ENT Flashcards
If you see speech delay in an infant or toddler, what should you suspect?
Hearing loss
What are some clues to hearing loss in older children?
- Ignoring commands
2. Increased volume of TV or music
What are the 2 types of hearing loss?
- Conductive
2. Sensorineural
What occurs when sound fails to progress to the cochlea?
Conductive hearing loss
Where can obstruction occur in conductive hearing loss?
Anywhere from external canal to ossicles
What is the most common cause of conductive hearing loss?
Effusion (usually due to OM)
Effusion is present in the absence of inflammation
Which type of hearing loss is often correctable with surgery or hearing devices?
Conductive
*Sensorineural are less-often correctable
What is needed to facilitate language development in children with all forms of hearing loss?
EI
What syndromes is hearing loss associated with?
- CHARGE
2. Syndromes involving cleft lip and palate
If you have a patients with an external or middle ear malformation, what else should you consider?
Craniofacial, renal, or inner ear malformations
What causes the most severe degree of conductive hearing loss?
Small, malformed ears (microtia or aural atresia)
What can large perforations from trauma result in?
Significant conductive hearing loss
What is post-taumatic conductive hearing loss usually associated with (besides perforation)?
Disruption of ossicles themselves
What is tympanosclerosis?
Scarring on TM (usually after recurrent OM)… results in minimal conductive hearing loss
What is the most common cause of conductive hearing loss?
OM with effusion
What is the result of keratinization of the epithelial cells in the middle ear?
Cholesteatoma
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?
Refer to ENT… this is a cholesteatoma
How are cholesteatomas managed?
Surgical removal- Technically benign, but they expand and destroy bone
Late recognition of what ear findings is a major cause of permanent hearing loss?
Cholesteatome
Foul smeeling discharge despite treatment of a perforated TM is a clue to what?
Cholesteatoma
What causes sensorineural hearing loss?
Malfunction of cochlea and/or auditor nerve
What are 4 general causes of sensorineural hearing loss?
- Toxic (drugs)
- Infectious
- Genetic
- Traumatic (physical or acoustic)
What 2 diuretics can cause a temporary hearing loss?
Lasix and ethacrynic acid (Loops)
The combination of a loop diuretic with what other type of drug amplifies ototoxic effects?
Aminoglycosides
What class of antibiotics and what 2 specific drugs are known to cause hearing loss?
Aminoglycosdes, Gentamicin and tobramycin
What drug can cause a reversible sensorineural hearing loss?
Salicylates
Upon stopping salicylates due to hearing loss, how long does it take for hearing to return to normal?
1 week
High-pitched tinnitus should make you think of hearing loss due to what?
Salicylate
Name 6 infectious causes of in utero sensorineural hearing loss
- CMV
- Measles
- Mumps
- Rubella
- Varicella
- Syphilis
Sudden onset of bilateral sensorineural deafness should make you think of what?
Viral labyrinthitis
What is the prognosis for viral labyrinthitis?
Variable
What is treatment for viral labyrinthitis?
No treatment, just watchful waiting
True or False: Repeated exposure to loud sounds (music, power tools) can lead to high frequency sensorineural hearing loss
True
What is the most common cause of sensorineural hearing loss?
Congenital CMV
True or False: Infants with congenital CMV may pass their newborn hearing screen
True (and they can develop profound hearing loss by age 1
What is the most common cause of childhood sensorineural hearing loss among acquired infections?
Bacterial meningitis
When does sensorineural hearing loss occur during bacterial meningitis?
Early (within first 24 hours)
What screening test is important to remember in all children with meningitis?
Hearing test ASAP
True or False: Development of sensorineural hearing loss in bacterial meningitis is directly related to the severity of illness?
False: Not related to severity of illness, age, or when antibiotics were started
True or False: More than 500 causes of syndromic hearing loss have been reported
True
What is an X-linked condition that has bilateral sensorineural hearing loss and hematuria?
Alport Syndrome
What category of disorders are a big cause of genetic hearing loss?
Mitochondrial disorders
What are risk factors for sensorineural hearing loss that are associated with prematurity?
- Extended assisted ventilation
- Hyperbilirubinemia
- Low birth weight
What type of therapy poses a risk factor for sensorineural hearing loss?
Radiation therapy (for head/neck tumors)
What type of anatomical abnormalities are associated with sensorineural hearing loss?
Craniofacial
Name 1 specific syndrome associated with sensorineural hearing loss
Waardenburg
When should identification of hearing loss be done by?
3 month
When is intervention for hearing loss optimal by?
6 months
What are the 2 screening tests for newborns in the nursery?
- Auditory brainstem response (ABR)
2. Otoacoustic emissions (OAE)
True or False: A completely deaf child will have normal language development until 9 months of age
True
*Cooing and babbling don’t depend on hearing
What test uses electroencephalographic waveforms to determine a child’s perceptual threshold?
Auditory Brainstem Response
After what age would a child likely need conscious sedation for an ABR (auditory brainstem response)?
