ENT cases

Question 1

What is the general anatomy of the respiratory epithelium and what disease is closely related?

Answer 1

has cilia or hair fibers = whisk broom to clear mucus out of the sinus

has mucociliary clearance ability

Asthma, sinus disease is closely related

Question 2

Common cold symptoms and what are common causes?

Answer 2

benign, self limited, w/ symptoms hours to days post infection:

sore throat/nasal congestions/rhinorrhea/sneeze/cough

Almost always viral

Rhionvirus = 50%

Corona virus, influenza, RSV or parainfluenza

Question 3

Common cold transmission

Answer 3

• Direct contact
• Aerosolized droplets
• Virus enters nose
• Mucociliary clearance to nasopharynx

Question 4

Mechanism of infection in common cold

Answer 4

Virus enters epithelial cells
– Via intercellular adhesion molecule-1
• Virus replicates once enters cell
– 75% of patients become symptomatic
– Viral shedding peaks by day 2
– Virus can be present for several weeks
• Vasodilation, increase mucus secretion, extensive respiratory epithelium damage

Question 5

Otitis Media
• Very commonly diagnosed childhood illness
• 2.2 million episodes diagnosed yearly
• Risk factors:

Answer 5

– Daycare, smoke exposure, l_ack of breast-feedin_g, ethnicity, family history, older siblings, low socioeconomic status, other health conditions (e.g. Downs’)

Question 6

Most common cause for Acute otitis media

Answer 6

• Streptococcus pneumoniae– 40%
• Haemophilus influenza– Nontypeable– 25%
• Moraxella catarhalis– 12%

Question 7

Causes of Chronic otitis media

Answer 7

Haemophilus influenza– Nontypeable– 15%
Moraxella catarhalis– 10%
Streptococcus pneumoniae– 7%

Question 8

What does a normal tympanic membrane look like?

Answer 8

Don’t need to memorize, just appreciate

Question 9

What is our first line tx for otitis media?

Answer 9

AMOXICILLIN

Question 10

What type of ear tubes are placed in child and why do they help?

How long do they last?

Answer 10

– Pressure equalizing (PE) tubes
– Myringotomy tubes
– Tympanostomy tubes
• Allows the middle ear to ventilate until the eustachian tube is mature

Ventilate middle ear space
• Usually last 6-18 months

Question 12

What are three indications for ear tubes?

Answer 12

• Chronic middle ear effusion ± conductive hearing loss
• Recurrent suppurative otitis media
• Atelectasis of middle ear
– Inadequate ventilation by auditory tube
– Retraction/deformation of tympanic membrane

Question 13

What are paranasal sinuses and how many do we have?

Answer 13

– Air filled cavities that are found in the bones of the face/head.

– Immature at birth, develop with age
• Named for the bone in which they form; 4 sets of sinuses
• Ethmoid
• Maxillary
• Sphenoid
• Frontal

Question 15

What is sinus disease?

Answer 15

Called Rhino-Sinusitis
– Inflammation/infection of the nasal passage and paranasal sinuses
• Several different types:

Acute bacterial/ recurrent acute rhinosinusitis and chronic rhinosinusitis

Question 16

What are causes of acute rhinosinusitis?

Answer 16

– Acute Rhinosinusitis
• Acute Bacterial
– Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarhalis
• Acute Viral

Question 18

What is the mechanism that leads to a sinus infection?

Answer 18

disease causes swelling–> narrows sinus ostia–> impedes draining

==> mucus fills sinus–> bacteria grow–> Sinus infection

(can also start right from ‘narrows sinus ostia’)

Question 19

What causes inflammation of the sinuses?

Answer 19

• Viral infections
• Environmental allergens
• Environmental irritants
• Mucus
• Medications
• Bacterial Infections
• Fungus

Question 20

guy has pain in mouth when eating spicy or acidic food. PMH of AIDs, not on meds, no temp and erythema of hard palate; flat, smooth areas of dorsal tongue but no white patches. Dx

Answer 20

Erythematous candidiasis!

Has candida infection even though no white plaques (thrush or pseudomembranous candidiasis)

Question 21

• Adherent white plaques
– Tongue, buccal mucosa, hard palate
– Plaques wipe off and underlying mucosa is erythematous
• Most common in infants and immunocompromised
• Can affect oropharynx and esophagus
• 2nd most common AIDS-defining opportunistic
infection (Pneumocystis carinii pneumonia is #1)

Answer 21

Psuedomembranous candidiasis = thrush

Question 22

HIV, poorly controlled diabetes, Sjorgens disease, steoid inhalers, broad spectrum antibiotics, head adn neck radiation predispose you to:

Answer 22

oral candidiasis

Question 23

What is the most common form of oral candidiasis?

Answer 23

Erythematous (atrophic) candidiasis

Question 24

What is this a picture of?

What agents are generally responsible?

