ENT Flashcards
What condition is trismus most commonly associated with?
- how do they present
- most common organisms?
- treatment?
- when to consider tonsillectomy? (2)
- most serious complication?
Peritonsillar abscess!!!!!
unilateral tonsil bulge
in palate
uvular deviation (away)
trismus (pterygoids go into spasm)
-most common in adolescents (older children and teenagers, less common in younger children)
-GAS most common cause; can also be from oral anaerobe
-treatment:
1. Surgical drainage (needle aspiration)
2. Abx against GAS and anaerobes (Amoxi-clav)
Consider tonsillectomy if:
- Recurrence
- No improvement after abx or needle aspiration
Most serious complication: aspiration pneumonia if BURSTS
What position worsens stridor in laryngomalacia/tracheomalacia?
Worsens when lying supine, improved when prone
What is a pathognomonic sign of a thyroglossal duct cyst?
Vertical motion of the mass with swallowing and tongue protrusion
When does rebound nasal congestion occur after the use of otrivin?
Use > 3 days
What is an associated condition that may worsen laryngomalacia?
Reflux = may need to treat to see improvement in laryngomalacia
how do you treat septal hematoma?
urgent incision and drainage- do not want to have perforation (associated with saddle nose deformity)
nasal packing and biaxin (prevents toxic shock from the nasal packs)
what is the most common extra cranial complication of acute otitis media?
TM perforation
what are the extracranial complications of acute otitis media? (8)
TM Perforation mastoiditis post-auricular abscess labyrinthitis labyrinthine fistula facial nerve paresis/paralysis Bezold’s Abscess cholesteatoma
what are the intracranial complications of acute otitis media? (7)
Intracranial (0.36% of all AOM) ** meningitis ** brain abscess (subdural/epidural) ** sino-venous thrombosis ** Gradenigo’s Syndrome (Petrositis) otic Hydrocephalus CSF Leak
** know the first 4
what is the criteria for Tympanostomy tubes
recurrent AOM with middle ear effusion
bilateral OME (>3 mos) with CHL
unilat/bilat OME (>3 mos) with other problems
vestibular, behavioural problems, discomfort, school performance
at-risk children (immuniocompromised)
other uncommon indication
complications of AOM (i.e. mastoiditis)
lack of response to medical therapy
chronic retraction of TM
what is the treatment for perforated TM? how long does it take to heal? when do we repair perforated TM?
ciprodex drops (heat them up)
most heal within 6 weeks
typically repair around 9 or 10 years of age
refer if otorrhea is persistent/ perf visible many months after acute otitis media
what should be used in the setting of a draining ear?
ciprodex drops!!
not ototoxic
12 years old draining left ear
x 1 year. What is the most
likely diagnosis?
cholesteatoma
what are the features of otorrhea from cholesteatoma
unilateral
foul smelling
persistent/recurrent
responds to ototopicals (Ciprodex) but recurs
what are the risk factors for hearing loss?
risk factors (ABCD’s)
affected family member
bilirubin
congenital intrauterine infection (TORCH)
defects of the ear, nose and throat
small at birth (<1500 g), low apgar, NICU
what percentage of children with SNHL have risk factors?
ONLY 50% of children with SNHL have risk factors
what is the most common congenital birth defect
sensorineural hearing loss
what is the goal of hearing tests?
diagnosis and rehabilitation by 6 months
prior to screening hearing loss was diagnosed at 18-30 months
**no child is too young to have a hearing test
what is connexion 26
- most common genetic cause of congenital SNHL
- autosomal recessive
- mutations in GJB2 gene
- codes trans-membrane gap junction protein
- allows fluids and small molecules to pass
- recycles K+ between endolymph and stria vascularis
most common non-genetic cause of hearing loss?
what percentage are symptomatic?asymptomatic?
congenital CMV
5-10% symptomatic (50% have SNHL)
90-95% asymptomatic (5-15% have SNH)
what are the features of SNHL associated with cCMV
high frequency
progressive (>50% in first 5 years)
unilateral loss (40%)
What percentage of newborn hearing screening misses congenital CMV induced SNHL?