After 6 months
What hearing test is used for infants who are under 6 months of age?
BOA- Behavioral Observational Audiometry (BOA)
What type of test is a BOA (behavioral observational audiometry)?
Screening
What is the next step for an infant who fails BOA?
They need ABR testing
What type of hearing test is used for older infants and toddlers (6 months-2 years)?
Visual reinforcement audiometry (VRA)
What test evaluates for bilateral hearing loss?
VRA
*This is important to do so that intervention to prevent language development impairment can be started ASAP
What is required is a patient fails a hearing screen or has equivocal results?
They need referral to audiology
What is done to assess hearing in a patient with physical, cognitive, or behavioral concerns that may interfere with administration of a hearing screen?
Referral to audiology
Who is the conventional pure-tone audiometry screen appropriate for?
School-age children (they have to be able to cooperate with commands)
True or False: The conventional pure-tone audiometry screen can test hearing in each ear independently?
True
What usually causes results of a tympanometry screen to be normal versus abnormal (on test)?
Technique
What is an example of poor technique for a tympanometry screen?
Probe being wedged against external canal
True or False: Tympanometry measures hearing sensitivity
False
*You can have a normal tympanogram with significant sensorineural hearing loss or an abnormal tympanogram with normal hearing
By what age should infants with significant congenital sensorineural hearing loss receive targeted intervention by?
6 months
What are 2 examples of targeted intervention for infants with significant congenital sensorineural hearing loss?
Hearing aids (external) or cochlear implant (implantable)
-This will allow them to hear and develop normally.
What does a flat line on a tympanogram mean?
Stiff tympanic membrane, middle ear fluid, or obstructed tympanostomy tube
What is another phrase for a flat line on a tympanogram?
Low amplitude
What is a high line on a tympanogram associated with?
Hypermobile TM
What does the area under the tympanogram curve reflect?
Area in the external canal
What does a high volume on a tympanogram curve reflect?
Continuity between the middle and outer ear- Perforated TM (trauma, myringotomy tubes)
What will you see on a tympanogram that reflects the absence of pressure and mobility?
High volume (from a perforated TM)
What 2 diagnoses fall under otitis media?
- Acute otitis media (AOM)
2. Otitis media with effusion (OME)
What are common features of presentation between AOM and OME?
Fluid behind TM
What distinguishes AOM from OME?
AOM: Inflammation (erythema of TM and pain)
OME: No inflammation
How are AOM and OME best diagnosed?
Pneumatic otoscopy
True or False: Erythema of the TM is enough to diagnose AOM?
False- Multiple things can make TM erythematous (fever, crying, ect.)
What are the most common bacteria to cause AOM?
- S. Pneumoniae
- H. Flu (non-typeable)
- Moraxella catarrhalis
- Strep pyogenes (Group A Strep)
Which cause of bacterial AOM is increasing in frequency and which is decreasing?
Non-typeable H. Flu is increasing
S. Pneumoniae is decreasing
4 year old with chronic purulent drainage through perforated left TM… best treatment?
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)
What is the most common cause of chronic suppurative otitis media?
Pseudomonas
What is treatment for chronic suppurative otitis media?
Topical/Otic ofloxacin with daily suctioning of canal (allows abx to reach infection)
Name 3 potential causes of chronic suppurative otitis media
- Pseudomonas
- Staph
- Fusobacterium necrophorum
True or False: Cholesteatoma and chronic suppurative otitis media can occur together
True
What can result from chronic suppurative otitis media?
Cholesteatoma
True or False: Chronic suppurative otitis media can occur without cholestatoma?
True
If a chronic suppurative otitis media doesn’t respond to treatment, what should you consider?
Cholesteatoma
True or False: Antibiotic prophylaxis is recommended for the prevention of recurrent otitis media
False
Antibiotic prophylaxis in the setting of prevention for recurrent otitis media is a risk factor for what?
Colonization with resistant pneumococcus
What is the treatment of choice for recurrent otitis media?
Tympanostomy tubes
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?
Meningitis
What % of the time do intracranial suppurative complications of otitis media occur?
1%
True or False: Withholding antibiotic treatment for 48-72 hours to see if symptoms persist in OM is considered correct treatment
True
In what % of time does OM resolve in 2 weeks without treatment?
80%
What is treatment warranted for OM?
Rapid onset of symptoms, severe pain and/or erythema, infants and toddlers under 2 years
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
True
What is initial antibiotic choice for OM?
High dose amoxicillin (90mg/kg/day)
For a patient with severe OM, what is the first line treatment?
Amoxicillin-clavulanate
If a child with OM has a type 1 allergy to PCN, what do you use?
Azithromycin or clarithromycin
What should you give for a child with OM who has a treatment failure after 3 days of amoxicillin?
- High-dose amoxicillin-calvulanate for 1-3 days
2. IM ceftriaxone (50mg/kg)
What can chronic otitis media with effusion result in?
- Hearing loss
2. Language delay
Which patients have an increased risk of otitis media with effusion?
