ENT/Ophtho/Gen Surg Flashcards
Describe your approach to a child presenting with confirmed hearing loss.
- Detailed family history
- Medical evaluation (history, physical examination for associated comorbidities and/or syndromic/nonsyndromic hearing loss)
- Consultations
- Paediatric otolaryngologist
- Paediatric ophthalmology
- Geneticist
- Prompt vision assessment to maximize sensory input (and r/o Usher syndrome)
List 4 risk factors for positional plagiocephaly
- Male sex
- Firstborn
- Congenital Torticollis
- Supeine sleeping position at birth and at six weeks
- Exclusive bottle feeding
- Awake “tummy time” < 3 X per day
- Lower activity level with slower achievement of milestones
Name 2 instances where imaging (x-rays) would be advised in an infant with flattening of his head
- Craniosynostosis is suspected
- Worsening of head shape between 4mo-2yo (when positional plagiocephaly would be expected to improve)
What features would you look for to differentiate craniosynostosis from positional plagiocephaly?
List 3 management strategies for positional plagiocephaly
- Ipsilateral occipitomastoid bossing
- Posterior displacement of ipsilateral ear
Management strategies
- Positioning
- Head to foot of bed on alternating days
- Encourage lying on each side in supine position
- Tummy time (minimum 3 x 10-15min)
- Physiotherapy
- Moulding therapy
When is moulding therapy considered for the treatment of positional plagiocephaly?
List 3 barriers to use of moulding therapy
Severe asymmetry + ≤8 months
- Side effects: contact dermatitis, pressure sores, local skin irritation
- Cost
- Accessibility - only available in select areas
- Time: treatment plan usually includes wearing for 23h/day
What vision tests should you ensure you complete to screen vision in these age groups?:
≤3 months
6-12 months
3-18 years
-
≤3 months:
- Red reflex
- Complete examination of skin and external eye structures
-
6-12 months
- As above AND:
- Corneal light reflex
- Cover-uncover test
- As above AND:
-
3-18 years:
- As above AND:
- Visual acuity examination with age-appropriate tool
- Snellen ≥6yo
- HOTV ≥3yo
- Visual acuity examination with age-appropriate tool
- As above AND:
At what age would a child be expected to obtain these milestones?
Face follow
Visual follow
Visual acuity measurable
- Face follow: Birth until 4 weeks
- Visual follow: 3mo
- Visual acuity measurable: 3.5y
List 2 causes of amblyopia and their respective management
(reduced vision in the absence of ocular disease)
- Difference in refractive error (inability to focus the image)
- Corrective lenses
- Strabismus (confusing image = poor aim)
- Penalization therapy
- Occlusion (patching)
- Pharmacologic (cycloplegic drops)
- Penalization therapy
- Media opacities (no image = poor clarity)
- Clear the media - surgery for cataract etc.
List 4 risk factors for acute otitis externa
- Trauma
- Foreign body in the ear
- Use of hearing aid
- Dermatological conditions
- Wearing tight head scarves
- Immunocompromise
- Chronic otorrhea
What are the elements one needs to consider in order to diagnose acute otitis externa?
- Rapid onset (usually ≤48h) in the past 3 weeks
- Symptoms of ear canal inflammation
- Otalgia (often severe), itching or fullness
- +/- hearing loss or jaw pain (TMJ/in ear canal worsened with jaw motion)
- Signs of ear canal inflammation (tender tragus, pinna or both) OR diffuse ear canal edema, erythema or both +/- otorrhea, regional lymphadenitis, TM erythema or cellulitis of pinna and adjacent skin
What are the 2 most common pathogens of acute otitis externa?
- Pseudomonas aeruginosa
- Staphylococcus aureus
Other bacteria: gram negative bacteria, Aspergillus, Candida
Describe the management of acute otitis external for both mild-moderate and severe presentations.
What should you consider if there is a lack of response to the management?
