ENT/Ophthal/Gen Surg SAQ

Question 1

1. A child presents with fever, ear pain and laterally displaced pinna
   a. Diagnosis
   b. Immediate treatment
   c. 3 complications

Answer 1

A. Mastoiditis
B. Start CFTX or cefuroxime
Get CT with contrast
C.
1. Sinus venous thrombosis
2. Meningitis
3. Conductive hearing loss
4. Facial palsy
5. Subdural + epidural abscess

Question 2

2.13 yo with sinusitis. Febrile for 24hrs on day 1 of Illness. Thick nasal discharge for past 2 weeks. Now worsening cough at night. Daily fevers over last 2 days.

a. What are 2 things in history that makes you suspect sinusitis?
b. What are 3 intracranial complications of sinusitis?

Answer 2

A. Thick nasal discahrge. Daily fever.
B.
1. Meningitis
2. Sinus venous thrombosis
3. Epidural abscess
4. Subdural empyema
5. Brain abscess

Extracranial

1. Periorbital cellulitis
2. Orbital cellulitis
3. Pott’s puffy tumour (osteomyelitis of frontal bone)

Question 3

3. 4 year old boy presents with erythematous, fluctuant swelling over the anterior cervical area on the left which has been present for 7-10 days.

A) What is the most common organisms responsible for this?
b) What are 4 other infectious causes of this?

Answer 3

A. Group A strep
B. 
1. Staph aureus
2. Non-tubeculous mycobacterium
3. Bartonella henselae
4. Tularemia
5. M tuberculosis
6. Plague (Y pestis)

Unilateral

Question 4

4. 6 year old with kissing tonsils on exam. History reveals signs of OSA. You do a sleep study and diagnose OSA, get an urgent ENT consult and the plan is for T&A within 3 days.

a. What investigation needs to be done before the surgery?
b. What are two complications of sleep apnea?

Answer 4

A.

1. Assess for signs of velopharyngeal insufficiency + contraindications (over cleft palate, submucosal cleft, neurologic or neuromuscular abN)
2. PMHx or FHx of bleeding disorders. If positive, screen CBC, INR, PTT
3. Assess for acute signs of infection. May need to delay surgery

B.

1. Pulmonary hypertension
2. Systemic hypertension
3. Daytime somnolence
4. Inattention
5. Fatigue
6. Metabolic syndrome

Question 5

5. A baby presents with a well-defined erythematous midline neck mass following a URTI.
   a) What is it?
   b) What physical exam maneuver can you do to prove it?

Answer 5

A. Thyroglossal duct cyst
2. On swallowing or sticking out their tongue, it should move up b/c located over hyoid bone (vs dermoid cysts moves with the overlying skin)

Question 6

6. Timeline for diagnosing acute sinusitis in a 5 year old

Answer 6

Acute sinusitis <30d
Subacute sinusitis: 1-3mo
Chronic sinusitis: >3mo

Question 7

7. List 4 non-infectious risk factors of hearing loss in the newborn period. (2 points)

Answer 7

1. Family history of SNHL
2. Craniofacial anomalies
3. Ototoxic medications
4. Hyperbilirubinemia at exchange transfusion level
5. BW <1500g
6. Mechanical ventilation >5d or ECMO
7. Dysmorphisms associated with syndromic causes of hearing loss

Question 8

8. A 3 month old child had a TEF repaired in the first few weeks of life. He now presents in your office with stridor. List 2 (or was it 3?) causes of his stridor.

Answer 8

1. Croup
2. Tracheomalacia
3. Vocal cord paralysis from recurrent laryngeal nerve injury during TEF repair
4. Foreign body
5. Anaphylaxis
6. Infantile hemangioma
7. Hypocalcemic laryngeal spasm

Question 9

9. A teenage girl reports respiratory distress with vigorous exercise. She has stridor and wheezing, and reports cough, chest and throat tightness. Ventolin and inhaled steroids are no help. During an episode, a CXR done in the ER is normal, and sats are 100% on room air.
   A. What is the MOST likely diagnosis?
   B. What treatment do you suggest?

Answer 9

A. Vocal cord dysfunction

B. Speech therapy for training in relaxation + control of VC movement

Question 10

10. A new mom wants to know about diminishing risk of otitis media. What 3 preventative measures can you tell her about?

What are the 11 RFs for AOM in the CPS statement?

Answer 10

1. No smoking in home, limit exposure to second hand smoke
2. Encourage breastfeeding
3. Routine vaccination + annual flu shot
4. Avoid pacifier
5. Young age
6. Orofacial abnormalities
7. Shorter duration of breastfeeding
8. Prolonged feeding with bottle while lying down
9. Pacifier use
10. FHx of AOM
11. Exposure to cigarette smoke
12. Exposure to other children
13. Household crowding
14. First Nations or Inuit ethnicity
15. Lower levels of secretory IgA or persistent biofilms in middle ear

Question 11

11. Description of a 2 week old baby whose mom is concerned because he has “noisy breathing?, gets worse when he cries or is upset. On exam, looks well; high pitched sound with breathing.
    A. Most likely diagnosis?
    B. What one thing can you do on physical exam to support your diagnosis?