- Allergic rhinitis
- Adenoidal hypertrophy
- Eustachian tube abnormalities
What is management for chronic otitis media with effusion?
Monitoring over time (periodic checks of TM mobility)
What situations would you consider prophylactic antibiotics in a child with middle ear effusion?
Underlying medical problem…
- Cleft palate
- Immunodeficiency
* Have to consider risks of potential bacterial resistance
If otitis media with effusion leads to recurrent acute OM or hearing loss, what may be indicated?
Tympanostomy
Name 8 conditions associated with recurrent otitis media
- Under 2
- Atopy
- Bottle propping
- Ciliary dysfunction
- Craniofacial abnormalities
- Child care attendance
- Immunocompromising conditions
- Sinusitis
True or False: Antihistamines, decongestants, and OTC cold remedies as treatment for or prevention of AOM have no proven value
True
Oral decongestants should not be used in children younger than what age?
6 years
Why can nasal decongestants be harmful to infants younger than 6 months of age?
Rebound nasal congestion can impact respiratory function (infants are nasal breathers)
5 year old with tympanostomy tubes has 3 days bloody otorrhea and nasal congestion, PE shows a large erythematous mass…most likely cause?
Tympanostomy tube granuloma (common complication of tympanostomy tubes)
What are 2 tumors that occur in the middle ear and can cause bloody otorrhea?
- Rhabdomyosarcoma
2. Eosinophilic granuloma
True or False: Otorrhea can occur after tympanostomy tubes are in place
True- Tympanostomy tubes don’t prevent URIs, they only equalize pressure
What are 3 sources of otalgia that don’t involve the ear?
- TMJ dysfunction
- C-spine abnormality
- Sore throat
What is a clue in history that could point to a foreign body in the ear?
Child with developmental delay
What are 2 findings you might see with a foreign body in the ear?
- Pain on movement of the pinna (similar to otitis externa)
2. Otorrhea
“Pain when the pinna is manipulated”
Otitis externa
What activity would you associate with otitis externa?
Swimming
True or False, you can see purulent discharge in otitis externa?
True
What is the usual cause of otitis externa?
Pseudomonas
What is treatment for otitis externa?
Antibiotic/steroid drops
How can you prevent swimmer’s ear?
Acidify ear canal (OTC boric acid or acetic acid solutions) before and after swimming
What should you do for a patient with swelling and deformity of the external ear following blunt trauma?
Needle aspiration to evacuate hematoma
What is the most common suppurative complication of AOM?
Mastoiditis
What are 3 findings commonly seen in mastoiditis?
- Postauricular swelling and erythema
- Tenderness over mastoid
- Outwardly displaced pinna
What are 4 most common bacteria to cause mastoiditis in children?
- Strep pneumo
- H. Flu (non-typeable)
- S. Pyogenes
- S. Aureus
How do you diagnose mastoiditis?
Confirmed by CT and tympanocentesis with culture
True or False: A negative culture rules out mastoiditis
False (especially if patient was already started on antibiotics)
What is treatment for mastoiditis?
IV antibiotics and surgery
Acute onset of self-limited vertigo in the absence of vomiting or loss of consciousness?
Benign paroxysmal vertigo
usually a brief episode presenting in a toddler
What are two additional symptoms you can see with benign paroxysmal vertigo?
Nystagmus and pallor
True or False: If vertigo lasts hours-days, benign paroxysmal vertigo is unlikely
True
If you see hearing loss with vertigo, what is the more likely diagnosis
Labyrinthitis
What are the most common causes of rhinitis?
Allergy, sinusitis, polyps, cystic fibrosis, foreign body
A nasal smear with lots of eosinophils is most likely what?
Allergic rhinitis
In an adolescent with nasal congestion, what should you remember to think of?
Cocaine use
Cyanosis with feeding that resolves with crying?
Choanal atresia
What syndrome is associated with choanal atresia?
CHARGE
[Coloboma, heart defects, atresia choanae, retardation of growth/development, GU problems, ear abnormalities]
In pre-adolescents, how can sinusitis present?
Persistent URI (not necessarily facial pain like in teens/adults)
Persistent nighttime cough, foul breath with persistent nasal congestion, toothache, sore throat, poorly controlled asthma, symptoms lasting longer than 7-10 days?
Acute sinusitis
Name 4 things nasal polyps are associated with
- CF
- Asthma
- Chronic allergic rhinitis
- Chronic sinusitis
You have a patient with nasal polyps, what test should you order next?
Sweat chloride test
What two sinuses are present at birth?
Maxillary and ethmoid
What age to the sphenoid and frontal sinuses develop?
5-6 years
What organisms cause most sinus infections?
- Pneumococcus
- Non-typeable H. Flu
- Moraxella catarrhalis
What is first line antibiotic for sinus infections?
Amoxicillin
Child with a sinus infection who recently got amoxicillin and/or goes to day care, what antibiotic should you consider?
