ENT DIseases Flashcards
Normal flora of external canal includes________
Pseudomonas aeruginosa (most common
cause), S. aureus (second most common cause), coagulase-negative Staphylococcus,
diphtheroids, Micrococcus spp., and viridans streptococci
____________ is invasive to temporal bone and skull base—with facial paralysis, vertigo, other cranial nerve abnormalities
Malignant external otitis
Mx of Malignant external otitis`
Requires immediate culture, intravenous antibiotics, and imaging (CT scan) → may need surgery
Etiology of OM
° S. pneumoniae (40%)
° Nontypeable H. influenzae (25–30%)
° Moraxella catarrhalis (10–15%)
Some Correlated Factors of Otitis Media
- Age: most in first 2 years
- Sex: boys > girls
- Race: more in Native Americans, Inuit
- SES: more with poverty
- Genetic: heritable component
- Breast milk versus formula: protective effect of breast milk
- Tobacco smoke: positive correlation
- Exposure to other children: positive correlation
- Season: cold weather
- Congenital anomalies: more with palatal clefts, other craniofacial anomalies, and Down syndrome
Pathogenesis of OM
Interruption of normal eustachian tube function (ventilation) by obstruction → inflammatory response → middle ear effusion → infection; most with URI
What makes children predisposed to OM
Shorter and more horizontal orientation of tube in infants and young children allows for reflux from pharynx (and in certain ethnic groups and syndromes)
Otoscopy of OM
fullness/bulging or extreme retraction, intense erythema
some degree of opacity (underlying effusion)
_______ is the most sensitive and specific factor to determine presence of a middle ear effusion (pneumatic otoscopy)
Mobility
Dx of OM
– Acute onset
– Tympanic membrane inflammation
– Middle ear effusion
First-line drug of choice for OM =
amoxicillin (high dose)
OM Tx
Alternate first-line drug or history of penicillin allergy = __________
azithromycin
OM Tx
Second-line drugs—if continued pain after 2–3 days
° Amoxicillin — clavulinic acid (effective against β-lactamase producing strains)
° Cefuroxime axetil (unpalatable, low acceptance)
° Also maybe cefdinir (very palatable, shorter duration
OM Tx
_________ (may need repeat 1–2×; for severe infection if oral not possible), if patient is not taking/tolerating oral medications
IM ceftriaxone
OM Tx
If clinical response to good second-line drug is unsatisfactory, perform ___________
myringotomy or tympanoscentesis
- Generally after repeated infections with insufficient time for effusion to resolve
- Fullness is absent or slight or TM retracted; no or very little erythema
Otitis media with effusion (OME)
T or F
Recent studies suggest that in otherwise healthy children an effusion up to 9 months in both ears during first 3 years of life poses no developmental risks at 3–4 years of life
T
Mx of Otitis media with effusion (OME)
° Suggested for children with bilateral OME and impaired hearing for >3 months; prolonged unilateral or bilateral OME with symptoms (school or behavioral problems, vestibular, ear discomfort); or prolonged OME in
cases of risk for developmental difficulties (Down syndrome, craniofacial disorders, developmental disorders
Tympanostomy tubes
Complications of Otitis media with effusion (OME)
_________—displacement of pinna inferiorly and anteriorly and inflammation of posterior auricular area; pain on percussion of mastoid process
Acute mastoiditis
CX of OME
cyst-like growth within middle ear or temporal bone;
lined by keratinized, stratified squamous epithelium
Acquired cholesteatoma
PE of Cholesteatoma
Discrete, white opacity of eardrum through a defect in TM or persistent
malodorous ear discharge
Acquired cholesteatoma Tx
tympanomastoid surgery
Unilateral or bilateral bony (most) or membranous septum between nose and pharynx
Choanal atresia
SSx of unilateral Choanal atresia
asymptomatic for long time until first URI, then persistent nasal discharge with obstruction
Dx of Choanal atresia
– Inability to pass catheter 3−4 cm into nasopharynx
– Fiberoptic rhinoscopy
– Best way to delineate anatomy is CT scan
polyps, aspirin sensitivity, asthma. What is the dx?