Newborn hearing screening miss over 50% CMV induced SNHL
What is the most common cause of bilateral
nasal obstruction in a child?
adenoid hypertrophy
when should a closed reduction be performed on the nose
within 7-14 days
If a child presents with nasal trauma what is the one thing you need to rule out
septal hematoma
requires emergent drainage
where does most epistaxis come from
little’s area in kiesselbach’s plexus
what are the treatment options for epistaxis
humidify lubrificate cauterize pack treat underlying coagulopathy
13 years old boy – severe
chronic unilateral epistaxis
– blood tests normal
what should you be worried about?
angiofibroma (Juvenile Nasal Angiofibroma)
teenage boy with unilateral epistaxis
What is Chandler’s classification
Chandler's classification- know this!! it is not a progression of infection I – pre-septal II – post-septal III – subperiosteal ABCESS IV – ORBITAL abscess V – cavernous sinus thrombosis (spread to the cavernous sinus back in the brain)
what is the treatment for complicated sinonasal infections?
medical management:
antibiotics
decongestants
nasal corticosteroids
surgical management:
abscess drainage
what are the indications for adenotonsillectomy
Absolute OSA (AHI>5/hr) and large tonsils *** Cor pulmonale suspected malignancy hemorrhagic tonsillitis severe dysphagia
Relative tonsillar hypertrophy (no need to take out if no symptoms) recurrent tonsillitis *** complications of tonsillitis tonsilloliths and halitosis
** two most common reasons
do not give routine preoperative antibiotics
what is the criteria for retropharyngeal abscess on x ray
prevertebral soft tissues > 7mm (c2),
14mm (c6/c7) or
> 1 x the width of the vertebral body
what does inspiratory stidor suggest? biphasic stridor? expiratory stridor?
inspiratory- supraglottis (chirpy sound)
biphasic (the most worrisome- smallest part of the pediatric airway)- level of the vocal cords
or the subglottis
expiratory- trachea
bronchiwhat is the differential for inspiratory (supraglottic) stridor? (5)
laryngomalacia vallecular cyst saccular cyst foreign body epiglottitis
what is the differential for biphasic stridor? (9)
bilateral vocal cord paresis subglottic stenosis glottic web subglottic hemangioma subglottic cyst laryngeal cleft foreign body papillomatosis croup
what is the differential for expiratory stridor?
tracheomalacia*
foreign body
tracheoesophageal fistula*
complete tracheal rings*
what is potts puffy tumor?
osteomyelitis of the frontal region coming typically from the frontal sinus (does not have to be overlying- can have vascular spread as opposed to direct spread)
what are the red flags for complicated sinusitis
proptosis diplopia altered vision severe pain headache altered LOC
Retropharyngeal abscess
what is it?
who gets them?
tratement?
*present with limited lateral motion of their neck
mid line bulge in the retropharynx
have to do a lateral x ray
posterior to the palate
younger children (1-toddler age) beacuse they have large lymph nodes in that area
tx: antibiotics
+/- drainage
Red flags for referral for stridor
biphasic stridor- often need surgery your comfort level parental concern diagnosis in question S- severity P- progression E- eating and feeding C- cyanosis S- sleep R- radiology
severity (getting work)
affecting eating and feeding
cyanosis
if it is happening in sleep or moving about
any radiographic evidence of narrowing (AP film)
How does someone with subglottic hemangioma present?
what is the treatment?