- Amoxicillin/clavulanate
2. IM ceftriaxone
True or False: Sinusitis is usually a clinical diagnosis
True
Why are sinus XR not a good diagnostic tool?
Cannot distinguish between URI and sinusitis
What is orbital cellulitis a direct result of?
Ethmoid sinusitis (Eye/Ethmoid)
What could result from frontal sinusitis?
Brain abscess (frontal assault)
What is needed for any trauma that involves a fracture of the frontal sinus?
Surgical consult and repair
Why must fractures that involve the frontal sinus be repaired?
Avoid a CNS infection
True or False: Nasal swab cultures and throat cultures correlate well with sinus cultures
False
True or False: Oral decongestants, nasal steroids, and antihistamines provide significant help in acute sinusitis?
False
How does chronic sinusitis present?
Profuse nasal discharge, tenderness over sinuses, fever, nighttime cough
Name predisposing factors for chronic sinusitis
Allergy, exposure to tobacco smoke, recurrent viral URIs, GER, anatomic abnormalities, immune deficiency, primary ciliary dyskinesis (immotile cilia syndrome), and CF
What is the treatment for chronic sinusitis?
Antibiotics
+ Surgery if needed
How long might chronic sinusitis take to resolve?
2-3 months (of treatment)
What should you think of with unilateral, blood-tinged, foul-smelling nasal discharge?
Nasal foreign body
What is the study of choice for chronic recurrent sinusitis?
CT
When is MRI indicated in chronic recurrent sinusitis?
If an intracranial complication is suggested in the history
What is epistaxis due to?
Dry air
What is the treatment for epistaxis?
Largely supportive
What 4 things should you think to question in epistaxis?
- Could it be foreign body
- Vascular anomalies
- Bleeding disorders in family history
- Bleeding/bruising elsewhere
What is required to identify a posterior bleeding source for epistaxis?
Nasopharyngoscopy
How do you identify an anterior bleeding source for epistaxis?
Often visible on exam
13 year old boy with recurrent epistaxis that is increasing in frequency and severity and takes more time to stop. Next step in management?
CT scan- Rule out posterior nasopharyngeal mass like a nasopharyngeal angiofibroma
Worsening epistaxis?
Consider a nasopharyngeal mass, consider CT
Malaise, anorexia, chills, pharyngitis with exudate, fever, palpable cervical lymph nodes, hepatosplenomegaly?
Mono
Generalized symptoms, gets ampicillin, develops a rash…?
Think Mono (this is not a penicillin allergy)
What virus causes Mono?
EBV
True or False: EBV is usually asymptomatic in preschool children
True
How long is the incubation period for mono in school age children (and beyond)?
2-7 weeks
What are the common features between strep pharyngitis and EBV mono?
Pharyngitis with exudate, enlarged tonsils, fever
How can you distinguish strep pharyngitis from EBV mono?
Hepatosplenomegaly is only with mono
True or False: A positive rapid strep or throat culture rules out mono
False- Make sure to watch out for signs that the patient is an asymptomatic carrier of strep
Whenever you have a patient with a positive strep, what is something you need to consider?
If they are an asymptomatic carrier and it is actually another diagnosis (Mono, ect.)
What 2 viruses can cause mono?
CMV and EMV
What is the difference between EBV mono and CMV mono?
CMV mono kids are older with mainly fever and malaise
3 year old with high fever, swollen lymph nodes, other signs suggestive of mono. Monospot is negative, next step?
Obtain EBV IgM/IgG titers- Monospot screen frequently negative in young children
In what age group is the monospot not as sensitive?
Children younger than 4
True or False: Patients with an initial negative monospot can become positive 2-3 weeks into their illness
True
How long can antibody titers for mono be detectable?
Up to 9 months after onset of illness
True or False: A positive monospot test means active/current illness?
True
What needs to be done for kids under 4 with a negative monospot and consistent symptoms?
Viral specific IgM
What are 2 lab findings consistent with mono?
Lymphocytosis and thrombocytopenia
What makes a definitive diagnosis of mono?
IgM antibodies (not isolation of the virus)
What are 2 components of treatment for mono?
- Restricted activity is spleen is big
2. Steroids if there is airway obstruction
What is the most common cause of pharyngitis in kids with fever and sore throat in absence of URI symptoms?
Group A beta hemolytic strep
Name cause of pharyngitis
- Strep
- EBV
- Neisseria
- Adenovirus
How is strep pharyngitis diagnosed?
Culture or rapid strep
What is the treatment of choice for strep?
PCN
True or False: Waiting for culture results doesn’t affect treatment outcome in strep pharyngitis
True
What is the purpose of treating strep?
- Shortens the course
2. Prevents development of complications (rheumatic fever or abscess)
True or False: Negative rapid strep needs a throat culture due to high rate of false negatives
True
What should be done for a patient with recurrent symptoms after treatment for strep throat?
Repeat culture
Why might a patient who was recently treated for strep throat have a repeat culture that is positive?
- Chronic carrier state
- Second infection (another group A strain)
- Noncompliance
Typical presentation for gonococcal pharyngitis?
