ENT Flashcards
1
Q
What condition is trismus most commonly associated with?
- how do they present
- most common organisms?
- treatment?
- when to consider tonsillectomy? (2)
- most serious complication?
A
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
2
Q
What position worsens stridor in laryngomalacia/tracheomalacia?
A
Worsens when lying supine, improved when prone
3
Q
What is a pathognomonic sign of a thyroglossal duct cyst?
A
Vertical motion of the mass with swallowing and tongue protrusion
4
Q
When does rebound nasal congestion occur after the use of otrivin?
A
Use > 3 days
5
Q
What is an associated condition that may worsen laryngomalacia?
A
Reflux = may need to treat to see improvement in laryngomalacia
6
Q
how do you treat septal hematoma?
A
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)
7
Q
what is the most common extra cranial complication of acute otitis media?
A
TM perforation
8
Q
what are the extracranial complications of acute otitis media? (8)
A
TM Perforation mastoiditis post-auricular abscess labyrinthitis labyrinthine fistula facial nerve paresis/paralysis Bezold’s Abscess cholesteatoma
9
Q
what are the intracranial complications of acute otitis media? (7)
A
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
10
Q
what is the criteria for Tympanostomy tubes
A
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
11
Q
what is the treatment for perforated TM? how long does it take to heal? when do we repair perforated TM?
A
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
12
Q
what should be used in the setting of a draining ear?
A
ciprodex drops!!
not ototoxic
13
Q
12 years old draining left ear
x 1 year. What is the most
likely diagnosis?
A
cholesteatoma
14
Q
what are the features of otorrhea from cholesteatoma
A
unilateral
foul smelling
persistent/recurrent
responds to ototopicals (Ciprodex) but recurs
15
Q
what are the risk factors for hearing loss?
A
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
16
Q
what percentage of children with SNHL have risk factors?
A
ONLY 50% of children with SNHL have risk factors
17
Q
what is the most common congenital birth defect
A
sensorineural hearing loss
18
Q
what is the goal of hearing tests?
A
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
19
Q
what is connexion 26
A
- 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
20
Q
most common non-genetic cause of hearing loss?
what percentage are symptomatic?asymptomatic?
A
congenital CMV
5-10% symptomatic (50% have SNHL)
90-95% asymptomatic (5-15% have SNH)
21
Q
what are the features of SNHL associated with cCMV
A
high frequency
progressive (>50% in first 5 years)
unilateral loss (40%)
22
Q
What percentage of newborn hearing screening misses congenital CMV induced SNHL?
A
Newborn hearing screening miss over 50% CMV induced SNHL
23
Q
What is the most common cause of bilateral
nasal obstruction in a child?
A
adenoid hypertrophy
24
Q
when should a closed reduction be performed on the nose
A
within 7-14 days
25
If a child presents with nasal trauma what is the one thing you need to rule out
septal hematoma
| requires emergent drainage
26
where does most epistaxis come from
little's area in kiesselbach's plexus
27
what are the treatment options for epistaxis
```
humidify
lubrificate
cauterize
pack
treat underlying coagulopathy
```
28
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
29
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)
```
30
what is the treatment for complicated sinonasal infections?
medical management:
antibiotics
decongestants
nasal corticosteroids
surgical management:
abscess drainage
31
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
32
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
33
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
bronchi
```
34
what is the differential for inspiratory (supraglottic) stridor? (5)
```
laryngomalacia
vallecular cyst
saccular cyst
foreign body
epiglottitis
```
35
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
```
36
what is the differential for expiratory stridor?
tracheomalacia*
foreign body
tracheoesophageal fistula*
complete tracheal rings*
37
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)
38
what are the red flags for complicated sinusitis
```
proptosis
diplopia
altered vision
severe pain
headache
altered LOC
```
39
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
40
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)
41
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
42
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
43
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 %)
44
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)
```
45
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)
46
what x ray views should you order for airway foreign body?