-
Mild-moderate
-
1st line: topical antibiotic +/- topical steroids (7-10d) AND tylenol/NSIDS or oral opioid for analgesia
- No low pH, corticosporin, gentamicin or neomycin with TM tubes or perforated membranes d/t ototoxicity risk
- If canal not visualized, an expandable wick can be placed to decrease canal edema and facilitate medication delivery
- Agents:
- Polymyxin B-gramicidin (Polysporin) 1-2 drops QID
- Ciprodex 4 drops QID x 7 days
- Buro-Sol 2-3 drops TID-QID
-
1st line: topical antibiotic +/- topical steroids (7-10d) AND tylenol/NSIDS or oral opioid for analgesia
-
Severe
-
PO antibiotics that cover S aureus and P aeruginosa
- Ciprofloxacin is a good option
-
PO antibiotics that cover S aureus and P aeruginosa
Not responding to treatment
- Foreign body
- Non-adherence
- Alternative diagnosis?
- Nickel dermatitis (allergic contact dermatitis)
- viral or fungal infection
- antimicrobial resistance
What 2 populations are at increased risk for malignant otitis externa?
What are prominent symptoms of malignant otitis externa?
What is the recommended management?
- Immunodeficiency
- Type 1 DM
Prominent symptoms
- Facial nerve palsy
- Pain
Risk of invasive infection of cartilage and bone of canal. May require CT/MRI to confirm diagnosis
Treatment
- Aggressive debridement with systemic antibiotics for Pseudomonas +/- Aspergillus
List 2 recommended preventative measures for acute otitis externa
- Keep water out of ears (plugs vs positioning, shaking head or hair dryer on low setting)
- Avoid cotton swabs (can impact cerumen)
- Daily prophylaxis with alcohol or acidic drops durign at-risk activities (not studied)
- Hard earplugs shoudl be avoided (can cause trauma)
- Orofacial abnormalities (e.g cleft palate)
- Indigenous
- Frequent contact with other children
- FMHx AOM
- Prolonged bottle-feeding while lying down
- Shorter duration of breastfeeding
- Pacifier use
- Exposure to cigarette smoke
- Household crowding
List 4 risk factors for acute otitis media
List 5 extracranial complications associated with acute otitis media
List 5 intracranial complications associated with acute otitis media.
Extracranial (local/temporal bone)
- Mastoiditis
- Meningitis
- Labyrinthitis
- TM Perforation
- usually heals in 6wks (repair at 9-10yo if not [when eustachian function improves)
- Cholesteatoma
- Bezold’s abscess (deep neck abscess)
Intracranial
- Meningitis
- Gradenigo’s syndrome (CNVII palsy, CNVI palsy can’t move ipsilateral eye outwards - due to petrous bone inflammation/infection)
- Cerebral sinus venous thrombosis (transverse, lateral or sigmoid sinuses)
- Brain abscess (subdural/epidural)
- Otic hydrocephalus
- CSF leak
List the 3 most common pathogens of acute otitis media
- Streptococcus pneumoniae
- Moraxella cattarhalis
- Haemophilus influenzae
Other common pathogens: Group A Streptococcus
What is a necessary minimal diagnostic criterion for the diagnosis of acute otitis media?
A middle ear effusion (MEE)
- Signs of MEE:
- Little or no mobility of TM when both positive and negative pressure is applied with pneumatic otoscope)
- Loss of bony landmarks
- Presence of air-fluid level
Desribe the management for acute otitis media
What would you prescribe if there had been a recent treatment with amoxcillin within the past month?