Answer 24

Angular chelitis = subtype of oral candidiasis

• Combination of bacterial and fungal infections
• Most caused by C. albicans and S. aureus
• Soreness, erythema, and fissuring at commissures
• Seen in patients who wear dentures (pooling of saliva at commissures)

Question 25

How do we Dx candidiasis?

Answer 25

Typically based on clinical signs/symptoms
Cytology
Mucosal biopsy
Culture

Question 26

– Acute atrophic
– Chronic atrophic
– Angular chelitis
– Median rhomboid glossitis
– Chronic multifocal

Are all subtypes of:

Answer 26

Oral candidiasis

Question 27

What is stomatitis and what are causes?

Answer 27

broad term for infection/inflammation of mouth

laundry list for: bacterial/ viral/ fungal

Question 28

Case: 14 yo boy, hurts to swallow, fever, chills, temperature. Has aches and headache and stomach ache.

Diffuse rash, lungs clear, bilater anterior cervical lymph adenopathy

throat injected, bilateral tonsillar hypertorphy + exudate, ill appearing

How would you make a correct Dx before kid leaves clinic?

Answer 28

Obtain rapid antigen detection test

Question 29

Pt has sore throat.. dx as strep.

How does organism adhere to the epithelial cells on surface of oropharnyx?

Answer 29

Via pili on the surface of the organism

Question 30

How does streptococcus (in strep throat) evade phagocytosis?

Answer 30

via hyaluronic acid in capsule of organism and via antiphagocytic proteins made and secreated by organism

Question 31

What causes constitutional illness we see associated with strep?

Answer 31

from exotoxins made by organism

Question 32

How is strep throat transmitted?

Answer 32

via large droplets containing organism; coughing, sneezing, conversation with sick individual or asymptomatic colonization of other students in John’s class

Question 33

What is waldyers ring?

Answer 33

• Waldeyer’s ring: aggregate lymphoid tissue upper
aerodigestive tract

Question 34

What are indicatiosn of adenotonsillectomy?

Answer 34

Upper airway obstruction (most common)

• Recurrent/chronic infection
– Tonsillitis from ß hemolytic strep Group A or Peritonsillitis / peri-tonsillar abscess
• Neoplasia (lymphoma/carcinoma): see unilateral hypertrophy

Question 35

You are deciding whether or not your pt has strep throat as it seems highly likely he has strep. What do you do next?

Answer 35

Rapid strep test or empiric antibiotics

Question 36

Pt you are seeing has a moderate probability of having strep.. what are your next steps?

Answer 36

Order rapid strep test

if positive treat

if negative consider other diagnosis

Question 37

If your patient is 10 - 25 years of age, what special considerations do we take into account when we suspect strep throat?

Answer 37

if rapid strep comes back negative, order a throat culture.

Test for mononucleosis

Question 38

How do you obtain a good throat culture?

Answer 38

Culture each tonsil + posterior pharngeal wall

twist, rotate swab into tissue to get good specimen

avoid touching the tongue and immediately transfer to tranpsort medium

Question 39

A kid comes in with a huge swelling on the side of his neck and when it is drained it’s full of pus. Dx?

Answer 39

Cervical abscess; kids with URI can get abcess in their cervicle lymph nodes

Question 40

A concerened father brings high son in. The son is drooling, has a fever and appears very sick. The boy as an inspiratory stridor and sitting upright in bed. Dad says this happened very quickly. What are you suspicious of right now?

Answer 40

Supraglottitis

rapid onset/ drooling/sitting up/fever/inspiratory stirdor

Question 41

What is the etiology and tx for supraglottis?

Answer 41

H. flu (type B)

Tx is antibiotics and secure airway

Question 42

A mother brings in her son because of his cough. She states this happened gradually and he had low grade fevers so she thought it was just a cold. He recently has had loud, barking like coughs. You note he has a biphasic stridor. What is a likely dx at this point?

Answer 42

Croup; subglottic infection

gradual onset/low fevers/barking cough/biphasic stridor

Question 43

What is the cause and tx for croup?

Answer 43

cause of croup is viral

tx with racemic epi, steroids and humidifier

Question 44

What do you notice on xray? This is typical of what illness?

Answer 44

Steeple sign seen in Croup

Question 45

What is the xray pointing to? When do we see this?

Answer 45

Thumb sign in Epiglottitis

Question 46

Young girl comes in with a bad cough, stridor, fever and toxic looking. Your attending does a physical and orders a PA and lateral chest xray as he suspects bacterial tracheitis

What would you see if this Dx was correct?

Answer 46

Tracheal air column ragged and irregular on PA and lateral

Question 47

Common cause for bacterial trachetis and treatement

Answer 47

S. Aureus

IV antibiotics, hydration and rigid bronchoscopy with debridement of tracheal crusts and exudate

(may need to intubate to prevent obstruction)