50% have an associated cutaneous hemangioma
present with a label of croup, but too young (baby who is 1 -3 months)
biphasic stridor
they will get better with steroids but the alarm bell is the age
“beard” distribution hemangioma- the probability goes up that they will have an airway hemangioma
tx: propranolol
steroid (systemic/intralesional)
laser/surgical excision
unilateral, more likely to be left sided
what are the features of laryngomalacia? what is the typical course?
omega epiglottis
short AE folds (pulling in both sides of epiglottis)
arytenoid prolapse
redundant tissue (often secondary to reflux)- often recommend anti reflux therapy
presents with in the first few days of life
worsens up to 6 months
plateaus 6-12 months
generally resolves by 18-24 months
what is the treatment for laryngomalacia?
the majority will never need surgery
need to monitor weight (stridor increases your caloric expenditure)
medical therapy- reflux therapy
surgical- if they fall off their growth curve
= aeryepiglottoplasty (Only about 5 %)
How does tracheomalacia present? causes? (3)
audible expiratory wheeze dying spells (ALTE) especially when sick causes: complete tracheal rings slings post TEF (every child that has TEF will have tracheomalacia)
Bronchoscopy indicated if
any 1 of :
Bronchoscopy indicated if
any 1 of :
choking spell (high density foods- peanut/carrot/apple; no high dense foods until molars present)
physical exam finding (wheeze, prolonged expiration, decreased breath sounds)
chest x-ray finding (air trapping, consolidation)
what x ray views should you order for airway foreign body?
inspiratory and expiratory views or
right and left lateral decubitus views
what will you see on xray with a button battery
double halo sign
always need a lateral film to make sure a coin is not a battery
will see step off on lateral film
requires urgent removal- priority 1 regardless of what orifice (Cause a significant burn)
what are the most common congenital neck masses?
most neck masses are congenital (>50%)
branchial cleft cyst- the most common (18%)
thyroglossal duct cyst (16%)
dermoid cyst (10%)- may enlarge rapidly after URTI
lymphangioma (8%)
hemangioma (2%)
2 year old, afebrile, nontender mass, growing.
What is the most likely
diagnosis? purplish discoloration overlying parotid
mycobacterial avium adenitis- purplish is the key for this
What is the treatment for Atypical Mycobacterium (MAI)
Biaxin (Clarithromycin) x 7-10 days, f/u 3 week
Lateral neck masses
Branchial cleft cyst Fibromatosis Colli Hemangioma Thymic cyst Vascular malformation Laryngocele
Midline neck masses (7)
Thyroglossal duct cyst Dermoid cyst Teratoma Cervical Cleft Foregut duplication cyst Ranula Vascular Malformation
Pathopnemonic exam finding: thyroglossal duct cyst dermoid cyst midline branchial cleft cyst laryngocele hemangioma mass lymphatic malformation sternocleidomastoid tumour cervical rib(s)
thyroglossal duct cyst moves w/ tongue protrusion / midline
dermoid cyst midline / calcifications on plain films
branchial cleft cyst smooth along SCM border
laryngocele enlarges with valsalva
hemangioma mass presents after birth, rapidly
grows, then plateaus, bluish in color
lymphatic malformation transilluminates / compressible
sternocleidomastoid tumour presents with torticollis
cervical rib(s) hard and immobile, may be bilateral
what are some features of reactive lymph node (4)
<1 cm
oval (S/L ratio <0.5cm)
normal hilar vascularity
low resistive index with high blood flow
what are some features of malignant lymph node
>1 cm round (S/L ratio >0.5cm) no echogenic hilus coagulative necrosis high resistive index with low blood flow extracapsular spread
Tympanometry
Type A
Type B
Type C
tympanometry is a middle ear test
pressure wave- if the ear drum is normal it will sail back and forth, if there is fluid it will be completely flat
Type A – Normal
Type B – Flat – suggests OME *** ALWAYS THE ANSWER
Type C – Retraction
what is the newborn hearing test for healthy babies with no risk factors? what test do they get if they fail this?
OME (otoacoustic emissions)- outer hair cells making a sound that gets picked up by the microphone, middle ear has to be clear
does not give us any information about the degree of hearing loss **
ABR (auditory brain-stem response)
what is the most common reason to fail OME?
middle ear effusion
what is the newborn hearing test for babies with risk factors?
