ENT

Question 1

Nasal septal hematomas

Answer 1

• Nasal obstruction, pain, rhinorrhea after trauma
• fluctuant red/blue mass arising from teh septum

Tx: PROMPT DRAINGE.
- can lead to nasal cartilage ischemia, necrosis, deformity within 72-96 hours

Question 2

BIfid Uvula and adenoidectomy predisposes you to?

Answer 2

Velopharyngeal insufficiency

• incomplete closure btwn soft palate and pharyngeal wall during speech = hypernasal voice
• also sometimes nasal regurg of fluids

Bc removal of adenoids increases size of the nasopharyngeal airway

Question 3

Preauricular skin tag

Answer 3

Doesn’t need renal US if isolated finding.
But if there are other congenital/dysmorphic features, or family hx, get a renal US.

Newborns with isolated preauricular skin tags or pits have a 5-fold higher risk of permanent hearing loss, compared to the general population.

Question 4

Lymphadenopathy > 1 cm

Answer 4

Reactive lymphadenopathy is a response to a distant infection or inflammation within the drainage area of the affected lymph node and typically presents with painless, enlarged lymph nodes that are firm (but not hard) and freely movable.

Infectious lymphadenitis occurs when the lymph node becomes infected by an organism (viral, bacterial, or fungal) and typically presents with enlarged, painful lymph nodes with overlying erythema and accompanying systemic symptoms, such as fever.

Malignant lymphadenopathy typically presents with enlarged, painless lymph nodes that are hard and often matted and accompanying systemic symptoms.

Question 5

Paradise criteria for tonsillectomy for recurrent phayngitis

Answer 5

file:///Users/vicky/Downloads/C121A.pdf

Question 6

Stickler Syndrome

Answer 6

Hereditary Arthro-opthalmopathy

• connective tissue disorder
• ocular abnormalities (myopia, cataracts, retinal detachment)
• midface abnl (flattened, depressed nose bridge, short nose, anteverted nares, micrognathia, cleft palate) = has the Pierre Robin sequence
• hearing loss
• joint hypermobility

Bifid uvula might be marker of underlying submucosal cleft palate. Can cause breastfeeding difficulty and poor weight gain.

Question 7

Ludwig Angina

Answer 7

Infection of the submandibular and sublingual spaces, following infection of 2/3rd mandibular molar roots

• fever, mouth pain, trismus, stiff neck, difficulty swallowing
• spreads aggressively leading to brawny or woody cellulitis with palpable crepitus within the submandibular and sublingual spaces

Tx: close monitoring for airway compromise
IV ampicillin-sulbactam or a combination of penicillin G and metronidazole, to cover oral anaerobic bacteria.
If no improvement or fluctuance - surgical intervention and drainage.

Question 8

Infantile Glaucoma

Answer 8

Emergency Optho - reduce intraocular pressure

Tearing, photophobia, blepharospasm
corneal edema, conjunctival injection, visual impairment

Question 9

Chronic Rhinosinusitis

Answer 9

S. aureus is most common pathogen.

>/= 12 wks of 
facial pain
mucopurulent nasal discharge
nasal obstruction/congestion
cough, worse when lying down and at night
halitosis 
decreased sense of smell 

Dx: documentation of sinus mucosal disease on CT or by direct endoscopic exam is required to dx and rule out anatomic abnormalities

Question 10

Branchial vs. Thyroglossal Duct cyst

Answer 10

Branchial
- anterior to SCM, preauricular, mandibular

Thyroglossal

• midline
• moves with swallowing or protrusion of tongue

Question 11

Spasmus Nutans

Answer 11

6-24 months of life
unknown etiology

nystagmus is often intermittent, asymmetrical, and either bilateral or unilateral. All symptoms (nystagmus, torticollis, and head nodding) may present at varying intervals or simultaneously.

Spontaneous resolution within months to several years usually occurs.

Question 12

Auricular Hematoma

Answer 12

initial treatment is drainage of the hematoma, followed by pressure bandaging of the auricle to reduce the risk for reaccumulation of the hematoma.

Following drainage, patients should be reevaluated daily for 3–5 days to examine for reaccumulation of the hematoma and/or infection.

Prophylactic antibiotics with activity against skin flora and Pseudomonas aeruginosa is often recommended, especially in those with associated lacerations and/or abrasions.

Augmentin in children.