Sexually active teen with history of STIs
What is seen on the physical exam in gonococcal pharyngitis?
Erythematous patches
If you are suspicious of gonococcal pharyngitis, what else should you test for?
Other STDs
Dysphagia, difficulty opening mouth, unilateral swelling around the tonsil, deviation of uvula to one side, exudate?
Peritonsillar abscess
Trismus, drooling, muffled “hot potato” voice, cervical adenopathy?
PTA
What typically causes a PTA?
Varies- Group A strep, mouth anaerobes
What are some antibiotic choices for PTA?
- Ampicillin/sulbactam
- Clindamycin
- Amoxicillin/clavulanate
How is a PTA diagnosed?
CT
What lab findings can you see with a PTA?
Elevated WBC
What is needed to protect the airway and provide symptomatic relief in a PTA?
Needle aspiration and drainage
Name indications for tonsillectomy
- Repeated throat infections
- Airway obstruction
- Malignancy
Name indications for adenoidectomy
- Chronic sinusitis and/or adenoiditis
2. OSA
What is velopharyngeal insufficiency?
Complications of tonsillectomy and/or adenoidectomy (presents with a hypernasal voice)
Young child with enlarged lymph nodes, high fever, difficulty swallowing, refusal of feedings, drooling, respiratory difficulties?
Retropharnygeal abscess (RPA)
How is a RPA diagnosis confirmed?
CT
How might a child with an RPA hold their neck?
Hyperextended, stiffly
Lateral neck film with widening of the retropharyngeal space or of the paravertebral soft tissues?
RPA
How can you distinguish epiglottitis versus RPA?
Epiglottitis is more toxic, scared and leaning forward (verus neck hyperextension or stiffness)
What usually causes epiglottitis?
H. Flu type B
What 3 things in history could make you think epiglottitis?
- Unknown immunization record
- Parental vaccine refusal
- From a developing country
True or False: RPA is a surgical emergency
True
What is management for RPA?
Needle aspiration under general anesthesia
What bacteria cause RPA?
- Strep viridans
- Group A strep
- S. Aureus
- Anaerobic bacteria
What are the best antibiotics for RPA?
- Clindamycin
2. Ampicillin/Sulbactam
True or False: Throat swab culture is helpful in RPA management
False
Which age group is RPA more common in?
Children under 4
Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?
Coxsackievirus Group A herpangina
Vesiculiopapular lesions on the hands and feet +/- Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?
Hand-Foot-Mouth (Coxsackievirus Group A herpangina)
Vesicles on the vermillion border of the lips and possibly in the anterior mouth, gums, and tongue with mucosal pain, fever, and adneopathy?
HSV gingivostomatitis
What is the name for a canker sore?
Apthous ulcer
Grayish-white coagulum surrounded by a thing rim of bright erythema in the mouth?
Apthous ulcer
What is the natural course of an apthous ulcer?
Resolve on their own over a week or so
Infant under 1 with tender red nodules on the cheek, afebrile, good PO intake?
Cold-Induced Panniculitis
What is a common cause of cold-induced panniculitis?
Sleeping with a water-filled pacifier or something else very cold
What is the description of the lesions in cold-induced panniculitis?
Deep-seated plaques and nodules that are tender and red on the cheeks
What is the treatment for cold-induced panniculitius?
None necessary. lesions clear on their own within weeks without scarring
Up to what age is the normal waiting time for a first tooth to erupt?
16 months (no intervention needed up to this point in the absence of other findings)
Name 5 common causes of delayed eruption of teeth
- Hypothyroidism
- Hypopituitarism
- Hypoplasia (ectodermal)
- Hypohidrosis (decreased sweating)
- Rickets
How long do you have to get an avulsed permanent tooth back into the socket to give it an excellent chance to survive?
5 minutes
True or False: Any capable adult should reimplant and avulsed tooth?
True
If you need to transport a permanent tooth, what should you transport it in?
Saliva (patients) or milk (chilled)
Should you attempt to replace an avulsed baby (deciduous) tooth?
No- this can cause damage to incoming permanent tooth
How can a maxillary dental abscess present?
Facial swelling- Impacts periorbital tissue which impacts ability to open eye
How does a mandibular dental abscess present?
Swelling below the jaw
What is the antibiotic of choice for a dental abscess?
PCN
In a PCN allergic patient, which antibiotic would you choose for a dental abscess?
Clindamycin or erythromycin
Which ethnic group are cleft palates most common in?
Native Americans and Asians
Which ethic group are cleft palates least common in?
African Americans
What should you always think of with a cleft palate?
Pierre-Robin Sequence (PRS)
What is involved in Pierre-Robin Sequence?
- Micrognathia
- Posteriorly-displaced tongue
- U-shaped cleft palate
What is the initial defect in Pierre-Robin Sequence?
Failure of mandible to grow properly
True or False: Cleft lip (with or without cleft palate) is more common in males
True
What proportion of children with a cleft lip have an associated cleft palate?