AABR (automated ABR)
analyzed by a computer and gives a result
will miss mild hearing loss, not the first line of screening for healthy babies
Normal AABR and if you are at risk- VRA (visual reinforced audiometry) when they are older (8-12 months)- behavioral test such as play audiometry to make sure they don’t have a mild hearing loss
abnormal AABR- diagnostic ABR at 6 weeks corrected (if normal and at risk then they get behavioral testing)
what investigations would you order for someone with profound hearing loss? (2)
- EKG
looking for Jervell and Lange- Nielson (Jervell and Lange-Nielsen syndrome (JLNS) is a type of long QT syndrome associated with severe, bilateral sensorineural hearing loss) - urinalysis and renal ultrasound
BOR
Cogans (Cogan syndrome is a rare disorder characterized by recurrent inflammation of the front of the eye (the cornea) and often fever, fatigue, and weight loss, episodes of vertigo (dizziness), tinnitus (ringing in the ears) and hearing loss)
when do you image for SNHL?
if hearing loss is severe to profound
- imaging required prior to cochlear implant
patients with cochleovestibular anomalies are at increased risk of what?
patients with cochleovestibular anomalies are at increased risk of meningitis from an otogenic source
How do you diagnose CMV <3 weeks? >3 weeks?
age <3 weeks
urine culture gold standard
saliva or urine PCR other options
age >3weeks
CMV PCR from neonatal dry blood spot
or MRI
what is the most common presentation of hearing loss with CMV
most common presentation is single sided deafness
probability of hearing loss in the contralateral ear is 75% (over 18 years)
What are the treatment options for hearing loss
hearing aids
- conventional
- bone conduction
surgical
- tympanostomy tubes (OME)
- cochlear impacts (severe to profound deafness)
implanted middle ear and other implants
what are some causes of conductive hearing loss?
OME
less common:
aural atresia
syndromic CHL: crouton’s, MPS, osteogenesis imperfects, treachery collins, achondroplasia, Klippel-feil, Apert, BOR
what is the treatment for tube otorrhea
topical antibiotics
resolution is quick
what is Bezold’s abcess?
an abscess deep to the STERNOCLEIDOMASTOID MUSCLE muscle where pus from mastoiditis erodes through the cortex of the mastoid part of the temporal bone
What is the triad for Gradenigo’s syndrome
retro-orbital pain (in the distribution of the trigeminal nerve)**
otorrhea **
abducens palsy**
fever
what is neonatal ophthalmia?
conjunctivitis in the first 4 weeks of life
what are the common bacterial pathogens for AOM and bacterial sinusitis:
Streptococcus pneumoniae
Nontypeable Haemophilus influenzae
Moraxella catarrhalis
Child with liver transplant. Has a unilateral peritonsillar mass. Cervical lymphadenopathy. Most likely diagnosis? What are 4 non-infectious complications that you have to monitor?
Upper airway obstruction
Rupture (can lead to aspiration)
Internal jugular thrombosis and thrombophlebitis - Lemierre syndrome
Carotid artery pseudoaneurysm and rupture
Give differential diagnoses for congenital torticollis other than sternocleidomastoid tumor.
Congenital
Osseous abnormalities - Klippel-Feil syndrome (abnormal joint fusion of the cervical spine vertebrae, short neck, low hairline at back) , unilateral atlanto-occipital fusion, hemivertebrae
Soft tissue abnormalities - unilateral absence of sternocleidomastoid, pterygium colli (webbed neck derformity)
fibromatosis colli
Acquired
Congenital muscular torticollis (most common)
Trauma - clavicle #, brachial plexus injury
Cervical instability (atlantooccipital or antlantoaxial subluxation)
what is the order for sinus development
Born with ME, then go to School (Sphenoid at 5 yo) then get Friends (Frontal at 7)
(mnemonic :Maxillaries Early, Sphenoids Follow)
❖ Maxillary and Ethmoidal sinuses: present at birth, but only the ethmoidal sinuses are
pneumatized
❖ Maxillary sinuses pneumatized at 4yr of age
❖ Sphenoidal sinuses are present by 5yr of age ( S for School age)
❖ Frontal sinuses begin development at age 7-8yr and are not completely developed until
adolescence.
