ENT Flashcards
Laryngomalacia clinical signs
- Inspiratory stridor (MCC stridor in infants)
- Symptoms worse when supine, crying, agitated, or feeding
- If severe: FTT, difficulty feeding, OSA, cyanosis
Laryngomalacia treatment
- Symptoms may progress until 6 months but majority of cases resolve by 12-18 months
- If severe: surgical management with supraglottoplasty or tracheostomy
Tracheomalacia etiologies
- Primary: intrinsic defect in cartilaginous tracheal rings
- Secondary (compression of trachea) - mediastinal vasculature, lymphatic malformations, neoplasm
Tracheomalacia clinical signs
Stridor, wheezing, recurrent barking cough, frequent respiratory infections
Nasal polyps signs/symptoms and treatment
- S/sx: persistent mucoid rhinorrhea, chronic nasal congestion, noisy breathing, disturbed sleep
- Exam: glistening fleshy color of polyps
- Treatment: intranasal steroids is first line
Disease associations with nasal polyps
- CF IS THE MOST COMMON AND ALL KIDS NEED A SWEAT TEST!
- Aspirin sensitivity, allergic rhinitis, recurrent sinusitis, and asthma are also associated
Causes of persistent/recurrent purulent otorrhea
- Cholesteatoma, foreign body, histiocytosis, and other inflammatory or malignant conditions
- Persistent purulent otorrhea for > 2 weeks despite treatment is indication to send to ENT
Cholesteatoma
- Squamous epithelium and keratin (white mass behind TM)
- Cause of persistent otorrhea and conductive hearing loss
- FOUL SMELLING discharge despite treatment of perforated TM
- Congenital or acquired
- Tx is surgical removal - can dissolve tissue/bone and reach into the CNS
Cleft palate complications
- Increased risk of eustachian tube dysfunction, middle ear effusions, and conductive hearing loss
- Also often have feeding/language difficulties.
Treatment of sensorineural hearing loss
- Cochlear implants placed by 12 months of age is ideal
Indications for surgical tympanostomy tube removal
- If tube is still in after 3 years
- Migration into middle ear
- Granulation tissue not responding to drops
- Chronic otorrhea that does not respond to treatment
- Resolution of the condition that prompted insertion (eg, repair of cleft palate), especially in an older child
Causes of conductive hearing loss
- Inner and outer ear malformations
- Trauma (perforations)
- Tympanosclerosis (minimal hearing loss, scarring from lots of OM)
- Chronic otitis with effusion (MOST COMMON cause)
- Cholesteatoma
Medication causes of sensorineural hearing loss
- Lasix and ethacrynic acid (temporary)
- aminoglycosides, salicylates
Hearing loss from loud sound exposure
High frequency sensorineural hearing loss
Sudden onset of bilateral sensorineural deafness
Viral labyrinthis - no treatment, some may get hearing back but not all
Infectious causes of sensorineural hearing loss
- In utero: CMV (most common), herpes, rubella, syphilis
- Acquired: bacterial meningitis (usually occurs within first 24 hours of illness – need a hearing test)
Preemie risk factors for sensorineural hearing loss
- Prolonged ventilation
- Hyperbili
- LBW
- Rh factor
- Maternal diabetes
At what age is language development affected by deafness
9 months
- Prior to that cooing and babbling do not depend on hearing
Types of hearing tests based on age
- Behavioral observation audiometry - less than 6 months (only a screening)
- Auditory brainstem response (uses EEG) - good for less than 6 months
- Visual reinforced audiometry (used for ages 6-24 months)
- Play audiometry - ages 2-4
- Conventional pure tone audiometry screen (age > 4)
Flat line or low amplitude tympanogram
Suggests stiff membrane or middle ear fluid (obstructed tympanostomy tube)
High volume tympanogram
Perforated TM
Three criteria for acute otitis media
- Recent abrupt onset
- Bulging TM with effusion
- Erythema of TM
Most common cause of chronic suppurative otitis media
Psuedomonas
Treat with topical/otic ofloxacin
Indications to watch with AOM before giving antibiotics
- Infants over 6 months with unilateral otitis and nonsevere symptoms
- Toddlers overa ge 2 with nonsevere symptoms (unilateral or bilateral
- Can withhold antibiotics for 48-72 hours, 80% will resolve on their own
Large erythematous mass in ears after tympanostomy tube placement
- Tympanostomy tube granuloma (common complication)
- Can lead to bloody drainage
Cause/symptoms of otitis externa
- Pain with movement of pinna
- Cause is pseudomonas
- Tx antibiotics/steroids (fluoroquinolone)
- Ppx: acidify ear following swimming and dry with hair dryer
Swelling/deformity of external ear following blunt trauma management
Cauliflower ear
- Ice packs and pressure then evacuation of hematoma by needle aspiration to prevent potential cartilage loss
Causes of mastoiditis
- MC complication of acute otitis media
- Strep pneumo, H. flu, S pyoenes, S aureus
- Dx with CT and tympanocentesis with culture
- Sx: swelling/erythema, tenderness over mastoid, outwardly displaced pinna
Associations with nasal polyps
- CF
- Asthma
- Chronic allergic rhinitis
- Chronic sinusitis