2/3
When is repair of a cleft lip done?
Around 10 weeks of age
Which gender is cleft palate alone more common in?
Females
True or False: Cleft palate alone has the highest risk of being associated with a syndrome
True
When is a cleft palate alone usually repaired?
Between 9-12 months of age
What is usually part of the surgery to correct a cleft palate?
PET placement (pressure equalizing tubes)
Which specialist should see any newborn with a cleft?
Genetics
What are some risks and complications that children with cleft palate have?
Eustachian tube dysfunction, vision, hearing, dental, and speech complications
What is needed for children with cleft palate to feed?
Special nipples initially
Name 3 syndromes besides Pierre-Robin Sequence that are associated with cleft palate
- Crouzon Syndrome
- Apert
- Tracher Collins Syndrome
What are 3 things a bifid uvula can be assocaited with?
- Submucous cleft palate
- Velopharyngeal insufficiency
- Middle ear effusion
What is it called when airflow ceases because the upper airway is occluded?
Obstructive apnea
What should you consider with behavior problems, FTT, developmental delay, or poor academic performance in a kid who snores or has restless sleep?
OSA and sleep-disordered breathing
Name 5 clues for underlying OSA or SDB
- Dysmorphic facies
- Persistent mouth breathing
- Hyponasal speech
- Cleft palate
What are 2 things that can result from untreated OSA?
- Cor pulmonale
2. Death
What is OSA often due to?
Adenoid hypertrophy
True or False: the adenoids are not typically visible on a routine exam
True- So still consider OSA even if there is no tonsillar hypertrophy
How is OSA usually diagnosed?
Clinically
What image may help confirm adenoid hypertrophy in diagnosing OSA?
Lateral neck radiographs
What is the gold standard for diagnosing OSA?
Polysomnography
True or False: Lab tests aren’t usually helpful in diagnosing OSA
True
What lab findings can be seen in severe cases of OSA?
- Polycythemia
- Respiratory acidosis
- Compensatory metabolic alkalosis
What EKG finding may be seen in severe OSA?
RVH
What is the treatment of choice for OSA?
Adenoidectomy
What is treatment if OSA is complete (complete laryngeal atresia or severe web)?
Tracheotomy
What are two examples of causes of OSA that may require a permanent tracheostomy?
Subglottic stenosis and complete vocal cord paralysis
Post-op patient from a T&A who is in respiratory distress (history of severe OSA)… most likely cause for acute distress?
Pulmonary edema (common post-op complication in severe OSA)
What causes stridor?
Turbulent flow through a narrowed segment of the respiratory tract
Why is stridor a prominent feature of respiratory disease of the newborn?
Because the normal airway in a newborn is so narrow (Kids over 2 will have stridor for other reasons)
What is important to note in the history of a kid with stridor?
Age
Name 4 causes of stridor in a neonate
- Choanal atresia
- Larngeal web/stenosis
- Vascular ring
- Vocal cord paralysis
Name 2 causes of stridor in a child who is 4-6 weeks old
- Laryngomalacia
2. Tracheomalacia
Name 3 causes of stridor in a child who is between 1 and 4
- Croup
- Epiglottitis
- FBA
Name 3 causes of stridor in a child over 5
- Vocal cord dysfunction
- PTA
- Anaphylaxis
What causes inspiratory stridor?
Extrathoracic (above the thoracic outlet) obstruction- All of these structures are soft and collapse inward with pressure of inspiration
Where are supraglottic, glottic, and subglottic areas located?
Extrathoracic (inspiratory stridor)
If the supraglottic, glottic, and subglottic areas are affected, what type of stridor will you have?
Prominent inspiratory (extrathoracic structures)
*If you are lower down there is a chance for expiratory stridor too
What is assocaited with swelling and inflammation of the tonsils and adenoids in addition to pharyngela and hypopharyngeal masses?
Inspiratory stridor
Name 4 causes of inspiratory stridor
INSP
- Immobile cords (Paralysis)
- Adenoid and tonsil enlargement
- Soft cartilage (laryngomalacia)
- Pharyngeal and hypopharyngeal amsses
What is the condition where the tissues at the entrance of the larynx collapse into the airway with inspiration?
Laryngomalacia
What is the most common cause of congenital stridor?
Laryngomalacia
What is a PE finding in laryngomalacia?
Suprasternal and subcostal retractions
When does stridor due to larngomalacia worsen?
With agitation (under 1 month of age) and when infant is supine
When does stridor due to laryngomalacia improve?
With expiration
Why does stridor due to laryngomalacia improve with expiration?
Pressure from below stents open the floppy airways
True or False: Stridor due to laryngomalacia improves with time
True (as cartilage becomes firmer
What is seen on spirometry in vocal cord paralysis?
Blunted inspiratory loop
Name 3 associations with vocal cord paralysis
- Recent viral URI
- Exposure to chemicals, fumes, or cold air
- GERD
What is the second most common cause of extra-thoracic airway obstruction and stridor in infancy?