6 week old with description of mild laryngomalacia, stridor when feeding, improves when placed supine. Growing well and otherwise well.
What do you tell parents about the prognosis?
Two indications for surgery for laryngomalacia
List four items on the differential diagnosis for a child < 12 months old with chronic stridor
6 week old with description of mild laryngomalacia, stridor when feeding, improves when placed supine. Growing well and otherwise well.
What do you tell parents about the prognosis?
Will spontaneously resolve
Two indications for surgery for laryngomalacia
Significant apenas
Unable to feed
Severe stridor
List four items on the differential diagnosis for a child < 12 months old with chronic stridor
Tracheomalacia
Vocal cord paralysis
Vascular ring
Bronchogenic cyst
Infantile hemangioma
Subglottic stenosis
Foreign body aspiration
Girl with large tonsils on exam and OSA (AHI 10) on a sleep study with desats. You consult ENT urgently and the surgery is scheduled in one week.
Name two consequences of OSA (2)?
What one investigation should she have done before the surgery (1)?
What are two things that you would do to manage her before the surgery (2)?
Name two consequences of OSA (2)? Hypertension RV hypertrophy Polycythemia Metabolic alkalosis - hypercapnea Daytime somnolence
What one investigation should she have done before the surgery (1)?
Cardiac assessment - Echo / ECG
What are two things that you would do to manage her before the surgery (2)?
CPAP
Oxygen at night
Nasal steroids if adenoids enlarged
Newborn who is IUGR, failed hearing screening, positive CMV PCR from urine, what do you treat them with and for how long?
Valganciclovir for 6 months
What condition is a bifid uvula associated with?
Submucosal cleft palate
16 month old boy has episodes (once weekly) of falling down suddenly and refusing to get up. Remains conscious during episodes and recovers within a few minutes. Sometime vomits with episodes. Eyes are noted to move during the episode.
What is the diagnosis?
What is one associated condition?
16 month old boy has episodes (once weekly) of falling down suddenly and refusing to get up. Remains conscious during episodes and recovers within a few minutes. Sometime vomits with episodes. Eyes are noted to move during the episode.
What is the diagnosis?
Benign paroxysmal vertigo
What is one associated condition?
Associated with migraine and motion sickness
2 year old with fever and right ear pain. She was treated with clarithromycin a few weeks ago for a respiratory infection. On exam has acute otitis media. What are three possible antibiotics she could be given?
amoxicillin
amox-clav
cefuroxime
ceftriaxone
Child with sinusitis, list 5 complications of bacterial sinusitis
Sinus venous thrombosis Meningitis Orbital/periorbital cellulitis Brain abscess Osteomyelitis of the frontal bone – pot puffy tumor mucocele
Branchial Oto Renal Syndrome, is it autosomal recessive or dominant?
autosomal dominant
6 years old – recurrent neck
abscess (x2) requiring I&D,
6 months apart?