- >6 months of age, generally healthy (no craniofacial abnormalities, tubes, recurrent AOM or immunocompromised)
-
NO MEE/MEE (mild erythematous TM or non-buldging TM)
- R/A in 24-48h
- If worsens or no improvement, verify presence of effusion and signs of inflammation
-
MEE present AND bulging TM
- Mildly ill
- Symptoms
- Alert, responsive, no rigors, responding to antipyretics, mild otalgia but able to sleep
- <39˚C in absence of antipyretics
- <48h illness
- Observe for 24-48h
- Either:
- Reassess in 24-48h to document course
- Have return in 24-48h if no improvement or worsens
- Provide antimicrobial prescription if no improvement
- Either:
- Analgesia
- If not improved or worsening clinically, PO Amoxicillin
- <2yo: 10 days
- ≥2yo: 5 days
- Symptoms
- Moderate-severely ill
- Either (≥1) of:
- Irritable, trouble sleeping, poor response to antipyretics, severe otalgia
- ≥39˚C in absence of antipyretics
- >48h of symptoms
- Treat with PO Amoxicililn
- <2yo: 10 days
- ≥2yo: 5 days
- Either (≥1) of:
- Mildly ill
-
TM perforated with purulent trainage
- PO Amoxicillin x 10 days
Antibiotic choice
- Amoxicillin 75-90mg/kg/day divided BID
- If allergy: 2nd gen (cefuroxime-axetil) or 3rd gen cephalosporin (cefotaxime)
- Other considerations: Macrolide (clarithromycin/azithromycin)
Previous Amoxicillin <30 days or relapse of recent infection
- Clavulin (Amoxicillin/clavulanate)
Failure of oral drugs or Clavulin failed
- IM Ceftriaxone 50mg/kg/day x 3 days
- Referral to ENT for tympanocentesis (sample of middle ear fluid)
What should you recommend for the management of a 7mo patient with acute otitis media and purulent conjunctivitis?
Otitis-conjunctivitis syndrome
- PO Antibiotic management
- Clavulin (Amoxicillin/Clavulanate), or
- 2nd generation cephalosporin (Cefuroxime-axetil)
- Obtain bacterial cultures of conjunctival discharge
At what age should childre have a dental home by?
12 months
What is the most common causative organism of dental caries?
List 2 ways that topical fluoride prevents caries.
What are risk factors for dental caries?
When should topical fluoride be administered?
Streptococcus mutans
Prevention
- Inhibits plaque
- Inhibits demineralization
- Enhances remineralization of enamel
Risk factors for dental caries
- Populations at risk
- Indigenous
- Low-income families
- Children with special health care needs
- New immigrants
- Prolonged use of bottle or training cups with sugar-containing drinks
- High frequency of sugary snacks per day
- Environmental tobacco smoke
- Maternal smoking status
Supplementation Indications
- Concentration in municipal water supply is <0.3ppm
- Teeth not brushed at least 2 times a day
- Dentist/HCP feel child is susceptible to cavities
How much fluoride is in a pea-sized amount of toothpaste?
How much supplemental fluoride should be provided?
What are signs of fluorosis? List 2.
Which teeth are at the greatest risk for fluorosis at 15-24mo?
Pea-sized amount = ~0.4mg
- Supplemental fluoride amount (daily)
- >6mo-3y = 0.25mg
- 3-6y = 0.5mg
- >6y = 1mg
Fluorosis
- Mottling and pitting of teeth
- Enamel striations
- “Snow capped cusps”
- Chalky-white teeth
Secondary teeth are at greatest risk for fluorosis at 15-24mo
List 4 strategies to decrease incidence of dental caries in Indigenous communities
List 3 examples of primary prevention of dental caries.
- Promote supervised use of fluoridated toothpaste in all Indigenous (and high-risk children) after 1st tooth erupts twice daily (infants - grain sized; child - pea-sized)
- HCPs should perform oral health screening during health assessments and provide referrals PRN to dental health providers
- Use motivational interviewing and anticipatory guidance for parents and caregivers of infants and children on oral hygiene and diet
- Provide women with preconception and prenatal screening for oral health, anticipatory guidance and referral to dental care PRN
- Ensure access to series of fluoride varnish and an assessment to determine need for sealant placement on deep grooves and fissures
Primary prevention
- Water fluoridation
- Topical fluoride if no fluoridation
- Oral health promotion
List 4 indications for tympanostomy tube insertion.
- Bilateral OME with conductive hearing loss if persisting ≥3mo
- Prior to chemotherapy for at-risk AOM groups (most common reason)
- Unilateral OME with conductive hearing loss AND concern (behavioural issues, school performance, vestibular symptoms, discomfort)
- Recurrent AOM with middle ear effusion (least common reason)
- Mastoiditis
- Chronic retraction of TM
- Lack of response to medical management (i.e. continuous Abx)
What rare condition should you consider with severe unilateral epistaxis?
List 4 management options for epistaxis.
Juvenile nasopharyngeal angiofibroma
Management
- Humidify
- Lubricate - vaseline
- Cauterize - silver nitrate
- Pack
- Treat underlying coagulopathy
List 3 indications for tonsillectomy
What is Paradise criteria?