Vocal cord paralysis
What is vocal cord paralysis usually due to?
Traumatic injury of the recurrent laryngeal nerve at time of birth or due to impairment in CNS
What does the cry sound like in vocal cord paralysis?
Weak
How do you differentiate between stridor due to laryngomalacia and vocal cord paralysis?
- Laryngomalacia is inspiratory stridor that is wet sounding or variably pitched
- Vocal cortd paralysis is inspiratory stridor that is high pitched
How does unilateral vocal cord paralysis present?
Persistent hoarseness
What are 2 things that can cause a weak cry in early infancy and how do you distinguish?
Vocal cord paralysis and laryngeal webs- Changing position will effect clinical symptoms in vocal cord paralysis, but not laryngeal webs
Child with FTT who has respiratory difficulties- Would laryngomalacia be on your differential?
No- infants with laryngomalacia feed without difficulty and gain weight
Progressive hoarseness that is less severe in the morning with no stridor or dysphagia?
Vocal cord nodules
Most cases of chronic hoarseness in children are caused by what?
Vocal cord nodules
Which gender are vocal cord nodules more common in?
Males
When do vocal cord nodules tend to improve?
With puberty
What diagnosis might be suspected in place of a vocal cord nodule?
Asthma
What is something to ask for in history if you suspect vocal cord nodule?
History of endotracheal extubation
What is often required to diagnose laryngeal and vocal cord disorders?
Larynoscopy
How can you distinguish asthma versus vocal cord dysfunction?
Vocal cord dysfunction has normal pulse ox reading, clear lung fields on exam, and no improvement with bronchodilators
Which phase of breathing is problematic in vocal cord dysfunction?
Inspiration (in asthma expiration is the problem)
Which lesions cause expiratory stridor?
Below the thoracic inlet
What are 2 classic examples of problems that cause expiratory stridor?
- Tracheomalacia
2. Bronchomalacia
What is tracheomalacia?
Weak tracheal wall rings- collapse during expiration (rare condition)
Besides expiratory stridor, what else can infants with tracheomalacia have?
Wheezing- extrinsic tracheal compression can cause fixed wheezing (also prolonged neonatal ventilator support can cause wheezing so consider this)
When is the symptom relief noted in laryngomalacia?
During expiration (opposite of tracheomalacia which is expiratory stridor)
What should you consider for a kid with history of TE fistula repair who presents with expiratory stridor?
Tracheomalacia
What should you consider for a kid with feeding difficulties and expiratory stridor?
Vascular ring (extrinsic compression-wraps around trachea and esophagus)
What type of stridor does congenital and acquired subglottic stenosis cause?
Biphasic stridor- this problem is both intra-thoracic and extra-thoracic
For subglottic stenosis, which phase of stridor is often louder?
Inspiratory component
What can a subglottic hemangioma result in?
Subglottic stenosis (biphasic stridor)
What can a critical obstruction along the airway result in?
Biphasic stridor
True or False: With tracheomalacia, if the obstruction is high enough, stridor can be biphasic
True
How do you assess for subglottic stenosis?
Direct laryngoscopy and bronchoscopy
*Bronch assess the patency of the subglottis
How do you assess for vocal cord function?
Flexible nasolaryngoscopy or direct laryngoscopy, plus a CXR and barium swallow
How do you assess for a vascular ring?
Barium swallow study
What should be the first thing done for an infant with noisy breathing?
Obtain thorough birth history and observe breathing patterns in different positions
What type of stridor does epiglottitis present with?
Biphasic (this is a supraglottic stenosis)
Why is epiglottitis rare today?
Hib vaccine
4-5 year old with inspiratory stridor, high fever, won’t lay down, is positioned leaning forward, tripoding, and drooling?
Epiglottitis
What is seen on lateral neck film in epiglottitis?
Thumb sign- Enlarged epiglottis
True or False: Cough is common in the presentation of epiglottitis?
False
5 D’s of epiglottitis?
- Drooling
- Dysphagia
- Dysphonia
- Distress
- Deafening stridor
What should you look for in history if you suspect epiglottitis?
Parental refusal of all immunizations
Child from another country
Hib vaccine not given
How do you evaluate for epiglottitis?
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
If your patient with suspected epiglottitis is table, what labs should you get?
CBCdiff and blood culture
What type of antibiotic should be started empirically for epiglottitis?
3rd generation cephalosporin (ceftriaxone or cefotaxime)
What is another name for laryngotracheobronchitis?
Viral croup
Toddler in fall/winter with a harsh, non-productive barking cough, low grade fever, URI symptoms?
Croup
What kind of stridor can be seen in croup?
Inspiratory or biphasic (with worsening of narrowing)
What is treatment for mild croup?
Humidified air, fever reduction, PO fluids, exposure to cold night air
What characterizes more severe croup?
Stridor at rest or retractions
What can be done for more severe croup?
- Single dose of dexamethasone
- Nebulized racemic epi
- Intubation
How frequently can racemic epinephrine be given?