Answer 11

A. Laryngomalacia

B. Should be more apparent in supine lying flat and improve with prone or upright

Question 12

12. List 2 xray findings compatible with retropharyngeal abscess. Is this xr adequate - why/why not?

Answer 12

1. Prevertebral soft tissue space in front of C2 >7mm, or C6 >14mm
2. Air fluid level in retropharyngeal space

Question 13

13. Teen with wheezing, stridor, dyspnea and cough intermittent with extreme exercise and anxiety. Inconsistent inspiratory and expiratory spirometry curves.
    A. Diagnosis?

Answer 13

Vocal cord dysfunction

Question 14

14. Young boy with chronic draining ears, pneumonia & widespread eczema. Platelets are low. Diagnosis?

Answer 14

Wiscott-Aldrich Syndrome

Thrombocytopenia
Immunodeficiency - recurrent bacterial, viral, fungal
Eczema

X-inked
Dx: sequence analysis of WAS gene

Question 15

Photo of leukocoria, though the photo was bad and also looked slightly like corneal clouding with glaucoma. 18 month boy brought because his eye “didn’t look right” - you do an exam and red reflex showed leukocoria.
A. What is most important diagnosis to consider (1)
B. What are 2 other possible diagnoses (2)

Answer 15

A. Retinoblastoma
B. 1. Cataract
2. ROP
3. Retinal detachment
4. Persistent hyperplastic primary vitreous

Question 16

A mother brings her 5 year old son in to see you because she wants him to be assessed for amblyopia (his 3 year old cousin was just diagnosed with amblyopia).

a. 2 ways you would assess him for amblyopia in the office (specific)
b. 3 most common causes of amblyopia

Answer 16

A. 1. Cover and uncover test + corneal light reflex to test for strabismus
2. Visual acuity
B.
1. Strabismus
2. Unequal need for vision correction between the eyes (anisometropic amblyopia)
3. High refractive error in both eyes (ametropic amblyopia)

Question 17

Picture of pseudostrabismus. Most likely diagnosis.

Answer 17

Pseudostrabismus?
Epicanthal folds, broad nasal bridge, narrow interpupillary distance
Normal corneal light reflex, normal cover + uncover

Question 18

4. Photo of child with leukocoria. Name 3 causes. → NOTE: also phrased in another question as “2 conditions associated with leukocoria that would require this child to be referred urgently to ophtho.”

Answer 18

1. Retinoblastoma
2. Cataract
3. ROP
4. Retinal detachment and retinoschisis
5. Persistent hyperplastic primary vitreous

Question 19

5. Fill in the following disorders with their eye manifestations: Marfan’s, JIA, congenital CMV, CHARGE syndrome

Answer 19

Marfan’s: ectopic lentis
JIA: anterior uveitis (ANA + oligo in girls <6yo are at greatest risk)
congenital CMV: chorioretinitis
CHARGE syndrome: coloboma

Question 20

6. A four year old boy has a cousin who was just diagnosed with amblyopia. His mother would like you to test him for it.
   A. Describe how you would perform the test (be specific).
   B. What are three causes of amblyopia?

Answer 20

A. Visual acuity testing appropriate for developmental age
Cover + uncover test and corneal reflex test to assess for strabismus
B. 1. Strabmisus
2. Unequal vision correction between eyes (anisometropic amblyopia)
3. High refractive error in both eyes (ametropic)
4. Deprivation

Question 21

7. Teenager playing sports with blunt trauma to the eye – on exam, red fluid covering lower half of anterior chamber.
   a) What 2 things do you do in your management?
   b) What is 1 long-term side-effect?

Answer 21

Hyphema
A. 1. Bed rest with HOB 30 deg with eye shield without patch
2. Urgent Ophthal consult
3. Cycloplegic agent to immobilize iris
4. Topic or systemic steroids to decrease inflammation
5. +/- topical or systemic antihypertensives if elevated intraocular pressure
6. Antiemetic if nauseous
AVOID NSAIDS + ASA

B. 1. Vision loss

2. Glaucoma
3. Posterior synechiae
4. Peripheral anterior synechiae
5. Optic atrophy
6. Corneal blood staining

Question 22

8. Young boy presenting with history of painful swelling of the eyelid. Picture given of ?hordeolum/stye/chalazion.
   a) What is the diagnosis?
   b) What is your management?

Answer 22

A. Likely stye or hordeolum (painful + swollen)
B.
1. Frequent warm compresses
2. May need surgical incision + drainage
3. Consider topical antibiotics. Change to oral ABx if signs of preseptal cellulitis.

Question 23

9. Mother concerned about 6 month-old infant with bright red lesion on upper eyelid, not present at birth, rapidly growing.
   a) What is the diagnosis?
   b) What are 2 things in management?