Cyanosis with feeding and resolution with crying
- Choanal atresia
- 50% are associated with genetic anomalies
- Evaluation by inability to pass catheter through nares
Timing of when sinuses develop
- Maxillary and ethmoid: at birth
- Sphenoid and frontal: 5-6 years of age
Persistent nighttime cough and/or bad breath with persistent nasal congestion for 7-10 days, can also have toothache or sore throat
- Acute sinusitis
- MC organisms: pneumococcus, H flu, moraxella
Tx: amox (unless they failed that or if they attend daycare then augmentin)
Complications of acute sinusitis
- Ehtmoid –> orbital cellulitis
- Frontal –> brain abscess
Treatment of chronic sinusitis
Antibiotics (surgery if necessary) - can take 2-3 months
- CT scan is diagnostic
Causes of epistaxis
- Foreign body
- Vascular anomalies
- Family history of bleeding disorders
- Mass (nasopharyngael angiofibroma)
Patient with dysphaia, difficulty opening mouth, unilateral swelling around the tonsil, deviation of uvula to one side (with exudates), trismus, drooling, hot potato voice
Peritonsillar abscess
Dx: CT scan
Tx: amp/sulbactam, clinda, amox/clav and needle aspiration/drainage
Hypernasal voice following T/A
Velopharyngeal insufficiency
Young child with fever, trouble swallowing, enlarged lymph nodes, hyperextended neck
Retropharyngeal abscess
- Dx: CT, can see widening of retropharyngeal space on lateral neck film
- Tx: needle aspiration, antibiotics (clinda, amp/sulbactam)
Retropharyngeal abscess vs peritonsillar abscess vs epiglottitis
- Retro: younger (less than age 4), hyperextended neck
- Peritonsillar: school age/adolescents
- Epiglottitis: toxic appearing, prefer to lean forward, air hungry
What to do with an avulsed tooth
- If permanent tooth: put it back in within 5 minutes (or transport it in chilled milk)
- DON’T put back in a baby tooth
Treatment for dental abscess
Penicillin
Cleft lip facts
- More common in males
- 2/3 have associated cleft palate
- Most common in Native Americans and Asians
- Repair around 10 weeks of age
Cleft palate facts
- More common in females
- Highest risk of being associated with a snydrome
- Repair between 9-12 months of age
Bifid uvula associations
- Submucosal cleft palate
- Velopharyngeal insufficiency
- Middle ear effusion
Genetic associations with clefts
- Pierre Robin
- Crouzon syndrome
- Apert syndrome
- Treacher collins snydrome
Symptoms of obstructive sleep apnea
Behavior issues, failure to thrive, developmental delay, poor school performance, snoring, restless sleep, dysmorphic facies, mouth breathing, hyponasal speech, cleft palate
Caused by adenoid hypertrophy
Causes of extreme OSA
- Complete laryngeal atresia
- Severe laryngeal web
- Severe subglottic stenosis
- Vocal cord paralysis
- Tx: tracheostomy
Causes of inspiratory stridor
- Pharyngeal and Hypopharyngeal masses
- Swelling/inflammation of tonsils and adenoids
- Vocal cord paralysis
- Laryngomalacia
MCC congenital stridor, suprasternal and subcostal retractions, infant < 1 month of age, worse in supine position, symptoms improve with expiration, growing and feeding well
Laryngomalacia - inspiratory stridor
Vocal cord paralysis symptoms
- Blunted inspiratory loop on spirometry
- Due to traumatic injury of recurrent laryngeal nerve at time of birth or CNS impairment
- Weak cry, high pitched inspiratory stridor
- Unilateral paralysis: persistent hoarseness
Progressive hoarseness that is less severe in the morning without stridor or dysphagia
- Vocal cord nodules (more common in males and improve with puberty)
Asthma like symptoms but normal pulse ox and clear lung fields with no response to bronchodilators, hoarseness following extubation
Vocal cord dysfunction - have inspiratory stridor (not wheezing)
Vascular ring symptoms
Present with expiratory stridor and feeding difficulties
Cause of biphasic stridor
Subglottic stenosis (congenital or acquired)
4-5 year old with inspiratory stridor, leaning forward, drooling, no cough
Epiglottitis
- Thumb sign on lateral neck film
- Hib is most common cause (less now b/c vaccine)
- Tx: OR for evaluation, blood culture, rocephin
Most common causes of croup
- Parainfluenza, influenza, RSV
- Measels (watch out for unimmunized)
Barky nonproductive cough
Spasmodic croup
Rapid deterioration of a patient with viral croup
Bacterial tracheitis
- Pseudomembranous croup
- Usually caused by S aureus but can also be moraxella or H flu
- Neck film with subglottic narrowing
- Tx: intubate, clear secretions, broad spectrum antibiotics
Thyroglossal duct cyst
Midline lesion on the anterior neck that moves upward with swallowing
- Can have functioning thyroid tissue in it
Causes of parotitis
- Viral: preschool/school age with vague symptoms, swelling/erythema around opening of Stensen’s duct, consider HIV/mumps
- Bacterial: before age 10, toxic, Staph aurerus
- Salivary gland stand - recurrent swelling of both parotid glands
Age 1-4 years, spells of vertigo without hearing loss or tinnitus
Benign paroxysmal vertigo of childhood
Hearing change/loss, vertigo, tinnitus
Viral labrynthitis