inspiratory and expiratory views or
| right and left lateral decubitus views
47
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)
48
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%)
49
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
50
What is the treatment for Atypical Mycobacterium (MAI)
Biaxin (Clarithromycin) x 7-10 days, f/u 3 week
51
Lateral neck masses
```
Branchial cleft cyst
Fibromatosis Colli
Hemangioma
Thymic cyst
Vascular malformation
Laryngocele
```
52
Midline neck masses (7)
```
Thyroglossal duct cyst
Dermoid cyst
Teratoma
Cervical Cleft
Foregut duplication cyst
Ranula
Vascular Malformation
```
53
```
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
54
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
55
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
```
56
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
57
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)
58
what is the most common reason to fail OME?
middle ear effusion
59
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)
60
what investigations would you order for someone with profound hearing loss? (2)
1. 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)
2. 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)
61
when do you image for SNHL?
if hearing loss is severe to profound
| - imaging required prior to cochlear implant
62
patients with cochleovestibular anomalies are at increased risk of what?
patients with cochleovestibular anomalies are at increased risk of meningitis from an otogenic source
63
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
64
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)
65
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
66
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
67
what is the treatment for tube otorrhea
topical antibiotics
| resolution is quick
68
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
69
What is the triad for Gradenigo's syndrome
retro-orbital pain (in the distribution of the trigeminal nerve)**
otorrhea **
abducens palsy**
fever
70
what is neonatal ophthalmia?
conjunctivitis in the first 4 weeks of life
71
what are the common bacterial pathogens for AOM and bacterial sinusitis:
Streptococcus pneumoniae
Nontypeable Haemophilus influenzae
Moraxella catarrhalis
72
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
73
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)
74
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 4 yr of age
❖ Sphenoidal sinuses are present by 5 yr of age ( S for School age)
❖ Frontal sinuses begin development at age 7-8 yr and are not completely developed until
adolescence.
75
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
76
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
77
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
78
What condition is a bifid uvula associated with?
Submucosal cleft palate
79
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
80
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
81
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
```
82
Branchial Oto Renal Syndrome, is it autosomal recessive or dominant?
autosomal dominant
83
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
84
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
85
what are 2 conditions associated with pyriform aperture stenosis
apert syndrome
| crouzon syndrome
86
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
87
3 midline things in the nose
encephalocele
glioma
dermoid
they could be connected to the brain so you should get imaging- CT or MRI
88
Ddx nasal polyps
CF
PCD
antrochoanal polyp
wegener's granulomatosis
89
indications for tonsillectomy for recurrent infections
7 episodes/yr in 1 year
5 episodes/yr in 2 years
3 episodes/yr in 3 years
90
what does thumb sign on x ray suggest? steeple sign?
thumb sign- epiglottitis
| steeple sign- croup
91
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
92
What are the features of Treacher-Collins syndrome?
1. Downslanted palpebral fissures
2. Malformed auricles
3. Malar hypoplasia
4. Mandibular hypoplasia
93
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)
94
What is the most common genetic cause of sensorineural hearing loss?
Connexin 26 protein defect from mutation = autosomal recessive
95
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
96
What is the most serious complication of peritonsillar abscess?
-what about retropharyngeal abscess?
Peritonsillar abscess: aspiration pneumonia
Retropharyngeal abscess: airway obstruction
97
What is the ddx for unilateral tonsillar enlargement?
True enlargement
1. Infectious: tonsillitis, peritonsillar abscess
2. Benign hypertrophy (chronic)
3. Neoplastic: lymphoma
- rapid growth
- dysphagia
- cervical nodes
- night sweats
98
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?
1. Pressure first x 5 minutes.
2. If that doesn't work: then pack with vaseline strip gauze or gel foam
3. 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
99
What is a possible complication of nasal fracture?
septal hematoma
100
2 most common causes of swollen midline neck mass?
| -first step in work-up?
1. Thyroglossal duct cyst = cystic mass
2. Dermoid cyst = solid mass
3. Lymphadenopathy
First step in work-up: ultrasound
101
What are the indications for adenoidectomy? (7)
1. Chronic nasal obstruction or obligate mouth breathing
2. OSA with FTT, cor pulmonale
3. Dysphagia
4. Speech problems
5. Severe orofacial/dental abn
6. Recurrent/chronic adenoiditis/sinusitis if medical management failed (3 or more episodes/yr)
7. Recurrent/chronic OME
102
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
103
what is the most common bug to cause mastoiditis
strep pneumonia
104
orbital cellulitis typically comes from which sinus?
ethmoid