- Absolute
- OSA (AHI >5) and large tonsils
- Cor pulmonale
- Suspected malignancy
- Hemorrhagic tonsillitis
- Severe dysphagia
- Relative
- Tonsillar hypertrophy
- Recurrent tonsillitis (Paradise criteria)
- Complications of tonsillitis
- Tonsilloliths and halitosis
Paradise Criteria
- Requirements for an episode (≥1 of):
- Fever >38.3˚C
- Cervical lymphadenopathy (tender or enlarged [>2cm])
- Tonsillar or pharyngeal exudates
- GAS+ Throat Cx
- ≥7 in 1 year
- ≥5 in 2 years
- ≥3 in each of last 3 years
What are the criteria of the Centor score?
When is treatment indicated for acute pharyngitis vs investigations vs reassurance?
- CENTOR (≤3 days of acute pharyngitis)
- Cough absent
- Exudate
- Nodes
- Temperature
- OR - young (≥3 to <15yo) OR old (lose a point)
- Scoring
- 0-1: reassurance
- 2-3: throat swab - treat if positive
- ≥4: throat swab and consider treating
Describe the signs and symptoms of a child with a peritonsillar abscess
- Unilateral tonsil bulge
- Uvular deviation
- Trismus
- Presents in older children/teenagers
Treated with antibiotics and surgical drainage
Describe signs and symptoms in keeping with a retropharyngeal abscess
- Midline bulge in retropharynx
- Posterior to palate
- Occurs in younger children
Treatment: antibiotics +/- drainage (if not improving)
Provide 3 possible diagnoses each for inspiratory, expiratory and biphasic stridor
-
Inspiratory (Supraglottis)
- Laryngomalacia
- Foreign body
- Epiglottitis
- Vallecular cyst
- Saccular cyst
-
Expiratory (Trachea/Bronchi)
- Tracheomalacia
- Foreign body
- Tracheoesophageal fistula
- Complete tracheal rings
-
Biphasic (Vocal cords/Subglottis)
- Subglottic stenosis
- Croup
- Bilateral vocal cord paresis
- Subglottic hemangioma
- Laryngeal cleft
- Croup
- Foreign body
Provide counselling to the parents of a child with laryngomalacia regarding expected prognosis
- Will worsen until about 6 months
- Plateaus between 6-12 months
- Improves 12-18 months (Hamilton Review says 18-24 months)
What is a differential diagnosis for Neck Masses?
“COIN”
-
Congenital
- midline vs lateral
-
Other
- Inflammatory: Kawasaki, Sarcoidosis
-
Infectious
- Acute: viral (EBV, CMV), bacterial (GAS/Staph), PFAPA, Lemierre’s syndrome
- Chronic: HIV lymphadenitis, bacterial (bartonella, TB, atypical mycobacterium, tularemia, syphilis, brucellosis, actinomycosis)
-
Neoplastic
- Benign
- Midline
- Thyroglossal cyst (moves w/tongue protrusion)
- Dermoid cyst (calcification on plain films)
- Teratoma
- Vascular malformation
- Cervical cleft
- Ranula
- Foregut duplication cyst
- Lateral
- Branchial cleft cyst (along SCM border)
- Hemangioma
- Thymic cyst
- Laryngocele (enlarges with Valsalva)
- Vascular malformation
- Midline
- Malignant
- Thyroid
- Lymphoma
- Ewing sarcoma
- Rhabdomyosarcoma
- Neuroblastoma
- Salivary gland tumours
- Benign
In regards to orbital cellulitis:
- Where does it usually originate from?
- What are 2 features unique it?
- What are the 2 most common causal organisms?
- What are 2 ophthalmologic complications
- Usually originates from:
- Ethmoidal sinusitis
- Features unique to it:
- Proptosis
- Pain with extraocular movements
- Restricted ocular motility
- Common causal pathogens?