Samter triad
Presents with _______ → hyponasal speech and mouth breathing; may have profuse mucopurulent rhinorrea
obstruction
Treatment of polyps—
intranasal steroids/systemic steroids may provide some shrinkage(helpful in CF
Sinus development
– Ethmoid and maxillary present at birth, but only ethmoid is_______
pneumatized
Sinus development
– Sphenoid present by______
– Frontal begins at________ years and not completely developed until adolescence
5 years
7–8
Etiology of sinusitis
S. pneumonia, nontypeable H. influenzae, M. catarrhalis; S. aureus in chronic cases
Cause of chronic sinusitis
immune deficiency, CF, ciliary dysfunction, abnormality of phagocytic function, GERD, cleft palate, nasal polyps, nasal foreign body
What is the dx?
° Rapid onset
° Severe sore throat and fever
° Headache and gastrointestinal symptoms frequently
Strep pharyngitis
PE of Strep phra
red pharynx, tonsilar enlargement with yellow, blood-tinged exudate, petechiae on palate and posterior pharynx, strawberry tongue, red swollen uvula, increased and tender anterior cervical nodes
T or F
in Scarlet fever
exposure to each confers a specific immunity to that
toxin, and so one can have scarlet fever up to three times
T
PE of Scarlet fever?
° Findings of pharyngitis plus circumoral pallor
° Red, finely papular erythematous rash diffusely that feels like sandpaper
° Pastia’s lines in intertriginous areas
Coxsackie: virus causes what diseases?
Herpangina
Acute lymphonodular pharyngitis
Hand-foot-mouth disease
What dse
small 1–2 mm vesicles and ulcers on posterior pharynx
Herpangina
What dse
small 3–6 mm yellowish-white nodules on posterior pharynx with lymphadenopathy
Acute lymphonodular pharyngitis
What dse?
inflamed oropharynx with scattered vesicles on tongue, buccal mucosa, gingiva, lips, and posterior pharynx
→ ulcerate; also on hands and feet and buttocks; tend to be painful
Hand-foot-mouth disease
Diagnosis of strep
– First—_______; if positive, do not need throat culture
° But must confirm a negative rapid test with cultures if clinical suspicion is high
rapid strep test
Treatment of Strep—early treatment only hastens recovery by 12–24 hours but prevents
acute rheumatic fever if treated within 9 days of illness
CX of Strep
Retropharyngeal and lateral pharyngeal abscess
PE of Retropharyngeal and lateral pharyngeal abscess
Examination—bulging of posterior or lateral pharyngeal wall
Cultures of Retropharyngeal and lateral pharyngeal abscess
S—most polymicrobial (GABHS, anaerobes, S. aureus)
Tx of Retropharyngeal and lateral pharyngeal abscess
Intravenous antibiotics + surgical drainage
Third-generation cephalosporin plus ampicillin/sulbactam or clindamycin
Surgical drainage needed if respiratory distress or failure to improve
Examination of Peritonsillar abscess—
asymmetric tonsillar bulge with displacement of uvula away from the affected side is diagnostic
TX of Peritonsillar abscess—
Antibiotics and needle aspiration
Incision and drainage
Tonsillectomy if recurrence or complications (rupture with aspiration
Indications for tonsillectomy
– Rate of strep pharyngitis: ≥7 documented infections within past year or 5/year for 2 years or 3/year for 3 years
– Unilateral enlarged tonsil (neoplasm most likely but rare)
Indications for Adenoidectomy
– Chronic nasal/sinus infection failing medical treatment
– Recurrent/chronic OM in children with tympanostomy tubes and persistent
otorrhea
– Nasal obstruction with chronic mouth-breathing and loud snoring
Tonsillectomy and adenoidectomy Indication
– > 7 infections
– Upper airway obstruction secondary to hypertrophy resulting in sleep-disordered breathing and complications