a) patient is at risk of rheumatic fever
b) patient at risk for coronary artery aneurysms
c) this is highly contagious
d) patient may have an underlying 2nd branchial cleft cyst
patient may have an underlying 2nd branchial cleft cyst
when to biopsy neck adenopathy, history, physical, duration
HISTORY Family history Previous cancer Previous Rtx Immunosuppressed 'B' symptoms
Physical: neonate size > 2 cm firm hard fixed CN abnormality supraclavicular
Duration:
increase at 2 wks
no change at 4 wks
what are 2 conditions associated with pyriform aperture stenosis
apert syndrome
crouzon syndrome
what is an encephalocele
brain has come through into the nose
bluish in color
pulsatile
if you decrease venous return to the heart they should expand (child crying and bearing down or turn the baby upside down and it will expand)
image with CT scan and MRI
versus: glioma- no longer connected to the brain, not pulsatile, not compressible still do CT and MRI
3 midline things in the nose
encephalocele
glioma
dermoid
they could be connected to the brain so you should get imaging- CT or MRI
Ddx nasal polyps
CF
PCD
antrochoanal polyp
wegener’s granulomatosis
indications for tonsillectomy for recurrent infections
7 episodes/yr in 1 year
5 episodes/yr in 2 years
3 episodes/yr in 3 years
what does thumb sign on x ray suggest? steeple sign?
thumb sign- epiglottitis
steeple sign- croup
What is the most objective test to detect a middle ear effusion?
tympanometry
looks at how much TM moves
-if stiff with effusion, moves less
What are the features of Treacher-Collins syndrome?
- Downslanted palpebral fissures
- Malformed auricles
- Malar hypoplasia
- Mandibular hypoplasia
What is the management of otitis media with effusion?
See middle ear fluid without signs or symptoms of inection
- management:
1. Observation = 90% resolve after 3 months
2. Document degree of hearing loss if > 3 mo and consider myringotomy for ear tubes (conductive hearing loss)
What is the most common genetic cause of sensorineural hearing loss?
Connexin 26 protein defect from mutation = autosomal recessive
1 mo boy presenting with progressively worsening biphasic stridor. No history of intubation. What is the most likely diagnosis? Next step in management?
-what if it was inspiratory stridor? Expiratory?
Vocal cord paralysis!! Next step: immediate ENT referral and get MRI of the brain!! Need to look at course of recurrent laryngeal nerves from Cranial nerve CN 9/10 to the nerve itself
- Insp stridor = think laryngomalacia
- exp stridor = think trachomalaceia
- biphasic stridor = think vocal cord paralysis
What is the most serious complication of peritonsillar abscess?
-what about retropharyngeal abscess?
Peritonsillar abscess: aspiration pneumonia
Retropharyngeal abscess: airway obstruction
What is the ddx for unilateral tonsillar enlargement?
True enlargement
- Infectious: tonsillitis, peritonsillar abscess
- Benign hypertrophy (chronic)
- Neoplastic: lymphoma
- rapid growth
- dysphagia
- cervical nodes
- night sweats
What is the treatment of acute epistaxis?
-adolescent male presents recurrently with epistaxis and it is always on the same side. What is the most likely diagnosis?
- Pressure first x 5 minutes.
- If that doesn’t work: then pack with vaseline strip gauze or gel foam
- If that doesn’t work: then call ENT to do nasal packing
* **cautery may not be great because it might traumatize the tissue around the bleed so if you do cauterize, need to do medical therapy x 2 wks post
Most nosebleeds originate from septal wall: Little’s area
Adolescent male: Juvenile angiofibroma = usually unilateral, always same side, may have element of nasal obstruction
What is a possible complication of nasal fracture?
septal hematoma
2 most common causes of swollen midline neck mass?
-first step in work-up?
- Thyroglossal duct cyst = cystic mass
- Dermoid cyst = solid mass
- Lymphadenopathy
First step in work-up: ultrasound
What are the indications for adenoidectomy? (7)
- Chronic nasal obstruction or obligate mouth breathing
- OSA with FTT, cor pulmonale
- Dysphagia
- Speech problems
- Severe orofacial/dental abn
- Recurrent/chronic adenoiditis/sinusitis if medical management failed (3 or more episodes/yr)
- Recurrent/chronic OME
who should be admitted for monitoring following tonsillectomy
Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea
what is the most common bug to cause mastoiditis
strep pneumonia
orbital cellulitis typically comes from which sinus?
ethmoid