Every 15-20 minutes as needed
How long do kids who have gotten racemic epinephrine need to be observed before they can be discharged home?
3-4 hours
What vaccine-preventable disease can cause croup?
Measles (rubeola)
*Keep this in mind with a kid who is unimmunized, recent immigrant, or unknown immunization status
What are the 3 common viruses that can cause croup
- RSV
- Influenza
- Parainfluenza
What causes spasmodic croup?
Allergies or psychological factors (no URI or fever)
*Described as a barky nonproductive cough
Name 2 other names for bacterial tracheitis
- Pseudomembranous croup
2. Membranous laryngotracheitis
What bacteria usually cases bacterial tracheitis?
- S. Aureus… also consider
- Moraxella catarrhalis
- Non-typeable H. influenza
- Oral anaerobes
What should you consider with rapid deterioration of a patient with viral croup?
Bacterial tracheitis- This can occur several days into a bout with viral croup
How do patients with bacterial tracheitits present?
Toxic appearing, thick/purulent secretions causing airway obstruction (may even lead to cardiopulmonary arrest)
What is seen on a neck film in bacterial tracheitis?
- Ragged air column
2. Subglottic narrowing
What position do kids with bacterial tracheitis prefer?
Comfortable supine (whereas epiglottitis is leaning forward and drooling)
What is management of bacterial tracheitis?
Typically the patient is deteriorating rapidly
- Intubation is required
- Clear purulent secretions
- Broad spectrum antibiotics (Staph coverage)
What are most cases of cervical lymph node enlargement due to?
Infection- Reactive cervical adenopathy
How are reactive lymph nodes described?
Mobile and tender (NOT erythematous or warm to touch)
When do reactive lymph nodes go away?
Swelling decreases in a few days-weeks
Preauricular adenopathy with conjunctivitis?
Adenovirus
What should you check for if cervical lymphadenopathy is unexplained or persists?
Check for HIV and TB
How does lymphadenitis present?
Node id tender, red, and warm to touch
*The node itself is infected versus being reactive
Which type of lymphadenitis is generally bilateral?
Acute viral cervical lymphadenitits
How does bacterial lymphadenitits present?
Unilateral, more local inflammation
What is the most common bacterial organisms causing acute cervical adenitits?
- S. aureus
2. Group A strep
What labs should you consider ordering when dealing with lymphadenitits?
CBC. ESR. blood cultures, PPD, and DNA
What is the antibiotic of choice for cervical lymphadenitits?
- Amoxicillin/clavulante
- Clindamycin
*Need something that can fight beta lactamase producers
What is a good antibiotic for a PCN allergic patient who has cervical lymphadenitits?
Erythromycin
What does atypical mycobacteria result in?
Persistent lymph node swelling
What happens with a PPD in atypical mycobacteria infection?
10mm or less (less than what you see with TB)
What is the treatment for atypical mycobacteria causing cervical adenopathy?
Leave it alone- drugs don’t work
What may be needed for cervical adenopathy due to atypical mycobacteria?
Surgical lymph node excision
When is needle excision indicated for atypical mycobacteria lymphadenopathy?
NEVER- it drains forever
What should you consider for a patient with cervical adenitis who isn’t responding to antibiotics?
Mycobacterium tuberculosis (look for other TB risk factors)
True or False: Both TB and nonTB mycobacteria turn a PPD positive
True
How can you differentiate TB and nonTB mycobacteria?
Check an IGRA (quantiferon or T-spot blood test)
*Positive in TB, Negative in nonTB
What age group is the IGRA (quantiferon or T-spot blood test) approved in?
Kids 5 and older
What bacteria is an important cause of acute cervical lymphadenitis in infants?
Staph (surgical drainage may be necessary)
Describe a lymph node that is malignant
Nontender, firm, non-mobile/fixed, doesn’t shrink in size over time (like a reactive node)
What do you need to think of if you have lymphadenopathy around the thyroid?
This could be thyroid carcinoma
What do you think of with any midline lesion on the anterior neck?
Thyroglossal cyst
When do you remove a thyroglossal cyst?
You don’t- this is often the only functioning thyroid tissue
Midline lesion on the anterior neck that moves vertically with swallowing or sticking the tongue out
Thyroglossal cyst
True or False: A thyroglossal cyst can have communication with the skin which results in draining
True
What is a mass of dilated lymph vessels that can be described as a large soft neck mass?
Cystic hygroma
How does viral parotitis present?
- 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
In a child with suspected viral parotitis who is unimmunized, what should you consider?
Mumps
With viral parotitis, what features should you consider in the presenting history?
Anything pointing towards HIV infection
How does bacterial parotitis present?
Occurs before age 10, child is toxic-appearing with very high temp
What bacteria is the most common cause of bacterial protitis?
S. Aureus
How does a salivary gland stone present?
Recurrent swelling of both parotid glands
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?
HIV testing- this is viral parotitis (no knowledge of biological parents and did get some vaccines- points away from mumps)