Question 13

Otitis Externa with Perforation - Tx

Answer 13

Pseudomonas and Staph aureus
Polymyxin B and Bacitracin

Corticosteroids do not improve outcomes.
Avoid gentimicin and ototoxic drugs

Question 14

Nasal foreign body removal

Answer 14

Use of topical vasoconstricting agent (Neosynephrine or Oxymetazoline) is recommended before any attempt to remove the nasal foreign body.
- Decrease localized swelling and decrease bleeding.

Question 15

Peritonsillar Abscess - Tx

Answer 15

NEEDLE ASPIRATION - diagnostic and therapeutic
Imaging is not needed
Antibiotics as adjunctive tx after drainage - Augmentin or Clindamycin. Plus MRSA coverage if not responsding or unstable.

Sx:
severe sore throat, fever, muffled hot potato voice, trismus, odonyphagia

Org:
GAS, S aureus, S anginosus, resp anerobes

Question 16

Sinus fracture - Tx

Answer 16

Isolated fracture to paranasal sinuses from injury to the nose or orbit

• 1 wk of augmentin**
• sinus precautions “avoidance of nose blowing, swimming, straw use, and playing wind instruments.”
• f/u in 1 week with ENT/plastics

Question 17

Benign Paroxysmal vertigo of childhood

Answer 17

• brief (minutes) episodic symptoms of vertigo in the absence of vomiting or LOC
• normal neurologic exam
• watchful waiting as it is self-limited***

DIFFERENT from benign paroxysmal positional vertigo in adults from the Ca debris in the semicircular canal

Most common cause of vertigo in young children is otitis media and middle ear conditions.

Question 18

Cochlear Implants

Answer 18

Used for severe to profound SNHL
Implanting device as soon as possible improves social and educational outcomes. Ideally at 12 months

They do not produce normal hearing, and the implantation actually destroys the cochlear n., resulting in loss of any residual hearing. Even with rehab, children don’t achieve the language skills of their peers.

Healthy People 2010 goals recommend hearing screening by 1 month of age, audiology evaluation for abnormal results by 3 months of age, and enrollment into intervention services by age 6 months. A hearing-impaired infant’s care team should include a primary care provider, audiologist, otolaryngologist, and a speech-language therapist. Hearing aids can be fitted as early as 3 months of age, and is the next step in management for those with confirmed hearing loss. Early intervention developmental services with a qualified speech therapist should commence as early as possible, and no later than 6 months of age.

Question 19

Tympanostomy Tubes

Answer 19

Indications:
otitis media with effusion > 3 months and is accompanied by hearing loss, pain, damage to the middle ear or tympanic membrane,
neurodevelopmental disabilities, or craniofacial anomalies.

OR children with recurrent acute otitis media who have middle ear effusion at the time of assessment.

Surgically removed if
- more than 3 years after insertion, migrate into the middle ear, or are associated with chronic otorrhea or granulation tissue that does not respond to treatment.

Tympanostomy tubes that remain in place longer than 3 years are not likely to spontaneously extrude; they are more likely to lead to chronic perforation of the tympanic membrane.

Question 20

Avulsed Teeth - REIMPLANT THEM

Answer 20

Avulsed permanent teeth should be immediately reimplanted. Prognosis is best when reimplantation is completed within 15 to 30 minutes of avulsion.

Avulsed primary teeth are generally not reimplanted, as this may actually damage the developing permanent tooth.

If an avulsed tooth has not already been replaced into its socket when a child presents for care, providers should hold the tooth by its crown and gently but firmly replace it directly into its socket.

Teeth that cannot be replaced into the socket immediately after avulsion can be transported in a specific storage media for avulsed teeth (Hanks solution), a glass of milk, or even held against the cheek inside the patient’s mouth.

Question 21

Otitis Media with Effusion

Answer 21

10% of children will have persistent OME at 12 weeks.

• 30% will experience resolution by 12 months.
• therefore, WATCHING WAITING is recommended with RPT exam at 12 week intervals

Presence of OME can cause
- conductive hearing loss:

Eval if b/l OME at 12 wks or unilat OME at 6 months
OR earlier if at risk for delays (CP, delay)

If hearing loss, refer to ENT for tubes
- reduced hearing during this period does NOT affect long term language dev

Question 22

Chronic Suppurative Otitis Media

Answer 22

Chronic inflammation of the middle ear and mastoid cavity which presents with recurrent ear discharge/otorrhea through a TM perf.

Associated with mild-mod hearing loss

Pseudomonas
S. aureus

Tx: topical antibiotic administered after aural cleaning (often performed with the help of an otomicroscope). Many experts prefer fluoroquinolone otic drops. IV abx reduce otorrhea also. Surgery includes mastoidectomy and or tympanoplasty