsils and adenoids in addition to pharyngela and hypopharyngeal masses?

A

Inspiratory stridor

288
Q

Name 4 causes of inspiratory stridor

A

INSP

  1. Immobile cords (Paralysis)
  2. Adenoid and tonsil enlargement
  3. Soft cartilage (laryngomalacia)
  4. Pharyngeal and hypopharyngeal amsses
289
Q

What is the condition where the tissues at the entrance of the larynx collapse into the airway with inspiration?

A

Laryngomalacia

290
Q

What is the most common cause of congenital stridor?

A

Laryngomalacia

291
Q

What is a PE finding in laryngomalacia?

A

Suprasternal and subcostal retractions

292
Q

When does stridor due to larngomalacia worsen?

A

With agitation (under 1 month of age) and when infant is supine

293
Q

When does stridor due to laryngomalacia improve?

A

With expiration

294
Q

Why does stridor due to laryngomalacia improve with expiration?

A

Pressure from below stents open the floppy airways

295
Q

True or False: Stridor due to laryngomalacia improves with time

A

True (as cartilage becomes firmer

296
Q

What is seen on spirometry in vocal cord paralysis?

A

Blunted inspiratory loop

297
Q

Name 3 associations with vocal cord paralysis

A
  1. Recent viral URI
  2. Exposure to chemicals, fumes, or cold air
  3. GERD
298
Q

What is the second most common cause of extra-thoracic airway obstruction and stridor in infancy?

A

Vocal cord paralysis

299
Q

What is vocal cord paralysis usually due to?

A

Traumatic injury of the recurrent laryngeal nerve at time of birth or due to impairment in CNS

300
Q

What does the cry sound like in vocal cord paralysis?

A

Weak

301
Q

How do you differentiate between stridor due to laryngomalacia and vocal cord paralysis?

A
  1. Laryngomalacia is inspiratory stridor that is wet sounding or variably pitched
  2. Vocal cortd paralysis is inspiratory stridor that is high pitched
302
Q

How does unilateral vocal cord paralysis present?

A

Persistent hoarseness

303
Q

What are 2 things that can cause a weak cry in early infancy and how do you distinguish?

A

Vocal cord paralysis and laryngeal webs- Changing position will effect clinical symptoms in vocal cord paralysis, but not laryngeal webs

304
Q

Child with FTT who has respiratory difficulties- Would laryngomalacia be on your differential?

A

No- infants with laryngomalacia feed without difficulty and gain weight

305
Q

Progressive hoarseness that is less severe in the morning with no stridor or dysphagia?

A

Vocal cord nodules

306
Q

Most cases of chronic hoarseness in children are caused by what?

A

Vocal cord nodules

307
Q

Which gender are vocal cord nodules more common in?

A

Males

308
Q

When do vocal cord nodules tend to improve?

A

With puberty

309
Q

What diagnosis might be suspected in place of a vocal cord nodule?

A

Asthma

310
Q

What is something to ask for in history if you suspect vocal cord nodule?

A

History of endotracheal extubation

311
Q

What is often required to diagnose laryngeal and vocal cord disorders?

A

Larynoscopy

312
Q

How can you distinguish asthma versus vocal cord dysfunction?

A

Vocal cord dysfunction has normal pulse ox reading, clear lung fields on exam, and no improvement with bronchodilators

313
Q

Which phase of breathing is problematic in vocal cord dysfunction?

A

Inspiration (in asthma expiration is the problem)

314
Q

Which lesions cause expiratory stridor?

A

Below the thoracic inlet

315
Q

What are 2 classic examples of problems that cause expiratory stridor?

A
  1. Tracheomalacia

2. Bronchomalacia

316
Q

What is tracheomalacia?

A

Weak tracheal wall rings- collapse during expiration (rare condition)

317
Q

Besides expiratory stridor, what else can infants with tracheomalacia have?

A

Wheezing- extrinsic tracheal compression can cause fixed wheezing (also prolonged neonatal ventilator support can cause wheezing so consider this)

318
Q

When is the symptom relief noted in laryngomalacia?

A

During expiration (opposite of tracheomalacia which is expiratory stridor)

319
Q

What should you consider for a kid with history of TE fistula repair who presents with expiratory stridor?

A

Tracheomalacia

320
Q

What should you consider for a kid with feeding difficulties and expiratory stridor?

A

Vascular ring (extrinsic compression-wraps around trachea and esophagus)

321
Q

What type of stridor does congenital and acquired subglottic stenosis cause?

A

Biphasic stridor- this problem is both intra-thoracic and extra-thoracic

322
Q

For subglottic stenosis, which phase of stridor is often louder?