- Staph aureus
- Streptococcus pneumoniae
- GAS
- Haemophilus influenzae
- Ophthalmologic Complications
- Loss of vision/Blindness
- Orbital abscess
Treatment: Cefuroxime IV
List 4 causes of ptosis
- Isolated congenital dystrophy of levator palpebrae superioris muscle
- Hemangioma (mechanical ptosis)
- Trauma
- Muscular dystrophy
- Myasthenia gravis
- CNIII palsy
- Idiopathic
When would you consider referral to ophthalmology for a chalazion?
Persistance for >3mo
Aesthetic issue
Why is a dacrocystocele concerning?
- Area for bacteria to proliferate → mucocele
- Tears go in but can’t get out → expanding → obstruction of respiratory passage → feeding difficulties
= Indications for surgical management
What is a classic finding in congenital Horner’s syndrome?
The affected eye’s iris appears lighter in colour than the opposite side
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/216/a_image_thumb.png?1598920611)
List 4 causes of anisocoria (asymmetric pupils)
- Physiologic
- Pharmacologic
- Mechanical (trauma, inflammation)
- Horner’s syndrome
- CNIII palsy (“down and out”)
List 4 possible diagnosis of a child presenting with leukocoria
- Retinoblastoma
- Cataract
- Persistent hyperplastic primary vitreous
- Retinopathy of prematurity
- Retinal detachment
- Retinoschisis
- Larval granulomatosis
What cranial nerve palsies are associated with a head tilt?
CNIV - usually congenital
CNVI - concern for increased ICP
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/220/q_image_thumb.png?1598919796)
Retinoblastoma
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/224/q_image_thumb.png?1598920017)
Left CN III palsy with ptosis and inability to elevate and adduct the eye
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/225/q_image_thumb.png?1598920367)
Limbal dermoid cyst
=
Goldenhar syndrome
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/227/q_image_thumb.png?1598920292)
Dacrocystocele
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/229/q_image_thumb.png?1598920408)
HSV keratitis
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/230/q_image_thumb.png?1598920441)
Congenital glaucoma
Rt eye hazy and opaque 2˚ corneal edema
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/231/q_image_thumb.png?1598920498)
Coloboma
Associated with CHARGE syndrome
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/234/q_image_thumb.png?1598920685)
Chorioretinitis
Photo of toxoplasmosis
Also see retinitis with rubella, syphilis, zika, CMV
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/236/q_image_thumb.png?1598920829)
Multiple retinal hemorrhages
Non-accidental trauma
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/237/q_image_thumb.png?1598921426)
Acute otitis media
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/239/q_image_thumb.png?1598921473)
Cholesteatoma
What is this?
What test should you consider in this child?
What are sequelae of this condition?
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/240/q_image_thumb.png?1598921552)
Nasal polyps
Sweat chloride
Facial changes → broadened nasal root, prominence of malar areas
What is this diagnosis?
What is the most common cause of this?
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/241/q_image_thumb.png?1598921701)
Pott puffy tumour (osteomyelitis of frontal bone)
Sinusitis
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/242/q_image_thumb.png?1598921790)
Bifid uvula - concern for submucosal cleft
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/244/q_image_thumb.png?1598921936)
Peritonsillar abscess
![](https://s3.amazonaws.com/brainscape-prod/system/cm/367/260/245/q_image_thumb.png?1598922006)
Retropharyngeal abscess
You see an 18mo boy in the clinic due to concerns his eye “didn’t look right” - on examination you note corneal clouding.
What are 3 possible diagoses?
STUMPED
- Sclerocornea
- Tears in membrane (d/t trauma or congenital glaucoma)
- Ulcers (infection)
- Metabolic (e.g MPS)
- Peters anomaly
- Edema
- Dermoid
How should you manage otorrhea associated with tympanostomy tubes?
Which topical drops are safe for use with tympanostomy tubes?
- Uncomplicated acute otorrhea (<4wks)
- Topical antibiotics x 7-10 days
- Systemic antibiotics are indicated when:
- Cellulitis of pinna or adjacent skin present
- Concurrent bacterial infection present
- Signs of severe infection exist (high fever, severe otalgia, toxic appearance)
- Acute otorrhea persists or worsens, despite topical tx
- Administration of eardrops not possible due to local discomfort or lack of tolerance by child
- Immunocompromised patient
Topical drops = safe
- Ofloxacin
- Ciprofloxacin-dexamethasone