Answer 23

A. Hemangioma - usually not present at birht or very faint red marks. Grow rapidly shortly after birth, then involute over several years.
(vs. vascular malformation present at birth + enlarges with child’s growth. Don’t involute, may become more apparent)
B.
1. Refer to ophthalmology to consider laser or surgical removal
2. Consider propranolol
3. Consider MRI of orbit to assess for orbital involvement
4. Consider steroid medications

Question 24

10. A 7(ish) year old boy comes to the ED with an acutely painful left eye. His eye is red and has slight watery discharge. He has photophobia and his acuity is 20/200 on the left and 20/20 on the right.
    A. What are the three most likely diagnoses?
    B. Slit lamp examination is normal. What’s your next investigation?

Answer 24

A.

1. Corneal abrasion
2. Infectious keratitis
3. Anterior uveitis

B. Fluorescein dye

Question 25

11. Child has worsening swelling around an eye. A. What is the difference in anatomical involvement between periorbital and orbital cellulitis? B. What are the common etiologies of periorbital vs. orbital cellulis? C. What signs would make you more concerned for orbital cellulits instead of periorbital cellulitis? D. What empiric Tx would you initiate for periorbital vs. orbital cellulitis?

Answer 25

A. Periorbital cellulitis involves infection of soft tissues anterior to orbital septum and orbital cellulitis involves infections posterior to it B. Periorbital - trauma, insect bite. GAS, Staph aureus, strep pneumo Orbital cellulitis - sinusitis. MSSA, MRSA, streptococcocus, Hemophilus, M catarrhalis, anaerobes C. Proptosis, decreased visual acuity, decreased EOM, pain with eye movement. D. Periorbital: cefazolin or keflex Orbital: ceftriaxone + vanco

Question 26

13. When would you refer a child with esotropia or exotropia to an ophthalmologist (2 lines)?

Answer 26

1. Any child with strabismus 2. Any infant with poor tracking by 3mo 3. Any infant with esotropia persisting >4mo 4. Any child with other abN: corneal opacities, cataracts, glaucoma, abN red light reflex

Question 27

14. 5 yo girl holding 2 month old baby sister who accidentally pokes her eye (corneal abrasion on fluorscein). 2 steps in managing.

Answer 27

1. Should first look for evidence of penetrating trauma (subconjunctival hemorrhage, hyphema, iris deformities, lens disruption) or foreign body 2. Frequent topical antibacterial eye drops until completely healed 3. Topical cycloplegic agent to relieve pain from ciliary spasm 4. Daily F/u until improved Do not use topical anesthetics, steroids, or patching

Question 28

15. Name 5 diagnoses associated with congenital cataracts.

Answer 28

1. Prematurity 2. T21 3. Galactosemia 4. TORCH infections 5. Trauma 6. Steroid induced

Question 29

1. Child presents with the following abdo X-ray. (Double bubble, page 210) A. What is the name of this sign? B. What is the associated diagnosis? C. What underlying condition is this disorder most commonly associated with? D. Now this child has L axis deviation on EKG. What is the most likely heart lesion?

Answer 29

A. Double bubble sign B. Duodenal atresia C. Trisomy 21 D. AVSD 2 causes of LAD 1. AVSD 2. Tricuspid atresia from hypoplastic RV

Question 30

2. Blunt abdominal trauma. One reason to take patient to OR for laparotomy.

Answer 30

1. Hemodynamic instability 2. Free intraperitonear air (pneumoperitoneum) or extravasated contrast on imaging 3. Intraabdominal bleeding >40mL/kg blood products 5. Peritonitis 6. Clinical deterioration during observation

Question 31

3. A. Name 2 situations where air enema for intussusception would be unsuccessful. B. Name 2 contraindications to air enema for intussusception

Answer 31

A. 1. Ileoileal intussusception 2. Prolonged intususcception B. 1. Recurrent intussuception/suspected lead point 2. Suspected intestinal perforation 4. Signs of shock

Question 32

4. Surgeon asks for a consult on two of his patients for elective surgeries next morning. Please give fluid type and rate for: A. 14 y.o. boy (50 kg) NPO from midnight onwards for inguinal hernia repair. B. 2 mos boy (5 kg) NPO from midnight for inguinal hernia repair.

Answer 32

A. 1. D5NS +20mmol/L of KCl (if voiding and normal K) at 90mL/hr 2. D5NS +20mmol/L of KCl (if voiding + normal K) at 20mL/hr

Question 33

5. List 3 indications for urgent surgical referral for endoscopic removal of an esophageal foreign body

Answer 33

1. Sharp objects 2. Disk button batteries 3. Foreign bodies associated with resp symptoms

Question 34

6. Description of a baby with a reducible hernia. When should he be referred to surgery for repair?

Answer 34

If inguinal hernia: As soon as possible. If <1yo, aim to repair within 2-3wks - won't spontaneously resolve, risk of incarceration, higher risk of complications if repair after incarceration If umbilical hernia, not until 1. Persistent at 4-5yo 2. Getting bigger by 1-2yo 3. >2cm diameter 4. Symptomatic 5. Strangulated

Question 35

7. 3 year old with a bite on his cheek. List 4 characteristics of the bite that would have an impact on the management of this patient.

Answer 35

1. Did the bite break the skin? 2. Was the bite by human, dog, cat, or other animal? 3. When was the child bitten? 4. Where is the bite? (sensitive areas = face, hands, genitals) 5. Are there signs of infection? 6. Is there ongoing bleeding?