A

Inspiratory component

323
Q

What can a subglottic hemangioma result in?

A

Subglottic stenosis (biphasic stridor)

324
Q

What can a critical obstruction along the airway result in?

A

Biphasic stridor

325
Q

True or False: With tracheomalacia, if the obstruction is high enough, stridor can be biphasic

A

True

326
Q

How do you assess for subglottic stenosis?

A

Direct laryngoscopy and bronchoscopy

*Bronch assess the patency of the subglottis

327
Q

How do you assess for vocal cord function?

A

Flexible nasolaryngoscopy or direct laryngoscopy, plus a CXR and barium swallow

328
Q

How do you assess for a vascular ring?

A

Barium swallow study

329
Q

What should be the first thing done for an infant with noisy breathing?

A

Obtain thorough birth history and observe breathing patterns in different positions

330
Q

What type of stridor does epiglottitis present with?

A

Biphasic (this is a supraglottic stenosis)

331
Q

Why is epiglottitis rare today?

A

Hib vaccine

332
Q

4-5 year old with inspiratory stridor, high fever, won’t lay down, is positioned leaning forward, tripoding, and drooling?

A

Epiglottitis

333
Q

What is seen on lateral neck film in epiglottitis?

A

Thumb sign- Enlarged epiglottis

334
Q

True or False: Cough is common in the presentation of epiglottitis?

A

False

335
Q

5 D’s of epiglottitis?

A
  1. Drooling
  2. Dysphagia
  3. Dysphonia
  4. Distress
  5. Deafening stridor
336
Q

What should you look for in history if you suspect epiglottitis?

A

Parental refusal of all immunizations
Child from another country

Hib vaccine not given

337
Q

How do you evaluate for epiglottitis?

A

Need to be prepared for intubation with anesthesia on board- this is a medical emergency. Until then, keep child in parent’s arms and calm

338
Q

If your patient with suspected epiglottitis is table, what labs should you get?

A

CBCdiff and blood culture

339
Q

What type of antibiotic should be started empirically for epiglottitis?

A

3rd generation cephalosporin (ceftriaxone or cefotaxime)

340
Q

What is another name for laryngotracheobronchitis?

A

Viral croup

341
Q

Toddler in fall/winter with a harsh, non-productive barking cough, low grade fever, URI symptoms?

A

Croup

342
Q

What kind of stridor can be seen in croup?

A

Inspiratory or biphasic (with worsening of narrowing)

343
Q

What is treatment for mild croup?

A

Humidified air, fever reduction, PO fluids, exposure to cold night air

344
Q

What characterizes more severe croup?

A

Stridor at rest or retractions

345
Q

What can be done for more severe croup?

A
  1. Single dose of dexamethasone
  2. Nebulized racemic epi
  3. Intubation
346
Q

How frequently can racemic epinephrine be given?

A

Every 15-20 minutes as needed

347
Q

How long do kids who have gotten racemic epinephrine need to be observed before they can be discharged home?

A

3-4 hours

348
Q

What vaccine-preventable disease can cause croup?

A

Measles (rubeola)

*Keep this in mind with a kid who is unimmunized, recent immigrant, or unknown immunization status

349
Q

What are the 3 common viruses that can cause croup

A
  1. RSV
  2. Influenza
  3. Parainfluenza
350
Q

What causes spasmodic croup?

A

Allergies or psychological factors (no URI or fever)

*Described as a barky nonproductive cough

351
Q

Name 2 other names for bacterial tracheitis

A
  1. Pseudomembranous croup

2. Membranous laryngotracheitis

352
Q

What bacteria usually cases bacterial tracheitis?

A
  1. S. Aureus… also consider
  2. Moraxella catarrhalis
  3. Non-typeable H. influenza
  4. Oral anaerobes
353
Q

What should you consider with rapid deterioration of a patient with viral croup?

A

Bacterial tracheitis- This can occur several days into a bout with viral croup

354
Q

How do patients with bacterial tracheitits present?

A

Toxic appearing, thick/purulent secretions causing airway obstruction (may even lead to cardiopulmonary arrest)

355
Q

What is seen on a neck film in bacterial tracheitis?

A
  1. Ragged air column

2. Subglottic narrowing

356
Q

What position do kids with bacterial tracheitis prefer?

A

Comfortable supine (whereas epiglottitis is leaning forward and drooling)

357
Q

What is management of bacterial tracheitis?

A

Typically the patient is deteriorating rapidly

  • Intubation is required
  • Clear purulent secretions
  • Broad spectrum antibiotics (Staph coverage)
358
Q

What are most cases of cervical lymph node enlargement due to?

A

Infection- Reactive cervical adenopathy

359
Q

How are reactive lymph nodes described?

A

Mobile and tender (NOT erythematous or warm to touch)

360
Q

When do reactive lymph nodes go away?

A

Swelling decreases in a few days-weeks

361
Q

Preauricular adenopathy with conjunctivitis?

A

Adenovirus

362
Q

What should you check for if cervical lymphadenopathy is unexplained or persists?

A

Check for HIV and TB

363
Q

How does lymphadenitis present?

A

Node id tender, red, and warm to touch

*The node itself is infected versus being reactive

364
Q

Which type of lymphadenitis is generally bilateral?

A

Acute viral cervical lymphadenitits

365
Q

How does bacterial lymphadenitits present?

A

Unilateral, more local inflammation

366
Q

What is the most common bacterial organisms causing acute cervical adenitits?

A
  1. S. aureus

2. Group A strep

367
Q

What labs should you consider ordering when dealing with lymphadenitits?

A

CBC. ESR. blood cultures, PPD, and DNA

368
Q

What is the antibiotic of choice for cervical lymphadenitits?

A
  1. Amoxicillin/clavulante
  2. Clindamycin

*Need something that can fight beta lactamase producers

369
Q

What is a good antibiotic for a PCN allergic patient who has cervical lymphadenitits?

A

Erythromycin

370
Q

What does atypical mycobacteria result in?

A

Persistent lymph node swelling

371
Q

What happens with a PPD in atypical mycobacteria infection?

A

10mm or less (less than what you see with TB)

372
Q

What is the treatment for atypical mycobacteria causing cervical adenopathy?

A

Leave it alone- drugs don’t work

373
Q

What may be needed for cervical adenopathy due to atypical mycobacteria?

A

Surgical lymph node excision

374
Q

When is needle excision indicated for atypical mycobacteria lymphadenopathy?

A

NEVER- it drains forever

375
Q

What should you consider for a patient with cervical adenitis who isn’t responding to antibiotics?

A

Mycobacterium tuberculosis (look for other TB risk factors)

376
Q

True or False: Both TB and nonTB mycobacteria turn a PPD positive

A

True

377
Q

How can you differentiate TB and nonTB mycobacteria?

A

Check an IGRA (quantiferon or T-spot blood test)

*Positive in TB, Negative in nonTB

378
Q

What age group is the IGRA (quantiferon or T-spot blood test) approved in?

A

Kids 5 and older

379
Q

What bacteria is an important cause of acute cervical lymphadenitis in infants?

A

Staph (surgical drainage may be necessary)

380
Q

Describe a lymph node that is malignant

A

Nontender, firm, non-mobile/fixed, doesn’t shrink in size over time (like a reactive node)

381
Q

What do you need to think of if you have lymphadenopathy around the thyroid?

A

This could be thyroid carcinoma

382
Q

What do you think of with any midline lesion on the anterior neck?

A

Thyroglossal cyst

383
Q

When do you remove a thyroglossal cyst?

A

You don’t- this is often the only functioning thyroid tissue

384
Q

Midline lesion on the anterior neck that moves vertically with swallowing or sticking the tongue out

A

Thyroglossal cyst

385
Q

True or False: A thyroglossal cyst can have communication with the skin which results in draining

A

True

386
Q

What is a mass of dilated lymph vessels that can be described as a large soft neck mass?

A

Cystic hygroma

387
Q

How does viral parotitis present?

A
  • Pre-school or school-age children
  • Parotid swelling
  • Vague symptoms (weakness, fever)
  • Swelling and erythema around opening of Stensen’s duct (typically no pus can be expressed)
  • No erythema of overlying skin
388
Q

In a child with suspected viral parotitis who is unimmunized, what should you consider?

A

Mumps

389
Q

With viral parotitis, what features should you consider in the presenting history?

A

Anything pointing towards HIV infection

390
Q

How does bacterial parotitis present?

A

Occurs before age 10, child is toxic-appearing with very high temp

391
Q

What bacteria is the most common cause of bacterial protitis?

A

S. Aureus

392
Q

How does a salivary gland stone present?

A

Recurrent swelling of both parotid glands

393
Q

Patient from developing country with parotid swelling of few weeks time that has been resistant to antibiotics. No information on parents, child got some vaccines, but not well-documented… Most appropriate study for diagnosis?

A

HIV testing- this is viral parotitis (no knowledge of biological parents and did get some vaccines- points away from mumps)

Peds (35 decks)

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